1. Trends in Cervical & Breast Cancer Screening Practices among Women in Rural & Urban Areas of the United States AcademyHealth 2008 Gender and Health Interest Group Meeting June 7, 2008 Mark P. Doescher, MD, MSPH J. Elizabeth Jackson, MA Department of Family Medicine University of Washington School of Medicine

2. Background  Disparities in cancer screening for rural women have been reported by others  A more refined definition of rural residence may allow identification of areas where need for services is especially great

3. Guidelines  Periodic screening for breast cancer and cervical cancer can reduce risk of premature death  USPSTF recommendations:  Mammogram for women aged 40+ every two years  Papanicoloau (Pap) smear for women aged 18+ every three years

4. Disparities  Rates of Pap screening fall short of Healthy People 2010 goal of 90%  Less frequent use of preventive services among rural women may be due to:  Greater distance to medical facilities  Less accessibility of services  Inadequate health insurance coverage  Rural disparity more pronounced among racial/ethnic minorities

5. Study Aims Aim 1 To examine the prevalence of and trends in mammography and Pap smear screening among adult women living in rural and urban locations between 1994 and 2004. Aim 2 To explore the uptake of these tests among groups of rural women who might be relatively unlikely to benefit from any temporal improvements in screening.

6. Data and Methods

7. Data  Behavioral Risk Factor Surveillance System (BRFSS)  Women aged 18+ for Pap screening and 40+ for mammography  Annual samples from 1994-2000, 2002 and 2004 (1994 n=105,853, 2004 n=303,822)  United States (excluding District of Columbia, New Jersey, Rhode Island and Alaska, and territories)

8. Data – Dependent Measures Women were asked:  If they had ever had a mammogram and the date of their most recent mammogram  If they had ever had a Pap smear and the date of their most recent test; also asked whether they had had a hysterectomy Classified as up-to-date if:  Mammogram within prior two years  Pap smear within prior three years

9. Data – Key Independent Measures  Rural/urban residence classified by county by 2003 Urban Influence Code (UIC)  Metropolitan  Non-metro: 1) adjacent non-metro; 2) remote micropolitan; 3) remote non-core  Sociodemographic factors examined: age; race/ethnicity; educational attainment; household income; labor force participation

10. Analysis  Logistic regression used to estimate rates of screening overall and by selected factors  SuDaAn 8.0 [RTI 2001] adjusts standard errors for complex sample design  Predicted marginal percentages are presented  Trends were examined by comparing estimates from individual years

11. Results

12. Percent Women with Current Mammogram or Pap Screening by Rural/Urban (2004)

13. Adjusted Percent Women Aged 40+ with Current Mammogram by Race/Ethnicity (2004)

14. Adjusted Percent Women Aged 40+ with Current Mammogram by Age (2004)

15. Adjusted Percent Women Aged 40+ with Current Mammogram by Educational Attainment (2004)

16. Adjusted Percent Women Aged 40+ with Current Mammogram by Income (2004)

17. Adjusted Percent Women Aged 40+ with Current Mammogram by Labor Force Participation (2004)

18. Adjusted Percent Women Aged 18+ with Current Pap Smear by Race/Ethnicity (2004)

19. Adjusted Percent Women Aged 18+ with Current Pap Smear by Age (2004)

20. Adjusted Percent Women Aged 18+ with Current Pap Smear by Educational Attainment (2004)

21. Adjusted Percent Women Aged 18+ with Current Pap Smear by Income (2004)

22. Adjusted Percent Women Aged 18+ with Current Pap Smear by Labor Force Participation (2004)

23. Adjusted Percent of Women Aged 40+ with Current Mammogram (1994-2004)

24. Adjusted Percentage of Women Aged 18+ with Current Pap Smear (1994-2004)

25. Adjusted Percent Women Aged 40+ with Current Mammography in Rural Counties by State

26. Adjusted Percent Women Aged 18+ with Current Pap Smear in Rural Counties by State

27. Discussion

28. Factors Influencing Screening Behavior  Rural residence is an independent risk factor for lacking current mammography  Low SES and advanced age are risk factors for lacking cervical and breast cancer screening  Rural disparities are pronounced for those without a high school diploma  Rural African Americans lagged behind urban counterparts in mammography  Latinas were more likely than whites to have current screening regardless of residence

29. Screening Trends Mammography  Participation improved 1994-2004  However, rates lower in all rural areas  Rural areas of many states lagged behind Healthy People 2010 target of 70% screened Pap screening  No significant increase in any area  Below Healthy People 2010 target of 90% screened

30. Variation by State  Wide variability by state in breast and cervical cancer screening in rural counties  Also wide variability by state in:  per-capita health spending  Medicaid spending per enrollee  States with higher personal spending tended to have higher screening rates

31. Limitations  Households without telephones were excluded  Attitudes and beliefs that may affect screening behavior could not be examined  Potential recall bias of self-report data  Data aggregated by county may overlook intra- county differences  Population-based research on travel distance and out-of-pocket costs needed to determine the effect of access to radiographic facilities

32. Policy Implications  Improvements in mammography are needed for rural residents  Improved access to mammography and Pap screening is needed for women with risk factors  Preservation and expansion of Medicaid coverage would improve screening rates for racial/ethnic minority groups  Expansion of programs like the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)