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      Estimating attendance for breast cancer screening in ethnic groups in London

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          Abstract

          Background

          Breast screening uptake in London is below the Government's target of 70% and we investigate whether ethnicity affects this. Information on the ethnicity for the individual women invited is unavailable, so we use an area-based method similar to that routinely used to derive a geographical measure for socioeconomic deprivation.

          Methods

          We extracted 742,786 observations on attendance for routine appointments between 2004 and 2007 collected by the London Quality Assurance Reference Centre. Each woman was assigned to a lower super output (LSOA) based on her postcode of residence. The proportions of the ethnic groups within each LSOA are known, so that the likelihood of a woman belonging to White, Black and Asian groups can be assigned. We investigated screening attendance by age group, socioeconomic deprivation using the Index of Deprivation 2004 income quintile, invitation type and breast screening service. Using logistic regression analysis we calculated odds ratios for attendance based on ethnic composition of the population, adjusting for age, socioeconomic status, the invitation type and screening service.

          Results

          The unadjusted attendance odds ratios were high for the White population (OR: 3.34 95% CI [3.26-3.42]) and low for the Black population (0.13 [0.12-0.13]) and the Asian population (0.55 [0.53-0.56]). Multivariate adjustment reduced the differences, but the Black population remained below unity (0.47 [0.44-0.50]); while the White (1.30 [1.26-1.35]) and Asian populations (1.10 [1.05-1.15]) were higher. There was little difference in the attendance between age groups. Attendance was highest for the most affluent group and fell sharply with increasing deprivation. For invitation type, the routine recall was higher than the first call. There were wide variations in the attendance for different ethnic groups between the individual screening services.

          Conclusions

          Overall breast screening attendance is low in communities with large Black populations, suggesting the need to improve participation of Black women. Variations in attendance for the Asian population require further investigation at an individual screening service level.

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          Most cited references18

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          Trends in breast cancer by race and ethnicity: update 2006.

          In this article, the American Cancer Society (ACS) provides estimates of new breast cancer cases and deaths in 2006 and describes trends in incidence, mortality, and survival for female breast cancer in the United States. These estimates are based on incidence data from the National Cancer Institute (NCI) and the North American Association of Central Cancer Registries, which includes state data from NCI and the National Program of Cancer Registries of the Centers for Disease Control and Prevention and mortality data from the National Center for Health Statistics for the most recent years available (1975 to 2002). This article also shows trends in screening mammography. Approximately 212,920 new cases of invasive breast cancer, 61,980 in situ cases, and 40,970 deaths are expected to occur among US women in 2006. As previously reported, breast cancer incidence rates increased rapidly among women of all races from 1980 to 1987, a period when there was increasing uptake of mammography by a growing proportion of US women, and then continued to increase, but at a much slower rate, from 1987 to 2002. Trends in incidence vary by age, race, socioeconomic status, and stage. The continuing increase in incidence (all stages combined) is limited to White women age 50 and older; recent trends are stable for African American women age 50 and older and White women under age 50 years and are decreasing for African American women under age 50 years. Although incidence rates (all races combined) are substantially higher for women age 50 and older (375.0 per 100,000 females) compared with women younger than 50 years (42.5 per 100,000 females), approximately 23% of breast cancers are diagnosed in women younger than 50 years because those women represent 73% of the female population. For women age 35 and younger, age-specific incidence rates are slightly higher among African Americans compared with Whites but then cross over so that Whites have substantially higher incidence at all later ages. Among women of all races and ages, breast cancer mortality rates declined at an average rate of 2.3% per year between 1990 and 2002, a trend that reflects progress in both early detection and treatment. However, death rates in African American women remain 37% higher than in Whites, despite lower incidence rates. Although, in national surveys, approximately 70% of women age 40 years and older report having had a mammogram in the past 2 years, rates vary by race/ethnicity and are markedly lower among women with lower levels of education, without health insurance, and in recent immigrants. Furthermore, a recent study suggests that the true percentage of women having regular mammography is lower than reported in survey data. Encouraging patients age 40 years and older to have annual mammography and clinical breast exam is the single most important step that clinicians can take to reduce suffering and death from breast cancer. Clinicians should also ensure that patients at high risk of breast cancer are identified and offered appropriate referrals and treatment. Continued progress in the control of breast cancer will require sustained and increased efforts to provide high-quality screening, diagnosis, and treatment to all segments of the population.
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            Prospective study of predictors of attendance for breast screening in inner London.

            To investigate the predictors of first-round attendance for breast screening in an inner city area. Prospective design in which women were interviewed or completed a postal questionnaire before being sent their invitation for breast screening. Sociodemographic factors, health behaviours, and attitudes, beliefs, and intentions were used as predictors of subsequent attendance. A randomised control group was included to assess the effect of being interviewed on attendance. Three neighbouring health districts in inner south east London. A total of 3291 women aged 50-64 years who were due to be called for breast screening for the first time. The analysis of predictors was based on a subsample of 1301, reflecting a response rate of 75% to interview and 36% to postal questionnaire. Attendance was 42% overall, and 70% in those who gave an interview or returned a questionnaire. There was little evidence for an interview effect on attendance. The main findings from the analysis of predictors are listed below. (These were necessarily based on those women who responded to interview/questionnaire and so may not be generalisable to the full sample.) (1) Sociodemographic factors: Women in rented accommodation were less likely to go for screening but other indicators of social class and education were not predictive of attendance. Age and other risk factors for breast cancer were unrelated to attendance, as was the distance between home and the screening centre. Married or single women were more likely to attend than divorced, separated, or widowed women, and black women had a higher than average attendance rate; however, neither of these relationships was found in the interview sample. (2) Health behaviours: Attenders were less likely to have had a recent breast screen, more likely to have had a cervical smear, more likely to go to the dentist for check ups, and differed from non-attenders with regard to drinking frequency. Exercise, smoking, diet change, and breast self-examination were unrelated to attendance. (3) Attitudes, beliefs, and intentions: The two best predictors were measures of the perceived importance of regular screening for cervical and breast cancer and intentions to go for breast screening. Also predictive were beliefs about the following: the personal consequences of going for breast screening, the effectiveness of breast screening, the chances of getting breast cancer, and the attitudes of significant others (the woman's husband/partner and children). Women who reported a moderate amount of worry about breast cancer were more likely to attend than those at the two extremes. Attenders and non-attenders differ in two broad areas: the health related behaviours they engage in and the attitudes, beliefs, and intentions they have towards breast cancer and breast screening. The latter are potentially amenable to change, and though different factors may operate among women who do not respond to questionnaires, the findings offer hope that attendance rates can be improved by targeting the relevant attitudes and beliefs. This could be done by changing the invitation letter and its accompanying literature, through national and local publicity campaigns, and by advice given by GPs, practice nurses, and other health professionals. It is essential that such interventions are properly evaluated, preferably in randomised controlled studies.
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              Non-attendance in breast cancer screening is associated with unfavourable socio-economic circumstances and advanced carcinoma.

              Our first objective was to assess changes in non-attendance, proportion of advanced breast cancer and survival in Malmö Mammographic Service Screening Program, MMSSP, compared to a former trial, Malmö Mammographic Screening Trial, MMST. Our second objective was to describe non-attenders in MMSSP in socio-economic terms and risk for advanced breast cancer compared to attenders. Information from hospital and national registers was used to identify 33,800 women invited to service screening in MMSSP 1990-93. Attendance rates at first screening, the proportion of advanced breast cancers (Stage II-IV) and survival among non-attenders in MMSSP were compared to the non-attenders and with the control group of the former trial, MMST. Various socio-economic factors were assessed as potential predictors of non-attendance in MMSSP. Odds ratios (OR) and 95% confidence interval (CI) were computed. Incidence of breast cancer during a 10-year-period, relative risks and 95% CI among non-attenders compared to attenders in MMSSP were computed. Attendance rates were significantly lower in MMSSP but a lower proportion of advanced breast cancers and a somewhat better survival among breast cancer cases (not significant) was seen in non-attenders in MMSSP compared to MMST. In MMSSP non-attendance was associated with being unmarried, being born abroad, being not currently employed, crowded housing conditions and low income. Incidence of advanced breast cancer was significantly higher among non-attenders than among attenders. Attendance has decreased over time and potential reasons are discussed. Stage distribution and survival among non-attenders seem to have improved. Several socio-economic factors predict non-attendance and non-attenders are at higher risk for advanced breast cancer. Copyright 2003 Wiley-Liss, Inc.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2010
                25 March 2010
                : 10
                : 157
                Affiliations
                [1 ]King's College London, Thames Cancer Registry, 42 Weston Street, London, SE1 3QD, UK
                [2 ]London Cancer Screening Quality Assurance Reference Centre, 4th Floor 50 Eastbourne Terrace, London, W2 6LG, UK
                Article
                1471-2458-10-157
                10.1186/1471-2458-10-157
                2850886
                20334699
                5e33d013-a197-4ff4-81fd-07385576c793
                Copyright ©2010 Renshaw et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 November 2009
                : 25 March 2010
                Categories
                Research article

                Public health
                Public health

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