Bottom Line: Uninsured women under age 65 were more likely than insured women to experience delays between an initial positive screening mammogram and a diagnostic follow-up.
Journal in Which the Study was Published: Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.
Author: Louise M. Henderson, PhD, an assistant professor in the Department of Radiology at the University of North Carolina Chapel Hill and a member of the UNC Lineberger Comprehensive Cancer Center.
Background: About 10 percent of women who undergo screening mammograms are referred for additional follow-up imaging, which could include a diagnostic mammogram, breast ultrasound, MRI, or a breast biopsy, Henderson explained.
Guidelines from the Centers for Disease Control and Prevention recommend that women with a positive screening mammogram receive a follow-up diagnostic workup within 60 days of the initial positive screen. Delays in follow-up may contribute to disparities in breast cancer outcomes, as they have been associated with larger tumor size at diagnosis and reduced survival.
How the Study Was Conducted: This study sought to examine the effect of insurance status on the time between the initial screening mammogram and the diagnostic follow-up procedure. Using data from the Carolina Mammography Registry, a North Carolina population-based registry of breast imaging and cancer outcomes, Henderson and colleagues identified women with a positive screening mammogram, and analyzed the receipt of follow-up by insurance status and age group. Among 43,026 women included in the study, 73 percent were under 65 years of age and 27 percent were 65 or older. In the under-65 age group, 89 percent had private insurance, 3 percent were uninsured, and the remainder had a combination of Medicare and private insurance.
Results: The study showed that uninsured women less than 65 years of age experienced a longer time to the start of diagnostic follow-up, and were 59 percent more likely to miss the CDC guideline than privately insured women in the same age group. In this age group, nearly 18 percent of women without insurance received their diagnostic follow-up after 60 days compared with 11 percent of women with private-only insurance. Among women 65 or older, there were no statistically significant delays.
Henderson noted that in many cases, the difference in follow-up time was small. For the overall study population, the median time to follow-up was 12 days. Among women under 65, those with no insurance had a median follow-up time of 16 days, compared with 12 days among women with private-only insurance.
However, she said the median time may mask more significant delays from some women, and noted that approximately 10 percent of women received no follow-up within a year of their initial positive screening mammogram. In women less than 65 years with no insurance, almost 14 percent had no follow-up within the year, compared with 11 percent of women with private- only insurance.
Author Comment: "The women with no insurance are consistently a little bit behind in terms of follow-up, and we need to work toward addressing that gap to ensure better outcomes for these women," Henderson said.
Henderson said that several factors could be responsible for the differences in time between initial positive screening and follow-up diagnostic tests. For example, she noted, women with private insurance may be more economically advantaged, with better access to care.
"If a woman experiences a positive screening mammogram and is called back for a follow-up diagnostic test, it's important that it gets taken care of in a timely fashion," Henderson said. "We want to encourage women to be aware that an abnormal result in a screening mammogram is not necessarily an emergency, but it must be resolved."
Study Limitations: Henderson said a limitation of the study is that insurance status was self-reported and may not be accurate. Also, certain personal factors like anxiety and stress, which have been shown to affect follow-up time, were outside the scope of this study.
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Funding & Disclosures: This study was funded by grants from the National Institutes of Health. Henderson declares no conflicts of interest.
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