Feature Article

Primary Care Referrals for Mammograms

An interesting article was published recently in the Journal of the American Board of Family Practice. Researchers led by Dr. Jeanne Ferrante of the University of South Florida and the H. Lee Moffitt Cancer Center in Tampa studied the relationship between the local supply of physicians and the early detection of breast cancer for women in the surrounding area.

Using data from the Florida cancer registry in 1994, the researchers specifically focused on the balance between medical specialists and primary care physicians, and how this ratio would impact the earlier detection of breast cancer through mammography screening.

"A physician's recommendation for screening and access to health care have been shown to be important predictors of breast cancer screening levels," they wrote. In addition, because primary care physicians order most mammograms (between 80 - 90 percent), they hypothesized that a greater supply of primary care physicians would be associated with an earlier stage at diagnosis for breast cancer.

They were right. After examining 11,740 Florida breast cancer patient records and comparing them to the distribution of physicians throughout the state, they found no relation between the total supply of physicians and earlier detection.

However, they did notice a significant relationship between the number of primary care physicians and earlier detection. "As the supply of primary care physicians increased, the odds of early-stage diagnosis increased," they wrote.

They also found that this impact of primary care physicians on earlier detection was more pronounced for patients with fee-for-service insurance, for those living in rural areas, for patients with invasive cancers, and for those in the 50- to 75-year-old range for which mammograms have a proven benefit.

In fact, patients residing in areas with the highest supply of primary care physician had a 37 percent greater chance of early-stage diagnosis compared with patients residing in areas having the fewest primary care physicians.

Fewer Referrals for Minorities

Another study in the American Journal of Public Health focused on the dramatically lower levels of mammography screening rates for African-American women in eastern North Carolina. One reason: fewer doctor referrals for minority patients.

Dr. Michael O'Malley of the University of North Carolina, Chapel Hill and colleagues compared approximately 2,000 African-American and white women aged 52 and older living in 10 rural North Carolina counties between 1993 and 1994. Their finding: The African-American women were only half as likely to have undergone mammography screening as their white counterparts.

Disturbingly, O'Malley's team also found that doctors were less likely to recommend screening mammography to their African-American patients as compared to their white patients. Fifty-five percent of the white women in the study said that a physician had recommended mammography to them within the past year, compared to only 45 percent of African-American women.

The researchers suggested that level of income-and to a lesser degree a woman's level of formal education-might have contributed to this racial disparity. "If it is chiefly a matter of cost, we may be able in some way to help African-American women overcome these financial barriers and increase their mammography rates," they wrote.

However, they noted that a significant hurdle must still be overcome concerning doctors themselves. "Previous research has shown that when a doctor recommends a mammogram, the chance that a woman will actually get screened increases dramatically," they wrote. "This study underscores the need for healthcare providers to be aware of their influence. They need to recommend mammograms to all women, even those they perceive as of limited means."

Talking About Breast Cancer

Finally, a report published in the British Medical Journal called for primary care physicians to be more proactive in asking female patients about their family history of breast cancer and other risk factors for the disease.

According to results from the Women's Concerns Study Group based at the University of Cambridge, England, women with a known family history of breast cancer rarely raised that issue with their primary care physician or nurse during regular medical visits.

In fact, women consulting their family doctors broached the subject of a family history of breast cancer in only 5 out of 1,000 consultations. Almost ten times the number of women in the study requested contraceptive advice, and three times that number brought up menstrual disorders.

Journal of the American Board of Family Practice, 2000; 13(6): 408-414
American Journal of Public Health, January 2001; 91(1):00-00
British Medical Journal, January 2001; 322:27-28

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