Inflamatory breast cancer

Death and disability associated with breast and cervical cancer and hypertension can be reduced by early detection and treatment. The authors examined the rates for having obtained a Papanicolaou (Pap) test or pelvic examination, a breast physical examination, and a blood pressure test within the last 12 months among women of reproductive age in the United States in 1988, as reported by the 8,450 women interviewed for the 1988 National Survey of Family Growth.

Overall, the annual rates of screening for women ages 15-44 years for those tests were 67 percent for a Pap test or pelvic examination, 67 percent for a breast examination, and 82 percent for a blood pressure test. Standard recommendations for the frequency of screening and survey data were examined to see whether actual screening practice was consistent with those recommendations.

More than 90 percent of women who had a family planning service visit within 12 months received each of the tests, regardless of who provided the service or who paid for the visit. Women who were not sexually active, women with little education or low income, American Indian women, Hispanic women, and women of Asian or Pacific Islander descent had lower rates of screening than others, regardless of their risk status.

These findings strongly suggest that the likelihood of having obtained screening among women 15-44 years old is determined primarily by how often a woman uses health care, rather than by her risk of disease.

Dr. Wilcox is with the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion, Office of the Director. Dr. Mosher is with the Centers for Disease Control and Prevention's National Center for Health Statistics, Division of Vital Statistics, Family Growth Survey Branch.

Tearsheet requests to Lynne S. Wilcox, MD, MPH; CDC, NCCDPHP, MS K41, Atlanta, GA 30333; tel. (404) 488-5396; fax (404) 488-5962.

ESTIMATES OF THE LIFETIME RISK for women of developing breast cancer are 9.5 per 100 among whites and 6.9 among blacks (data for those born in 1980). Their risk for cervical cancer is 0.9 per 100 for whites and 2.0 for blacks (1). The National Health and Nutrition Examination Survey II (NHANES II) found women's rates of hypertension to be 31 per 100 among blacks and 15 per 100 among whites in the period 1976-80 (2).

The racial differences in risk increase with age and are much larger by ages 35-39 years (3). Screening tests are readily available, and disability and death associated with those conditions can be lessened through early detection and treatment.

We examined screening tests and estimated screening rates among women of reproductive age, 15-44 years, to identify those with low levels of screening. The screening tests examined were the Papanicolaou (Pap) test or pelvic examination for cervical cancer and pelvic disease, breast physical examination for breast cancer, and sphygmomanometry for hypertension. The findings may be applied to evaluations of current disease screening practices.

Because rates of breast cancer and hypertension increase with age, women most at risk for those disorders are beyond the age range of the reproductive age women considered in the survey that formed the basis for our study. However, because the incidence of invasive cervical cancer is almost as high among women ages 35-54 years as for women 55 years and older, a Pap test and pelvic screening are of special interest for women in the younger age group (,f). Screening for hypertension is important for those women because of concerns about pregnancy-related hypertension or contraindications for hormonal contraception.

We provide national estimates of recent health screening of women from the 1988 National Survey of Family Growth (NSFG), with demographic and health characteristics. In the survey, a national sample of reproductive age women (15-44 years) was asked whether the woman had a Pap test or pelvic examination, a breast physical examination, or a blood pressure test during a visit for health services in the 12 months before the survey interview.

We examined the health screening rates reported by the women in the survey and determined the characteristics of the women that were associated with the screening rates. We addressed three related questions: how many reproductive age women received the screening tests, were women at most risk for those diseases the women most likely to be tested for them, and were those testing procedures directed to the appropriate women?

Recommendations and Risks

The standard recommendations for the frequency of the tests and the risk factors for the diseases that the tests detect follow. The American Cancer Society (ACS), the National Cancer Institute (NCI), and the American College of Obstetricians and Gynecologists recommend that women who are sexually active or 18 years or older have a Pap test and pelvic examination annually for 3 years, followed by the option of reducing the frequency of screening if the first three tests are negative (5). Several characteristics place women at increased risk for cervical cancer. The risk of invasive cervical cancer is high among women in their late reproductive years (4). Black, Hispanic, and American Indian women have twice the risk of white women. Women are at increased risk who report an early age for first intercourse, more than one sexual partner, or a history of sexually transmitted disease (STD) (6). An increased risk associated with smoking has been reported (6). Some controversial evidence suggests that the use of oral contraceptives may be associated with the risk for cervical cancer (7).

ACS recommends breast physical examination by a health provider every 3 years for asymptomatic women ages 20 to 40 years and every year for women older than 40 (8). NCI has no stated policy for screening women younger than 40 years (9). ACS encourages women with a history or diagnosis of breast cancer or atypical epithelial hyperplasia to receive at least annual examinations. More frequent physical examinations are recommended for women with a family history of breast cancer. Mammography increases breast cancer detection and reduces mortality. While this screening modality detects smaller lesions than does the physical examination, there are reports of 5 to 10 percent of palpable lesions not being detected by mammography (10, 11). Thus, physical examinations and mammography are complementary tools in the effort to detect early breast cancer.

The 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommended that blood pressure be measured at each patient visit (12). Patients with a diastolic blood pressure of less than 85 milimeters of mercury (mm of Hg) should recheck their pressure within 2 years. Those with pressures in the 85 to 89 mm of Hg range are encouraged to have their pressure rechecked within 1 year. Oral contraceptives may elevate blood pressure in otherwise normotensive women (13). The prevalence of hypertension is higher among blacks than among whites and appears to be a special problem for blacks living in the southeastern United States (12). Among women, the black-white difference in prevalence of hypertension is small among teenagers, but is large by ages 35-39 (3).

Methods and Materials

Our report is based on data from the 1988 NSFG, a national sample of 8,450 women who were between the ages of 15 and 44 on March 15, 1988. The women were selected from the civilian, noninstitutionalized population. Personal interviews lasting an average of 70 minutes were conducted by female interviewers between January and August of 1988. The questionnaire focused on the women's reproductive health history and included questions related to pregnancies, contraceptive use, infertility, and use of family planning services. This survey was conducted by the National Center for HeaRh Statistics (NCHS) and has been described in detail (14, 15).

The survey sample was drawn from households that had participated in the National Health Interview Survey (NHIS) in the 18-month period from October 1985 through March 1987. The response rate to the NSFG was high (82.5 percent) and similar for blacks (82.2 percent) and whites (82.6 percent). If the 4 percent nonresponse rate to the NHIS is counted as nonresponse to the NSFG, the overall NSFG response rate is 96 percent times 82.5 percent, or about 79 percent (16).