One of the nation's Year 2015 public health goals has been to reduce breast cancer mortality by 50%.25,26
This study explored stage of breast cancer detection because it is a reliable surrogate for survival rates. To increase the detection of early stage breast cancer, the national goal has been to increase adherence to breast cancer screening guidelines among women aged ≥40 years to 90%.25,26
However, as the data in this analysis show, there has been a plateau in the percentage of early stage breast cancers detected in California since the mid-1990s, and the level of this plateau falls considerably below the national goal for annual screening rate.
Data from the Behavioral Risk Factor Surveillance Survey (BRFSS) have shown a parallel plateau in the annual rates of reported mammography screening. This suggests that if the 50% reduction in the breast cancer mortality rate is to be achieved, adherence to mammography screening guidelines and, hence, early detection rates must first be increased.
Several sociological models of behavior can help us to understand why adherence to mammography is lower than the national goal. Rogers' Diffusion of Innovations Theory states that peoples' willingness to adopt change is based on their evaluation of the innovation and that this process is influenced by their level of education and awareness of the innovation.27
According to Rogers' Diffusion Theory some people adopt a change very rapidly (early adopters) and with minimal evidence of its value, whereas the majority of people who adopt a new innovation will require increasing levels of evidence to support the value of adopting the new behavior. In addition, a small group of late adopters will be hesitant to adopt change even after it has become a social norm or may not have the awareness of the product or financial capacity to make the transition. A final group (laggards) may find that the product simply does not comply with their values and may never become adopters. Among these groups of women, socioeconomic factors, environmental factors, and cultural factors will also influence adoption of health promotion behaviors. Unfortunately, the limitations of the CCR database prevent the study of such factors in relation to the impact of educational programs and socioeconomic, environmental, and cultural factors on mortality.
When Rogers' theory is applied to mammography use, it is clear that there will be some women in the laggard group who are highly unlikely to engage in breast cancer screening. This raises the question of what is the realistic goal to set for early breast cancer detection. The limits of screening technology result in missing between 8% and 10% of breast cancers.28,29
This suggests that the maximal attainable screening rate is about 90%–92%. Although we cannot predict the exact number of woman who as members of the laggard group, will never use mammography, it is reasonable to assume it will be a small percentage. However, the screening rates attained for white and Asian women clearly underscore that the ceiling of the rate of early detection rates certainly has not been achieved for Hispanic and African American women.24
Equally important, as the white women's screening rates suggest, higher rates of early detection are also feasible for the Pacific Islander/Asian American women.24
There are some known exceptions that may lower the limit on early breast cancer detection. At least a proportion of women aged ≥50 will have life-limiting comorbidities of sufficient gravity to make breast cancer screening of questionable value and, in some instances, a physical impossibility. This circumstance most likely accounts for a small but unknown number of additional women who are not appropriate to refer for screening.
To optimize early breast cancer detection rates for the rest of each of these groups of slow-to-adopt women, efforts need to be focused on identifying and understanding the motivators and barriers to screening that are faced by the members of each of these comparatively small groups of nonadherent women.
Along with Rogers' Diffusion of Innovations theory, other psychosocial theories offer models related to decision-making behaviors that may be helpful in pinpointing more effective strategies for addressing this challenge. Prochaska's Stages of Change Theory, for example, proposes that people transition through several distinct phases on their way toward acting on a recommendation to behave differently.30
In the precontemplative stage are those women who have not even heard of the value of breast cancer screening; also, low-income women may not yet know that they can get free mammograms in California. Thus, it is possible that these slow-to-adopt women are merely at an earlier stage of change than the early adopters.
Another theoretical framework, offered by the Health Belief Model, recognizes that people need to perceive the presence of a health threat, believe in the efficacy of the intervention, believe that the benefits outweigh the negatives that accompany the intervention, and receive repeated cues to action.
These three theories and others help explain the gradual spread of a new health promoting behavior. Health policymakers and others witnessed the sudden jump in breast cancer detection that occurred after President Gerald Ford and Vice President Nelson Rockefeller and later President Reagan publicly announced that their wives had breast cancer. Dubbed “the Betty Ford effect,” the jump in breast cancer early detection rates that followed these announcements was believed to be the result of the early adopters engaging in screening activities. These same appearances also made it possible to use both the word “breast” and the word “cancer” in public everyday conversation. Although these announcements created a measurable increase in detection/screening rates, the medical plights of these highly visible white women may not have produced the equivalent uptake in screening rates among nonwhite women that it did among white women, thereby delaying the start of the screening uptake trend in nonwhite women.31,32
Subsequently, it became increasingly acceptable to discuss breast cancer in public. In the following decades, breast cancer educational campaigns were launched by such groups as the ACS, the NCI, the Susan G. Komen Breast Cancer Foundation, and state and local health agencies. In addition to mainstream campaigns, new campaigns focused on nonwhite women were launched. The combined effect of all these various efforts was to prompt early adopters among the nonwhite women to engage in screening behaviors and to prompt the intermediate adopters among the white women to take up screening activities on a regular basis.
The obvious, and possibly erroneous, conclusion from these impressions is that the screening gap is largely due to the earlier personalization and, hence, impact of this breast cancer information on white women than nonwhite women and that the discrepancy will naturally correct itself over time. However, the plateau in mammography screening rates reported in the BRFSS and California Facts and Figures24
and the plateau in early detection rates identified in this data analysis raise questions about the feasibility of this expectation occurring without further interventions to promote screening among African American and Hispanic women. The plateau in screening and early detection rates suggests that alternative strategies will be needed to reach African American and Hispanic women. New dissemination and intervention strategies that go beyond the scope of traditional educational approaches may be needed to reach women who are among the slowest to adopt the recommended breast cancer guidelines.33
While new intervention strategies are being developed, tested, and implemented, healthcare providers continue to be in an optimal position to help reduce the disparities in breast cancer early detection rates. Given that women are more likely to be screened if a healthcare provider tells them to do so and that providers know which of their patients are not adhering to screening guidelines, providers are clearly in a position to accomplish the greatest immediate increase in the breast cancer screening rates and to sustain that increase.