We sought to identify the determinants of medical detection vs. self-detection of breast cancer in a cohort of low-income women in the California BCCTP. The method of detection was characterized as self if the lump was felt through a self-examination, the spouse/partner felt the lump, or if the woman perceived the breast to be abnormal or had an abnormal sensation or bleeding from the nipple. If the lesion was detected by a routine mammogram or if the doctor felt a lump, the method of detection was categorized as medical.
The BCCTP is a coverage option through Medicaid that was created as part of the federal government Breast and Cervical Cancer Prevention and Treatment Act of 2000. It was designed to provide immediate coverage for medical treatment for individuals diagnosed with breast and cervical cancer. In California, applicants must be a resident of the state and have an income that does not exceed 200% of the Federal Poverty Level (FPL) (based on annual income and family size). Benefits are provided through either the state-funded or federally funded arm of the program. In the federal program, the individual must be uninsured, a citizen or national of the United States or have satisfactory immigration status, and <age 65. The state program provides safety net coverage for individuals not eligible for the federal program. Eligibility in the state program includes individuals with undocumented immigration status, age ≥65, or insured but with expected premiums, copays, or deductibles >$750 per year. The federal program provides full scope, no-cost Medi-Cal coverage for the duration of the cancer treatment and includes coverage for other medical conditions. The state program only covers breast cancer treatment for a maximum of 18 months. Women are enrolled through authorized providers in the Every Woman Counts (EWC) or the Family Planning and Access to Care and Treatment (FPACT) breast cancer screening and diagnostic programs for low-income women.
The EWC program provides breast and cervical screening services for underserved women in California and is funded by federal grants and state tobacco tax revenue. For breast screening, women must be California residents ≥40 years of age, have low income, and be uninsured or have high deductibles or copayments that prevent them from accessing these services.13
The FPACT program aims to provide a package of family planning and reproductive health services (including screening mammography) to low-income residents. Women must be ≥40 years and have income <200% of the FPL to be eligible for screening mammography.14
A total of 1511 English-speaking and Spanish-speaking women aged ≥18 years who had been diagnosed with breast cancer between 2003 and 2005 and were enrolled in the California BCCTP were contacted for participation in the study. Of these, 921 agreed to participate, a 61% overall response rate. Participants were interviewed by phone within 6 months of their definitive surgical treatment. Compared with survey responders, nonresponders were older (52 vs. 50 years) and had a greater percentage of Asians (8.9% vs. 4.3%) and African Americans (8.1% vs. 5.6%) and a lesser percentage of Hispanics (45.6% vs. 55.9%). Exclusion criteria included a previous history of breast cancer, active treatment for another cancer, and cognitive impairment. We limited our analysis to women aged ≥40 years, as routine screening mammography is recommended only for this population.
The dependent variable was based on participants' responses to the question: How did you first know something was wrong? The response categories were coded as self (if the woman reported she felt a lump through self-examination, her spouse/partner felt a lump, her breast appeared abnormal, she felt an abnormal sensation, or she experienced bleeding from the nipple) or medical (if the woman reported a routine mammogram or the doctor felt a lump). We decided to code these response categories together, as there were very few women who reported that the lump was felt by a doctor (n
Independent variables included age, marital status (married/partnered or single/divorced/widowed), education status (high school graduate or less, some college or more), and income (<
$10,000 per year, $10,000–$20,000 per year, >
$20,000 up to $30,000 per year, and >$30,000 per year).15–18
Ethnicity was coded as white, African American, Latina, and other. Self-reported general health was based on the SF-36 and was categorized as poor, fair, good, very good, or excellent.19
Whether participants had a regular source of care before diagnosis and any health insurance before diagnosis were binary variables (yes or no).20,21
Data analysis was carried out using Stata/SE 10 (Stata Corporation, College Station, TX). Unadjusted bivariate relationships between the dependent and independent variables were examined. Logistic regression models were used to estimate the predictors of medical vs. self-detection of breast cancer; independent variables in the regression were age, marital status, ethnicity, education, income, self-reported general health, having a regular source of care, and having health insurance before diagnosis. The overall fit of the model to the data was assessed with the maximum log likelihood ratio chi-square statistic.