Chronic disease as a barrier to breast and cervical cancer screening

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Abstract
To assess whether chronic disease is a barrier to screening for breast and cervical cancer. Structured medical record review of a retrospectively defined cohort. Two primary care clinics of one academic medical center. All eligible women at least 43 years of age seen during a 6-month period in each of the two study clinics (n = 1,764). Study outcomes were whether women had been screened: for mammogram, every 2 years for ages 50-74; for clinical breast examinations (CBEs), every year for all ages; and for Pap smears, every 3 years for ages under 65. An index of comorbidity, adapted from Charlson (0 for no disease, maximum index of 8 among our patients), and specific chronic diseases were the main independent variables. Demographics, clinic use, insurance, and clinical data were covariates. In the appropriate age groups for each test, 58% of women had a mammogram, 43% had a CBE, and 66% had a Pap smear. As comorbidity increased, screening rates decreased (p < .05 for linear trend). After adjustment, each unit increase in the comorbidity index corresponded to a 17% decrease in the likelihood of mammography (p = .005), 13% decrease in CBE (p = .006), and 20% decrease in Pap smears (p = .002). The rate of mammography in women with stable angina was only two fifths of that in women without. Among women who sought outpatient care, screening rates decreased as comorbidity increased. Whether clinicians and patients are making appropriate decisions about screening is not known.