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This CDC Vital Signs report was posted on April 9, 2024, and reflects the breast cancer screening recommendations in force then, which it notes were under review.
Breast cancer kills approximately 40,000 women in the United States every year. Death rates have been falling, but not equally: Black women and women with low incomes are more likely to die of it. Mammograms find breast cancers early, when they are easier to treat. When the report was written, the U.S. Preventive Services Task Force recommended a screening mammogram every 2 years for women aged 50–74, and an informed decision with a health care provider for women aged 40–49; it had recently released a draft recommending screening every 2 years from 40 to 74.
Yet many women are not up to date. Screening is lowest among women without health insurance, with low incomes, or without a usual source of care — women who often face social disadvantages that get in the way of health care. CDC set out to measure how specific disadvantages relate to whether women get mammograms.
Two kinds of disadvantage
- Social determinants of health (SDOH), in the U.S. Department of Health and Human Services' definition, are the conditions in the places where people are born, live, learn, work, play, worship and age that affect their health, functioning and quality of life.
- Health-related social needs (HRSNs) are an individual's adverse social conditions that can harm their health or health care — food insecurity, unstable housing, no way to get to appointments.
The survey
The Behavioral Risk Factor Surveillance System (BRFSS) is a yearly state-based telephone survey, by landline and cell phone, of civilian adults living outside institutions; in 2022 its median response rate across jurisdictions was 45.1%. Women aged 40 and over in every state and the District of Columbia were asked whether and when they had last had a mammogram. The final sample was 117,466 women aged 40–74, after excluding those who did not answer the mammography or breast cancer history questions and those who had had breast cancer.
Thirty-nine states and DC also asked a new set of questions on social determinants and health equity:
| Adverse social determinants | Health-related social needs |
|---|---|
| lost job or reduced hours in the past 12 months | dissatisfaction with life |
| food running out with no money for more | lack of social and emotional support |
| unable to pay mortgage, rent or utility bills | feeling socially isolated |
| a utility company threatening to cut off service | receiving food stamps (SNAP) |
| no reliable transportation for appointments, work or daily needs | stress in the past 30 days |
A further question, from the survey's core, asked whether cost had kept a woman from seeing a doctor she needed in the past 12 months.
Who had a mammogram
In 2022, 59.1% of women aged 40–49 and 76.5% of women aged 50–74 had had a mammogram in the previous 2 years.
- By state. Among women 40–49, from 44.5% in New Mexico to 77.8% in South Dakota; among women 50–74, from 64.0% in Wyoming to 85.5% in Rhode Island. The younger group's rate was significantly lower everywhere except Mississippi, Pennsylvania and South Dakota.
- By race. Black women had the highest rates in both age groups: 65.2% at 40–49 and 82.9% at 50–74.
- By income and education. Rates rose with both.
- By access to care:
| Women | Aged 40–49 | Aged 50–74 |
|---|---|---|
| without health insurance | 32.7% | 37.4% |
| with health insurance | 58.7% | 73.9% |
| without a personal health care provider | 32.7% | 42.2% |
| with a personal provider | 63.4% | 79.1% |
The more hardships, the fewer mammograms
Among women aged 50–74, mammography fell as the number of adverse conditions rose. The figures below are the median across jurisdictions.
| Adverse conditions reported | Median share with a mammogram in 2 years | Range across jurisdictions |
|---|---|---|
| none | 83.2% | 69.6%–91.0% |
| one | 77.1% | 57.9%–89.5% |
| two | 73.3% | 63.6%–83.5% |
| three to 11 | 65.7% | 44.8%–83.8% |
Too few women aged 40–49 reported more than one to give stable estimates.
Mammography in the past 2 years among women aged 50–74, by jurisdiction and number of adverse social determinants of health and health-related social needs, 2022. Credit: Centers for Disease Control and Prevention.
Taking all the conditions into account together, the ones significantly linked to not having had a mammogram were:
- women aged 40–49: feeling socially isolated, lost or reduced work hours, and cost as a barrier to care;
- women aged 50–74: dissatisfaction with life, feeling socially isolated, lost or reduced work hours, receiving food stamps, lack of reliable transportation, and cost as a barrier.
In both age groups, cost as a barrier to care had the strongest link. That may stand for much more than the price of care itself — transport, child care, time off work. The COVID-19 pandemic, which kept people at home, may have made isolation and job loss worse.
What can help
Programs that offer healthy food and fair access to transportation have been shown to improve people's follow-through on care and their health. Tackling social needs may take several approaches at once. A White House playbook on social determinants of health calls for better understanding and sharing of information on these needs, funding for community organisations that address them, and coordination between health care, public health and social services.
Mammograms are available free or at low cost through insurance requirements under the Affordable Care Act, through Medicare, and through CDC's National Breast and Cervical Cancer Early Detection Program. In 2024 the Centers for Medicare & Medicaid Services introduced a billing code that pays providers for assessing patients' social needs, and it encourages providers to record those needs in medical records with diagnosis codes — an incentive to ask during visits and to connect patients to services.
Alongside proven ways to raise screening — reminders, videos, brochures, postcards, newsletters and removing practical barriers — the authors suggest that health care facilities, providers and public health programs assess patients for adverse social conditions and address needs such as the cost of care, isolation, transport and food insecurity.
Limits
Answers were self-reported and not checked against medical records. The question did not separate screening from diagnostic mammograms, which could overstate screening. The sample may include women at high risk who need more frequent screening than the recommendations cover. The social questions were not about mammography specifically and were asked in only some states. And with a 45% response rate, the results may not represent all adults.
Sources
Based on "Vital Signs: Mammography Use and Association with Social Determinants of Health and Health-Related Social Needs Among Women — United States, 2022," by Jacqueline W. Miller and colleagues (CDC), Morbidity and Mortality Weekly Report 73(15), posted as an MMWR Early Release on April 9, 2024, published by the Centers for Disease Control and Prevention; rewritten in hubnx's own words.
- State-level results are in the report's supplementary table: https://stacks.cdc.gov/view/cdc/150461
- The report's social media graphic is not reproduced.
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