Objective
The objective of the study was to assess women’s attitudes toward 2009 US Preventive Services Task Force mammography screening guideline changes and evaluate the role of media in shaping opinions.
Study Design
Two hundred forty-nine women, aged 39-49 years, presenting for annual examinations randomized to read 1 of 2 articles, and survey completion comprised the design of the study.
Results
Eighty-eight percent overestimated the lifetime breast cancer (BrCa) risk. Eighty-nine percent want yearly mammograms in their 40s. Eighty-six percent felt the changes were unsafe, and even if the changes were doctor recommended, 84% would not delay screening until age 50 years. Those with a friend/relative with BrCa were more likely to want annual mammography in their forties (92% vs 77%, P = .001), and feel changes unsafe (91% vs 69%, P ≤ .0001). Participants with previous false-positive mammograms were less likely to accept doctor-recommended screening delay until age 50 years (8% vs 21%, P = .01).
Conclusion
Women overestimate BrCa risk. Skepticism of new mammogram guidelines exists, and is increased by exposure to negative media. Those with prior false-positive mammograms are less likely to accept changes.
Breast cancer is the second leading cause of cancer death among women in the United States. The breast cancer awareness movement in the United States has brought this issue to the forefront of the contemporary women’s health agenda. As a result, routine mammography has increased significantly since 1989 when the first US Preventive Services Task Force (USPSTF) recommendations were published. In 2005, 67% of American women over the age of 40 years reported having a screening mammogram in the past 2 years.
For Editors’ Commentary, see Table of Contents
The USPSTF published its updated mammogram screening guideline recommendations in November 2009. Notable among the changes was to initiate routine mammography screening at age 50 years, rather than the previously recommended age of 40 years. Despite extensive international study of mammography screening over the last 50 years, the issue of when to start routine screening remains one of the most contentious in the current debate regarding evidence based medical practice. Although there is convincing evidence that screening mammography reduces breast cancer mortality, the greatest absolute reduction is for women between the ages of 50 and 74 years.
In formulating its new recommendations, the USPSTF guidelines reflect recent data suggesting that 1904 women would need to be screened to prevent 1 breast cancer death of a woman in her fifth decade. In fact, the USPSTF concluded that the harm associated with routine screening among women in this age group may outweigh the benefit. Harms included psychological stress associated with false-positive results, unnecessary imaging and associated radiation exposure, biopsies in women without cancer, and morbidity associated with diagnosis of nonclinically significant cancer treatment.
The USPSTF guidelines were published at a time when national attention was turned toward health care reform. Intense debate within the popular media erupted immediately in the wake of the guideline release. A literature search of popular media articles in major publications indexed in LexisNexis (LexisNexis, Miamisburg, OH) in the 10 weeks following the guideline release yielded 1344 results. Although many leaders within the breast cancer awareness movement endorsed the guideline changes, accusations that the new proposals were antiwoman, and potentially politically motivated, soared. The guideline changes sent a confusing and potentially frustrating message to American women.
To date, little has been published on the public’s attitudes toward these guideline changes. Furthermore, it is unclear what influence the media controversy has had in shaping public opinion. In this study, we aimed to assess women’s attitudes toward the screening changes and to evaluate the role of the popular media in shaping these opinions. Are women’s attitudes influenced by the popular media? What personal factors may affect their attitudes? Overall, how are the new recommendations being received?
Materials and Methods
This study was performed as a randomized trial using a convenience sample to assess attitudes about the new USPSTF breast cancer guidelines and assess whether these attitudes were influenced by exposure to opinion pieces that appeared in the popular media.
Subjects consisted of English-speaking women between the ages of 39 and 49 years presenting to their primary obstetrician-gynecologist for annual well-woman examinations. All patients meeting the above criteria were invited to participate in the study at the time of registration by the receptionist in 1 of 4 private practice obstetrician-gynecologist offices.
The study period ran over 3 months in the spring of 2010. After verbal consent was obtained, patients were given an anonymous questionnaire addressing their personal experience with mammography as well as listing their age, breast cancer history, family/friends with breast cancer (up to second-degree relatives), and education level. After this demographic information was obtained, participants were instructed to read a media article on the new guidelines. Participants were given 1 of 2 newspaper articles to read (a 1:1 ratio was obtained).
Subjects in the first group were asked to read “A backlash of mistrust,” an article written by columnist Ellen Goodman, which was published in the Washington Post shortly after the release of the guidelines. In this piece, Goodman argues in favor of the guideline changes. She suggests these changes are sound and expresses confidence in the evidence-based conclusions on which the guidelines were based. Goodman criticized the way in which the changes were announced to the public, arguing that the media, rather than the USPSTF, was to blame for the public outcry.
Subjects in the second group were asked to read “Taking a hit on health care? Why, that’s woman’s work,” an article written by Joan Vennochi, published in the Boston Globe , which was highly critical of the new guidelines. She suggested the guidelines were politically motivated and potentially dangerous for women.
After reading the assigned article, subjects completed additional questions related to their attitudes toward mammography and personal plans regarding mammogram screening. The answers were provided prior to completing the doctor’s appointment, generally within 15 minutes of reading the article. Answers were compared across study groups. After completing the survey, all subjects were provided a fact sheet about mammogram screening that was written by the investigators. This fact sheet explained data behind the guideline changes as well as a brief explanation of the makeup and mission of the USPSTF. Respondents with a personal history of breast cancer were excluded.
Continuous variables were summarized by mean and SD, and Student t tests were used for comparisons between groups. Categorical variables were summarized using frequency measures, and χ 2 tests were used as appropriate.
Our primary analysis was to detect whether participants had different responses on the new breast cancer screening guidelines after they were randomly given 1 of the 2 related articles. Our secondary analysis was to detect whether other factors may also affect their responses. Comparisons on demographical information were made between 2 groups to assure they have similar demographics. P values for all hypothesis tests were 2 sided and statistical significance was set at P < .05. All statistical analysis was performed using SAS (version 9.2; SAS Institute Inc, Cary, NC) statistical analysis software.
The study was approved by the University of Massachusetts Medical School Institutional Review Board.
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