Factors Associated with Mammography Utilization: A Systematic Quantitative Review of the Literature

OBJECTIVE: A significant segment of women remains underscreened with mammography. We sought to summarize literature related to factors associated with receipt of mammography. For data sources, we used English language papers published between 1988 and 2007, including 221 studies describing 4,957,347 women. METHODS: We calculated odds ratios (ORs) associated with receipt of mammography. Random effects modeling was used to assess trends in mammography utilization and to calculate summary multivariate point estimates. Results were stratified by age, race/ethnicity, and study year. We summarized results between 1988 and 2004 and compared recent years with these results. RESULTS: Physician access barriers, such as not having a physician-recommend mammography (adjusted OR 0.16, 95% CI 0.08-0.33) and having no primary care provider (OR 0.41, 95% CI 0.32-0.53), were highly predictive of not obtaining mammography. Past screening behavior correlated strongly with receipt of mammography (clinical breast examination, adjusted OR 9.15, 95% CI 3.49-23.98) and Pap test (adjusted OR 3.45, 95% CI 2.12-5.62). With the exception of having no insurance (adjusted OR 0.47, 95% CI 0.39-0.57), several potential socioeconomic barriers did not appear to have an important impact on screening. Racial and ethnic differences were seen. Concerns about cost, mammography safety, and pain were more important to African American and Latina women, and having no insurance was more important to white and Chinese women. Cost concerns and the presence of a family history of breast cancer were less important to older women, whereas screening knowledge had a stronger impact on mammography use in women aged > or =65 years. When we compared study results before 2004 with those later, we found very little difference in the multivariate, adjusted ORs over time. CONCLUSIONS: Women with poor access to physicians are much less likely to undergo mammography. Improving the frequency and scope of mammography recommendation by primary care providers is the single most important direct contribution the medical community can make toward increasing mammography use.