Barriers to Breast Cancer Screening and Mammograms


The mammography screening recommendations have been ambiguous and disagree with suggesting institute to institute.  Thus, it is up to women to make choices about mammogram inspection based on their

personal health beliefs

.  This paper explores 6 published articles that report results from various research conducted on women with an average

risk of breast cancer

. These studies examined the connection between observed benefits and alleged barriers to mammography and compliance with mammography screening in women age 40 and older and among minorities.  It also discusses the latest findings and guidelines according to the American Cancer Society.  Other articles discuss their reviews to support mammogram screening for women under 50, a systemic review of the benefits and harms of breast cancer screening and factors that influence breast cancer screening in Asian countries.


Currently, breast cancer is one of
the most common cancers in women and one of the chief causes of death
worldwide. (Oeffinger,Fontham, Etzioni, et al.)
According to the American Cancer Society 2015, it is the leading
contributor to cancer mortality in women aged 40 to 55.  Several risk factors increase the likelihood
of the disease occurring.  These factors
include: (1) aging, (2) personal history of breast cancer, (3) family history
of breast cancer, (4) history of benign breast disease, (5) menarche younger
than 12 years, (6) nulliparous, or a first child after age 30, (7) higher
education or socioeconomic level, (8) obesity and/or high fats diets, (9)
menopause after age 50, (10) lengthy exposure to cyclic estrogen and (11)
environment exposure (American Cancer Society, 2015).  The cause of breast cancer is still unspecified,
yet these risk factors are known to play a part in the risk of developing this
disease.  Essentially all women can be
considered at risk.  No successful cure
or preventative methods exist, and early recognition offers the best
opportunity for decreasing morbidity and mortality.

Literature Review

The first article that I reviewed is
titled “Benefits and Harms of Breast Cancer Screening, A Systemic Review”.  According to Myers, et al., mortality from
breast cancer has declined substantially since the 1970’s, a drop attributable
to both the accessibility of screening methods, particularly mammography, and better-quality
treatment of more advanced cancer.  This
literature pointed out that, although there has been stable evidence that
screening with mammography reduces breast cancer mortality, there are a number
of possible harms, including false-positive results, which result in both needless
biopsies and added distress and anxiety associated to the potential diagnosis of
cancer.  In addition, screening may lead
to over diagnosis of cancers that may not have become life-threatening.  With their investigation in the meta-analyses
of RTCs (randomized clinical trials) that stratified by age, screening women
younger than 50 years was constantly associated with a statistically
significant reduction in breast cancer mortality of approximately 15% while
screening women 50 years or older was linked with slightly greater mortality
reduction (14-23%).  In general, based on
their research, they have concluded that “regular screening with mammography in
women 40 years or older at average risk of breast cancer reduces breast cancer
mortality over at least 13 years of follow-up, but there is uncertainty about
the magnitude of this association, particularly in the context of current
practice in the United States.”

In summary, this review concluded
that among women of all ages at average risk of breast cancer, screening was related
with a reduction in breast cancer mortality of approximately 20%, although
there was ambiguity about quantitative estimates of the association of
different breast cancer screening strategies in the United States.  These findings and the related uncertainty
should be considered when making suggestions based on judgments about the
balance of benefits and harms of breast cancer screening. (Myers et al. 2015).

Mammography can pinpoint tumors too
small to be detected by palpitation of the breast by the woman or her health
care provider.  Early detection of breast
cancer in women improves the possibility of successful treatment and thus cuts
morbidity and mortality from the disease (American Cancer Society, 2015).  Yet, there still exists an observable lack of
compliance with the recommended screening guidelines.  According to an article in the Journal of the
American College of Radiology by Monticciolo, et al. (2015), they pointed out
that previous to the presentation of widespread mammographic screening in the
mid-1980s, the mortality rate from breast cancer in the US had stayed unaffected
for more than 4 decades.  From 1990, the fatality
rate has fallen by at least 38%.  Considerably,
this change is recognized to prompt detection with mammography.

In this next article, Miranda-Diaz,
et al. (2016) studied the Hispanics Puerto Rican subjects, inner-city women and
determinants of breast cancer screening and suggested that women with low
incomes and education were less likely to partake in mammography.  Lack of submission of breast cancer screening
tests is more prevalent among minorities.
They added that Hispanic women are less likely to receive a Physician’s
recommendation for breast cancer screening, therefore, it was the primary
reason for not doing a mammogram.  Other
barriers for lack of compliance among Hispanic women and Latinas living in California
are lack of health insurance, age, usual source of care, having a busy
schedule, fear, cost and feeling uncomfortable during the procedure.

In conclusion, the authors of this
article did a study that was limited by the small sample size and may not be
generalizable to the entire population of the island. In order to improve
compliance as well as educating health care providers about the importance of
referral, a tailored health education interventions directed to describe the
nature and benefit of cancer screening test needed to be put in place.

Similarly, another article stated
that early detection of breast cancer, while the tumor is still small and
localized, provides the opportunity for the most effective treatment.
(Mandelblatt, Armetta, Yabroff, et al.) According to the American Cancer
Society 2015, detection guidelines recommended that women with an average risk
of breast cancer should undergo regular screening mammography starting at age
45 years.  Women aged 45- 54 years should
be inspected annually and women 55 years and older should changeover to
biennial screening or have the opportunity to begin annual screening between
the ages of 40 and 44 years.  The suggested
outcome of the guideline would result in earlier detection because breast
cancers found by mammography in women in their forties are smaller and more
treatable than those found by self-breast exam or clinical breast exam.  Consequently, earlier detection by
mammography could save lives.

According to an article by Kathy
Boltz, Ph.D. (2013), amid the 609 definite breast cancer deaths, 29% were including
women who had been screened with mammography, while 71% were among unscreened
women.  In tally, her investigation found
that of all breast cancer deaths, only 13% happened in women aged 70 years or
older, but 50% occurred in women under 50 years old. Her studies were done to
support mammogram screening for women under age 50.  In the meantime, Dr. Cady, MD, Professor of
Surgery of Harvard Medical School in Boston, Massachusetts, and his teammates
set out to deliver complete information on the value of mammography screening
through a technique called “failure analysis”.
Such evaluations look backward from the time of death to determine the
connections at diagnosis, rather than looking forward from the start of a
study.  Only one other failure analysis
related to cancer has been published to date.
In this evaluation, invasive breast cancers analyzed at Partners
HealthCare hospitals in Boston between 1990 and 1999 were followed through
2007.  Facts for the study comprised
demographics, mammography use, surgical and pathology reports, and recurrence
and death dates.  The article also stated
that the study showed a dramatic shift in survival from breast cancer
associated with the introduction of screening.
In 1969, half of the women diagnosed with breast cancer had died by 12.5
years after diagnosis.  Between the women
with aggressive breast cancer in this review who were spotted between 1990 and
1999, only 9.3% had expired.  “This is a
remarkable achievement, and the fact that 71% of the women who died were women
who were not participating in screening clearly supports the importance of
early detection,” said co-author Daniel Kopans, MD, also of Harvard Medical

The study of the “perception of
breast cancer risk and screening effectiveness” was studied by Black, Nease,
& Tosteson (1995).  The purpose of
the study was to determine how women 40-50 years of age perceive their risk of
breast cancer and the effectiveness of screening and how these perceptions
compare with estimates derived from epidemiologic studies of breast cancer
incidence and randomized clinical trials of screening. A random sample of 200
women, age 40-50 years old who had no history of breast cancer was chosen
through the computerized medical records of Dartmouth-Hitchcock Medical Center.  Thirty-nine percent had an annual family
income of $50,000 to $100,000, and 62% had at least a college education.  The subjects received the questionnaire in
the mail which asked questions pertaining to breast cancer risk and screening
effectiveness.  Seventy-three percent
responded with a complete questionnaire.
The results showed that the women overestimated their probability of
dying of breast cancer within ten years by more than twenty times.  When asked about their relative risk
reduction from breast cancer screening, they overestimated by six times.  These results are based on assuming a 10%
relative risk reduction from cancer screening.
Eighty-eight percent of the subjects agreed that the benefits to
screening mammography outweighed the barriers.
The generalizability of this study is very limited because of this
population is better educated and of higher income than the general U.S.
population of women of the same age range.
Also, the subjects’ breast cancer risk was not precisely known, and the
effectiveness of modern screening mammography is unknown.  The limitations also include the
questionnaire which has not been previously tested.

The last article is a literature
review of “factors influencing breast cancer screening in Asian countries.”  Studies done by Ahmadian and Samah (2012),
found that breast cancer arises in the younger age group of Asian women, 40 to
49 years old compared to the other Western counterparts, where the peak
prevalence is realized between 50 to 59 years.
According to multiple sources and authors, in Singapore, Malaysia, Iran,
Thailand, Pakistan, and Arab women in Palestine, more than half of new cases of
breast cancer were diagnosed in women below the age of 50 years and in advanced
stages III or IV.   Schwartz et al. (2008), discovered that breast
cancer screening activities among Asian women living in their native country
are low and mammography screening in Middle Eastern countries are also low.  Analyses of the information have shown that
only 23% of Turkish people testified having at least one mammogram.  Fewer women about 10.3% in the United Arab
Emirates had mammography, which was attributed to poor knowledge of breast cancer
screening and infrequent offering of screening by healthcare workers (Schwartz
et al., 2008)  In conclusion of this
article, the authors stated that in order to improve women’s participation in
breast cancer prevention programs/ screenings, especially among the at-risk
subgroup, the intervention strategies should be tailored to their knowledge and
socio-demographic factor.  The approaches
accepted should also take into account the women’s emotional and ethnic matters
in order to support lifelong mammography screening practice for Asian people
which is based on hypothetical interventions. In addition, healthcare
professionals working with Asian women should cautiously tackle the misapprehensions
such as worry about mammogram devices and fatalism. (Ahmadian & Samah, 2012)


In summary, after reading and reviewing
the 6 related articles pertaining to breast cancer and mammogram screening for
women under 50, I have concluded that there are both pros and cons, benefits
and harms, perceived benefits and alleged barriers, and compliance factors that
affect women worldwide.

Breast cancer has claimed millions
of lives throughout the world and women should be encouraged to be mindful of
and to consider their family history and medical history with a physician to determine
if early detection is a warrant.  If the
woman has an average risk of developing breast cancer, the American Cancer
Society supports a discussion of screening around the age of 40 years.  According to the guideline, ACS recommends
that women be provided with information about risk factors, risk reduction, and
the benefits, limitations, and harms associated with mammography screening.  While it is recognized that there is a
balance of risks and benefits to the mammogram, women should be provided with
guidance so that they can make the best choice about when to start and stop
screening and how frequently to be screened for breast cancer.  So, if you or your loved ones have an average
risk of breast cancer and over 40 years old, would you prefer to have a checkup
once a year or once every two years?
This is rather a personal choice but with early detection, the benefit
of mammogram will prove to outweigh the risk and could possibly save your life.


Ahmadian, M and Samah, A.(2012) A Literature Review of Factors Influencing Breast Cancer Screening in Asian Countries.Life Sci J 2012;9(2):585-594.  (ISSN: 1097-8135).

.  Accessed January 16, 2018

Breast Cancer Screening and Diagnosis (version 1.2015).  National Comprehensive Cancer Network.

Accessed January 16, 2018.

Mandelblatt, JS, Cronin, KA, Bailey, S, et al. (2009) Breast Cancer Working Group of Cancer             Intervention and Surveillance Modeling Network.  Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern. Med. 2009;15(10):738-747.

Mandeltblatt, JS, Armatta, C, Yabroff, R, Liang, W, Lawrence, W. (2004) Descriptive Review of the Literature on Breast Cancer Outcomes: 1990 Through 2000. JNCI Monographs, Volume 2004, Issue 33, 1 October 2004, Pages 8-44.

Accessed January 17, 2018.

Oeffinger, KC, Fontham, ETH, Etzioni, R, et al. (2015). Breast Cancer Screening for Women at average risk: 2015 Guideline Update from the American Cancer Society. Jama.2015. doi:10.1001/jama.2015.12783.

Accessed January 17, 2018.

Schwartz, LM, Woloshin, S, Sox, HC, Fischloff, B, Welch, HG.(2000) US Women’s Attitudes to False Positive Mammography Results and Detection of Ductal Carcinoma in Situ:  Cross Sectional Survey. BMJ. 2000;320 (7250):

January 20, 2018