title: Geographical and seasonal barriers to mammography services and breast cancer stage at diagnosis.
abstract: BACKGROUND
  Routine mammography screening and early detection are important prognostic indicators for breast cancer. Geographical and seasonal barriers to mammography services and relationship to breast cancer stage at diagnosis were examined.
  
  
  METHODS
  Travel time to mammography center, seasonal distribution of mammogram use, mammography frequency, and stage of cancer were retrospectively examined in 1428 female patients diagnosed with primary breast cancer at a tertiary care clinic system in Wisconsin, USA, from 2002 to 2008.
  
  
  RESULTS
  Women with no missed mammograms before diagnosis lived a median of 15 minutes from the nearest facility, while those who missed five of their past five annual mammograms lived nearly twice as far, with a median travel time of 27 minutes (p<0.0001). There was a direct relationship between travel time to nearest mammogram facility and stage of breast cancer at diagnosis, with travel time increasing from 17 to 24 minutes for stage 0 and stage 4 breast cancers, respectively (p=0.0586). Women were less likely to undergo mammography screening during the winter months (p<0.0001), especially women with greater than 30 mi (48.3 km) to travel to the nearest mammogram facility (p=0.0448).
  
  
  CONCLUSIONS
  In the studied service area, travel time to nearest mammogram center appears inversely related to regular mammography screening and breast cancer stage at diagnosis. Mammograms are less common in the winter, especially in women with further to travel. This is the first study to demonstrate that inclement winter weather may impact on screening behaviors in rural areas and demonstrates the importance of considering climate as part of geographical access to preventative care.
authors.affiliation: Hematology, Weston Center, Marshfield Clinic, Weston, Wisconsin, USA. onitilo.adedayo@marshfieldclinic.org.
authors.forename: Adedayo A
authors.initials: AA
authors.lastname: Onitilo
authors.affiliation: Research Foundation, Marshfield Clinic, Weston, Wisconsin, USA. liang.hong@mcrf.mfldclin.edu.
authors.forename: Hong
authors.initials: H
authors.lastname: Liang
authors.affiliation: Research Foundation, Marshfield Clinic, Weston, Wisconsin, USA. stankowski.rachel@mcrf.mfldclin.edu.
authors.forename: Rachel V
authors.initials: RV
authors.lastname: Stankowski
authors.affiliation: Cancer Care at St. Michael's, Marshfield Clinic, Stevens Point, Wisconsin, USA. engel.jessica@marshfieldclinic.org.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Engel
authors.affiliation: Department of Geography/Geology, UW, Stevens Point, Wisconsin, USA. mbroton@uwsp.edu.
authors.forename: Michael
authors.initials: M
authors.lastname: Broton
authors.affiliation: Clinical Epidemiology Unit, School of Population Health, University of Queensland, Brisbane, Queensland, Australia. s.doi@sph.uq.edu.au.
authors.forename: Suhail A
authors.initials: SA
authors.lastname: Doi
authors.affiliation: Department of Geography/Geology, UW, Stevens Point, Wisconsin, USA. miskowi@uwsp.edu.
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Miskowiak
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005260:Female; D062305:Geographic Mapping; D006801:Humans; D008327:Mammography / Q000706:statistics & numerical data*; D008875:Middle Aged; D009367:Neoplasm Staging; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012621:Seasons; D013997:Time Factors; D014481:United States / Q000453:epidemiology