title: Screening Mammography in a Public Hospital Serving Predominantly African-American Women: A Stage-Survival-Cost Model.
abstract: BACKGROUND
  Ethnic and socioeconomic disparities pervade breast cancer patterns and outcomes. Mammography guidelines reflect the difficulty in optimizing mortality reduction and cost-effectiveness, with controversy still surrounding the 2009 U.S. Preventive Services Task Force (USPSTF) recommendations. This study simulates USPSTF and American Cancer Society (ACS) guidelines' effects on stage, survival, and cost of treatment in an urban public hospital.
  
  
  METHODS
  Charts of 274 women diagnosed with stage I, II, or III breast cancer (2008-2010) were reviewed. Published tumor doubling times were used to predict size at diagnosis under simulated screening guidelines. Stage distributions under ACS and USPSTF guidelines were compared with those observed. Cohort survival for observed and hypothetical scenarios was estimated using national statistics. Treatment costs by stage, calculated from Georgia Medicaid claims data, were similarly applied.
  
  
  RESULTS
  Mean age at diagnosis was 56 years. African Americans predominated (82.5%), with 96% publically insured or uninsured. Simulated stages at diagnosis significantly favored ACS guidelines (43.1% stage 1/38.3% stage 2/9.9% stage 3 vs. USPSTF 23.0%/53.3 %/15.0%), as did 5-year survival and cost of treatment relative to both observed and USPSTF-predicted schema (p<.0001). Following USPSTF guidelines predicted lower survival and additional costs.
  
  
  CONCLUSIONS
  Following ACS guidelines seems to lead to earlier diagnosis for low-income African-American women and increase 5-year survival with lower overall and breast-specific costs. The data suggest that adjusting screening practices for lower socioeconomic status, ethnic minority women may prove essential in addressing cancer disparities.
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia. Electronic address: crfarle@emory.edu.
authors.forename: Clara
authors.initials: C
authors.lastname: Farley
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Danielle
authors.initials: D
authors.lastname: Friedman
authors.affiliation: Winthrop University Medical Center, Rock Hill, South Carolina; Georgia Cancer Center for Excellence/AVON Foundation Comprehensive Breast Center, Grady Memorial Hospital, Atlanta, Georgia.
authors.forename: Imnett
authors.initials: I
authors.lastname: Habtes
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Raskind-Hood
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: E Kathleen
authors.initials: EK
authors.lastname: Adams
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Edmund R
authors.initials: ER
authors.lastname: Becker
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia; Georgia Cancer Center for Excellence/AVON Foundation Comprehensive Breast Center, Grady Memorial Hospital, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Carl
authors.initials: C
authors.lastname: D'Orsi
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia; Georgia Cancer Center for Excellence/AVON Foundation Comprehensive Breast Center, Grady Memorial Hospital, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Gundry
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia; Georgia Cancer Center for Excellence/AVON Foundation Comprehensive Breast Center, Grady Memorial Hospital, Atlanta, Georgia.
authors.forename: George
authors.initials: G
authors.lastname: Birdsong
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia; Georgia Cancer Center for Excellence/AVON Foundation Comprehensive Breast Center, Grady Memorial Hospital, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Gabram-Mendola
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000191:economics* / Q000208:ethnology / Q000401:mortality; D003365:Costs and Cost Analysis; D003430:Cross-Sectional Studies; D055088:Early Detection of Cancer / Q000191:economics* / Q000706:statistics & numerical data; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D005845:Georgia / Q000453:epidemiology; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006779:Hospitals, Public / Q000706:statistics & numerical data*; D006801:Humans; D008327:Mammography / Q000191:economics* / Q000706:statistics & numerical data; D008403:Mass Screening / Q000191:economics; D008875:Middle Aged; D009367:Neoplasm Staging; D017410:Practice Guidelines as Topic; D012959:Socioeconomic Factors; D015996:Survival Rate