Studies have suggested that women with low incomes residing in metropolitan areas might be less likely to be screened for breast cancer than more affluent women residing in the same areas (1,2). However, few studies have examined the associations between breast cancer screening and both individual and area-based measures of socioeconomic status (SES) among women in metropolitan areas (3,4). To examine these associations, CDC analyzed the percentage of women who had a mammogram by using individual data (i.e., household income and education level) from the 2000 and 2002 Behavioral Risk Factor Surveillance System (BRFSS) surveys and area-based data (i.e., percentages classified as living in poverty * or at a low education level[dagger]) from the 2000 U.S. Census. This report summarizes the results of those analyses, which suggested that, among women in 35 metropolitan statistical areas (MSAs),[section] those with annual household incomes of <$15,000 were less likely to have had a mammogram than more affluent women (especially in areas where a greater proportion of women were affluent) and those without a high school education were less likely to have had a mammogram than women with more education (especially in areas where a greater proportion of women had higher education levels). Studies are needed to determine how to increase the percentage of women having mammograms among women in low-income and low-education populations.

BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized, U.S. civilian population aged [greater than or equal to]18 years (5). During 2000 and 2002, BRFSS interviews were conducted with 251,269 women. Data from 2000 and 2002 were used to provide the best match between individual-level information and MSA data from the 2000 U.S. Census. Weights were used to adjust for differences in probability of selection, nonresponse, and noncoverage. The CASRO-estimated median response rates among reporting states in 2000 and 2002 were 48.9% and 58.3%, respectively (5). Questions were asked regarding general health status, demographic and socioeconomic characteristics, and breast cancer screenings. Female respondents were asked, "Have you ever had a mammogram?" Those who said "yes" were then asked, "How long has it been since you had your last mammogram?" Self-reported county of residence was used to classify respondents as residents of MSAs using Office of Management and Budget definitions for MSAs (6). To reduce the heterogeneity of the MSAs and ensure a sufficient number of respondents in each, only BRFSS respondents who resided in MSAs with populations of [greater than or equal to]l.5 million in 2000 were included in this analysis. The 35 MSAs included in this analysis ranged in population from 1,500,741 to 18,323,002. Analyses were limited to 38,117 women aged [greater than or equal to]40 years with no missing information about recent mammography. Area-based data regarding SES (i.e., percentage of residents in an MSA classified as living in poverty or having a low education level) were obtained from the 2000 U.S. Census and categorized using previously described cutpoints (7). Percentage of residents living below the poverty level was based on the 1999 federal definition of a poverty area. Rates for having a mammogram during the preceding 2 years were calculated with combined data from 2000 and 2002. In examining the bivariate associations between screening and both demographic and health factors, the levels of statistical significance were obtained using Pearson's chi-square tests; 95% confidence intervals (CIs) and p-values were calculated. Multivariate analyses of the associations between individual-level and area-based data and breast cancer screening were conducted using logistic regression analyses that employed the following variables: year (2000 versus 2002), age, race, ethnicity, marital status, health insurance, and physician checkup during the preceding year.

Approximately 9.6% of the women aged [greater than or equal to]40 years who responded had household incomes of <$15,000 per year, a level just above that identified by 1999 federal poverty level guidelines as 100% of poverty ($13,410) for a family of three with one member aged <18 years (8); 23.7% had household incomes of $15,000-$34,999 per year, or approximately $1,500 above 250% of the 1999 federal poverty level for a family of three with one member aged <18 years. Among the participants, 11.8% had less than a high school education, 8.0% had never been married, and 9.1% had no health insurance.

Overall, 78.5% of women aged [greater than or equal to]40 years reported having a mammogram during the preceding 2 years (Table 1). Among women who reported annual household incomes of <$15,000, 68.4% (95% confidence interval [CI] = 65.5%-71.3%) received a mammogram in the preceding 2 years; 75.3% (CI = 73.9%-76.8%) of women with household incomes of $15,000-$34,999 and 82.5% of women with household incomes of [greater than or equal to]$50,000 (CI = 81.4%-83.6%) had received a mammogram in the preceding 2 years. Women with less than a high school education, those who were never married, and those who had no health insurance also had lower mammography rates than those who were college graduates, married, or had health insurance. The percentages of residents in MSAs who were living in poverty or who had a low education level were both inversely associated with breast cancer screening.

Despite an increasing trend in the use of breast conserving surgery (B CS) to treat early-stage breast cancer (Silliman et al. 1997; Guadagnoli et al. 1998), substantial variability exists in use of BCS among older women (Nattinger et al. 1996; Wennberg and Cooper, 1996), with the oldest women receiving less BCS, and when treated by BCS, receiving radiotherapy less often than others (Mandelblatt et al. 2000; Busch et al. 1996; Bahlard-Barbash et al. 1996). Numerous studies have examined the roles of factors such as underlying health (Silliman et al. 1997; Albain et al. 1996), age, or socioeconomic biases (Lazovich et al. 1991; Albain et al. 1996; Michalski and Nattinger 1997), physicians' attitudes toward treatment, and patient involvement in treatment decisions (Silliman et al. 1989; Liberati et a). 1987; Liberati et al. 1991), geographic variations or barriers in access to services (Farrow, Hunt, and Samet 1992; Nattinger et al. 1992; Nattinger et al. 1996; Albain et al. 1996; Osteen et al. 1994; Hand et al . 1991), and different care delivery systems (Riley et al. 1999; Potosky et al. 1997).

Only one study (Hadiley, Mitchell, and Mandelblatt 2001) has investigated whether variations in Medicare's fees for BCS and mastectomy (MST) influence the surgical treatment received by elderly Medicare beneficiaries who had breast surgery. Analyzing small-area data on the percentage of elderly Medicare breast surgery patients receiving BCS in 1994, that study found that a 10 percent higher fee for BCS was associated with a 7-10 percent increase in the percentage of beneficiaries receiving BOS in an area, while a 10 percent lower MST fee increased the BCS percentage by 2-3 percent. While suggestive of a fee effect, these findings may have been influenced by several potential limitations. The results may reflect an ecological fallacy because the analysis was conducted at the area level--the same results may not hold for individual patients. The Medicare claims data used in the analysis were not limited to confirmed cases of newly diagnosed localized breast cancer. Thus, it was not possible to exclude cases wh ere minimally invasive surgery was used to rule out a cancer diagnosis from those where the procedure was used as a treatment. Nor was it possible to distinguish women who received breast conserving surgery only (BCSO) from those who received breast conserving surgery plus radiation therapy (BCSRT). If there are differences in the factors that determine the receipt of either of these treatments relative to mastectomy, then the inability to distinguish between them may have biased the earlier result. In particular, it is not clear that the potential effects of the MST and BCS fees should be the same in considering these two treatments relative to mastectomy.

The promise of health benefits from soy has contributed to the recent increase in the availability of soy-containing foods. Since 1995, sales of soy-based products have increased 20% per year, with a large boost in 1999 when the US Food and Drug Administration (FDA) approved a health claim for soy's cardiovascular benefits. Large-scale dietary trends toward vegetarianism and ready-to-eat meals are also driving an increase in the consumption of soy-based meat alternatives. As a result, soy foods are moving rapidly from a niche market to mainstream acceptance. Given recent studies reporting an inverse relationship between soy intake and breast cancer risk, awareness and use of soy foods may be particularly high among women at increased risk for breast cancer. Likewise, beliefs about the benefits of soy in reducing menopausal symptoms may motivate women at risk for breast cancer who are perimenopausal or postmenopausal to try alternatives to estrogen to treat menopausal symptoms.

However, despite the widespread promotion of soy and evidence of its health benefits with respect to heart disease risk, its effects on breast health, especially in non-Asian women, are unknown. Indeed, studies of soy effects on breast density and fluid suggest the possibility that high levels of intake might actually increase breast cancer risk in US women, of particular concern among women already at increased risk for the disease. The objectives of the present study were to: (a) examine sociodemographic and lifestyle correlates of soy food consumption among women at increased risk for breast cancer, (b) describe primary reasons for consumption or nonconsumption of soy foods, and (c) identify sources from which at-risk women obtain information about soy food.

Questionnaires were sent to 893 women enrolled in a family risk assessment program, an education/counseling program for first- and second-degree relatives of cancer patients. A sample of 452 respondents (54% response rate) took part in the study. A self-report questionnaire was used to elicit information about the frequency of consumption of soy and other isoflavone-containing foods, reasons for consumption or nonconsumption, and sources of information about soy foods.

Thirty-two percent reported soy food consumption. Commonly consumed soy foods were vegetable burgers, tofu, and soymilk. Consumers of soy foods were more likely to have higher levels of education and report eating five or more daily servings of fruits and vegetables. The primary reason for consumption of soy foods was eating a healthful diet, whereas insufficient knowledge about soy food preparation was the primary reason stated for nonconsumption. Both consumers and nonconsumers reported obtaining information about soy foods from magazines, friends, and newspapers. Consumers also indicated using the Internet to seek information. Overall, 43% (n=193) of participants reported eating at least one soy food per month, regardless of how they classified themselves with respect to soy food consumption. The majority (123 of 193, 64%) consumed soy foods more than twice a month. One hundred and eighteen women categorized themselves as consumers, and 283 women categorized themselves as nonconsumers. The remaining 51 women who described themselves as both (n=l 5) or neither (n=36) were categorized as consumers or nonconsumers based on their soy food consumption. Mean frequency of soy food intake among consumers was 18.35 servings per month. The soy food items eaten by the highest percentages of consumers were vegetable burgers, tofu, soymilk, soynuts, and green soybeans. The most frequently consumed soy foods on average were soymilk, soynuts, vegetable burgers, and tofu.

This is one of the first studies to evaluate soy food intake among women at increased risk for breast cancer. Interestingly, although 32% of respondents self-reported being consumers of soy food, 43% recounted consuming some soy food at least once per month. Thus, a significant proportion of respondents were getting soy in their diets, even without making concerted efforts to consume soy. It is also notable that compared with other studies in which consumers incorporated soy foods into their diets only once or twice per month, the majority of consumers (64%) in the present sample reported consumption in a frequency more than twice per month. The higher prevalence and frequency of soy consumption in the present sample suggests that at-risk women may be more inclined to incorporate soy foods into their diets, perhaps in an effort to establish healthful dietary behaviors. Women cited several reasons for consuming soy foods, with the majority of consumers being motivated to eat a more healthful diet. In addition, nearly half of the consumers cited cancer risk reduction as motivating their soy food consumption. Notably, a greater proportion of women reported consuming soy to reduce cancer risk than to reduce their risk of heart disease, even though the only health claim for soy permitted by the FDA is related to heart disease.

Mammography and other types of breast cancer screening have been recommended for many years. In most mammography studies, women are observed in the highly controlled setting of randomized trials. Elmore and colleagues conducted a systematic review of breast cancer mortality and new screening modality test characteristics. The aim was to provide information about the effectiveness of mammography, based on community practice, and to look at the role of new imaging techniques in screening for breast cancer. The authors conducted a search of the Cochrane Library, MEDLINE, and other resources to find English-language studies about breast cancer screening.

Recent concerns about study flaws, which led to questioning of mammography's effectiveness, have not been confirmed. This is especially true among women 50 to 69 years of age, in whom meta-analysis shows a reduction in breast cancer mortality of 20 to 35 percent with mammography. In women in their 40s, the benefit is less clear. An estimated 500 to 1,800 40-year-old women would need to be screened on a regular basis to prevent one breast cancer death in 14 to 20 years. Few studies have included women older than 70 years; however, it is reasonable to continue screening older women who have a life expectancy greater than five years.

Overall sensitivity of mammography is 75 percent, and specificity is 92.3 percent; sensitivity increases with age. The recall rate is twice as high in the United States as in the United Kingdom, with no difference in cancer detection rate. This could be caused by many factors, including the United Kingdom's more stringent requirements for minimum number of yearly mammography interpretations, or because of increased malpractice concerns in the United States.

Newer screening modalities include full-field digital mammography, computer-aided detection programs, magnetic resonance imaging (MRI), and ultrasonography. Digital mammography provides convenience but has not proved to be as successful at detecting cancer as screen-film mammography; it also costs more and may result in higher recall rates. Computer-aided detection programs show mixed results, with the largest study showing no differences in detection and recall rates. High-risk women may benefit from the apparent increased sensitivity of MRI; however, MRI may have decreased specificity and is much more expensive than mammography. Ultrasonography has not been well studied in the general population. The review found that false-positive rates ranged from 2.4 to 12.9 percent. In high-risk women, ultrasonography may detect three to four additional cancers per 1,000 women.

Clinical breast examinations probably are not highly accurate in the community setting, with 40 percent of physicians in one study using no methodical approach to the search for breast masses. Breast cancer diagnosis is increased by a likelihood ratio of 2.1 when a breast abnormality is found in a community practice, substantially lower than the likelihood ratio with mammography. Breast self-examination has not improved mortality outcomes but has increased false-positive rates.

The authors note that in addition to discomfort and false-positive rates related to mammography, radiation exposure may pose an additional risk to the breast. However, the benefit-to-harm ratio increases with age.

Breast cancer incidence increases with age. The use of systemic adjuvant chemotherapy to treat early-stage breast cancer has been shown to improve overall and relapse-free survival in women 50 to 69 years of age, but it is not known whether older women receive the same benefit. Because of increased risk of toxic effects, adjuvant chemotherapy may be underused in older patients. Muss and colleagues, for the Cancer and Leukemia Group B (CALGB), reported on the retrospective review of four trials comparing less aggressive with more aggressive chemotherapy to determine the effects of dose-intensive regimens on older patients.

The four CALGB trials (7581, 8082, 8541, and 9344) compared various dosage regimens in patients with node-positive breast cancer. In the 7581 trial, cyclophosphamide (Cytoxan), methotrexate (Trexall), and fluorouracil (Efudex) plus vincristine (Oncovin) and prednisone improved disease-free survival but not overall survival compared with cyclophosphamide, methotrexate, and fluorouracil alone or cyclophosphamide, methotrexate, and f luorouracil plus methanol extraction residue of bacillus Calmette-Guerin.

In trial 8082, two cyclophosphamide, methotrexate, and fluorouracil regimens were found to be equivalent, but when a follow-up regimen based on doxorubicin (Adriamycin) was added to one arm, it was associated with improved disease-free and overall survival.

In the 8541 trial, three dosage and duration ranges of cyclophosphamide, doxorubicin, and fluorouracil found that moderate- and high-dosage groups had longer disease-free and overall survival. A subset of patients with human epidermal growth factor 2 tumors in the high-dosage groups had significantly better disease-free and overall survival.

The 9344 trial found no differences among groups randomized to three doses of doxorubicin combined with cyclophosphamide, but patients subsequently randomized to receive additional paclitaxel (Taxol) had improved five-year disease-free and overall survival.

These four trials represent a span of 24 years and 6,487 patients. Tumor sizes did not differ significantly among age groups, but the number of positive nodes increased with age. Overall treatment-related mortality was 0.5 percent, with chemotherapy-related mortality increasing linearly with age. Age was unrelated to disease-free or overall survival. Predictors of shortened survival included higher number of positive nodes, larger tumor size, no tamoxifen (Nolvadex) use, and estrogen receptor-negative tumors. More chemotherapy improved overall survival compared with less chemotherapy, regardless of age.

The authors conclude that older patients who receive more chemotherapy do as well as younger patients, though their risk of recurrence is higher because of the greater number of positive lymph nodes in this group. Only 8 percent of the women enrolled in the CALGB trials were older than 65 years, which may be because of an age bias on the part of physicians when offering participation in clinical trials. The authors caution that participation in new trials should be limited to women in otherwise good health.

The Centers for Disease Control and Prevention (CDC) has released a report on breast cancer screening for women in 35 major metropolitan areas in 2000 and 2002. Data for the report were collected from surveillance surveys and the 2000 U.S. Census. The findings were published in the October 7, 2005, edition of Morbidity and Morality Weekly Report and can be accessed online at

More than 250,000 women 18 years and older were interviewed to determine general demographic status and were asked if they had ever had a mammogram. Those who answered yes were asked the date of their last mammogram. Analyses for this report focused on women 40 years or older. Of these women, 9.6 percent had household incomes of less than $15,000 per year, and 23.7 percent had incomes of $15,000 to $34,999 per year. Overall, 78.5 percent reported having a mammogram during the two years preceding the study. Among women who reported annual household incomes of less than $15,000, 68.4 percent received a mammogram in the preceding two years; 75.3 percent of women with household incomes of $15,000 to $34,999 and 82.5 percent of women with household incomes of more than $50,000 had received a mammogram in the preceding two years. Women who did not complete high school or were never married and women who had no health insurance had lower mammography rates than those who were college graduates or had married, or who had health insurance.

The report shows that women with household incomes of less than $15,000 per year were less likely to have had a breast cancer screening test in the past two years than wealthier women, especially those living in affluent areas. Women with less education also were less likely to have had a mammogram.

Women who carry a BRCA1 or BRCA2 mutation are 9 to 36 times more likely to develop breast cancer than women without the mutation, and 6 to 61 times more likely to develop ovarian cancer. But to assess the degree of increased ovarian cancer risk in women with a family history of breast cancer who do not carry the genetic mutation, researchers at Memorial Sloan-Kettering Cancer Center followed 199 families with a strong family history of breast cancer but who were BRCA mutation-negative. Forty months (equivalent to 2,534 years of follow-up) after genetic testing to determine their BRCA status, only one case of ovarian cancer was diagnosed, considered normal for women at average risk. But 19 new cases of breast cancer were found, when only six were anticipated. "The study was actually designed to look at these women's subsequent risk of ovarian cancer, which was not elevated compared to women in the general population," explains lead author Noah D. Kauff, MD. "The fact that these women had a three-fold higher risk of breast cancer than women in the general population was not surprising, as the women in our study were selected from inherited breast cancer families." But the research provides the first prospective evidence that women with a strong family history of breast cancer who do not have the genetic mutation are not at increased risk for ovarian cancer. "These results need to be confirmed in a larger study with longer follow-up," says Dr. Kauff. "If they are confirmed, it will allow for (re-)tailoring of ovarian cancer risk-reduction strategies for women with a family history of breast cancer but with no identifiable BRCA mutation." The study appeared in a recent issue of the Journal of the National Cancer Institute

Vitamin D--or the dairy foods that often supply it--may help cut the risk of breast cancer in postmenopausal women.

Researchers at the American Cancer Society tracked more than 68,000 women in the Cancer Prevention Study. After nearly a decade, those who got more vitamin D or ate more dairy foods had a lower risk of estrogen-positive breast cancer, but only if they lived in the northern half of the country, which gets little or no ultraviolet light from the sun in the winter.

In those areas, women who consumed the most vitamin D from their food (more than 300 IU a day) had a 20 percent lower risk of postmenopausal breast cancer than women who consumed the least vitamin D (100 IU or less). And women who averaged at least two low-fat dairy foods a day (usually low-fat milk) had a 23 percent lower risk than those who averaged less than half a serving a day.

Vitamin D and dairy foods had no impact on women from southern states, presumably because they get enough vitamin D from the sun's UV light year-round. (The sun's ultraviolet rays are strongest at the equator, and weaken as you go north or south from there.)