Health Care Delivery
Original Contribution
Mobile Mammography, Race, and Insurance: Use Trends Over a Decade at a Comprehensive Urban Cancer Center By Sarah Mizuguchi, MD, Laura Barkley, MD, Shesh Rai, PhD, Jianmin Pan, Lane Roland, MD, Stacey Crawford, MD, and Elizabeth C. Riley, MD
Abstract Purpose: To assess the use of a mobile mammography unit (MMU) as it relates to race and insurance status in the largest county in Kentucky. Methods: We retrospectively reviewed 48,324 screening mammograms of 21,857 patients conducted over a 10-year period. Descriptive statistics for patient age, race, and insurance status were computed by entire cohort and within subsets of cohorts. This analysis was limited to trends in use by race and insurance status. To study the patterns of frequency distributions, indiscrete variables were performed using the Pearson 2 test. For continuous variable range, a 95% CI of
Introduction Breast cancer is the most common nonskin cancer among women in the United States and the second leading cause of cancer-related death.1 The efficiency of screening mammography for early detection and increased survival has been shown in several randomized trials.2-6 Medically underserved women have higher rates of breast cancer mortality, which has been attributed to underscreening and disproportionate rates of latestage disease at diagnosis.7 Traditionally medically underserved populations include racial and ethnic minorities, those with low socioeconomic status, and under- or uninsured patients. In 2002, Derose et al8 reported that mobile mammography, partnered with churches, offered the potential to increase screening adherence for traditionally underscreened women. By bringing screening to neighborhoods and places of work or worship, barriers involving lack of transportation or inability to take time off work could be eliminated. Although churches have traditionally been centers for outreach efforts in the African American community, Derose et al found an encouraging potential to reach Spanish-speaking Latinas as well. This has important implications, because the population of Spanishspeaking Latinas has increased,9 and prior data have shown that Latinas are the least-likely group to undergo routine screening mammography.10,11 The goal of mobile mammography since its nationwide onset has been to increase access to screening.12 Previous studies have suggested that mobile programs increase access to screening mammography.13 According to a 1996 national survey of mobile mammography programs, groups targeted include working women, the economically disadvantaged, rural popuCopyright © 2014 by American Society of Clinical Oncology
mean was estimated. Comparisons with a P value less than .05 were considered statistically significant.
Results: Self-reported blacks constituted significant use of the MMU (29% v census data demographic reports of 19%). Race significantly correlated with likelihood to screen ⱖ three times, with blacks (30.5%) more likely, and whites (27.8%) and Hispanics (20.2%) less likely (P ⬍ .001). Insurance status also affected frequency of use (P ⬍ .001). Conclusion: In this data set, blacks were more likely to repeat use of the MMU. Although preliminary, these data suggest outreach efforts of mobile mammography are appropriately reaching certain targeted populations.
lations, Hispanic women, black women, Native American women, and Asian American women.14 Mobile mammography units (MMUs) have become a model of community outreach, although there has been little published on whether mobile mammography optimally targets medically underserved women most in need of breast cancer screening.15 This study assessed the use of mobile mammography in the largest and most racially diverse county in Kentucky as it relates to race and insurance, thereby attempting to support the hypothesis that our MMU is reaching its appropriate target population. Establishing effectiveness of mobile mammography objectives is vital to ongoing efforts to decrease health care disparities among traditionally socially and economically disadvantaged populations. In the era of pay for performance and health care budgets, the ability to show value, efficiency, and competence carries implications for ensuring ongoing local, state, and federal support.
Methods This retrospective study was approved by the University of Louisville Hospital Institutional Review Board and was compliant with the Health Insurance Portability and Accountability Act.
Study Population The data in this project were collected through a retrospective medical record review conducted at the Breast Care Center of the James Graham Brown Cancer Center. We searched the database to identify patients who underwent routine screening
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James Graham Brown Cancer Center, University of Louisville; and University of Louisville, Louisville, KY
Mizuguchi et al
Imaging Technique and Analysis Mammograms were performed on two functioning mobile units during this time period and included both analog and digital mammographies. One van performed only analog mammograms and was in service from January 1, 2001, through e76
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April 4, 2008 (Sophie Classic; Planmed, Helsinki, Finland). A second van performed analog examinations from January 1, 2001, through July 30, 2005, and then performed only digital examinations from August 1, 2005, through December 31, 2010 (Lorad M IV and Selenia; Hologic, Bedford, MA). For the 10-year period, frequency of analog examinations was 15,075 (68.97%), and frequency of digital examinations was 6,782 (31.03%; Appendix Table A1, online only). Examinations were read independently by a total of 14 different radiologists, with experience ranging from ⬍ 1 to ⬎ 20 years; seven of the 14 radiologists had received fellowship training in breast imaging. Throughout this 10-year retrospective review, the James Graham Brown Cancer Center and its MMUs were accredited through the Mammography Quality Standards Acts and Program.
Data Analysis The women using the MMU were categorized by age, study completion date, Hispanic ethnicity, race, Common Procedural Terminology code of the screening mammogram (analog or digital), BI-RADS assessment from the screening mammogram, insurance status, and screening location. All data were deidentified for statistical analysis. For purposes of this study, we analyzed race, insurance, and MMU use. Planned analysis of location and multivariable analysis are ongoing. Patients completed an information history form, on which they self-selected race and ethnicity; patients self-selected the yes or no box for the question of Hispanic origin and selfselected race from the following options: white, black/African American, American Indian/Alaskan native, Asian, Pacific Islander, or other (other included blank line for race self-description). For the retrospective data analysis, if a woman selfselected yes for Hispanic origin, she was included in the Hispanic ethnicity category. Therefore, the category of Hispanic ethnicity included Hispanics of any race. Patients who self-selected no for Hispanic origin were then divided among the self-selected race categories of non-Hispanic white, nonHispanic black, and other. For the purposes of this study, nonHispanic whites were denoted as white and non-Hispanic blacks were denoted as black. The race category of other included women who self-selected American Indian/Alaskan native, Asian, Pacific Islander, and other; the blank line on which participants could self-describe race included additional ethnicities and races, making this third race category of other extremely heterogeneous. Also included in the race category of other were women who declined to fill out this part of their history form. Insurance status was obtained from database records, and participants were divided into two categories: insured or uninsured. In the insured category, there were three subgroups: privately insured, publicly insured–Medicare, and publicly insured–Medicaid. The uninsured category included patients who relied on self-pay and those who qualified for state-aided assistance. In the case of patients who were screened at the MMU more than once, the demographic and insurance information from their first mammogram was entered.
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mammography at our MMU from January 1, 2001, through December 31, 2010. Mobile mammography is offered to asymptomatic women age ⱖ 40 years, consistent with American Cancer Society guidelines. It is offered to women age 25 to 40 years if they are considered high risk based on family history or genetic testing. Those included for analysis were women age ⱖ 25 years and noninstitutionalized. Median age was 50 years (range, 25 to 89). Mean age was 52.7 years. Patients age ⬍ 25 or ⱖ 90 years were excluded from these data. The total number of screening examinations included in the study was 48,324. The total number of women included was 21,857. During the data analysis, a total of 1,013 women were excluded from this study: 184 did not meet age criteria; 58 were assessed as 3, 4, or 5 according to the Breast Imaging-Reporting and Data System (BI-RADS) after the screening mammogram (standard of care recommended only for those assessed as BI-RADS 0, 1, or 2); and 771 were institutionalized. Women with a personal history of prior breast cancer were included in the data. At our facility, women with a personal history of conservation therapy for breast cancer fall back into screening mammography after follow-up with diagnostic mammography for 2 years after treatment. Also included were women undergoing unilateral screening mammography because of a history of contralateral mastectomy. During this 10-year period, the MMU traveled to many different locations, ranging from corporate employment locations and health clinics to community locations and events, places of worship, fairs, and festivals. The schedule of the MMU varies from year to year depending on availability of partnered sites. Some sites may only have been visited once in the 10-year period (eg, certain corporate sites), whereas others were consistently visited (eg, Kentucky State Fair). Clinic sites reflect partnerships with the public health center in the community. The schedule for these sites is set on an annual basis and varies depending on the clinic. Some sites are visited multiple times each month; others are visited monthly or quarterly. Schedules are provided to the medical providers at each clinic to coordinate patient visits throughout the year. Most of the corporate sites as well as churches and community centers are visited each year in the same month. Repeated visits to these locations depend on participation each year. Methods most commonly used by these locations to make women aware of the MMU visit include flyers, e-mails, lunch-and-learn events, and company intranets. Less common methods include mailers to the home and paycheck stuffers. Additionally, the Kentucky Cancer Program often uses patient navigators to target certain underserved populations in the community. The MMU primarily serves Jefferson County, which is the most populated county in the state, but it does occasionally travel outside to other surrounding Kentucky locations and southern Indiana.
Race and Mobile Mammography Use
Table 1. Description of Mobile Breast Screening Data (N ⫽ 21,857) Variable
No.
%
White
13,981
63.97
Black
6,362
29.11
Hispanic
851
3.89
Other
663
3.03
Race/ethnicity
Yes
851
3.89
21,006
96.11
Analog
15,075
68.97
Digital
6,782
31.03
No Screening modality
Statistical Analysis Descriptive statistics related to study characteristics were produced, and statistical comparisons were conducted among one-visit patients (n ⫽ 11,816), two-visit patients (n ⫽ 3,983), and ⱖ three-visit patients (n ⫽ 6,058). In the analysis, the frequency with row or column percentage was presented, and the P value was calculated using the 2 test for comparison.16 All calculations were performed with SAS statistical software (SAS Institute, Cary, NC).
Results Table 1 summarizes the percentage use by race and ethnicity of the MMU over the 10-year period and breaks down the examinations between percent analog versus digital. Whites used the MMU in greatest percentage, followed by blacks and then patients of Hispanic ethnicity. Analog mammograms were seen in greater number than digital, largely based on years available. To discern whether use of the MMU paralleled census data statistics, we compared MMU use with both state and county population censusdatafrom2010,assummarizedinTable2.Whitesmadeupthe majority of racial and ethnic use of the MMU, and whites made up the majority of the female population age 25 to 89 years at both state (89.05%) and Jefferson County levels (74.34%). Minorities were present in higher percentages in Jefferson County, as compared with statewide numbers (blacks, 19.30% v 6.95%; Hispanics, 2.96% v 1.83%. This was statistically significant across both races and ethnicities (P ⬍ .001). These numbers were even more disparate when looking at our MMU data, because minorities used the van in larger percentages than census data would suggest. Blacks comprised
Discussion This large retrospective review of mobile mammography use demonstrates the outreach results of the MMU in the largest and most racially diverse county in Kentucky. To date, there is little evidence that mobile mammography increases access and reduces barriers12; however, we believe these data suggest that mobile mammography does in Jefferson County, Kentucky,
Table 2. Comparison of MMU Database With 2010 Population Census Data (N ⫽ 21,857) P of MMU Versus: Ethnicity
Kentucky (%)
Jefferson (%)
MMU Data (%)
Kentucky
Jefferson
Non-Hispanic white
89.05
74.34
63.97
⬍ .001
⬍ .001
Non-Hispanic black
6.95
19.30
29.11
⬍ .001
⬍ .001
Hispanic
1.83
2.96
3.89
⬍ .001
⬍ .001
Other
2.17
3.40
3.03
⬍ .001
.003
Abbreviation: MMU, mobile mammography unit.
Copyright © 2014 by American Society of Clinical Oncology
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Hispanic origin
29.11% of MMU use, compared with the 2010 census data of 19.30% for the county and 6.95% for the state. Hispanics made up 3.89% of MMU use, compared with the 2010 census data of 2.96% for the county and 1.83% for the state. Whites constituted 63.97% of MMU use over the 10-year period, which was the greatest use by race; however, when compared with census data, this was less than expected, because whites made up 74.34% of the county and 89.05% of the state census (Table 2). Appendix Table A1 (online only) summarizes the numbers and frequencies of repeat MMU use. There were 21,857 users over the 10-year period, and 11,816 (54.06%) were screened only one time in the 10-year period. Table 3 lists the rates of patients receiving one, two, or ⱖ three mammograms based on patient self-described race. There were statistically significant differences between these categories of race and their rate of return for repeat screening mammography at the MMU. Blacks (30.5%) were more likely to have ⱖ three repeat screening mammograms than whites (27.8%; P ⬍ .001). Hispanics were the least likely group to repeat their use of the MMU (20.2%; P ⬍ .001). However, the difference between these categories of race lost statistical significance when the minority groups of black and Hispanic were combined and compared with the white group. This can be explained by the fact that blacks had increased repeat use compared with whites, and Hispanics had decreased repeat use. When compared with whites and blacks, Hispanic patients were more likely to have only one screening mammogram during the 10-year period (Hispanics, 61.5% v non-Hispanics, 53.8%). With regard to insurance, the uninsured made up the largest cohort of MMU use at 43.1%, followed by private insurance (36.1%), Medicare (16.1%), and Medicaid (4.7%). The Medicare cohort was most likely to repeat use of the van at 31.5%, followed by those with private insurance (27.6%) and the uninsured (26.7%.) The Medicaid cohort was least likely at 24.9%, although this group represented only 4.7% of the study population (P ⬍ .001).
Mizuguchi et al
Table 3. Race/Ethnicity and Insurance by Screening Number Total (N ⴝ 21,857) Variable
One (n ⴝ 11,816)
Two (n ⴝ 3,983)
> Three (n ⴝ 6,058)
No.
%
No.
%
No.
%
No.
%
White
13,981
64.0
7,525
53.8
2,566
18.4
3,890
27.8
Black
29.1
3,221
50.6
1,201
18.9
1,940
30.5
851
3.9
523
61.5
156
18.3
172
20.2
Other
663
3.0
547
82.5
60
9.0
56
8.4 ⬍ .001
Private
7,881
36.1
4,378
55.6
1,329
16.9
2,174
Medicaid
1,033
4.7
585
56.6
191
18.5
257
24.9
Medicare
3,521
16.1
1,788
50.8
624
17.7
1,109
31.5
Uninsured
9,422
43.1
5,065
53.8
1,839
19.5
2,518
26.7
largely because of efforts of the Kentucky Cancer Program. A targeted approach of directed screening in communities as well as places of work and worship has successfully delivered screening mammography to groups with historically lower rates of screening and access in our community. Our data show MMU use by blacks and Hispanics in Jefferson County is higher than the census data would suggest, supporting the goal of targeting traditionally low health care use groups. It has been reported that black and Hispanic patients are more likely than white patients to cite distance to a screening facility as a reason for not having a mammogram in the past.17 Louisville is an urban center of Kentucky, with many opportunities for screening mammography, including free-standing radiology centers, women’s centers, and cancer centers. Screening mammography in Kentucky is offered independent of physician referral or order. We believe the results of our study offer evidence and validity of mobile mammography as a successful outreach to blacks and Hispanics, likely reflecting the conscious strategy of the van to go where urban racial and ethnic minorities work, live, and worship rather than a lack of screening options elsewhere. Perhaps the hardest goal to measure is consistent use of the van over the 10-year period. This is largely because of women entering and exiting the data set based on age, cancer diagnosis, competing comorbidities, and relocation and women possibly being screened elsewhere for successive mammograms. Similarly, the age at which screening should occur and the interval of screening mammography are controversial topics, and mammography may not be consistently offered to women age ⬍ 50 years or on an annual basis. Despite these limitations, only slightly less than half of the participants used the van more than once in the 10-year period. However, the number of women consistently using the MMU ⬎ three times over the 10-year period was extremely low. On the basis of this data set, we cannot conclude which race or ethnic group or insurance group most adheres to screening guidelines. However, there was a significant association with race and insurance status and likelihood to repeat screen. Previous studies have reported that minority races and ethnicities have lower mammography return rates as compared with the population as a whole.18 In contrast, we demonstrate that blacks were more likely JOURNAL
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to repeat their use of the MMU than whites. Our data do not confirm the same success with repeat mobile mammography by women of Hispanic ethnicity, because they were the least likely to repeat, which is consistent with previous work.19 More research is needed to understand this pattern within our community, but one hypothesis is that a large portion of the Hispanic community targeted for outreach in this particular data set may have been migratory with the horse industry and thus not available for repeat mammography from year to year. The same hypothesis can be applied to the high use but low repeat use of the MMU by the uninsured cohort. Insurance status of a patient may not be consistent from year to year, therefore affecting the repeat use analysis. The private insurance cohort was likely higher than one would expect for an MMU, given the intended outreach. This was largely the result of partnership with corporate locations throughout Louisville, because these patients were more likely to have private insurance. The corporate partnership may also partially explain the younger-than-expected median age. We recognize there may be inherent selection bias in the racial and/or insurance breakdown of MMU use based on the targeted sites. As an effort to increase screening rates in traditionally underserved populations, they may be overrepresented in the data set, and thus, conclusions about use may be biased. However, not all of the sites were geared toward targeted populations. The community centers and corporate venues may have been more heterogeneous. Further analysis including comparison of racial breakdown of mammography use in the office or hospital setting as well as location of screening within our community could be used in future projects to balance the analysis. Limitations of our data set include the inability to comment on use of the MMU by racial or ethnic minorities other than blacks and Hispanics. The race category of other included American Indians/Alaskan natives, Asians, and Pacific Islanders, those of selfdescribed races, and patients who chose to leave the self-selection description of race/ethnicity blank. Because of the heterogeneity of this group, with no clear correlative comparison group in the census data, this category was not compared with census data. Likewise, trends in use could not be identified. Additional limitations of this study include lack of identification of confounders for repeat
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6,362
Hispanic
Insurance
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P ⬍ .001
Race/ethnicity
Race and Mobile Mammography Use
Acknowledgment Supported by the James Graham Brown Cancer Center. Presented orally at the 99th Annual Meeting of the Radiological Society of North
America, Chicago, IL, December 1-6, 2013. We thank Donald Miller, MD, PhD, director of the James Graham Brown Cancer Center, for graciously providing local funding for this and ongoing projects; Connie Sorrell, director of the Kentucky Cancer Program, who oversees the mobile mammography program in Jefferson County and surrounding areas and contributed to project design and analysis; and Laura Fry, who was instrumental in data assembly and collection. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Author Contributions Conception and design: Sarah Mizuguchi, Lane Roland, Elizabeth C. Riley Collection and assembly of data: Sarah Mizuguchi, Laura Barkley Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Elizabeth C. Riley, MD, FACP, James Graham Brown Cancer Center, 529 S. Jackson St, Louisville, KY 40202; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001477; published online ahead of print at jop.ascopubs.org on November 4, 2014.
References 1. National Cancer Institute: A snapshot of breast cancer. http://www.cancer. gov/researchandfunding/snapshots/breast
12. Buzek N: Mobile mammography for underserved women: What does the evidence say? Adv Nurse Pract 18:29-32, 2010
2. Smith RA, Saslow D, Sawyer KA, et al: American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin 53:141-169, 2003
13. Brown ML, Fintor L: U.S. screening mammography services with mobile units: Results from the National Survey of Mammography Facilities. Radiology 195:529-532, 1995
3. Tabár L, Vitak B, Chen TH, et al: Swedish Two-County Trial: Impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 260:658-663, 2011
14. DeBruhl ND, Bassett LW, Jessop NW, et al: Mobile mammography: Results of a national survey. Radiology 201:433-437, 1996
4. Tabár L, Vitak B, Chen HH, et al: The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up. Radiol Clin North Am 38:625-651, 2000
15. Peek ME, Han J: Mobile mammography: Assessment of self-referral in reaching medically underserved women. J Natl Med Assoc 99:398-403, 2007
5. Smith RA, Duffy SW, Gabe R, et al: The randomized trials of breast cancer screening: What have we learned? Radiol Clin North Am 42:793-806, 2004
17. Blackman DJ, Masi CM: Racial and ethnic disparities in breast cancer mortality: Are we doing enough to address the root causes? J Clin Oncol 24:21702178, 2006
6. Humphry LL, Helfand M, Chan BK, et al: Breast cancer screening: A summary of the evidence for the U.S. Preventative Services Task Force. Ann Intern Med 137:347-360, 2002 7. Clegg LX, Li FP, Hankey BF, et al: Cancer survival among US whites and minorities: A SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med 162:1985-1993, 2002 8. Derose KP, Duan N, Fox SA: Women’s receptivity to church-based mobile mammography. J Health Care Poor Underserved 13:199-213, 2002 9. Pew Research Center: Spanish is the most spoken non-English language in U.S. homes, even among non-Hispanics. http://www.pewresearch.org/fact-tank/2013/08/ 13/spanish-is-the-most-spoken-non-english-language-in-u-s-homes-even-amongnon-hispanics/ 10. American Cancer Society: Cancer facts and figures for Hispanics/Latinos, 2006-2008. http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures forhispanicslatinos/cancer-facts--figures-for-hispanics-latinos-2006-2008 11. Anderson LM, May DS: Has the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health 85:840-842, 1995
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16. Agresti A: Categorical Data Analysis (ed 2). New York, NY, Wiley, 2002
18. Blanchard K, Colbert JA, Puri D, et al: Mammographic screening: Patterns of use and estimated impact on breast carcinoma survival. Cancer 101:495-507, 2004 19. Moy B, Park ER, Feibelmann S, et al: Barriers to repeat mammography: Cultural perspectives of African-American, Asian, and Hispanic women Psychooncology 15:623-634, 2006 20. Coughlin SS, Uhler RJ: Breast and cervical cancer screening practices among Hispanic women in the United States and Puerto Rico, 1998-1999. Prev Med 34:242-251, 2002 21. Martin PP: Hispanics, social security, and supplemental security income. Soc Secur Bull 67:73-100, 2007 22. US Census Bureau: 2010 Census shows America’s diversity. http://www. census.gov/newsroom/releases/archives/2010_census/cb11-cn125.html 23. Skaer TL, Robison LM, Sclar DA, et al: Cancer-screening determinants among Hispanic women using migrant health clinics. J Health Care Poor Underserved 7:338-354, 1996
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use, such as socioeconomic status, strong family history, and personal history of breast cancer or other cancers, because these factors may increase compliance with screening. Despite these limitations, this study suggests that outreach to the Jefferson County black and Hispanic ethnicity communities as well as the uninsured is successful. However, we also highlight needed areas of further work, such as improved repeat use rates among Hispanics. This is important for future outcomes of Hispanic initiatives, because the Hispanic population continues to increase in the United States.20-22 Other articles have attempted to identify cultural barriers to repeat mammography among racial groups, including Hispanics.23 Future work should be aimed at clearer delineation of these barriers and how they can be addressed in prospective efforts to increase screening access to patients of Hispanic ethnicity. It is important to note that conclusions drawn from this data set are specific to mobile mammography in Jefferson County, given that MMU procedures likely differ regionally and across the country. However, this data set may provide insight into future analysis of mobile mammography programs. Further study of mobile mammography programs that include multiple regions will be necessary to draw stronger conclusions about mobile mammography use and race and/or insurance as a whole.
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Appendix Table A1. MMU Repeat Screening Use (N ⫽ 21,857) Screening No.
%
11,816
54.06
Cumulative % 54.06
2
3,983
18.22
72.28
3
2,098
9.60
81.88
4
1,392
6.37
88.25
5
902
4.13
92.38
6
636
2.91
95.29
7
419
1.92
97.20
8
281
1.29
98.49
9
179
0.82
99.31
10
151
0.69
100.00
Abbreviation: MMU, mobile mammography unit.
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Original Contribution
Mobile Mammography, Race, and Insurance: Use Trends Over a Decade at a Comprehensive Urban Cancer Center By Sarah Mizuguchi, MD, Laura Barkley, MD, Shesh Rai, PhD, Jianmin Pan, Lane Roland, MD, Stacey Crawford, MD, and Elizabeth C. Riley, MD
Abstract Purpose: To assess the use of a mobile mammography unit (MMU) as it relates to race and insurance status in the largest county in Kentucky. Methods: We retrospectively reviewed 48,324 screening mammograms of 21,857 patients conducted over a 10-year period. Descriptive statistics for patient age, race, and insurance status were computed by entire cohort and within subsets of cohorts. This analysis was limited to trends in use by race and insurance status. To study the patterns of frequency distributions, indiscrete variables were performed using the Pearson 2 test. For continuous variable range, a 95% CI of
Introduction Breast cancer is the most common nonskin cancer among women in the United States and the second leading cause of cancer-related death.1 The efficiency of screening mammography for early detection and increased survival has been shown in several randomized trials.2-6 Medically underserved women have higher rates of breast cancer mortality, which has been attributed to underscreening and disproportionate rates of latestage disease at diagnosis.7 Traditionally medically underserved populations include racial and ethnic minorities, those with low socioeconomic status, and under- or uninsured patients. In 2002, Derose et al8 reported that mobile mammography, partnered with churches, offered the potential to increase screening adherence for traditionally underscreened women. By bringing screening to neighborhoods and places of work or worship, barriers involving lack of transportation or inability to take time off work could be eliminated. Although churches have traditionally been centers for outreach efforts in the African American community, Derose et al found an encouraging potential to reach Spanish-speaking Latinas as well. This has important implications, because the population of Spanishspeaking Latinas has increased,9 and prior data have shown that Latinas are the least-likely group to undergo routine screening mammography.10,11 The goal of mobile mammography since its nationwide onset has been to increase access to screening.12 Previous studies have suggested that mobile programs increase access to screening mammography.13 According to a 1996 national survey of mobile mammography programs, groups targeted include working women, the economically disadvantaged, rural popuCopyright © 2014 by American Society of Clinical Oncology
mean was estimated. Comparisons with a P value less than .05 were considered statistically significant.
Results: Self-reported blacks constituted significant use of the MMU (29% v census data demographic reports of 19%). Race significantly correlated with likelihood to screen ⱖ three times, with blacks (30.5%) more likely, and whites (27.8%) and Hispanics (20.2%) less likely (P ⬍ .001). Insurance status also affected frequency of use (P ⬍ .001). Conclusion: In this data set, blacks were more likely to repeat use of the MMU. Although preliminary, these data suggest outreach efforts of mobile mammography are appropriately reaching certain targeted populations.
lations, Hispanic women, black women, Native American women, and Asian American women.14 Mobile mammography units (MMUs) have become a model of community outreach, although there has been little published on whether mobile mammography optimally targets medically underserved women most in need of breast cancer screening.15 This study assessed the use of mobile mammography in the largest and most racially diverse county in Kentucky as it relates to race and insurance, thereby attempting to support the hypothesis that our MMU is reaching its appropriate target population. Establishing effectiveness of mobile mammography objectives is vital to ongoing efforts to decrease health care disparities among traditionally socially and economically disadvantaged populations. In the era of pay for performance and health care budgets, the ability to show value, efficiency, and competence carries implications for ensuring ongoing local, state, and federal support.
Methods This retrospective study was approved by the University of Louisville Hospital Institutional Review Board and was compliant with the Health Insurance Portability and Accountability Act.
Study Population The data in this project were collected through a retrospective medical record review conducted at the Breast Care Center of the James Graham Brown Cancer Center. We searched the database to identify patients who underwent routine screening
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James Graham Brown Cancer Center, University of Louisville; and University of Louisville, Louisville, KY
Mizuguchi et al
Imaging Technique and Analysis Mammograms were performed on two functioning mobile units during this time period and included both analog and digital mammographies. One van performed only analog mammograms and was in service from January 1, 2001, through e76
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April 4, 2008 (Sophie Classic; Planmed, Helsinki, Finland). A second van performed analog examinations from January 1, 2001, through July 30, 2005, and then performed only digital examinations from August 1, 2005, through December 31, 2010 (Lorad M IV and Selenia; Hologic, Bedford, MA). For the 10-year period, frequency of analog examinations was 15,075 (68.97%), and frequency of digital examinations was 6,782 (31.03%; Appendix Table A1, online only). Examinations were read independently by a total of 14 different radiologists, with experience ranging from ⬍ 1 to ⬎ 20 years; seven of the 14 radiologists had received fellowship training in breast imaging. Throughout this 10-year retrospective review, the James Graham Brown Cancer Center and its MMUs were accredited through the Mammography Quality Standards Acts and Program.
Data Analysis The women using the MMU were categorized by age, study completion date, Hispanic ethnicity, race, Common Procedural Terminology code of the screening mammogram (analog or digital), BI-RADS assessment from the screening mammogram, insurance status, and screening location. All data were deidentified for statistical analysis. For purposes of this study, we analyzed race, insurance, and MMU use. Planned analysis of location and multivariable analysis are ongoing. Patients completed an information history form, on which they self-selected race and ethnicity; patients self-selected the yes or no box for the question of Hispanic origin and selfselected race from the following options: white, black/African American, American Indian/Alaskan native, Asian, Pacific Islander, or other (other included blank line for race self-description). For the retrospective data analysis, if a woman selfselected yes for Hispanic origin, she was included in the Hispanic ethnicity category. Therefore, the category of Hispanic ethnicity included Hispanics of any race. Patients who self-selected no for Hispanic origin were then divided among the self-selected race categories of non-Hispanic white, nonHispanic black, and other. For the purposes of this study, nonHispanic whites were denoted as white and non-Hispanic blacks were denoted as black. The race category of other included women who self-selected American Indian/Alaskan native, Asian, Pacific Islander, and other; the blank line on which participants could self-describe race included additional ethnicities and races, making this third race category of other extremely heterogeneous. Also included in the race category of other were women who declined to fill out this part of their history form. Insurance status was obtained from database records, and participants were divided into two categories: insured or uninsured. In the insured category, there were three subgroups: privately insured, publicly insured–Medicare, and publicly insured–Medicaid. The uninsured category included patients who relied on self-pay and those who qualified for state-aided assistance. In the case of patients who were screened at the MMU more than once, the demographic and insurance information from their first mammogram was entered.
V O L . 11, I S S U E 1
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mammography at our MMU from January 1, 2001, through December 31, 2010. Mobile mammography is offered to asymptomatic women age ⱖ 40 years, consistent with American Cancer Society guidelines. It is offered to women age 25 to 40 years if they are considered high risk based on family history or genetic testing. Those included for analysis were women age ⱖ 25 years and noninstitutionalized. Median age was 50 years (range, 25 to 89). Mean age was 52.7 years. Patients age ⬍ 25 or ⱖ 90 years were excluded from these data. The total number of screening examinations included in the study was 48,324. The total number of women included was 21,857. During the data analysis, a total of 1,013 women were excluded from this study: 184 did not meet age criteria; 58 were assessed as 3, 4, or 5 according to the Breast Imaging-Reporting and Data System (BI-RADS) after the screening mammogram (standard of care recommended only for those assessed as BI-RADS 0, 1, or 2); and 771 were institutionalized. Women with a personal history of prior breast cancer were included in the data. At our facility, women with a personal history of conservation therapy for breast cancer fall back into screening mammography after follow-up with diagnostic mammography for 2 years after treatment. Also included were women undergoing unilateral screening mammography because of a history of contralateral mastectomy. During this 10-year period, the MMU traveled to many different locations, ranging from corporate employment locations and health clinics to community locations and events, places of worship, fairs, and festivals. The schedule of the MMU varies from year to year depending on availability of partnered sites. Some sites may only have been visited once in the 10-year period (eg, certain corporate sites), whereas others were consistently visited (eg, Kentucky State Fair). Clinic sites reflect partnerships with the public health center in the community. The schedule for these sites is set on an annual basis and varies depending on the clinic. Some sites are visited multiple times each month; others are visited monthly or quarterly. Schedules are provided to the medical providers at each clinic to coordinate patient visits throughout the year. Most of the corporate sites as well as churches and community centers are visited each year in the same month. Repeated visits to these locations depend on participation each year. Methods most commonly used by these locations to make women aware of the MMU visit include flyers, e-mails, lunch-and-learn events, and company intranets. Less common methods include mailers to the home and paycheck stuffers. Additionally, the Kentucky Cancer Program often uses patient navigators to target certain underserved populations in the community. The MMU primarily serves Jefferson County, which is the most populated county in the state, but it does occasionally travel outside to other surrounding Kentucky locations and southern Indiana.
Race and Mobile Mammography Use
Table 1. Description of Mobile Breast Screening Data (N ⫽ 21,857) Variable
No.
%
White
13,981
63.97
Black
6,362
29.11
Hispanic
851
3.89
Other
663
3.03
Race/ethnicity
Yes
851
3.89
21,006
96.11
Analog
15,075
68.97
Digital
6,782
31.03
No Screening modality
Statistical Analysis Descriptive statistics related to study characteristics were produced, and statistical comparisons were conducted among one-visit patients (n ⫽ 11,816), two-visit patients (n ⫽ 3,983), and ⱖ three-visit patients (n ⫽ 6,058). In the analysis, the frequency with row or column percentage was presented, and the P value was calculated using the 2 test for comparison.16 All calculations were performed with SAS statistical software (SAS Institute, Cary, NC).
Results Table 1 summarizes the percentage use by race and ethnicity of the MMU over the 10-year period and breaks down the examinations between percent analog versus digital. Whites used the MMU in greatest percentage, followed by blacks and then patients of Hispanic ethnicity. Analog mammograms were seen in greater number than digital, largely based on years available. To discern whether use of the MMU paralleled census data statistics, we compared MMU use with both state and county population censusdatafrom2010,assummarizedinTable2.Whitesmadeupthe majority of racial and ethnic use of the MMU, and whites made up the majority of the female population age 25 to 89 years at both state (89.05%) and Jefferson County levels (74.34%). Minorities were present in higher percentages in Jefferson County, as compared with statewide numbers (blacks, 19.30% v 6.95%; Hispanics, 2.96% v 1.83%. This was statistically significant across both races and ethnicities (P ⬍ .001). These numbers were even more disparate when looking at our MMU data, because minorities used the van in larger percentages than census data would suggest. Blacks comprised
Discussion This large retrospective review of mobile mammography use demonstrates the outreach results of the MMU in the largest and most racially diverse county in Kentucky. To date, there is little evidence that mobile mammography increases access and reduces barriers12; however, we believe these data suggest that mobile mammography does in Jefferson County, Kentucky,
Table 2. Comparison of MMU Database With 2010 Population Census Data (N ⫽ 21,857) P of MMU Versus: Ethnicity
Kentucky (%)
Jefferson (%)
MMU Data (%)
Kentucky
Jefferson
Non-Hispanic white
89.05
74.34
63.97
⬍ .001
⬍ .001
Non-Hispanic black
6.95
19.30
29.11
⬍ .001
⬍ .001
Hispanic
1.83
2.96
3.89
⬍ .001
⬍ .001
Other
2.17
3.40
3.03
⬍ .001
.003
Abbreviation: MMU, mobile mammography unit.
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Hispanic origin
29.11% of MMU use, compared with the 2010 census data of 19.30% for the county and 6.95% for the state. Hispanics made up 3.89% of MMU use, compared with the 2010 census data of 2.96% for the county and 1.83% for the state. Whites constituted 63.97% of MMU use over the 10-year period, which was the greatest use by race; however, when compared with census data, this was less than expected, because whites made up 74.34% of the county and 89.05% of the state census (Table 2). Appendix Table A1 (online only) summarizes the numbers and frequencies of repeat MMU use. There were 21,857 users over the 10-year period, and 11,816 (54.06%) were screened only one time in the 10-year period. Table 3 lists the rates of patients receiving one, two, or ⱖ three mammograms based on patient self-described race. There were statistically significant differences between these categories of race and their rate of return for repeat screening mammography at the MMU. Blacks (30.5%) were more likely to have ⱖ three repeat screening mammograms than whites (27.8%; P ⬍ .001). Hispanics were the least likely group to repeat their use of the MMU (20.2%; P ⬍ .001). However, the difference between these categories of race lost statistical significance when the minority groups of black and Hispanic were combined and compared with the white group. This can be explained by the fact that blacks had increased repeat use compared with whites, and Hispanics had decreased repeat use. When compared with whites and blacks, Hispanic patients were more likely to have only one screening mammogram during the 10-year period (Hispanics, 61.5% v non-Hispanics, 53.8%). With regard to insurance, the uninsured made up the largest cohort of MMU use at 43.1%, followed by private insurance (36.1%), Medicare (16.1%), and Medicaid (4.7%). The Medicare cohort was most likely to repeat use of the van at 31.5%, followed by those with private insurance (27.6%) and the uninsured (26.7%.) The Medicaid cohort was least likely at 24.9%, although this group represented only 4.7% of the study population (P ⬍ .001).
Mizuguchi et al
Table 3. Race/Ethnicity and Insurance by Screening Number Total (N ⴝ 21,857) Variable
One (n ⴝ 11,816)
Two (n ⴝ 3,983)
> Three (n ⴝ 6,058)
No.
%
No.
%
No.
%
No.
%
White
13,981
64.0
7,525
53.8
2,566
18.4
3,890
27.8
Black
29.1
3,221
50.6
1,201
18.9
1,940
30.5
851
3.9
523
61.5
156
18.3
172
20.2
Other
663
3.0
547
82.5
60
9.0
56
8.4 ⬍ .001
Private
7,881
36.1
4,378
55.6
1,329
16.9
2,174
Medicaid
1,033
4.7
585
56.6
191
18.5
257
24.9
Medicare
3,521
16.1
1,788
50.8
624
17.7
1,109
31.5
Uninsured
9,422
43.1
5,065
53.8
1,839
19.5
2,518
26.7
largely because of efforts of the Kentucky Cancer Program. A targeted approach of directed screening in communities as well as places of work and worship has successfully delivered screening mammography to groups with historically lower rates of screening and access in our community. Our data show MMU use by blacks and Hispanics in Jefferson County is higher than the census data would suggest, supporting the goal of targeting traditionally low health care use groups. It has been reported that black and Hispanic patients are more likely than white patients to cite distance to a screening facility as a reason for not having a mammogram in the past.17 Louisville is an urban center of Kentucky, with many opportunities for screening mammography, including free-standing radiology centers, women’s centers, and cancer centers. Screening mammography in Kentucky is offered independent of physician referral or order. We believe the results of our study offer evidence and validity of mobile mammography as a successful outreach to blacks and Hispanics, likely reflecting the conscious strategy of the van to go where urban racial and ethnic minorities work, live, and worship rather than a lack of screening options elsewhere. Perhaps the hardest goal to measure is consistent use of the van over the 10-year period. This is largely because of women entering and exiting the data set based on age, cancer diagnosis, competing comorbidities, and relocation and women possibly being screened elsewhere for successive mammograms. Similarly, the age at which screening should occur and the interval of screening mammography are controversial topics, and mammography may not be consistently offered to women age ⬍ 50 years or on an annual basis. Despite these limitations, only slightly less than half of the participants used the van more than once in the 10-year period. However, the number of women consistently using the MMU ⬎ three times over the 10-year period was extremely low. On the basis of this data set, we cannot conclude which race or ethnic group or insurance group most adheres to screening guidelines. However, there was a significant association with race and insurance status and likelihood to repeat screen. Previous studies have reported that minority races and ethnicities have lower mammography return rates as compared with the population as a whole.18 In contrast, we demonstrate that blacks were more likely JOURNAL
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to repeat their use of the MMU than whites. Our data do not confirm the same success with repeat mobile mammography by women of Hispanic ethnicity, because they were the least likely to repeat, which is consistent with previous work.19 More research is needed to understand this pattern within our community, but one hypothesis is that a large portion of the Hispanic community targeted for outreach in this particular data set may have been migratory with the horse industry and thus not available for repeat mammography from year to year. The same hypothesis can be applied to the high use but low repeat use of the MMU by the uninsured cohort. Insurance status of a patient may not be consistent from year to year, therefore affecting the repeat use analysis. The private insurance cohort was likely higher than one would expect for an MMU, given the intended outreach. This was largely the result of partnership with corporate locations throughout Louisville, because these patients were more likely to have private insurance. The corporate partnership may also partially explain the younger-than-expected median age. We recognize there may be inherent selection bias in the racial and/or insurance breakdown of MMU use based on the targeted sites. As an effort to increase screening rates in traditionally underserved populations, they may be overrepresented in the data set, and thus, conclusions about use may be biased. However, not all of the sites were geared toward targeted populations. The community centers and corporate venues may have been more heterogeneous. Further analysis including comparison of racial breakdown of mammography use in the office or hospital setting as well as location of screening within our community could be used in future projects to balance the analysis. Limitations of our data set include the inability to comment on use of the MMU by racial or ethnic minorities other than blacks and Hispanics. The race category of other included American Indians/Alaskan natives, Asians, and Pacific Islanders, those of selfdescribed races, and patients who chose to leave the self-selection description of race/ethnicity blank. Because of the heterogeneity of this group, with no clear correlative comparison group in the census data, this category was not compared with census data. Likewise, trends in use could not be identified. Additional limitations of this study include lack of identification of confounders for repeat
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6,362
Hispanic
Insurance
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P ⬍ .001
Race/ethnicity
Race and Mobile Mammography Use
Acknowledgment Supported by the James Graham Brown Cancer Center. Presented orally at the 99th Annual Meeting of the Radiological Society of North
America, Chicago, IL, December 1-6, 2013. We thank Donald Miller, MD, PhD, director of the James Graham Brown Cancer Center, for graciously providing local funding for this and ongoing projects; Connie Sorrell, director of the Kentucky Cancer Program, who oversees the mobile mammography program in Jefferson County and surrounding areas and contributed to project design and analysis; and Laura Fry, who was instrumental in data assembly and collection. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Author Contributions Conception and design: Sarah Mizuguchi, Lane Roland, Elizabeth C. Riley Collection and assembly of data: Sarah Mizuguchi, Laura Barkley Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Elizabeth C. Riley, MD, FACP, James Graham Brown Cancer Center, 529 S. Jackson St, Louisville, KY 40202; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001477; published online ahead of print at jop.ascopubs.org on November 4, 2014.
References 1. National Cancer Institute: A snapshot of breast cancer. http://www.cancer. gov/researchandfunding/snapshots/breast
12. Buzek N: Mobile mammography for underserved women: What does the evidence say? Adv Nurse Pract 18:29-32, 2010
2. Smith RA, Saslow D, Sawyer KA, et al: American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin 53:141-169, 2003
13. Brown ML, Fintor L: U.S. screening mammography services with mobile units: Results from the National Survey of Mammography Facilities. Radiology 195:529-532, 1995
3. Tabár L, Vitak B, Chen TH, et al: Swedish Two-County Trial: Impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 260:658-663, 2011
14. DeBruhl ND, Bassett LW, Jessop NW, et al: Mobile mammography: Results of a national survey. Radiology 201:433-437, 1996
4. Tabár L, Vitak B, Chen HH, et al: The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up. Radiol Clin North Am 38:625-651, 2000
15. Peek ME, Han J: Mobile mammography: Assessment of self-referral in reaching medically underserved women. J Natl Med Assoc 99:398-403, 2007
5. Smith RA, Duffy SW, Gabe R, et al: The randomized trials of breast cancer screening: What have we learned? Radiol Clin North Am 42:793-806, 2004
17. Blackman DJ, Masi CM: Racial and ethnic disparities in breast cancer mortality: Are we doing enough to address the root causes? J Clin Oncol 24:21702178, 2006
6. Humphry LL, Helfand M, Chan BK, et al: Breast cancer screening: A summary of the evidence for the U.S. Preventative Services Task Force. Ann Intern Med 137:347-360, 2002 7. Clegg LX, Li FP, Hankey BF, et al: Cancer survival among US whites and minorities: A SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med 162:1985-1993, 2002 8. Derose KP, Duan N, Fox SA: Women’s receptivity to church-based mobile mammography. J Health Care Poor Underserved 13:199-213, 2002 9. Pew Research Center: Spanish is the most spoken non-English language in U.S. homes, even among non-Hispanics. http://www.pewresearch.org/fact-tank/2013/08/ 13/spanish-is-the-most-spoken-non-english-language-in-u-s-homes-even-amongnon-hispanics/ 10. American Cancer Society: Cancer facts and figures for Hispanics/Latinos, 2006-2008. http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures forhispanicslatinos/cancer-facts--figures-for-hispanics-latinos-2006-2008 11. Anderson LM, May DS: Has the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health 85:840-842, 1995
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16. Agresti A: Categorical Data Analysis (ed 2). New York, NY, Wiley, 2002
18. Blanchard K, Colbert JA, Puri D, et al: Mammographic screening: Patterns of use and estimated impact on breast carcinoma survival. Cancer 101:495-507, 2004 19. Moy B, Park ER, Feibelmann S, et al: Barriers to repeat mammography: Cultural perspectives of African-American, Asian, and Hispanic women Psychooncology 15:623-634, 2006 20. Coughlin SS, Uhler RJ: Breast and cervical cancer screening practices among Hispanic women in the United States and Puerto Rico, 1998-1999. Prev Med 34:242-251, 2002 21. Martin PP: Hispanics, social security, and supplemental security income. Soc Secur Bull 67:73-100, 2007 22. US Census Bureau: 2010 Census shows America’s diversity. http://www. census.gov/newsroom/releases/archives/2010_census/cb11-cn125.html 23. Skaer TL, Robison LM, Sclar DA, et al: Cancer-screening determinants among Hispanic women using migrant health clinics. J Health Care Poor Underserved 7:338-354, 1996
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use, such as socioeconomic status, strong family history, and personal history of breast cancer or other cancers, because these factors may increase compliance with screening. Despite these limitations, this study suggests that outreach to the Jefferson County black and Hispanic ethnicity communities as well as the uninsured is successful. However, we also highlight needed areas of further work, such as improved repeat use rates among Hispanics. This is important for future outcomes of Hispanic initiatives, because the Hispanic population continues to increase in the United States.20-22 Other articles have attempted to identify cultural barriers to repeat mammography among racial groups, including Hispanics.23 Future work should be aimed at clearer delineation of these barriers and how they can be addressed in prospective efforts to increase screening access to patients of Hispanic ethnicity. It is important to note that conclusions drawn from this data set are specific to mobile mammography in Jefferson County, given that MMU procedures likely differ regionally and across the country. However, this data set may provide insight into future analysis of mobile mammography programs. Further study of mobile mammography programs that include multiple regions will be necessary to draw stronger conclusions about mobile mammography use and race and/or insurance as a whole.
Mizuguchi et al
Appendix Table A1. MMU Repeat Screening Use (N ⫽ 21,857) Screening No.
%
11,816
54.06
Cumulative % 54.06
2
3,983
18.22
72.28
3
2,098
9.60
81.88
4
1,392
6.37
88.25
5
902
4.13
92.38
6
636
2.91
95.29
7
419
1.92
97.20
8
281
1.29
98.49
9
179
0.82
99.31
10
151
0.69
100.00
Abbreviation: MMU, mobile mammography unit.
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