Descriptive Analysis of Maryland Breast and Cervical Cancer Screening Program (BCCP) Enrollees to Inform Program Management Activities
Christine Prosperi
ScM Candidate, Department of Epidemiology
May 9, 2014
Maryland Breast and Cervical Cancer Program
Preceptors: Kaplan, Epidemiologist; Sara Seitz, Partnerships, Outreach, and Grants Manager Outline
Maryland Breast and Cervical Cancer Program
Analysis Aim 1
Analysis Aim 2
Limitations and Challenges
Lessons Learned
Policy Implications
Maryland Breast and Cervical Cancer Screening Program (BCCP)
 Comprehensive screening program established by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), funded via the Centers for Disease Control and Prevention and the State of Maryland
Objective
Decrease mortality from breast and cervical cancers by providing breast and cervical cancer screening tests, such as clinical breast exams, mammograms, and Pap tests
Eligibility
Maryland resident between the ages of 40 and 64
Uninsured or underinsured
Household income at or below 250% of the federal poverty level
Analysis Aims
Compare Program enrollees to a group of eligible women from the larger Maryland population using data from the Maryland Behavioral Risk Factor Surveillance System (BRFSS)
Compare Program clients diagnosed with breast cancer to women diagnosed with breast cancer who were identified through the Maryland Cancer Registry (MCR)
Aim 1: BCCP compared to BRFSS COMPARE PROGRAM ENROLLEES TO THE LARGER MARYLAND POPULATION USING DATA FROM THE MARYLAND BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS)
Study Population
BCCP
Included all active clients aged 40‐64 who received a Program‐funded mammogram, clinical breast exam, or Pap test between July 1, 2008 and June 30, 2013 (FY 2009‐13)
Behavioral Risk Factor Surveillance System (BRFSS)
Nationwide surveillance system to collect standardized data at the state‐level on preventive health practices and risk behaviors
Restricted to female respondents 40‐64 in the 2011 and 2012 surveys
Definition of ‘BCCP Eligible’
Female MD Residents 40‐64 from BRFSS
YES
BCCP Eligible 1887 (27%)
NO
< 250% Federal Poverty Level?
BCCP Ineligible 4308 (61%)
UNKNOWN
YES
Uninsured or underinsured?
NO OR UNKNOWN
BCCP Eligibility Unknown 863 (12%)
Breakdown of Eligibility
Income Eligibility
Health Insurance Eligibility
Eligible
Ineligible
Unknown
Total
Eligible
648
1,088
2
1,738 (24.6%)
Ineligible
334
3,971
3
4,308 (61.0%)
Unknown
149
859
4
1,012 (14.3%)
Total
1,131 (16%)
5,918 (83.9%)
9 (0.1%)
7,058
Race: BCCP Clients Compared to BRFSS
100
90
80
Percent
70
60
50
40
30
20
10
0
White
Black
BCCP
BCCP Eligible
Asian
BCCP Ineligible
BCCP Eligible Unknown
Other
Ethnicity: BCCP Clients Compared to BRFSS
100
90
80
Percent
70
60
50
40
30
20
10
0
Hispanic
Non‐Hispanic
BCCP
BCCP Eligible
BCCP Ineligible
Unknown Ethnicity
BCCP Eligible Unknown
Race/Ethnicity: BCCP Clients Compared to BRFSS
100
90
80
Percent
70
55.7
60
50
46.1
36.2
40
39.7
30
16.7
20
10
3.9
1.1
0.7
0
White Non‐Hispanic
White Hispanic
BCCP
Restricted to women of White or Black race. Black Non‐Hispanic
BCCP Eligible
Black Hispanic
Prior Mammogram: BCCP Clients Compared to BRFSS
100
86.2
90
80
Percent
70
68.0
60
50
40
30
20
10
0
Prior Mammogram
BCCP
BCCP Eligible
Cancer screening data from BRFSS restricted to data from 2012. Cancer screening data from BCCP is restricted to women in their first screening cycle. Restricted to women with available data.
Duration Since Prior Mammogram: BCCP Clients Compared to BRFSS
90
79.3
80
70
Percent
60
50
40
37.1
37.9
30
19.8
20
13.0
7.4
10
5.2
0.3
0
Mammogram Within 2 years
Mammogram 2 to < 5 years
BCCP
Mammogram 5 or more years
BCCP Eligible
Cancer screening data from BRFSS restricted to data from 2012. Cancer screening data from BCCP is restricted to women in their first screening cycle. Restricted to women reporting a prior mammogram.
Unknown Prior Mammogram
Duration
Prior Pap Exam: BCCP Clients Compared to BRFSS
100
90
80
Percent
70
60
50
40
30
20
10
0
Prior Pap
BCCP
BCCP Eligible
Cancer screening data from BRFSS restricted to data from 2012. Cancer screening data from BCCP is restricted to women in their first screening cycle. Restricted to women with available data.
Duration Since Prior Pap Exam: BCCP Clients Compared to BRFSS
90
80
70
Percent
60
50
40
30
20
10
0
PAP Within 3 years
PAP 3 to < 5 years
BCCP
PAP 5 or more years
BCCP Eligible
Cancer screening data from BRFSS restricted to data from 2012. Cancer screening data from BCCP is restricted to women in their first screening cycle. Restricted to women reporting a prior Pap.
Unknown Prior PAP Duration
Aim 1 Summary
 Percent of women who are Black non‐Hispanic is similar comparing BCCP clients and the ‘BCCP eligible’ population
 Higher percent of BCCP clients are White Hispanic compared to the ‘BCCP eligible’ population
 BCCP clients were less likely to report prior cancer screening services than the ‘BCCP eligible’ population
 Of those reporting a prior cancer screening service, many BCCP clients reported delays between screenings compared to the ‘BCCP eligible’ population
Aim 2:
BCCP compared to Maryland Cancer Registry
COMPARE PROGRAM CLIENTS DIAGNOSED WITH BREAST CANCER TO WOMEN DIAGNOSED WITH BREAST CANCER WHO WERE IDENTIFIED THROUGH THE MARYLAND CANCER REGISTRY (MCR)
Study Population
 BCCP
 Active Program clients who were diagnosed with breast cancer between 2004 and 2009
Maryland Cancer Registry (MCR)
Collects information regarding new cases of cancer diagnosed in Maryland from hospitals, physicians, radiation centers, ambulatory facilities and laboratories
 Dataset included all women aged 40‐64 who were diagnosed with breast cancer between 2004 and 2009 identified from the Registry
Stage at Diagnosis
AJCC* Stage
Stage 0
Stage I
Stage IB
Stage IIA
Stage IIB
Stage III NOS
Stage IIIA
Stage IIIB
Stage IIIC
Stage IV
Stage Unknown
*American Joint Committee on Cancer Early/Late Stage
Stage 0
Early Stage
Late Stage
Stage Unknown
Race/Ethnicity: BCCP Clients Compared to MCR
80
70.3
70
60
52.9
Percent
50
36.3
40
28.0
30
20
9.8
10
1.6
0
White Non‐Hispanic
White Hispanic
BCCP (N=475)
Restricted to women of White or Black race. MCR (N=16,337)
Black Non‐Hispanic
AJCC Stage: BCCP Clients Compared to MCR
50
45
40
Percent
35
30
25
20
15
10
5
0
Stage 0
Stage 1
Stage 2
BCCP (N=475)
Stage 3
MCR (N=16,337)
Stage 4
Stage Unknown
Early/Late Stage: BCCP Clients Compared to MCR
80
70
57.3
60
57.7
Percent
50
40
30
20
17.7
20.0
21.1
13.7
10
5.1
7.6
0
Stage 0
Early Stage
BCCP (N=475)
Late Stage
MCR (N=16,337)
Stage Unknown
Early/Late Stage, Black Non‐Hispanic: BCCP Clients Compared to MCR
80
70
60
54.2
54.8
Percent
50
40
30
20.6
20
19.4
19.3
18.1
10
5.8
7.8
0
Stage 0
Early Stage
BCCP (N=155)
Late Stage
MCR (N=3,994)
Stage Unknown
Early/Late Stage, White Hispanic: BCCP Clients Compared to MCR
80
70
59.5
60
54.9
Percent
50
40
30
23.8
24.3
16.7
20
15.5
10
5.3
0.0
0
Stage 0
Early Stage
BCCP (N=42)
Late Stage
MCR (N=226)
Stage Unknown
Early/Late Stage, White Non‐Hispanic: BCCP Clients Compared to MCR
80
70
58.4
60
60.9
Percent
50
40
30
21.7
21.6
20
15.0
12.6
10
4.9
4.9
0
Stage 0
Early Stage
BCCP (N=226)
Late Stage
MCR (N=10,012)
Stage Unknown
Early/Late Stage, BCCP
80
70
60
50
40
30
20
10
0
Stage 0
Early Stage
White Non‐Hispanic (N=226)
Late Stage
Black Non‐Hispanic (N=155)
Stage Unknown
Early/Late Stage, MCR
80
70
60
50
40
30
20
10
0
Stage 0
Early Stage
Late Stage
White Non‐Hispanic (N=10,012)
Black Non‐Hispanic (N=3,994)
Stage Unknown
Aim 2 Summary
 Overall see higher percent of BCCP clients diagnosed at later stages of breast cancer compared to women identified through the MCR
 Difference in stage at diagnosis primarily among White non‐
Hispanics
Limitations and Challenges
Project required obtaining data from external sources (BRFSS and MCR) Difficulty in defining BCCP eligibility among the BRFSS data
 Impact of missing data on defining eligibility, tumor staging, and analyses
 Differences in data sources and sample sizes made statistical comparisons difficult
 Additional factors associated with screening history and stage at diagnosis may not be accounted for in analysis
Lessons Learned
 Gained familiarity working with large datasets, including survey data
 Exposure to survey methodologies
 Improved analytic, presentation, and reporting skills
Policy Implications
 The Program appears successful in recruiting its target population of underserved minority populations, particularly in identifying women in high need of screening services
 Changes in healthcare policy may impact retention and recruitment of eligible women in the future Minority women in the Program appear to have similar stages at diagnosis as compared to women in the larger Maryland population White non‐Hispanic BCCP clients appear to be diagnosed at a later stage compared to their counterparts in larger Maryland population, which may be an area of future research Acknowledgements
 Preceptors: Doug Kaplan and Sara Seitz
Maryland Breast and Cervical Cancer Program
Maryland Department of Health and Mental Hygiene
Johns Hopkins School of Public Health PHASE Administrators References
1.
Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program Factsheet. Atlanta: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention. Accessed: November 22, 2013. Available at: www.cdc.gov/cancer/nbccedp/pdf/NBCCEDP_FactSheet.pdf.
2.
Henson RM, Wyatt SW, Lee NC. The National Breast and Cervical Cancer Early Detection Program: A comprehensive public health response to two major health issues for women. J Public Health Management Practice. 1996, 2(2): 36‐47.
3.
Maryland Department of Health and Mental Hygiene. Maryland Breast and Cervical Cancer Screening Program. Accessed: November 22, 2013. Available at: http://phpa.dhmh.maryland.gov/cancer/SitePages/bccp_home.aspx
4.
Centers for Disease Control and Prevent. Behavioral Risk Factor Surveillance System, Overview: BRFSS 2012. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. Available at: www.cdc.gov/brfss/annual_data/2012/pdf/Overview_2012.pdf.
5.
Maryland Cancer Register. Maryland Cancer Registry Reporting Requirements. 2008. Available at: http://phpa.dhmh.maryland.gov/cancer/Documents/MCRReportingRequirements.pdf. Accessed February 26, 2014.