Vital and Health Statistics; Series 10, No. 172 (1/90) 10: Data From the National Health Interview...

VitalandHealthStatisticsBreast CancerRisk Factorsand Screening:United States, 1987

Series 10:Data From the National HealthInterview SurveyNo. 172This report presents national estimates of the prevalence of selected riskfactors and preventive behaviors related to breast cancer for women 40years of age and over, Estimates are presented by race and age. Data onpreventive practice=breast self-examinations, breast physical examinations,and mammogram=lso are presented within categories of education,income, place of residence, and geographic region, all adjusted for raceand age, Data are from the 1987 National Health Interview Survey of CancerEpidemiology and Control.

US. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceCenters for Disease ControlNational Center for Heallh Statistics

Hyaftsville, MarylandJanuary 1990DHHS Publication No. (PHS) 90-1500

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All material appearing in this repori is in the publii domain and may bereproduced or copied without permission; station as to source, however, isappreciated.

Sufx$sated Oitafim

Dawson DA, Thompson GB. Breast cancer risk factors and screening: Unitad

States, 19S7. National Center for Health Statktice. Vii Health Stat 10(172).19s9.

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Dawson, Dabcwah A.Breast cancer risk faotore end screening: United States, 19S7.p. cm.-(viil and health statistics. Series 10, Data from the National Health

Interview Survey ; no. 172) (DHHS pubiiition ; no. (PHS) 90-1500)By Deborah A. Daweon and Grey B. Thompson.“Dafs are from the 1967 National Health Interview SUIVSY of Cancer

Epidemiology and Control.”Includes biblbgraphicsl references.ISBN 04406+421-11. Breest-&ncer-Unifad States-statistics. 2. Braasf+cef+nited

Ststae-ftisk faotors. 3. United Statae--stefietii, Medical. 4. Health SuIVSys-

Unitad states. 1.Thompson, Gray B. Il. National Center for Heatth Statietii(U.S.) Ill. National Heeflh Interview Survey (U.S.) IV. T*. V. Series. V1. Series:

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89-14566CIP

National Center for Health Statistics

Manning Feinleib, M. D., Dr. P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysisand Epidemiology

Gail F. Fisher, Ph.D., Associate Director for Planning andExtramural Programs

Peter L. Hurley, Associate Director for Vital and HealthStatistics Systems

Stephen E. Nieberding, Associate Director for Management

Charles J. RothweU, Associate Director for Data Processingand Services

Monroe G. Sirken, Ph.D., Associate Director for Researchand Methodology

Division of Health Interview Statistics

Owen T. Thornberry, Jr., Ph.D., Director

Deborah M. Winn, Ph. D., Depup Director

Gerry E. Hendershot, Ph.D., Chiej Illness and Disabili@Statistics Branch

Nelma B. Keen, Chiej Systems and Programming Branch

Stewart C. Rice, Jr., ChieJ Survey Planning andDevelopment Branch

Robert A. Wright, ChieJ Utilization and E.qenditureStatistics Branch

Cooperation of the fJ.S. Bureau ofthe Census

Under the Iegishdion esttahlkhing the Nationti Health Intemiew Swvey, thePublic Health Service is authorized to use, insofar ns possible, the services orfacilities of other Federn~ State, or private agencies.

In accordance with specifications est,nblished by the Division of HealthInterview Statistics, the U.S. Bureau of the Census, under a contractualmmngement, participated in pLmrring the survey and eoflecting the data.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sources and limitations ofthedata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . , . . . . . . . . . . . . . . . . . . . .. .Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......”......,.Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . , , . .survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . .Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s..Preventive behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Progress note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Screening trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Legislative trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . .. . ... .. . . .. . .. . . .. . .. .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendixes

1. Technical notes on methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IL Definitions ofcertain terms usedin this report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .III. Survey instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List oftext figures

1. Percent distribution ofestimated female cancer incidencebysite: United States, 1988 . . . . . . . . . . . . . . . . . . . . . .2. Percent distribution of estimated female cancer deaths by sitti United States, 1988 . . . . . . . . . . . . . . . . . . . . . . . . .

List of text tables

A.B.c.

D.

E.

F.

G.

H,

J.

K.

Average annual age-specific incidencerates for female breast cancer by race: United States, 1982–86 . . . . . . . . .Average annual age-specific mortalityrates for female breast cancer by race: United States, 1982–86 . . . . . . . . .Percent distribution of female breast cancer cases and 5-year relative survival rates for female breast cancer bysite ofcancerat time ofdiagnosis, according toracti United States, 1974-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trends in 5-year relative survival rates for female breast cancer by race: United States, 1950–54 through

1980-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent ofwomen 40yearsofage and overwith breast cancer reported unselected primary relatives byrace andage: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .- . . . . . . . . . . . . .. . .. .Percent distribution ofwomen40years ofage andoverby age atlst full-term pregnancy, according to race andagti United States, 19&; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution ofwom~n 40years of age and overby status of lactation, according to race and agtiUnited States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..”...... .“.Percent distribution of women 40years of age and over by age at menarche, according to race and age:United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...”.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...Percent distribution ofwomen40years ofage andoverby menstrual status and age atmenopause, accordingtorace and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....”.......Percent distribution ofwomen40 years ofage and overby duration ofuseof oral contraceptives, accordingtorace and age: UnitedStates,1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

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3

44455

13

272727

29

344446

45

45

6

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12

...Ill

L.

M.

N.

o.

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Percent distribution of women 40 years of age and over who have stopped menstruating by duration of use ofpostmenopausal estrogen (PME), according to race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by relative weight, according to race and age UnitedStates, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by level of alcohol consumption in past year, according torace andage: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by frequency of breast self-examination (BSE), accordingto race and age: United States, 1987. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by frequency of breast self-examination (BSE), accordingto selected characteristics adjusted for race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by interval since last breast physical examination (BPE),according toraceand age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over by interval since last breast physical examination (BPE),according to selected characteristics adjusted for race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over who had a breast physical examination (BPE) in the past3 years by reason for last BPE, according to race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over who had a breast physical examination (BPE)in the past3 years by reason for last BPE, according to selected characteristics adjusted for race and age: United States,1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4...Percent distribution of women 40 years of age and over who had a breast physical examination (BPE) in the past3 years by method of communication of results of last BPE, according to race and age: United States,1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over who had a breast physical examination (BPE)in the past3 years by method of communication of results of last BPE, according to selected characteristics adjusted for raceandage: United States, 1987... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Percent distribution of women 40 years of age and over who had no breast physical examination (BPE) in the past3 years by most important reason for not having a BPE, according to race and age: United States, 1987 . . . . . . .Percent distribution of women 40 years of age and over who had no breast physical examination (BPE) in the past3 years by most important reason for not having a BPE, according to selected characteristics adjusted for race andagti United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AA. Percent distribution of women 40 years of age and over by interval since last mammogram, according to race andage: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BB. Percent distribution of women 40 years of age and over by interval since last mammogram, according to selectedcharacteristics adjusted for race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CC. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by reason forlast mammogram, according to race and age: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DD. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by reason forlast mammogram, according to selected characteristics adjusted for race and age: United States, 1987 . . . . . . . . .

EE. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by method ofcommunication of results of last mammogram, according to race and age: United States, 1987 . . . . . . . . . . . . . . .

FF. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by method ofcommunication of results of last mammogram, according to selected characteristics adjusted for race and age:United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

GG. Percent distribution of women 40 years of age and over who had no mammogram in the past 3 years by mostimportant reason for not having a mammogram, according to race and age: United States, 1987 . . . . . . . . . . . . . .

HH. Percent distribution of women 40 years of age and over who had no mammogram in the past 3 years by mostimportant reason for not having a mammogram, according to selected characteristics adjusted for race and agtiUnited States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Breast Cancer RiskFactors and Screening:UnitedStates, 1987by Deborah A. Dawson, Ph. D.,Division of Health Interview Statistics,and Grey B. Thompson, Ph. D.,Division of Vital Statistics,National Center for Health Statistics

Introduction

Data in this report include national estimates of theprevalence of selected risk factors and preventive practicesrelated to breast cancer for women 40 years of age andover. The risk factors examined are family history of breastcancer, number of pregnancies, age at first pregnancy,history of lactation, age at menarche and menopause, typeof menopause, use of oral contraceptives and postmeno-pausal estrogen, relative body weight, and alcohol con-sumption. The preventive practices described in this reportinclude frequency of breast self-examination and severalmeasures presented for both breast physical examinationsand mammogram familiarity with and time since lastexamination, reason for last examination, method of com-munication of results of last examination, and most impor-tant reason for not having had an examination in the 3 yearspreceding interview.

Estimates of risk factors and preventive practices arepresented by age, and they are shown separately for blackand white women as well as for women of all races com-bined. In addition, data on preventive practices are pre-sented within categories of education, income, region, andplace of residence, all adjusted for race and age.

The 1987 National Health Interview Survey (NHIS) ofCancer Epidemiology and Control, the results of whichprovide the basis for this report, was the first NHIS to focusprimarily on risk factors and preventive practices related tocancer; thus most of the data presented in this reportcannot be compared with previously published reportsbased on the NEUS. Only two of the risk factors examinedin this report, relative body weight and alcohol consump-tion, are topics that have been included in earlier NationalHealth Interview Surveys. The 1977 and 1983 NHIS’S in-cluded questions on alcohol consumption, and the 1985NHIS of Health Promotion and Disease Prevention col-lected data on alcohol consumption and relative bodyweight.

The questions used to measure alcohol consumption in1983 and 1985 were quite different from those asked in1987; accordingly, estimates presented in this report shouldnot be compared with those from earlier reports. Therelative body weight measure used in this report is identical

to that used in a number of published reports based on the1985 NHIS (l–3). However, the context in which thequestions about height and weight were asked differed in1985 and 1987; therefore, comparisons between the twoyears should be interpreted with caution.

Data on routine physical examinations, including breastphysical examinations, were collected in three previousNHIS’K 1973, 1982, and 1985. The 1985 NHIS also in-cluded a question on frequency of breast self-examination.Although the wording of the questions included in theearlier surveys was not identical to that used in 1987,readers may refer to published reports (4-6) for estimatesof preventive practices based on the 1973, 1982, and 1985NHIS’S. In addition to the NHIS, several other studiesconducted by the National Center for Health Statistics haveincluded questions on breast examinations: the NationalSurvey of Family Growth Cycles HI and IV, conducted in1982 and 1988, and the Hispanic Health and NutritionExamination Survey, conducted in 1982–84.

This report contains no comparisons with data fromprior NHIS’S because its focus is not on trends in riskfactors or in preventive practices. Rather, the purpose ofthis report is to present in a single document the mostcurrent data available on numerous aspects of femalebreast cancer: incidence, mortality, and survival, in additionto risk factors and preventive practices. Data on incidence,mortality, and survival were taken from published reportsprepared by the National Cancer Institute and are summa-rized in the text and accompanying text tables and figures.Data on risk factors and preventive practices were derivedexclusively from the 1987 NHIS. These data are presentedin full in the text tables and are summarized in the text.

In addition to this and other published reports, datafrom the NHIS are available on microdata tapes. Public usedata tapes are available for the Cancer Epidemiology andControl Surveys as well as for many other special healthtopics included in the NHIS’S from 1973 through 1987.Information on these tapes is available from the NationalCenter for Health Statistics, Division of Health InterviewStatistics, Systems and Programming Branch, 3700 East-West Highway, Hyattsville, MD 20782.

Highlights

The following highlights summarize data described indetail in the text and tables that follow.

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Eight percent of U.S. women 40 years of age and overreported having one primary female relative (mother,sister, or daughter) or more who had had breast can-cer. According to previous studies, women whosemothers or sisters had breast cancer are up to 4 timesas likely as other women to have or develop the diseasethemselves.Risk of breast cancer is higher among women with nolive births or with first births occurring at relatively lateages than among women bearing children at relativelyearly ages. The 1987 NHIS found that 14 percent ofwomen age 40 years and over had had no full-termpregnancies, and 7 percent had had their first full-termpregnancy at age 30 years and over.History of lactation is thought to reduce the risk ofbreast cancer. Fewer than half of U.S. women 40 yearsof age and over had ever breast-fed an infant. Thisproportion was lower for younger than older women,decreasing from 63 percent of women 85 years of ageand over to 36 percent of those age 4044 years, andwas lower for white than black women (45 versus52 percent after age adjustment).Early age at menarche is associated with an increasedrisk of breast cancer in a number of studies. Twenty-two percent of women age 40-44 years in 1987 re-ported having reached menarche before age 12 years;among women 75 years of age and over, the proportionwas one-third that size (7 percent).Almost half (47 percent) of U.S. women age 40 yearsand over reported examining their breasts once amonth or more frequently. Twenty percent reporteddoing so less frequently, and 6 percent on an irregularschedule (for example, “when I think of it”). Elevenpercent stated that they did not know how to examinetheir own breasts.

One-third of women age 40 years and over had had abreast physical examination (BPE) in the year preced-ing the NHIS interview, and 81 percent reported everhaving had a BPE. Seven percent had never heard ofthis procedure.Among women who reported having had a BPE in the3 years preceding interview, 88 percent stated that theBPE was a routine examination. Eleven percent said itwas performed for medical reasons. Forty-six percentof those who had not had a BPE in the preceding 3years said the most important reason was that tlhe examwas not needed (because they had experienced noproblems, for example) or that they did not know theyshould have one.Although experts recommend that women have amammogram every year at ages 50 and over and every1–2 years at ages 40-49 years, only 38 percent ofwomen 40 years of age and over reported ever havinghad a mammogram, and just 15 percent said they hadhad a mammogram in the year preceding interview.Women with 13 years or more of school were almosttwice as likely as those with fewer than 12 years ofschool to have ever had a mammogram, 48 versus26 percent. The percent also increased with income,from 27 percent of women with annual family incomesof less than $10,000 to 47 percent of those with familyincomes of $35,000 or more per year (all figuresadjusted for race and age).Almost half (48 percent) of all women who had nothad a mammogram in the 3 years preceding interviewsaid their failure to do so was because it had not beenneeded or they had not known they should have one.Twenty-nine percent said their doctors had rmt sug-gested they have a mammogram; this proportion washigher for black than for white women (41 versus28 percent after age adjustment).

Sources and limitationsof the data

The estimates presented in this report are based ondata from the National Health Interview Survey (NHIS), acontinuous nationwide household interview survey con-ducted by the National Center for Health Statistics(NCHS). For this survey, a probability sample of the civil-ian noninstitutionrdized population of the United States isinterviewed each week by personnel of the U.S. Bureau ofthe Census. Information is obtained about the health andother characteristics of each member of the household.

The NHIS consists of two parts: (a) the basic healthand sociodemographic section, which remains the sameevery year, and (b) the special topics section, which changesfrom year to year. For 1987, the special topics were adop-tion, poliomyelitis, acquired immunodeficiency syndrome,cancer epidemiology, and cancer control. The latter hvotopics were contained in the National Health InterviewSurvey of Cancer Epidemiology and Control (NHIS-CEC),a collaborative effort of NCHS and the National CancerInstitute. Both agencies provided funding and participatedin planning and development of the questionnaires. Thestaffs of NCHS and the National Cancer Institute areperforming analyses and preparing reports based on theNHIS-CEC data. Some of these are collaborative projectsof the two agencies.

The NHIS-CEC consisted of two components: theCancer Epidemiology Study (CES) and the Cancer ControlStudy (CCS), each of which was administered to a ran-domly chosen sample of adults 18 years of age and over.One adult in each family was chosen as the sample respon-dent for the NHIS-CEC, and that adult was systematicallyassigned to be asked one of the two questionnaires. Thus,for each sample respondent in the cancer survey, data werecollected for either the CES or the CCS. This split sampledesign increased the range of data collected but limits dataanalysis to the extent that the information on cancer riskfactors (collected in the CES) is not available for the samepersons that provided data on preventive practices (col-lected in the CCS). The only topics that appeared on bothquestionnaires were smoking habits, height, and weight.Another limitation of the split sample design is the rela-tively small size of each of the samples. For the black andHispanic populations, in particular, the small sample sizesresulted in estimates with large sampling errors.

The interviewed sample for 1987 for the basic healthquestionnaire comprised 47,240 households containing122,859 persons. The total noninterview rate was about

4.7 percent—2.9 percent was due to respondent refusaland the remainder primarily was due to failure to locate aneligible respondent at home after repeated calls.

Self-response was required for the NHIS-CEC. A totalof 22,080 questionnaires were completed with the CESquestionnaire. For the CCS, the total number of completedinterviews was 22,043. The total of 44,123 completed inter-views for the NHIS-CEC represents an estimated86 percent of identified eligible respondents. The com-bined overall response rate for the NHIS-CEC, 82 percent,can be estimated as the product of the response rate for thebasic health questionnaire (0.95) and the CEC question-naire (0.86).

A description of the survey design, methods used inestimation, and general qualifications of the data obtainedfrom the survey are presented in appendix I. Because theestimates shown in this report are based on a sample of thepopulation, they are subject to sampling errors. Therefore,readers should pay particular attention to the section enti-tled “Reliability of estimates.” Formulas for computingestimated standard errors are shown in appendix I.

Many of the terms used in this report are defined inappendix IL Questionnaire items pertaining to data pre-sented are shown in appendix III. The entire NHIS-CECquestionnaire is reproduced in the 1987 edition of theannual NHIS report entitled Current Estikztes From theNational Health Interview Survey (7).

In this report, persons for whom valid responses forparticular items were not obtained are included in thepopulation totals and denominators for percent distribu-tions. All forms of item nonresponse are included in the“unknown” response category this category generally is notpresented in the detailed tables, but its value can becalculated by subtracting the sum of the known responsecategories from the total. Item nonresponse was low, gen-erally less than 3 percent.

In this report, terms such as “similar” and “no differ-ence” mean that there is no statistically significant differencebetween the categories being compared. Terms relating todifference (for example, “greater than” or “less than”)indicate that differences are statistically significant. Thet-test, with a critical value of 1.96 (0.05 level of signifi-cance), was used to test all comparisons. Lack of commentregarding the difference between any two statistics does notmean that the difference was tested and found to be notstatistically significant.

3

Selected topics

Incidence

Cancer of the breast accounts for approximately28 percent of the total cancer incidence among U.S.women, more than any other single type of cancer(figure 1). In 1988, an estimated 135,000 cases of femalebreast cancer will be diagnosed in the United States, anincidence rate of about 109 cases per 100,000 women (8).

The incidence rate for breast cancer increased at a rateof less than 1 percent annually between 1950 (74.4 casesper 100,000 white women) and 1975 (91.5 cases per100,000 white women), based on data collected in cancerregistries in five geographic areas. Most of this increasetook place in the early 1970’s, when media coverage ofbreast cancer in two public figures may have increasedAmerican women’s awareness of the disease and of thevalue of routine screening examinations. The initiation in1972 of the Breast Cancer Detection DemonstrationProject also may have contributed to this sudden upturn indiagnoses (9).

Incidence rates for female breast cancer decreasedfrom 1975 to 1977 and began increasing again in 1978, at amore rapid rate than in the period 1950-75. Between 1975and 1985, breast cancer incidence rates for white women inthe five geographic areas rose from 91.5 to 107. On the

Colon and rectum

Lung

uterus

Laukemla and Iymphomes

Urinary

Ovary

Skin

Psncreae

All other

o 10 20 30

Percent diatrlbutlon

NOIE Excludesrmwwlanornsakinsanosrandcaminomsh situ.

SOURCE AmericanCancer3ociaty.Cancerfactsml figuree-1988, New Yorkk-nerifxn Cancer Soalefy. 1985.

Fkrure 1. Peroent distributionof estimated female sancer incidence bysik: United state% 198S

4

basis of the 11 population-based cancer registries includedin the National Cancer Institute’s Cancer Surveillance,Epidemiology, and End Results (SEER) Program, inci-dence among women of all races rose from 87.6 to 102.1, anincrease of 17 percent (9).

Breast cancer incidence increases through age 85 yearsand then begins to decline. Between 1982 and 1986, theincidence rate per 100,000 women of all races varied from0.1 at ages 15–19 years to 388.7 at 85 years of age and over(table A). Below age 45 years, breast cancer occurred morefrequently among black than white women; at ages 45 yearsand over, the incidence rates were higher for white women.Because the majority of cases of breast cancer occur atolder ages, the overall incidence rate was higher for whitethan for black women, 107.3 compared to 92.7 in 1986 (10).

Tabie A. Average annuai age-specific incidence rates for femaiebreast cancer by race: United Statea, 1982-66

Age All raoe.d White Black

15-19 years . . . . . . . . . . . . . . . . . . .20-24 yeare. . . . . . . . . . . . . . . . . . .25-28 years . . . . . . . . . . . . . . . . . . .W-34years. . . . . . . . . . . . . . . . . . .3S-39yeare . . . . . . . . . . . . . . . . . . .4044ye8rs, . . . . . . . . . . . . . . . . . .45-49 ye8rs . . . . . . . . . . . . . . . . . . .60-54 yeare . . . . . . . . . . . . . . . . . . .55-59 year8 . . . . . . . . . . . . . ..d. . .60-84 years . . . . . . . . . . . . . . . . . . .65-89 years . . . . . . . . . . . . . . . . . . .70-74 yeare . . . . . . . . . . . . . . . . . . .7S-79yeare . . . . . . . . . . . . . . . . . . .80-84 years . . . . . . . . . . . . . . . . . . .85year88nd over . . . . . . . . . . . . . . .

Rate per 100,000 women2

0.1 0.11.1 0.9 1.7

7.9 11.52% 27.1 39.066.3 66.3 74.5

120.1 119.6 130.2175.1 179.1 159.2200.8 207.9 169.8250.8 259,4 215.7304.9 317.1 248.6352.0 366.2 271.5382.3 392.8 325.5400.0 411.1 332.0412.0 416.6 419.7366.7 397.9 329.1

1Inc!udes other rams not shown separately.

‘Estimates based on SEER program dat&

SOU13CE Netional Canaar Institute. Cancer siatisllcs rev!ew 1978-1928, including a report on

the status o+ cancar conhok May, 1989. NIH pub no 89-27S9. Washlngtom Public Haelth

Swvlce. 19S9.

Mortality

An estimated 42,000 U.S. women will die of breastcancer in 1988. Long the leading cause of cancer mortalityamong women, breast cancer is now ranked second tocancer of the lung (figure 2). In 1988, the AmericanCancer Society estimates that breast cancer will account for18 percent of all female cancer deaths, compared with20 percent for lung cancer. In the 15–54 year age group,

Lung

Breast

Colon End reofum

Leukemia and Iymphxnes

ovary

Pancreas

Uterus

Urinary

Skin

20

All other 20

0 5 10 15 m

Percent distribution

NOTE Excludes norrmela.nmra skn cancer and carckmra in situ.

SCURC!2 &-norkan Cancer Scdety. Cwwer facts and @uree-1 B@. Ww YOI%.4nraican Cancer Society. 1SS8.

FknJre2. PercenttfiaWMonof estimaleit fen@e cancer deaths bv M=h-ited States. 19SS

though, breast cancer continues to cause more deathsamong U.S. women than any other form of cancer (8).

Despite the increase in breast cancer incidence since1950, mortali~ attributed to female breast cancer hasremained almost constant. The age-adjusted mortality rateper 100,000 women was 26.0 in 1950, compared with 27.4in 1985 (9).

The age-speeific mortality rate for female breast cancerincreases with age, reflecting the increasing incidence of thedisease at older ages (table B). For the period 1982-86,mortality varied horn 0.1 deaths per 100,000 women 20-24years of age to 178.9 for women 85 years of age and over(lo).

Among women younger than 50 years of age, mortali&rates were slightly higher for black than for white women;

Table B. Average annual age-specific mortality rates for femalebreast cancer by race: United States, 1982-86

Age All raced White Black

Rate per 100,000 womerf

15-19 yeara . . . . . . . . . . . . . . . . . 0.0 0.02&24yeara . . . . . . . . . . . . . . . . . . . 0.1 0.1 0.325-29 yeare . . . . . . . . . . . . . . . . . . . 1.2 1.1 2.330-34 yeara . . . . . . . . . . . . . . . . . . . 5.3 5.0 8.135-39 yeare . . . . . . . . . . . . . . . . . . . 13.0 12.3 20.040-14 yeare . . . . . . . . . . . . . . . . . . . 23.5 22.7 33.145-49 years. . . . . . . . . . . . . . . . . . . 37.2 36.2 49.550-54 yeara . . . . . . . . . . . . . . . . . . . 55.5 55.3 62.955-59 years . . . . . . . . . . . . . . . . . . 74.0 74.4 78.560-64 years . . . . . . . . . . . . . . . . . . . 89.2 90.0 91.765-69 years . . . . . . . . . . . . . . . . . . . 101.5 103.4 93.470-74 yearn . . . . . . . . . . . . . . . . . . 114.7 116.7 103.675-79 years . . . . . . . . . . . . . . . . . . . 127.5 130.2 110.48C-84yeara . . . . . . . . . . . . . . . . . . . 147.4 149.1 142.685years andover . . . . . . . . . . . . . . . 176.9 182.1 152.3

1Inc!udes other races not skwn separately.

‘Estimatesbased on vital statistics system.

SOURCE: NatIoneJ Cancer Institute. Cancer slak.tics review 197s-1 980, including a report on

the status cd cancer controh May, 19S9. NIH pub no s9-27S9. Weshlngto!x Public Health

Service. 19SS.

at ages 65 years and over, the reverse was true. For all agescombined, there were no differences by race in breastcancer mortality 27.3 deaths per 100,000 white women in1986, compared with 29.0 deaths per 100,000 black women(lo).

Survival

Among women diagnosed as having breast cancer inthe period 1974-85, the 5-year relative survival rate (theactual number of women surviving 5 years or more dividedby the number who would have been expected to survive hadthey not had breast cancer) was 74 percent. As shown intable C, survival was strongly influenced by the site of thedisease at diagnosis. For women whose breast cancer wasstill localized when diagnosed, the 5-year relative suMvalrate was 90 percent; for women diagnosed with regional-ized breast cancer, the rate was 68 percent. Of the smallproportion of women whose breast cancer had spread todistant sites by the time of diagnosis, only 18 percentsurvived for 5 years or more.

There is a strong racial differential in female breastcancer survival, part of which is explained by differencesbetween black and white women in the stage at which thedisease is diagnosed. Forty-nine percent of the breast can-cer diagnosed in white women in 1979–84 was still local-ized, compared with 41 percent for black women. Amongwomen whose breast cancer was diagnosed in a localizedsite, 5-year relative survival rates were only slightly higherfor white than black women, 91 compared with 86 percent.Survival rates for black and white women differed moresharply when regionalized cancer was diagnosed, 55 com-pared with 69 percent.

McWhorter and Mayer (11), using SEER data forfemale breast cancers diagnosed in 1978-82 and followedfor survival through 1984, found racial differences in treat-ment that may be related to the survival differential. Afteradjusting for age, site at diagnosis, and histology, blackwomen were less likely than white women to have beensurgically treated and more likely to have received nonsur-gical treatment or no cancer-directed therapy.

Breast cancer suMval rates have improved since the1950’s, which explains why mortality has remained constantin the face of the rising incidence of the disease. For whitewomen, the 5-year relative survival rate for breast cancerincreased from 60 percent in 1950-54 (9) to 76 percent in1980-85 (table D). The more limited data available forblack women show an even more rapid increase in survival,from 46 percent in 1960-63 to 64 percent in 1980-85.Thus, the racial differential in breast cancer survival, al-though still apparent, has narrowed over time.

Risk factors

Past research has identified numerous risk factors forfemale breast cancer. The most powerful of these is age, aswas evident in the age-specific incidence rates presentedearlier. For other risk factors, there is evidence that they

5

Table C. Percent diatributlon of female breast cancer casea and 5-year relative survival rates for female breast cancer by site of cancerat time of diagnosis, according to race: United Statea,l 974-85

Breast cw’mer ceeed 5-year ralative survivld

All AllSfle rad White Black racd Whfle Black

Percent distribution Percent

Allsnee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 100 100 74 75 83

Localized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 49 41 90 91 86Reglonalized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 41 44 88 69 5sDlsianl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 7 11 18 19 14Unknown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 4 55 56 45

1Estimatesbasadon SEER prcgram‘Imhdes other races not shown aaparately.

SOIJRCE National Career Insthute. cancer statistics review 197S-1986, Including a repart on the status of cancer cortrok May, 1989. NIH pub w 8S-2789. Washington Public Health Service. 19S9.

Table D. Trenda In 5-year relative survival rates for female breastcancer byrace: United States, l 950-54 through 1980-85

5-year relatlve survlvafi

Period White Black

Percent1950-54 . . . . . . . . . . . . . . . . . . . 60 ——-

1960-83 . . . . . . . . . . . . . . . . . . . 63 481970-73 . . . . . . . . . . . . . . . . . ,. 66 511974-76 . . . . . . . . . . . . . . . . . . . 74 821977-79 . . . . . . . . . . . . . . . . . . . 75 821980-65 . . . . . . . . . . . . . . . . . . . 76 64

1Estimatesbased on SEER !xcgramdata

SOURCES Natloml Carwsr Institute. 19S7 anrual cancer statistics review. NIH pub ma

.SS-27S9. WasHngtom i%bllc Health Sefvlce. IeSti and National Cancer Institute. Cancer

stdidl= rwlewle7&l*e, lmludl~a mpflmtk datus&ca~r cotiml: May, leSe. NIH

pubno S9-27S9. Washlngtom Public Health Sewlce. 19S9.

may differ or have varying effects at older and younger ages(12,13) .Petrakis, Ernster, and King (14) have suggestedthat ’’environmental factors play amore important role inthe etiology of postmenopausal breast cancer, whereasgenetic, endocrinologic, and other endogenous factorsstrongly influence thepremenopausal disease.”

The followingreview briefly summarizes resultsofpastresearchon each generally accepted risk factor for femalebreast cancer. For those factors for which data were col-Iected in the 1987 National Health Interview Survey ofCancer Epidemiology and Control (NHIS-CEC), the distri-bution of the risk factor in the population of women 40years of age and over is described and compared for womenof different ages and races.

History of benign breast disease

Results of past studies generally are consistent in show-ing that a history of benign breast disease (that is, nonma-lignant abnormalities of the breast tissue and ducts)increases the risk of breast cancer. Estimates of relative riskassociated with benign breast disease have varied widely(13,15-21), and many of the studies examining this associ-ation have been criticized for insufficient followup (eithertoo short an interval or too small a proportion of cases andcontrols) or failure to adequately match cases and controls(22), In a well-designed prospective study by Coombs andLillienfeld (23), women diagnosed with benign breast dis-

6

ease during the period 1957–65 were three times as likelyas their matched controls to have developed breast cancerby 1977. A case control study using data collected between1976-80 as part of a larger drug surveillance programfound that benign breast disease increased the risk of breastcancer by a factor of belsveen 2.4 and 2.9, depending on theinterval since diagnosis of the benign disease (24).

Recent evidence suggests that excess risk associatedwith benign breast disease may vary according to IIevel ofductal atypia (15,25) or may occur only among women withproliferative lesions (26,27) or fibrocystic disease (28).Risks associated with certain types of benign breast diseasehave been found to interact with other risk factors forbreast cancer, including breast size and age at first birth(26).

The NHIS-CEC did not collect data on history ofbenign breast disease, so data from this study cannot beutilized to estimate the prevalence of this risk factor amongwomen 40 years of age and over.

Family history of breast cancer

Women whose mothers or sisters have had breastcancer are up to four times as likely as other women todevelop or to have the disease themselves (24,28-32).Excess risk associated with a family history of breast canceris increased when two close female relatives or more havehad breast cancer (28,33-36). Dupont and Page (26) foundthat family history modified the effect of breast size on therisk of breast cancer. Among women who had a first-degreerelative with female breast cancer, the risk of developingbreast cancer increased with breast size; among womenwithout such a family history, breast size had no effect.

The etiology of family history as a risk factor for femalebreast cancer is not yet fully understood. Either geneticsusceptibility, common exposures/practices, or a combina-tion of the two could explain the excess risk observedamong women with family histories of breast cancer. Ifgenetic factors play a role, science has not yet determinedthe specific biochemical or physiological processes involved(14).

According to the data collected in the 1987 NHIS-CEC, 8 percent of U.S. women 40 years of age and over

Table E. Percent of women 40 years of age and over with breast cancer reported in selected primary relatives by race and age:United States, 1987

Breast cancer reported in—

No 1 prlmayRace and age primary twattved relatlvd or mom Mother Sister

All race#

40years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Cr-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-84yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-84yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6E-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-89years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70-74yeam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79yeere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-84yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85yearesndover . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-84years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 yeare and ove~Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5E-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

92.1

92.994.562.091.892.293.191.590.289.591.092.793.691.092.9

91.791.8

92.691.769.792.1

95.595.6

95.1e8.493.798.2

7.9

7.15.56.06.27.66.98.59.6

10.59.07.36.49.0

*7. 1

8.38.2

7.48.3

10.27.9

4.54.5

●4.9*3.6●6.3*1.6

4.0

5.14.05.66.03.83.54.03.23.82.52.1

*1.8*2.6*2.2

4.24.2

5.63.93.22.3

*2.2*2.2

%2.1*2.O*4.1*0.5

3.7

2.6w .4

4.02.43.83.63.95.86.15.44.23.8

*5.2*3.5

3.93.9

2.53.96.34.5

*2.1*2. 1

%2.8*1.6*1.7*0.9

1Mothw,sister, or deughter.zlmbdmotkrms ndsm=wbly.

had one primary relative or more (that is, mother, sister, ordaughter) who had had breast cancer (table E). Fourpercent reported mothers with breast cancer, and4 percent reported sisters with breast cancer. Thepropor-tionofwomen reporting breast cancerin adaughterwassosmall (less than 1 percent) that its reliability was question-able, as was the proportion reporting a mother and a sisterwith breast cancer (less than 1 percent).

The percent ofwomen reporting mothers with breastcancer increased with age through ages 50–54 years, con-sistent with a mean generational length ofabout25 yearsand thepattern ofrisingincidence ofbreast cancer throughage 75. At ages 55 years and over, the percents ofwomenwho had mothers withbreastcancer declined. This reflectsthe lower overall incidence of the disease in the periodprior to 1970. The percent of women reporting breastcancer in sisters increased through ages 65-69 years, re-flecting the relatively small age differences among sisters.

Generally speaking, black women were less likely thanwhitewomen to report having one primery relative ormorewith breast cancer (5eompared with8 percent for all ages40 years andover after age adjustment) .Although suchapattern is consistent with racial differences in incidence offemale breast cancer, these comparisons should be inter-

preted with caution because of the small numbers uponwhich the estimates for black women are based.

Reproductive factors

Numerous reproductive and menstrual factors havebeen linked with female breast cancer. Because these fac-tors are highly correlated, it has been difficult to assesstheir individual effects. In general, associations betweenthese reproductive factors and breast cancer risk appear tobe related to the sensitivity of the breast epitheliums toestrogen, prolactin, and other substances produced by theovaries, pituitary, adrenal gland, and hypothalamus(14,37,38).

Parity md age atjirst birth-Nulliparity and late age(that is, 30 years and over) at first full-term pregnancy havebeen associated with excess risk of female breast cancer;conversely, early age (less than 25 years) at first full-termpregnancy has been shown to have a protective effect(24,26,28,39-44). Helmrich et al. (24) found that excessrisk of breast cancer associated with increasing age at firstbirth was not accounted for by parity, but Kv”~e and Heuch(42) reported that adjusting for parity and age at last birthremoved the association initially observed between cancer

7

risk and age at first birth. Additional research is needed toascertain the net effects of these two closely related riskfactors.

The protective effect of parity and early pregnancy maybe related to beneficial hormonal changes occurring duringpregnancy. For example, one hypothesis in the late 1960’swas that pregnancy, because of associated increases in theratio of estriol to estradiol and estrone, impeded the carci-nogenic effects of the latter two (45). More recently, Museyet al. (38) concluded that pregnancy leads to a long-term(12-13 years) decrease in the secretion of prolactin, apituitary hormone identified as a cocarcinogen in mammarycancer in rats (46).

The 1987 NHIS-CEC data indicated that 14 percent ofall U.S. women 40 years of age and over were nulliparousand that 24 percent had their first full-term (6 months’duration or longer) pregnancy at age 25 years or over(table F). Seven percent were 30 years of age or over at thetime of their first full-term pregnancy. Women 75 years ofage and over, most of whom were in their peak childbearingyears during the Great Depression of the 1930s, were themost likely to be nulliparous. Nearly one-fourth of thesewomen had no full-term pregnancies, compared with about

1 in every 9 women age 40-54 years. The proportion ofwomen with a first full-term pregnancy at age 30 years orover was greatest-about 1 in 10—among women 65 yearsof age and over.

Black women were slightly more likely than whitewomen to have had no full-term pregnancies (16 versus14 percent after age adjustment), but white women weremore likely to have had their first full-term pregnancy atage 30 years or over (7 versus 3 percent). Racial differ-ences in parity and age at first pregnancy were greatestamong the oldest women.

Lactation-Findings concerning the effects of lactationon the risk of female breast cancer have been inconsistent.Geographic patterns of breast cancer support the hypothe-sis that lactation has a protective effect, with incidence ofthe disease being lower in areas where breast-feeding ismost common and prolonged (14). Although a large inter-national case control study conducted between 1964 and1967 found no association between history ofbreast-feeding and breast cancer after adjusting for theeffect of age at first pregnancy (47), two recent studies thatadjusted for parity and age at first pregnancy did find aprotective effect in premenopausal women (48,49). The

Table F. Percent distribution of women 40 years of age and over by age at 1st full-term pregnancy, according to age and race:United States, 1987

Ist full-term pregnancfl at age—

No fu//-tenn All Less than 20-24 25-29 30 yearsRace and age Totafi pregnanclasi age.# 20 years years years or more

All races4

40yeare and over . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . .

5S-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69 yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . .70-74 yeare . . . . . . . . . . . . . . . . . . . . . . .

75yeare and over . . . . . . . . . . . . . . . . . . . . . . . . .75-79 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-84 year n . . . . . . . . . . . . . . . . . . . . . . . . . . . .85years and over . . . . . . . . . . . . . . . . . . . . . .

White

40 yeare and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 year3, . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-84 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 years And over . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64 year3. . . . . . . . . . . . . . . . . . . . . . . . . . .65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . .75years And over . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100,0100,0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

14.2

10,811,810.7

9.612.310.314.117.514.920.722.724.420.421,8


65.8 22.0

89.2 26.766.2 26.989.3 29.090.4 23.887.7 21.069.7 25.385.9 17.482.5 17.565.1 19.079.3 15.777.3 17.075.6 16.779.6 17.376.2 17.4

14.0 86.0 19.713.9 66.7 19.9

10.4 89.6 24.712.2 87,6 16.217.3 62.7 15.622.2 77.9 14.5

15.5 84.4 43.216.2 83.9 43.0

10.6 89.4 43.414.4 85.6 46.620.8 79.2 38.528.8 71.1 42.3

36.8

39.335.939.942.941.341.241.532.235.428.328.425.632.130.2

38.438.5

41.043.533.130.2

26.325.7

31.625.325.5*9.6

16.8

15,616.614.015.916.214.917.420.120.120.016.317.215.415.3

17.717.7

16.417.221.517.0

7.98.0

7.6*7.7*7.4

*10.O

7.1

5.26.63.65.06.35.27.19.98.9

11.210.010.310.2*9.O

7.47.3

5.16.3

10.510.9

3.13.1

*3.6*2. 1*4.8*0.9

i Includesunknownif any full-termpregnancies.2Pregnsncieslasting6 rnanthsw more.Slncludes unlmown age at firstfull-termpre9namcy.41ncludesotherracesnotshownseparately.

8

second of these studies found a weak protective effect inpostmenopausal women as well, but the postmenopausalwomen studied were relatively young, less than 55 years.

Byers and others (48) found that duration of lactationwas a more powerful correlate of breast cancer risk thanwas the crude measure of ever having breast-fed. Womenwho breast-fed for less than 1 month after their first livebirth actually were at higher risk of breast cancer thanwomen who did not breast-feed, but among women whobreast-fed for 1 month or longer, the estimated relative riskdecreased with increased duration of lactation. The authorssuggested that the process of lactation either might beinherently beneficial, as a result of changes in the breastresulting from breast-feeding, or might simply act as anindicator of a normally balanced endocrine system, withfailure to lactate indicating an underlying endocrine prob-lem that might increase the risk of breast cancer. Someevidence in support of the hypothesis of inherent benefitwas offered by a study that reported a disproportionateamount of postmenopausal breast cancer in the left breastsof Tanka women in Hong Kong, who traditionally nursewith the right breast only (50,51).

Slightly fewer than half of all U.S. women 40 years ofage and over ever breast-fed (table G). Fifteen percent

never had a live birth, and 39 percent never breast-feddespite having had 1 live birth or more. The proportion ofwomen who ever breast-fed increased steadily with age,reflecting the more widespread practice of lactation amongearlier cohorts of American women. Sixty-three percent ofwomen 85 years of age and over ever breast-fed, comparedwith 36 percent of women 40-44 years of age.

Black women were more likely than white women everto have breast-fed a child (52 versus 45 percent after ageadjustment) despite the fact that they were more likely tohave never had a live birth (17compared with 14 percentfor white women after age adjustment). Women 55 years ofage and over accounted for the racial differential in lacta-tion histoqq among women age 40–54 years, black andwhite women were equally likely to have breast-fed.

Age at mermrche—Early menarche has been associ-ated with an increased risk of breast cancer in a number ofstudies (13,24,40,44,52-55). As is evident in table H, age atmenarche has declined in successive cohorts of U.S.women. Twenty-two percent of women age 40-44 years in1987 reported reaching menarche before age 12; amongwomen 75 years of age and over, the proportion wasone-third that size, 7 percent. Part of this difference can beattributed to a greater proportion of older women who

Table G. Percent distribution of women 40 years of age and over by status of Iaotation, according to race and age: United States, 1987

Never breest-f9d

1 live EverRace and age Totafi No live births birth or more breast-fed

All race~

40yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49yeare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-64yeare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64yeers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74yeere. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70-74years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeare and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76-79 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85years andover . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

40 years and over:Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66-74 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yeare and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yeare andover . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0i00.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

14.6

11.112.211.09.9

12.610.514.318.015.221.323.225.020.722.2

14.314.2

10.812.417.622.5

16.317.0

11.115.322.130.2


39.2

48.851.247.547.140.941.740.231.633.629.119.519.223.214.1

40.240.4

49.443.332.620.6

31.230.0

48.324.917.7*7.5

45.6

39.335.840.542.546.147.444.950.150.949.356.654.855.763.0

44.944.9

39.243.949.456.1

51.351.9

40.859.160.361.4

1Inckdes unknown If ever had any live blrlim and unknown If ever breast-fed.

‘Mudes other mea not shown separately.

9

.——

Table H. Percent distribution of women 40 years of age and over by age at menarche, according to race and age: United States, 1987

Age at menarche

Less than 12 13 14 15 Greater thanRace and age Total 12 years years’ years years years 15 years Unknown

All racesl

40years And over . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . .40-44years . . . . . . . . . . . . . . . . . . . . . . . . .45-49years . . . . . . . . . . . . . . . . . . . . . . . .50-54years . . . . . . . . . . . . . . . . . . . . . . . . .

5E-64yeafs . . . . . . . . . . . . . . . . . . . . . . . . .56-59years . . . . . . . . . . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . .65-89years . . . . . . . . . . . . . . . . . . . . . . .70-74yeaB . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsand over . . . . . . . . . . . . . . . . . . . . . .75-79yeare . . . . . . . . . . . . . . . . . . . . . . . . .80-84yeaB . . . . . . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . . . . . . .

White

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . .55-84years . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . .

40-64years . . . . . . . . . . . . . . . . . . . . . . . . . .55-84yeare . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeam . . . . . . . . . . . . . . . . . . . . . . . . . .75yeersandover . . . . . . . . . . . . . . . . . . . .

100.0

100.0100.0100,0100,0100,0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100,0100.0100.0

100.0100.0

100.0100.0100.0100,0

16.0

20.421.622.516,415.416.814.214.216.711.17.07.96.3

*5.8

16.016.1

20.615.514.4

6.7

17.417.0

21.416.413.4

*10.5

19.9

22.423.321.222.720.119.620.616,616,916.816.315.478.714.5

19.920.0

22.920.116.716.1

19.819.7

20.420.116.7

*18.6

Percent distrlbutkm

24.5

25.624.725.726.526.226.426,022.924.421.120.623.721.311.0

24.924.9

25.727.123.421.3

22.422.2

26.620.519.6

*14.6

15.9

i3.313.0i 3.613.515.517.314.019.5~7.721.716.520.017.515.8

15.915.8

13.415,718.718.9

14.314.6

11.114.122.4

*14.8

7.8

6.96.18.16.57.97.36.47.97.38.69.9

10.110.9*7.7

7.77.7

7.07.48.39.7

7.86.0

5.512.2*5.O

*11.4

8.1 7.9

6.6 4.76.1 5$15.2 3.68.8 5.38.0 6.96.4 6,39.4 7.49.4 9,18.7 8,1

10.3 10,510.6 17.1

8.7 14.210.2 15.116.4 28.7

7.9 7.57.9 7.5

6.1 4.27.8 6.49.6 6.9

10.9 16.4

6.7 9.68.6 10.0

9.0 5.9*8.7 *8. 1*8.5 *1 2.2*7.7 22.3

i Includesother- nat sham separately.

could not recall how old they were when they startedmenstruating. Age-specific patterns in age at menarchewere similar for black and white women.

Ageatmenopause —Pastresearchhas shownthatearlymenopause, whether natural or surgical, is associated witha reduced risk of female breast cancer. For cases of earlysurgical menopause, a protective effeet generally has beenidentified only when both ovaries were removed(40,44,52,55,56).

The 1987 NHIS-CECdata indicated that24 percentofU.S. women 40years ofage andover still were menstrual-ing, 44 percent had reached natural menopause, and30 percent had experienced surgical termination ofmenses(table J). Approximately one-fifth reported an early age atmenopause. Seven percent had reached natural menopauseprior to age45 years, and 13 percent reported surgicallyinduced menopause before age40 years. Thesed atado notindicate the specific nature of the surgical procedure forwomen with surgical menopause; presumably not all ofthese women had both ovaries removed, so not all of thewomen with an early reported age at surgical menopausewere at reduced risk ofbreast cancer.

Among women 55years ofage and over, the propor-tion who experienced natural menopause decreased withage, while the proportion reporting surgical menopause

10

increased. The small proportions ofolderwomen reportedas still menstruating are those who answered negativelytothe question ’’Have your menstrual cycles stopped perma-nently?” These women may have confused irregular spot-ting or bleeding with continued menses.

Exogenous estrogens

Oral contraceptives-Many case control and cohortstudies have attempted to assess the effect of oral contra-ceptive use on the risk of female breast cancer. AIthoughmost of these studies have found that use of oral eontracep-tives neither increased nordecreased risk (53,57–61), sev-eral studies observed an increased risk of breast canceramong women with prolonged use of oral contraceptives ifthey also had benign breast disease (62,63) or if the useoccurred at early ages (64-66). One recent case controlstudy found that women who ever used oral ccmtraceptiveshad double the risk of breast cancer before age 45 years; forwomen with 10years ormore of use, the estimated relativerisk was 4.1 (67).

Most investigators agree that the existing data do notyet permit definite conclusions about the association be-tween oral contraceptives and the risk of breast cancer.Larger scale studies and research that consider the estro-

Table J. Percent distribution of women 40 years of age and over by menstrual status and age at menopause, according to race and age:United States, 1987

Natural menopause at– Surgkal menopause at–

5.5SW All Under 45 45-f950-54 years All UnUer 40 40-49 50 years

Race and age Toiaf menstruating age# years w WE and over age.+ years years and over

All r8ces4

40yeafeand over . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . .40-44 yeafs . . . . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . . . . .50-54 yeafs, . . . . . . . . . . . . . . . . . . .

55-64 yeare . . . . . . . . . . . . . . . . . . . . .55-59 yeat3. . . . . . . . . . . . . . . . . . . .60-64 yeers . . . . . . . . . . . . . . . . . . . .

85-74 yeafs . . . . . . . . . . . . . . . . . . . . .65-89 yeara . . . . . . . . . . . . . . . . . . . .70-74yeers . . . . . . . . . . . . . . . . . . . .

75yeareanclover . . . . . . . . . . . . . . . . .75-79yeafs . . . . . . . . . . . . . . . . . . . .80-64yeare . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . .

White

40 years and overCrude . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . .5S-64yeare . . . . . . . . . . . . . . . . . . . . .65-74yesrs . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . .

Black

40 years and ove~Crude . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . .

40-54yeers . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.010+3.0100.0

24.3

54.976.358.523.0

3.34.52.23.53.13.93.5

*2.9*3.3●5.4

24.225.1

55.93.43.23.3

23.422.4

48.5*2.6*6.1*5.O

44.115.0*1.39.1

39.659.554.983.564.e64.565.171.466.972.077.2

44.743.8

14.859.365.471.7

40.542.3

14.756.962.16s.2

7.1

4.0*1.13.78.17.75.69.29.6

11.07.8

11.511.613.1*8.6

7.27.1

3.97.89.7

11.5

6.56.6

*4.6*6.5*7.6

*12.1


11.8

5.6. . .5.4

13.214.713.515.715.616.714.219.217.619.223.7

12.112.0

5.515.216.019.8

9.49.6

5.911.5

*12.5*13.9

17.2

5.0. . .. . .17.125.727.324.425.423.226.125.927.525.522.2

17.817.5

5.025.626.626.6

13.013.4

*3.725.515.8

‘*8.4

5.8

. . .

. . .

. . .

. . .9.56.3

12.310.810.311.3

8.67.68.6

11.0

5.65.4

. . .9.1

10.38.2

7.37.9

. . .12.216.3

*I 1.4

29.7

28.520.631.335.335.436.233.020.330.426.023.827.223.015.5

29.429.3

27.935.42e.123.9

33.833.1

36.536.427.723.4

12.7

16.316.716.215.712.112.411.910.311.66.76.88.26.4

*3.4

12.512.5

16.111.910.46.2

15.515.3

18.614.7

+10.4*12.9

12.5

10.93.6

14.716.016.519.613.911.712.011.311.411.312.89.6

12.412.3

10.516.711.211.6

13.913.2

15.816.3

*I 0.0+7.5

3.6

0.6. . .. . .2.15.84.96.56.55.97.34.24.9

*3.8*2.5

3.73.6

*0.56.06.64.3

3.33.4

*1.3*5.1*6.6*2.3

1lw~de~ MWr ~~t~tied, unk-n if war memtwatad, unknown if stopped menstruating, snd unknownif I_IatUrdor SW@d m~~.9E.

‘Mudes unkrmwn age at natural meriqxwa.31w~deB unk~ age at surgical ~~-.

41neludee other r=as not shown separately.

gen/progesterone ratio ofthe oral contraceptives used mayhelp to clarify this association (53).

The importanceof the relationship between oral con-traceptive use and breast cancer risk is evident in table &which shows the rapidly increasing proportions of U.S.women who ever used birth control pills. Seventy-fourpercent ofU.S. women age 40-44 years ever used oralcontraceptives, compared with 58 and 38 percent, respec-tively, ofthose 45-49 and50-54 years. Just 20 percentofwomen 55–64 years of age ever used oral contraceptives,and the proportion was less than 5 percent for olderwomen. Thus, if any excess risk can be attributed to use oforal contraceptives, it would have important implicationsfor the future trend in breast cancer incidence.

White women were slightly more likely than blackwomen ever to have used oral contraceptives, 31 comparedwith 27 percent for all ages 40 years and over after ageadjustment. Black and white women who ever used oralcontraceptives were fairly evenly divided between thosereporting3 years or less and more than 3 years of use.

Postmenopausal estrogens —Studies of estrogen re-placement therapy have provided mixed evidence as to the

effects of postmenopausal estrogen (PME) on breast can-cer risk. The majority of studies found no association orsuggested a decreased risk among women who ever usedPME (53,59,68-70), but two studies (71,72) suggested apositive association in some groups of women.

In 1987, almost one-third of women age 40 years andover who had stopped menstruating had used postmeno-pausal estrogen (table L). Eighteen percent had used PMEfor 3 years or less; 13 percent reported more than 3 yearsof use. Three percent of women did not know if they hadused PME, and 65 percent never used PME. The propor-tion of women who had used this form of estrogen replace-ment generally declined with age, although the pattern wassomewhat irregular. White women were considerably morelikely than black women to have used PME (36 comparedwith 20 percent after age adjustment), and this differencewas most pronounced at older ages.

Body weight

Several studies have found that the association betweenrisk of breast cancer and body weight or body mass index(weight for height) differs for premenopausal and post-

11

Table K. Percent distribution of women 40 years of age and over by duration of use of oral contraceptives, according to race and age:United Statas, 1987

Ever used oret contraceptivesNever used

oral All 3 years More thanRace and age Tota~ corrh-aceptives durat/orr# or 1ss3 3 yesrs

All races3

40years and over . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5$64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69yeais . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsanctover . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-%4yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .05yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .


29.6

58.474.258.138.220.127.813.53.95.6

*1.9*0.3*0.2*0.6

100.0

100.0100.010+J.O100.0100.0100,0100.0100.0100.0100.0100.0100.0100.0100.0

69.0

40.324.440.960.478.370.585.094.493.395.898.398.998.297.2

14.5 14.2

28.434.327.821.410.5

29.038529.616.06.5

12.05.61.52.2

*0.7

14.57.21.82.7

*0.7

White

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0Ageadjustad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

40-S4years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.055-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.065-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.075yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

66.767.6

39.177.494.198.5

29.930.9

59.821.0

4.2*0.3

14.615.1

29.010.8

1.9

14.515.0

29.89.21.6

Black

40 years end ovecCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.055-64year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.085-74year3 . . . . . . ..4...... . . . . . . . . . . . . . . . 100.075yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

69.671.6

42.185.998.696.6

29.027.0

56.014.0*0.8

14,213.3

13.912.6

26.6*6. 1*0.5

28.4*3.8*0.4

1Incbdes unkrmvm If ever used CA contraceptives.‘Inchdes unknown duretion of use of oral c.mhceptlves.%hdesotherrms Patshowr%perately.

menopausal women. Prior to menopause, leaner womenare at greater risk than are heavier women; after meno-pause, risk increases directly with weight (13,24,53). Choiand others (52) found no evidence of a protective effect ofweight prior to menopause but did find risk positivelyassociated with body weight among postmenopausalwomen. Other studies that have found a positive associationbetween weightor body mass index and breast cancer riskin postmenopausal women include Verreault and others(73) and de Waard (74,75), but Staszewski (76) found thatweight had no independent effect after controlling forheight.

Table M shows the distribution of U.S. women byrelative body weight, that is, by actual weight comparedwith desirable weight as defined by the Metropolitan LifeInsurance Company height/weight charts (see appendix II).More than40f 10women40 years of age andover wereeither 5 percent or more below their desirable weight(21 percent) orwithin5 percent ofthatwei@t (another21 percent). One-fourthof the women were slightly over-weight, and more than one-fourth, 28 percent, wereobese—20 percent or more above their desirable weight.

There was little variation by age in the proportionofwomen whowere20 percent or more overweight, but thepercent of women who were 5 percent or more under-weightwas highest among women 75years ofage andoverand lowest among women age55–74 years. Relative weightwas considerably higher, on average, for black than whitewomen.After adjusting forage, blackwomen were twieeaslikely tobe30 percent or more overweight (33 comparedwith 16 percent for white women), and were less likelytobe at or below their desirable weight.

Alcohol consumption

A number of recent studies have found a ,positiverelationship between alcohol consumption and the risk offemale breast cancer. Two large cohort studies (77,78)reported dose response effects, with estimates of relativerisk increasing with level of alcohol consumed. Both studiesadjusted for the effects of other important risk factors suchas parity and history of benign breast disease. An earliercohort study by Hiatt and Bawol (79) found similar resultsbut did not consider the effects of other known risk factors.While numerous case control studies reported findings

12

Table L. Percent distribution of women 40 yeara of age and over who have stopped menstruating by duration of use of postmenopausalestrogen (PME), acoording to race and age: United States, 1987

Ever used PMENever UnknownUs@ All 3 years More then

Race and ageFever

Total PA.4E dumtionsi or 16ss 3 pars used PME

All rSCSS2

40yearsand over . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4S-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64yeers, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-454years, . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70-74yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeafsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S5yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . .

Whiie

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .M-64years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yesfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yesfsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

Imo

100.0100.0100.0100.0100.0100.0100.0100.0100.0IM.O100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

64.6

60.85a.25a.463.260.362556.464.360.569.177.773.061.065.5

62.661.4

59.057.362.276.6

79.576.7

69.782.463.966.9

32.4

36.840.040.233.537.136.138.033.137.226.017.220.915.410.0


17.6

23.324.724.320.217.716.6?8.416.020.215.410.412.210.4*5.O

34.4 16.535.9 19.9

33.7 23.339.9 18.635.4 19.318.3 11.0

17.1 10.119.7 12.3

27.0 16.716.3 9.9

*12.4 ●6.O*5.2 *3. 1

13.1

12.914.513.412017.216.817.613.315.011.15.67.6

*3.8+3.0

14.014.1

13.618.914.1

6.0

6.57.0

10.3*5.9*5.6●1.O

3.0

2.4*1.8*1.43.32.6

*1.43.62.6232.95.16.1

*3.6●4.5

3.028

2.32.82.44.9

3.43.6

*3.3*1.3*3.7*7.7

tlm~d~~nkmm durs.tlonOfUSeOfpM~+chdmothsrrac.gs notshownseps.mtejc

supportive of the hypothesis that moderate to heavy levelsofdrinking increase the risk ofbreast cancer (8&87), fourstudies did not find a positive association (88-91). Al-though some of these negative studies suffered method-ologieal limitations, the study by Webster, Layde, and Ory(91) was large and well designed. Their negative findingsuggests the need for additional research to confirm theassociation between alcohol consumption and breastcancer.

The data on alcohol consumption in the 1987 NHIS-CECwerecollected aspartofaseries ofquestionsonfoodintake that asked about consumption ofvarious foods andbeverages, including beer, wine, and liquor, in the yearpreceding the interview. Women were classified as abstain-ers or light drinkers (less than three drinks per week, onaverage), moderate drinkers (three drinks per week to lessthan two drinks per day, on average), or heavy drinkers(two drinks or more per day, on average). These categorieshave been usedin anumber ofsurveys ofdrinking habits(92-95). The criteria used in assigning women to thesecategories are presented in detail in appendix IL

Eighty-onepercent ofwomen40years ofage andoverwere either light drinkers or abstainers in theyearpreced-

ing their NHIS interview (table N). Twelve percent wereclassified as moderate drinkers, and 4 percent as heavydrinkers. Level of alcohol consumption was unknown for3 percent ofwomen. Theproportion ofwomenclassifiedasabstainers or light drinkers increased with age, while thepercent of moderate drinkers declined. B1ack women weremore likely than white women to be classified as abstainersor light drinkers, 85 versus 81 percent after ageadjustment.

Preventive behaviors

Breast self-examination

The American Cancer Society recommends that allwomen begin practicing monthly breast self-examination(BSE) by the age of 20 (8). Although not citing benefits forany specific age groups, the National Cancer Institute’sguidelines for breast cancer screening state that “physiciansshould encourage their female patients in doing monthlybreast self-examination” (96). TIICU.S.PreventiveServicesTask Force and the World Health Organization, however,have stated that the existing evidence as to the value of BSE

13

Table M. Percent distribution of women 40 years of age and over by reiative weight, according to race and age: United States, 1987

5-9.9 10-19.9 .20-.%.9 30 percent5 percent or Within 5 percent percent percent or moremore below percent H above above above above

desirable desirabfe desirable desirable deslretrle desirableRaoe and age Total we!ght weight weight weight weight we@ht Unknown

All racesi

40years and over . . . . . . . . . . . . . . .

40-54 yesrs . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . . . .

5E-64yeafs . . . . . . . . . . . . . . . . . .55-59 years . . . . . . . . . . . . . . . . .60-64 years . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . .65-69 years . . . . . . . . . . . . . . . .70-74 years . . . . . . . . . . . . . . . . .

75yeers and over . . . . . . . . . . . . . . .75-79 years . . . . . . . . . . . . . . . . .80-84 years . . . . . . . . . . . . . . . . .65 years and over . . . . . . . . . . . . .

whne

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . .Agead]usted . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . .55-64yeers . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . .75yeatsandover . . . . . . . . . . . . . . .

Black

40 years md ove~Crude . . . . . . . . . . . . . . . . . . . . .Agead]ustad . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . .55-64years. . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . .75yesrsandover . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

21.3

22.625.422.618.916.916.717.216.616.721.228.826,230,034.1

22.522.6

24.317.919.230.0

6.99.3

7.5*8.3

*10.4+14.0

21.1

22.323.921.121.320.621.220.118.619.318.222.020.222.625.5

22,022,1

23.321.819.522.1

13.313.4

14.3*8. 9

*13.O*19.3


10.2 15.3

9.3 14.09.0 12.59.1 15.2

10.1 14.710.5 16.411.0 16.210.1 16.611.8 16.811.8 17.811.7 15.4

9.6 14.89.6 15.39.4 15.5

10.1 12.5

10.6 15.010.5 14.9

9.7 13.611.2 16.112.2 16.69.7 14.6

7.5 17.37.5 17.5

6.1 15.5*5.5 ~8.8%0 18.9*9. 1 *18.7

10.4

9.96.6

10.610.411.310.711.911.812.111.58,5

10.87.2

*4.O

10.110.1

9.410.911.98.2

13.913.8

14.714.3

*12.5*12.3

17.7

18.116.817.720.320.420.720.218.519.317.410.413.19.2

*5.3

15.915.9

16.216.316.910.0

33.532.6

34.140.632.3

416.1

4.1

3.83.63.64.33.83.64.03.73.04.65.94.86.0

*8.6

3.93.9

3.53.83.65.4

5.65.8

5.9*3.4*4.9

*10.4

1ln~~des ~M races not shown separately.

NOTE Relative welgM is actual weight relative to desirable welgM bawl on Metropolitan Life Insurance Company height-weight charts (see appendix II),

is insufficient to recommend BSE screening programs aspublic health policy (97).

The screening value of BSE is a source of somecontroversy among researchers and clinicians. While someretrospective studies have shown that BSE is associatedwith earlier detection of breast cancer (98-102) or pro-longed survival (99), there are not yet any prospectivesurvey results linking BSEwith reduced mortality. Frankand Mai (103) have argued that BSE may do more harmthan good, citing the risk ofunwarranted reassurance asso-ciated with false negative results and the inconvenience,anxiety, and potential morbidity stemming from unneces-sary medical investigation of false positives.

As of 1987, according todataeollected in the NHlS-CEC, more than three-fourths of U.S. women practicedBSEon at least an irregular basis (table 0). Almost half(47 percent) claimed to examine their breasts once amonth or more often, in concurrence with the recommen-dation of the American Cancer Society. Twenty percentpracticed BSE less than once a month, and 6 percentspecified some irregular schedule, for example, “when Ithink of it” or “rarely.” Eleven percent of U.S. women 40years of age and over did not know how to examine their

14

own breasts, and 10 percent did not ever practice BSEdespite knowing how to do so.

The proportions of women who never examined theirbreasts, including those who knew how to do so and thosewho did not, increased with age. Almost half of women age85 years and over never performed BSE, 30 percent be-cause they did not know how. Among women who didreport examining their breasts, there was no consistentvariation by age in the frequency of BSE.

Black women were more likely than white women to beunaware of how to perform BSE (18 compamd with9 percent) but less likely to never practice BSE despiteknowing how (5 compared with 11 percent). Amongwomen who did examine their breasts, black women weremore likely than white women to do so once a week ormore often.

Socioeconomic status, as indicated by education andincome, was strongly associated with the practice of BSEeven after adjusting for the potentially eonfounding effectsof age and race (table P). The proportion of women whodid not know how to examine their own breasts decreasedfrom 18 percent of women with less than 12 years of schoolto 5 percent of those with more than 12 years of school.

Table N. Percent distribution of women 40 years of age and over by level of alcohol consumption in past year, according to race andage: United States, 1987

Abstaineror light Moderate Heavy

Race and age Total dr/rri@rl drinke~ Urinke~ Unknown

All I’SCSS4

40yeare and over . . . . . . . . . . . . . . . . . . . . . .

40-54 yeere . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . . . . . . . . . .50-54 years . . . . . . . . . . . . . . . . . . . . . . . . .

55-84years . . . . . . . . . . . . . . . . . . . . . . . . . .55-69year3 . . . . . . . . . . . . . . . . . . . . . . . . .60-64yeara . . . . . . . . . . . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . .65-89yeare . . . . . . . . . . . . . . . . . . . . . . . . .70-74year3 . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . .75-79year3 . . . . . . . . . . . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . . . . . . . . . . . .65yeareandover . . . . . . . . . . . . . . . . . . . . .

whne


40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yeara . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovefiCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . .Agaad]usled . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.010+3.0100.0100.0100.0100.0100.0IQO.O

100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0

61.3

78.278.179.976.681.682.880.983.482.384.888.588.9S8.881.8

60.880.8

77.881.282.586.1

84.384.6

78.885.691.691.1

l%rcentd~tribution

11.7

14.314.313.715.011.210.411.810.511.6

9.27.06.26.1

10.6

12.312.3

15.011.511.57.4

8.47.9

11.79.7

*2O*2.5

3.5

4.14.03.64.53.83.73.93.23.52.82.1

*2.3*2.4*1.0

3.4

3.43.72.73.83.33.13.43.0273.34.34.6

*2.6*6.5

3.7 3.23.7 3.2

4.1 3.14.? 3.13.3 2.82.2 4.3

*2.3 5.0*2. 2 5.1

*3.7 5.6*0.3 *4.4*1.9 *4.4*1.8 *4.6

I l-esstti 3 drinks per week, on average (Se appendix lo.

~hreedrinksperweek tolessttmn2drinksper day,onaverage (seeappsndix Ii).

*WO drinks per dey or more, on averege (see appendix 11).%ciudes other raxs not sbwn separately.

With respect to income, the percent ofwomen who did notknow how to perform BSE dropped from 15 percent ofwomen with family incomes of less than $10,000 to5 percent of those with incomesof $35,0000rmore. Thepercent of women who practiced BSE less than once amonthorbetween onceamonth andonceaweek increasedwith income and education, but the percent of womenpracticing BSEonce aweekor more was highest amongwomenwiththeleast education and lowest incomes.

Breast physical examination

Abreast physical examination (BPE), also referredtoas a clinical breast examinatlcm, consists of manual exami-nation (palpation) of the br~asts ‘ y a physician or othertrained professionaL The American Cancer Society and theU.S. Preventive Services Task Force concur in recommend-ing annual BPE’s for women 40 years of age and over(8,97). Between the ages of 20 and 39 years, the AmericanCancer Society recommends a BPE every 3 years. TheNational Cancer Institute does not recommend a specificfrequeney for BPE, stating instead that “physicians shouldbe encouraged to do clinical breast examinations on allfemale patients in whom they are doing a periodic

examination” (96). While two retrospective studies foundevidence of an association between early detection of breastcancer and BPE alone (104,105), most studies have exam-ined the effects of BPE in conjunction with mammographyrather than as an independent procedure.

In 1987, only one-third of U.S. women age 40 years andover reported having had a BPE in the preceding year,although more than 8 in 10 reported ever having had a BPE(table Q). For 30 percent of women, the interval since lastBPE was 1–3 years, and for 14 percent it was more than 3years. Fifteen percent had never had a BPE—this includes7 percent who had never heard of the procedure.

The proportion of women who had ever had a breastphysical examination decreased sharply with age, from87 percent of women 40-44 years of age to 59 percent ofthose 85 years and over. The proportion of women who hadnever heard of the procedure increased with age from 4 to16 percent, respectively, of those age 40-44 years and 85years and over. Black women were as likely as white womento have had a BPE in the preceding year but were morelikely to have never had one (22 compared with14 pereent). White women were more likely to have had aBPE more than 1 year before the NHIS interview.

15

Table O. Percent distribution of women 40 years of age and over by frequency of breast self-examination (BSE), according to race andage: United States, 1987

Never perform BSE Perform BSE

Less than Once a month Once aDo not Do know once a to less thavr week or Unknown

Race and age Tota~ know how how month once a week more Othe# frequency

All racesz

40yeam And over . . . . . . . . . . . . . . . . . . . . . .

4&54years . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . .45-49 yeare . . . . . . . . . . . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . .

55-64yeafs . . . . . . . . . . . . . . . . . . . . . . . . . .55-59yeare . . . . . . . . . . . . . . . . . . . . . . . . .60-64years . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . .70-74years . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . .75-79year3 . . . . . . . . . . . . . . . . . . . . . . . . .80-64yeafs . . . . . . . . . . . . . . . . . . . . . . . . .85yearsand over . . . . . . . . . . . . . . . . . . . . .

White

40 years and overCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yeatsandovar, . . . . . . . . . . . . . . . . . . . .

Black

40 years end over:Crude . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . .5E-64years . . . . . . . . . . . . . . . . . . . . . . . .65-74yeara . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . .


20.0 32.8

24.5 37.427.4 42.022.8 35.222.3 33.218.6 35.019.4 35.517.7 34.417.2 30.416.4 33.618.3 26.113.1 18.814.6 23.010.7 17.712.9 9.2

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100,0100.0100.0100,0

100,0100,0

100,0100,0100.0100,0

10.5

6.35.18.77.49.69.69.7

12,613,112.521.517.822,430,2

10.4

8.47.19.09,5

10.49,7

11,111.311.011,715,015,114,315,7

14.5

13.49.7

15.816.114.814.315.415.715.915.615.313.718.614.5

6.4 3.7

5.4 3,14.6 3,25.2 3.26.9 2.96.4 3.46.9 3.15.9 3.77.1 3.56.0 2.58.5 4,98.0 6.17.3 6.58.7 *5.5

*8.7 *5.7

9,49,4

5,38,1

11,520,0

11.1

11,1

8,911.212,115,7

20.9 33.520.9 33.4

26.1 38.219.0 36.017.8 31.313.6 19.2

13.513.5

11.913.715.114.9

6.5 3.66.4 3.6

5.1 3.06.8 3.47.4 3.48.3 6.2

15,817,9

8,814.326,736.5

5,25,1

6,1*3,8*4,3*5,6

14.5 30.113.7 28.4

16.3 35.116.5 32.3

*12.1 21.4*4.4 *14.5

21.922.2

20.523.523.7

*22.1

5.0 4.65.0 4.6

5.8 4.9*4.O *4.O*4.O *4.4*4.6 *5.2

1Includesunkcavn If ever pefiormBSE

‘For example,When I thinkof it.”

Table P. Percent distribution of women 40 years of age and over by frequency of breast self-examination (BSE), according to selectedcharacteristics adjusted for race and age: United States, 1987

NeverperfonnBSE Perform BSE

Las than Onceamonth Once aDo not Do know once a to /ess than weak or Unknown

Characterisi~ Tota~ know how how month oncaa week more Ofhe# frequency

Educational level

Lessthan 12years . . . . . . . . . . . . . . . . . . . . . .12year3, . . . . . . . . . . . . . . . . . . . . . . . . . .Morethan 12years .,..... . . . . . . . . . . . . . .

Family income

Lessthan$lO,OOO . . . . . . . . . . . . . . . . . . . . . .$10,00LX19,999 . . . . . . . . . . . . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . . . . . . . . . . .

Place of residence3

MSA, centralchy . . . . . . . . . . . . . . . . . . . .MSA, notcentralcify . . . . . . . . . . . . . . . . . . .NollnMSA . . . . . . . . . . . . . . . . . . . . . . . .

Geographic region

Northeast . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


15.9 26.021.9 33.623.1 35.0

100.0100.0100.0

17.68.15.1

9.710.711.7

16.413.913.2

5.76.27.4

4.73.53.4

100.0

100.0100,0100.0

i4.812,48.04.8

10.610.410.612.7

19.6 27.120.2 31.022.3 34.124.2 37.2

16.914.113.911.0

5.76.67.75.9

3.93.22.62.5

100.0100.0100.0

12.09.1

11.1

12.69.59.3

20.2 29.719.5 36.020.6 30.8

13.515.414.1

6.95.37.4

3.53.25.1

100.0100.0100.0100.0

11.47.7

11.411.3

11.010.210.111.6

20.5 32.722.6 35.217.5 31.820.9 31.4

14.712.915,813.2

4.76.57.26.8

3.23.44.33.0

1Includesunknown if ever perform BSE.

‘For example, When I think of It.”WA =metropolltan statistlcd area.

16

Table Q. Percent distribution of women 40 years of age and over by interval since last breast physical examination (BPE), according torace and age: United States, 1987

Ever had BPE

Never had BPE Interval since lest BPE

Never Ewrheard heard 0-11

Race and age1246 37 months

Totap Total 2 of BPE of BPE Tota13 months months or more

All race#

40years andover . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 year3 . . . . . . . . . . . . . . . . . . . . . . . . . .55-59 years . . . . . . . . . . . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . . . . . . . . . . . .

6~74yeare . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . .7&74years . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . .75-79yeare . . . . . . . . . . . . . . . . . . . . . . . . .80-64years . . . . . . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . . . . . . .

Whfie


40-54year3 . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeaE . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . .

40-54yaare . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yeasandover . . . . . . . . . . . . . . . . . . . . . .

ll~tid~unk~~ ifeverhsdBPE.21m~d= “nkm If ever Fe@ of EPE.%5ud.gg unkm Interval she last BPE.ql~tide~ oibr races not shown separately.

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.01eo.o100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

15.0

9.27.89.5

11.113.310.316.620.577.424.727.023.629.5324

6.9

4.13.74.34.36.25.27.49.06.7

12113.510.716.816.0

Percentdietrlb@m

8.1 81.3 33.2

5.2 86.7 88.04.0 B7.3 39.45.2 66.6 39.16.8 86.1 38.57.1 83.1 31.95.1 65.9 34.59.3 60.0 26.9

11.4 76.8 30.710.6 79.8 33.312.5 72.7 27.113.5 66.2 21.812.9 73.1 23.612.7 65.5 20.116.4 56.8 19.7

30.4

32.332.530.434.332.433.631.126.326.026.926.727.729.619.4

14.1

12.212.014.010.515.114.516.015.716.514.715.417.013.614.2

13.7 6.1 7.6 62.8 33.6 30.913.7

14.96.1 7.6 62.8 33.6 31.0 15.0

8.1 3.5 4.5 68.6 39.5 32.9 13.311.6 4.9 6.8 64.8 32.5 33.2 16.019.0 8.1 10.9 78.3 31.0 26.9 16.325.3 12.5 12.8 70.2 22.7 27.3 16.0

19.9 10.7 9.2 73.7 33.4 25.8 8.322.2 11.7 10.5 71.6 31.8 25.1 8.5

12.0 6.6 5.4 79.6 38.6 27.4 6.518.5 10.7 7.8 76.0 31.2 28.031.6

10.716.8 14.7 85.7 30.4 21.7 *8.6

43.2 *20.9 22.3 47.6 * 12.7 *1 9.7 *1O.O

Socioeconomic status was strongly associated within-

terval since last BPE (table R). Women with less than 12yearsofschoolwere twice as likely asthose withmore than12 years of school to have never had a BPE (22 versus10 percent), and a similar pattern occurred within catego-riesofincome.The proportionofwomen havinghadaBPEin the preceding year increased with both of these indica-tors of socioeconomic status, as did the percent ofwomenwho had ever had aBPE. Interval since last BPEdid notvary by geographic region, but women livingin metropoli-tan statistical areas (MSA’S) were more likely than thoseliving outside MSA’s tohavehada BPE in the precedingyear.

Eighty-eightpercent ofwomenwho had aBPEinthe3years preceding interview said that their last BPE was aroutine examination (table S), while 11 percent cited reed-ical reason~ lumps (4 percent); soreness, swelling, andpain(2 percent) ;othermedical problems, including follow-up tests/treatment and discharge from the breasts(3 percent); and unrelated medical problems (2 percent).

There was little variation by age andnoneby race in thereason for last BPE. Similarly, socioeconomic status andgeographiclresidential factors were not associated with rea-son for last examination (table T).

More than three-fourths (78 percent) of the womenwho reported having had a BPE in the 3 years precedinginterview stated that they were told the results of their lastBPE in person (table U). Nine percent received the resultsof the examination over the telephone, and 4 percent werenotified by mail. Six percent stated that they were never toldthe results of the exam; many of these women volunteeredthat they were told they would not be contacted unlessthere was a problem. Method of notification did not vary byrace, age, or socioeconomic status (table W); however,women residing in the West were twice as likely as thosefrom other geographic regions to have never been told theresults of their last BPE.

Almost half (46 percent) of the women who had nothad a BPE in the 3 years preceding interview said that themost important reason for not doing so was that it was not

17

Table R. Percent distribution of women 40 years of age and over by interval since last breast physical examination (BPE), according toselected characteristics adjusted for raoe and age: United States, 1987

Ever had BPE

Never had BPE Interval since last BPE–

Never Everheard heard &ll 12-36 37 months

Characteristic Told Total z of BPE of BPE Total 3 months months or more

Educational level Percent distribution

Lessthan 12yaare . . . . . . . . . . . . . . . . . . . 100,0 22.1 10.4 11.7 73.5 25.912yaars . . . . . . . . . . . . . . . . . . . . . . . . . .

27.8100.0 12.9

16.45.5 7.4 63.5 33.6

Morethan 12yeare . . . . . . . . . . . . . . . . . . . . .32.2

100.014.3

9.7 4.3 5.5 87.2 40.1 30.7 12.1

Family income

Lcssthan $10,000 . . . . . . . . . . . . . . . . . 100.0 21.4 9.2 12.2 75.7$lo,oo&$19,999 . . . . . . . . . . . . . . . . . .

26.2 26.7100.0 i 6.6

18.87.7 9.1 80.5

$20,000-$34,999 . . . . . . . . . . . . . . . .29.7 30.1

100,0 11.417.5

4.9 6.4 85.4$35,0000rmore . . . . . . . . . . . . . . . . .

34.9 33.2i 00,0 10.9

14.33.7 7.2 86.2 41.9 29.2 11.2

Place of residence4

MSA, central c~y . . . . . . . . . . . . . . . . . . . . . . 100,0 15.5 6.7 8.8 80.6 34.1MSA, notcantral city. . . . . . . . . . . . . .

31.1 12.3100.0 13.0 6.2 6.8 63.4 36.0

NotIn MSA . . . . . . . . . . . . . . . . . . . . . . . . . .29.7

i 00,013.5

1&o 8.7 9.3 78.0 26.5 30.5 17.6

Geographic region

Northeast. . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 14.7 5.4 9.3 80.8 34.7Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . .

27.1100.0 14.7

12.66.2 8.5 81.9 32.1

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31.8

100.0 15.315.6

7.7 7.6 80.7 33.9West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30.2100.0 15.1

13:98.1 7.0 82.6 31.6 33.0 14.3

1Includes unknown if ever had BPE.

21ncludes unknown If ever head of BPE.sln~bdes unknown Metval skxe last BPE.4MSA- metropolitan statlsilcalaree-

neededor that theyhad experienced noproblems (tab leY).This category includes women who stated that they did notknow they should have aBPEand women whose doctorsexplicitly told them the examination was not needed. Anadditional 10 percent reported that their doctors had neversuggested that theyhaveaBPE. Fourteen percent said theyhad’’putitoff/’and22 percent cited other reasons, includ-ing cost (3 percent); lack of insurance coverage(1 percent); no regular doctor, including not going todoctors ata11(7 percent) ;embarrassment(l percent) ;fear(1 percent); and substitution of breast self-examination(2 percent).

The percent of women who claimed to have postponedhaving a BPE decreased with age, while the proportionswho felt the examination was not needed or whose doctorshad not suggested having aBPE increased with age. Overtwice as many black as white women reported that theexamination had not been suggested by their doctors, 22eompared with 8 percent.

Most of the variation by socioeconomic and geograph-ic/residential characteristics in the main reason for nothaving had a BPE in the past 3 years was within samplingerror or displayed no meaningful pattern (table Z); how-ever, the proportion of women citing procrastination in-creased consistently with ineome (7 percent ofwomen withincomes of less than $10,000, compared with 24 percent ofthose with incomes of $35,000 or more).

Mammography

Mammography-film screen or xerographic-is themain imaging technique used in screening for female breastcancer. This procedure is far more sensitive than manualbreast examination, capable of detecting lumps 2–3 yearsearlier than when they would be palpable (106). However,it involves exposure to low-dose irradiation and is a fairlyexpensive procedure. Thus, many experts disagree aboutthe optimum interval for mammograms in asymptomaticwomen (107–1 11).

The American Cancer Society (8) recommends that allwomen have a baseline mammogram between the ages of35 and 40 years. Between ages 40 and 49 years, theyrecommend mammograms every 1 to 2 years, dependingupon presence of risk factors. At ages 50 years and over,annual mammograms are recommended. The NationalCancer Institute concurs in recommending mammogramsevery 1 to 2 years between ages 40 and 49 years, withannual examinations starting at age 50 years; however, theydo not reeommend use of mammography below the age of40 except among women with a personal history of breastcancer (96). The U.S. Preventive Services Task Force (97)also recommends yearly mammograms for women 50 yearsof age and over, but they do not support “the general use ofmammography for women younger than 50 years except inthe context of studies designed to evaluate effectiveness.”

18

Table S. Percent distribution of women 40 years of age and overwho had a breast physical examination (SPE) in the past 3 yearsby reason for laat BPE, according to race and age UnitedStates, 1987

Roui/rre MadkalRace and age Tota~ exam[natkm reason

All races?

40yeare endover, . . . . . . . . . . . . . .

4&54years . . . . . . . . . . . . . . . . . . .40-44 yeare . . . . . . . . . . . . . . . . .45-49 yeare . . . . . . . . . . . . . . . . .SG54yeera . . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . . . . .55-59 yeet3 . . . . . . . . . . . . . . . . .60-64 years . . . . . . . . . . . . . . . . .

65-74ye8re . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . .70-74yeam . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . .75-79yeare . . . . . . . . . . . . . . . . .80-64yeare . . . . . . . . . . . . . . . . .65yeareandover . . . . . . . . . . . . . .

White

40 yeara and over:Crude . . . . . . . . . . . . . . . . . . . . .Agead]usted . . . . . . . . . . . . . . . . .

40-54yeere . . . . . . . . . . . . . . . . . . .55-64yeere . . . . . . . . . . . . . . . . . . .65-74yeam . . . . . . . . . . . . . . . . . . .75yeareendover . . . . . . . . . . . . . . .

Black

40 yeara and overCrude . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . .

40-54yeam . . . . . . . . . . . . . . . . . . .55-64yeare . . . . . . . . . . . . . . . . . . .65-74yeare . . . . . . . . . . . . . . . . . . .75yeareandover . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

lrm.o100.0

100.0100.0100.0100.0


88.3

87.185.886.669.569.887.592.887.686.889.291.391.093.069.3

87.966.2

E6.289.887.891.1

91.091.4

91.791.266.595.0

11.0

12.613.513.210.59.5

11.56.9

10.511.8

8.48.36.8

*6.6*9.9

11.411.1

13.69.4

10.58.5

8.07.6

7.1*8.8

*1 0.9*5.O

1IWMSS““k- if for m.sdlcal ressen.

‘Irhdee other -S not shown separately.

Table T. Percent distribution of women 40 years of age and overwho had abreastphyslcal examination (BPE) lnthepast3yearsby reason for Iaat BPE, according to selected characteristicsadjuated for race andage: United Statea,1987

Routine MedkdCharactet#stk Told examination reason

Educational level

Leasthan 12yeare . . . . . . . . . . . . . . .12yeare . . . . . . . . . . . . . . . . . . . . .Morethan12yeare . . . . . . . . . . . . . .

FamilyIncome

Lessthan$lO,OOO . . . . . . . . . . . . . . .$lcWoU-$’19,999.. . .. . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . . . .

Place of resldenc~

MSA,oenValcIfy. . . . . . . . . . . . . . . .MSA,notcentr61ctty . . . . . . . . . . . . .NotInMSA . . . . . . . . . . . . . . . . . . .

Geogmphic region

Northeast . . . . . . . . . . . . . . . . . . . .Midwes t . . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . . . .


100.0 87.5 11.8100.0 66.8 10.5100.0 69.0 10.3

Iwo 87.3 123100.0 87.2 11.9100.0 69.1 10.2100.0 66.2 10.9

100.0 90.0 8.9100.0 8a.o 11.5100.0 87.1 124

100.0 30.4 9.1100.0 67.5 11.7l(XI.O 86.7 12.4100.0 90.7 8.9

1l~~des unkm if for medical reason.

2MSA = metropolitan statistical area.

Two major studies have investigated the effectivenessof mammography as a means of secondary prevention ofbreast eancen the Health Insurance Plan of Greater NewYork Screening Proj ect(HIP) and the Breast Cancer De-tection Demonstration Project (BCDDP). The HIP studywas a prospective case control study in which half of the62,000women were randomly assigned to receive intensivescreening (BPE and mammography). The remainingwomen were assigned no intervention during the studyperiod from 1963-70. Results of this study showed thatamong women age 50 years and over upon entry, those whoreeeived intensive screening had significantly lower mortal-ity than those in the control group (112,113). While noclear evidence of screening benefits among younger womenwas found in the initial analysis of the HIP data, a re-analysis using cases oecurnng up to 6years after entry intothe study suggested possible benefits for younger women aswell (107). These results may be questionable in light of thedeeision to exclude noncases. The HIP study did not assessthe relative contribution of BPE and mammography in thereduced mortality observed, but it is estimated that at leastone-third of the reduction can be attributed tomammography (113,114).

The BCDDP, begun in 1973, was not a randomizedtrial; however, it involved followup of 280,000 women in 29screening centers across the country. Recent results of theBCDDP established a protective effect of mammographywith respect to breast cancer mortality at all ages 40 yearsand over (115,116). Reflecting improvements in mammog-raphy technology over the past three decades, mammo-grams played a role in 91 pereent of all program-detectedcancers and was solely responsible for 42 percent of thebreast cancer cases detected (115).

Despite the demonstrated benefits of mammography inearly detection of breast cancer, the NHIS-CEC found that59 percent of U.S. women 40 years of age and over hadnever had a mammogram (table M). Thirteen percent hadnever heard of mammography, and 46 percent had neverhad a mammogram despite having heard of the procedure.Fifteen percent of all women 40 years of age and over had amammogram in the preeeding year, 14 pereent reported aninterval of 1–3 years since their last mammogram, and7 percent reported an interval of more than 3 years.

The proportion of women who had ever had a mammo-gram increased with age between ages 40-44 years(39 percent) and 50-54 years (46 percent), then decreasedsteadily to 18 percent of those 85 years and over. Theproportion of women who had never heard of mammogra-phy increased with age, from 8 percent of those age 40-44years to 40 percent of those age 85 years and over. Whitewomen were more likely than black women to have everhad a mammogram, 39 compared with 30 percent after ageadjustment. Anong women who had never had a mammo-gram, the proportion who had never heard of the procedurewas higher for black than for white women.

History of mammography was strongly associated witheducation and income (table BB). The proportion ofwomen who had ever had a mammogram rose from

19

Table U. Percent distribution of women 40 years of age and over who had a breast physical examination (BPE) in the paat 3 yearn bymethod of communication of results of Iaat BPE, according to race and age: United States, 1987

Method of communlcatkwr

Never Face By tele- WRace and age Totat told to faw phone mail

All racesz

40years And over . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 yearn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7C-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-S4yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .

White40 years and ovec

Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-S4yeam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6E-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . . .


78.4

77.777.178.178,179.1

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

6.3

5.96.16.15.46.96.67.05.15.05.28.68.8

*8.6*7.7

8.6

9.39.26.8

10.17.78.46.99.3

10.18.16.0

*5. 1*9. 1

4.0

3.94.5

*2.25.04.63.56.13.64.1

*3.O3.6

*2.8*5.1*3.2

79.9

79.979.682.072.585.3 *3.O

100.0100.0

100.0100.0100.0100.0

6.16.2

5.66.55.18.9

78.478.4

77.878.978.479.1

6.98.7

9.97.99.56.4

3.93.9

3.74.93.3

*3.4

Black

40 years and ove~Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AgeadJusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6%74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0100.0100.0100.0

7.06.6

*6.6*9.7*5.5*2.5

79.761.2

5.64.9

*6.3*5.7*5.O

5.04.7

*5.5*2.8*5.9*6.8

77.681.182.787.0

llnc!udesother,unknown, ardcamblnatlonof Methods.

%dudes other races rmt sh=awmseparately.

Table W. Percent distribution ofwomen 40years ofage andoverwho had abreast physical examination (BPE) in thepast3 years bymethod ofcommunication of results oflast BPE, according to selected characteristics adjusted for race andage: United States, 1987

Method of communication

Never Face By tele- ByCharacterktb Toti# told to face phone mail

Educational level Percent dlstrlbutlon

79.577.978.0

Lessthan 12years . . . . . . . . . . . . . . . . . . . . . . . . . . .12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Morethan 12yeare . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0

7.26.65.5

7.78.88.5

2.64.74.4

Family Income

Lesathan$lO,OOO . . . . . . . . . . . . . . . . . . . . . . . . . . .$10030-$19.999.. . . . . . . . . . . . . . . . . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0100.0

6.85.97.05.5

80.778.578.978.7

7.38.38.78.9

3.24.84.74.3

Place of resldencez

MSA,centrelcrty . . . . . . . . . . . . . . . . . . . . . . . . . . . .MSA, nolcentrelcity . . . . . . . . . . . . . . . . . . . . . . . . .NotIn MSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0

7.76.15.6

77.179.079.3

8.49.06.9

3.53.65.6

Geographic regionNortheast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82.675.179.675.0

7.011.97.47.3

2.45.44.04.3

100.0100.0100.0100.0

5.45.65.9

10.4

1lnclud~ other, unknown, and combination of methods.

2MSA= metropolitan statistical area.

20

Table Y. Percent distribution of women 40 years of age and over who had no breast physical examination (BPE) in the past 3 years bymost important reason for not having a BPE, according to race and age: United States, 1987

Not needed Never suggested PutRace and age Total or no piublems~ by doctor t Ofr Othe? Unknown

All races3

40yeafsand over . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 yeafa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56-64 yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59yeats . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64yeafe . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66-74yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7C-74yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeetsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-84yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .

White

40 years and over:Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageacfjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-84yeafa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and overCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearesndover . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

46.2

35.534.430.842.945.441.648.652.846.85a.257.662.156.447.0

46.845.0

34.745.454.559.0

42.442.2

*36.550.9

*42.3*40.7


10.4

6.4+5.4*6.7*7.O

6.111.3*5.212.37.9

18.218.316.7

*I 5.3*27. 1

9.38.4

4.27.9

11.616.7

21.721.8

*19.8‘12.1%23.3*37.O

14.2

22.225.128.1

*1O.916.818.615.09.2

11.7*5.6*3.3*4.2W .5W. 1

14.716.0

23.217.7

9.3*3.6

*1 2.4*1 3.2

%22.9*1 1.6

*7.9

21.6

30.330.027.833.921.621.621.717.623.2

*lO. I11.411.2

+15.0*6.7

21.923.7

32.520.917.011.9

16.516.3

*12.8*24.1%22.2

*4.9

7.6

5.6*5.O*6.4*5.5

8.1*6.5

9.58.18.4

*7.79.5

*5.8*1 1.9*16.O

7.26.9

5.48.17.6&8

*7.O*6.6

*8.O*1.3*4.2

*16.7

i Incbdes “did I’@ know I should.”

‘Inchdesmst,l ackofinaurance coverage,noregular dcctor,fear,embarmssmeni ,andsulxtltution ofbreastself-exs,mlnsfion.%cfudesother~es notshownseparately.

TabIeZ Percent distribution ofwomen 40 years ofage and overwho hadno breaet physical examination (BPE)inthe past 3yearsbymost important reaaon for not having aBPE, accordhg to selected.characteristics acfjusted for race andage: United States, 1987

Not needed Never suggested PutCharaotetistb Total ornoproblems~ by doctor it off Ofhe# Unknown

Educational level PercentdistritwXion

Lesslhan 12years . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 46.3 10.0 12.712yeans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20.2 8.8100.0 42.5 10.0 16.2 24.5

Morethen 12years . . . . . . . . . . . . . . . . . . . . . . . . . .4.7

100.0 43.2 9.6 15.5 22.6 9.1

Family income

Lessthan$lO,OOO . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 47.2 12.5 7.3 28.0$10,000-$19,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5.0100.0 42.6 10.7 12.6

$20,00(+$34,999 . . . . . . . . . . . . . . . . . . . . . . . . . . .27.3 6.8

$35,0000rmore . . . . . . . . . . . . . . . . . . . . . . . . . . . .100.0 45.9 8.0 18.2 19.6 8.4100.0 33.9 10.3 23.7 21.4 10.7

Place of residences

MSA, centralcity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 43.4 11.8 15.0 20.0MSA, notcentreJcity . . . . . . . . . . . . . . . . . . . . . . . . .

9.6i 00.0 42.3 8.6 16.0 26.5

Notin MSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.6

100.0 47.1 11.4 14.4 20.4 6.5

Geogrephicreglon

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47.4 7.8 14.9 25.4 *4.4100.0 39.2 11.5 20.1 19.2

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1

100.0 47.0 10.1 16.8 20.2 5.9West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 47.5 9.1 9.5 25.7 8.3

1lnc~des ‘“M nd know 1should.”

2]nc~des ~~t, lack of i“~uranw coverage, no regular dcctor, fear, embarrassment, and subM@iOn of bre=t self-~mi~ion.

3MSA= ~tmpOltsn 5fatlsticd area.

21

Table AA. Percent distribution of women 40 yeara of age and over by interval since last mammogram, according to race and age:United States, 1987

Ever had mammogram

Never trad mammogram Inierval since last mammogram

Never heard of Ever heard of 0-11 12-36 37 monthsRace and age Total t Totalz mammogram mammogram Total 3 months months or more

All races4

40yeefs and over . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . . . . . . . . . . . .46-49yaars . . . . . . . . . . . . . . . . . . . . . . . . .50-54years . . . . . . . . . . . . . . . . . . . . . . . . .

5E-84yesrs . . . . . . . . . . . . . . . . . . . . . . . . . .55-59yaare . . . . . . . . . . . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . .70-74yeare . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . . . . . . . . . . . .60-64yeare . . . . . . . . . . . . . . . . . . . . . . . . .65yearsandover . . . . . . . . . . . . . . . . . . . . .

While40 years and ovec

Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . .AgeadJustad . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeats . . . . . . . . . . . . . . . . . . . . . . . . .55-84years . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yaareandover . . . . . . . . . . . . . . . . . . . . . .

BlacK40 yeare end over:

Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusled . . . . . . . . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . .55-64yesrs . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . .75yeefsandover . . . . . . . . . . . . . . . . . . . . . .


45.9 3a.1

46.5 42.250.5 38.843.6 43.544.1 45.545.2 41.144.7 43.245.9 38.747.9 35.248.4 37.547.4 32.142.5 24.845.0 30.043.0 20.435.0 17.5

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100,0100.0100.0100.0100.0

100.0100.0

100.0100,0100.0100.0

100.0100.0

100.0100,0100.0100.0

58.9

55.05$.652.452.656.654.958.661.75a.464.770.666.874.175.2

13.08.58.38.78.5

11.410.212.713.711.117.326.121.831.140.2

14.8

16.614.718.118.316.917.616.112.914.710.58.09.6

*5. 1*7.9

14.3

16.115.316.716.613.614.912.114.314.014.79.9

12.49.4

*3.6

7.2

7.36.76.98.78.39.57.06.77.26.05.56.4

*4.8*3.9

58.1 11.2 46.9 39.258.1 11.2 46.8 39.2

53.7 7.0 46.7 43.955.7 8.6 46.9 42.280.8 11.6 49.1 38.570.3 26.1 44.1 25.5

15.3 14.8 7.415.3 14.8 7.4

17.6 16.8 7,417,1 14.1 8.913.4 14.9 7.08.3 10.3 5.3

83.3 23.9 39.4 31.264.1 26.0 38.1 30.1

61.2 15.1 46,2 33.780.4 25.1 35.2 38.467,9 33.3 34.6 24.773.1 48.6 24.5 *17.1

12.9 10.4 5.712.2 10.0 5.6

13.7 11.5 6,617.9 10.7 *4.5*8.4 *10.O *4.2*3.4 *5.2 *7.4

i Includes unknown If ever had mammogram.

‘Inchdes unknown If ever heard of mammogram.%hdes unknown Intewal sl~e last rrWWnogram.

41rwhdes other races not stmwm separately.

Table BB. Percent distribution of women 40 years of age and over by interval since last mammogram, according to selectedcharacteristics adjusted for race and age: United States, 1987

Ever had mammogram

Never had mammogram Irdervalsincelast mammogtanr

New treard of Ever heard of 0-11 12-36 37monthsCharacteristk Total q Total z mammogram mammogram Total 3 months months or more

Educational Ieval

Lessthan 12years . . . . . . . . . . . . . . . . . . . . . . 100.0 71.312years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 57.3Morettran 12yeare . . . . . . . . . . . . . . . . . . . . . 100.0 49.2

Percant distribution

44.3 25.748.9 39,744.4 48.1

27.08.44.9

6.715.219.4

10.015.217.3

Family IncomeLassthan$lO,OOO . . . . . . . . . . . . . . . . . . . . . . 100.0 70.8$10,000-$19,999 . . . . . . . . . . . . . . . . . . . . . . . 100.0 84,4$20,000-$34,999 . . . . . . . . . . . . . . . . . . . . . . . 100.0 56,1$35,0000rmora . . . . . . . . . . . . . . . . . . . . . . . 100,0 50,9

24.615.4

8.85.9

46,2 27.049.0 32.947.3 41.645.0 47.4

9.211.416.320.9

10.012.715.916.6

6.47.88.07.4

Place of resldence4MSA,centralcity . . . . . . . . . . . . . . . . . . . . . . . 100.0 57.4MSA, notcentralctty . . . . . . . . . . . . . . . . . . . . . 100.0 56.4NotIn MSA . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 65.0

GeographlcregionNortheael . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 59.7Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 57.7South . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 61.6West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 54.1

13.911.415.0

43.5 39.745.1 40.150.1 32.1

15.316.710.5

14.914.213.2

8.07.07.1

11.811.515.511.5

47.9 37.246.2 39,146.3 35.242.5 43.0

13.914.814.316.5

13.414.213.616.8

6.88.46.07.9

1Ixhdes unknown If ever had mammogram.

21ncludes unknown If ever head of mammogram.‘%hdesunknown Intetvalslncelast mammogram.4MSA - metropolitan statistical area..

22

26 percent of those with less than 12 years of education to48 percent of those with more than 12 years of school andfrom 27 percent of those with family incomes of less than$10,000 to 47 percent of those with incomes of $35,000 ormore. Among women who had ever had a mammogram,the proportion whose last examination had occurred withinthe year prior to interview increased steadily with educationand income.

Women residing in MSA’S were more likely than theirnonmetropolitan counterparts to have ever had a mammo-gram, 40 compared with 32 percent. Regional variationwas evident as wel, with women living in the West the mostlikely to have ever had a mammogram (117,118).

As would be expected, mammograms were more likelythan BPE’s to be performed for medical reasons, 22 com-pared with 11 percent. Among women who had a mammo-gram in the preceding 3 years, the proportion whose lastmammogram was performed as a routine examinationincreased sharply between ages 40-49 and 50-54 years (70to 82 percent). This reflects the more widespread accep-tance of mammography as a routine screening procedure atages 50 years and over than at younger ages (table CC).

Table CC. Percent distribution of women 40 years of age andover who had a mammogram in the past 3 years by reason forlast mammogram, according to race and age: United States,1987

Routine MedicalRace and age Totafi exarrrinatbr reason

All racesz

40years And over . . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . . . . .4044years . . . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . . . .50-5.4 year3 . . . . . . . . . . . . . . . . .

55-64 yeers . . . . . . . . . . . . . . . . . . .55-59 years . . . . . . . . . . . . . . . . .60-64 yeare . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . .65-69 years . . . . . . . . . . . . . . . . .70-74 yeafs . . . . . . . . . . . . . . . . .

75years and over . . . . . . . . . . . . . . .75-79 yeare . . . . . . . . . . . . . . . . .i30-84yeare . . . . . . . . . . . . . . . . .65years and over . . . . . . . . . . . . . .

White

40 years and ovenCrude . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . .

4&54yeers . . . . . . . . . . . . . . . . . . .55-64 yeare . . . . . . . . . . . . . . . . . . .65-74 years . . . . . . . . . . . . . . . . . . .75years andover . . . . . . . . . . . . . . .

Black

40 years and ovecCrude . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . .55-84 years . . . . . . . . . . . . . . . . . . .65-74 years . . . . . . . . . . . . . . . . . . .75years and over . . . . . . . . . . . . . . .

100.0

100.0100.0100.0100.0100.0100.0100,0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0100.0Icro.o


77.0

74.069.072.461.978.475.861.879.379.976.563.686.064.2

*69.7

77.177.4

74.677.979.083.5

74.778.9

65.484.963.2

*93.O

22.3

25.430.626.216.120.922.918.219.718.920.915.0

*13.4*12.O%30.3

22.221.9

25.024.320.215.1

23.719.2

32.5*15.1*13.4

*7.O

i ln~l”des unkmm if for medfc+d reason.

%c!udes other races not shown separately.

Table DD. Percent distribution of women 40 years of age andover who had a mammogram in the past 3 years by reason forlast mammogram, according to selected characteristicsadjustedfor race and age: United States, 1987

Routine MedicalCharacierktb Tot& exmlnatlon reason

Educational level

Lessthan 12yeare . . . . . . . . . . . . . . .12years . . . . . . . . . . . . . . . . . . . . .Morethan 12yeare . . . . . . . . . . . . . .

Family income

Lesethan $10,000 . . . . . . . . . . . . . . .$10,-$19,9W . . . . . . . . . . . . . . . .$20,000-$34,992 . . . . . . . . . . . . . . . .$35,0000 rmore . . . . . . . . . . . . . . . .

Place of res”dencez

MSA, centret c”~ . . . . . . . . . . . . . . . .MSA, notcantral c’Ry . . . . . . . . . . . . .Notin MSA . . . . . . . . . . . . . . . . . . .

Geographw region

Northeast . . . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . . . .

i hwhdes unknown if for rredicsl reason.

2MeA = metropolbn statistical ares.


100.0 73.6 25.9100.0 77.5 21.8100.0 79,6 19.4

100.0 70.9 28.9100.0 72,8 26.6100.0 75.6 24.0100.0 79.2 19.6

100.0 83.6 15.3100.0 76.8 22.4100.0 70.7 28.5

100.0 77.5 22.0100.0 76.5 20.6100.0 75.7 23.8100.0 80.7 18.1

The proportion of women reporting that their lastmammogram was for routine, nonmedical reasons in-creased with education, and increased even more withincome (table DD), suggesting that the cost of mammogra-phy may be a factor in the prevalence of its use as apreventive screening procedure. However, recent analysesby Bernstein, Thompson, and Harlan (117) and Thompson,Kessler, and Boss (118) indicate that even when cost is nota factor, that is, when cost is covered by health maintenanceorganizations, mammography is more common amongthose with more educatiomd and financird resources.

Reason for last mammogram was strongly related toplace of residence, with a pattern that may reflect ease ofaccess to irradiation centers. Women living in central citiesof MSA’S were the most likely to have had their lastmammogram for routine, nonmedical reasons(84 percent), followed by those living in other areas ofMSA’S (77 percent) and those living outside MSA’S(71 percent).

Almost half (46 percent) of all women who had amammogram in the 3 years preceding the NHIS-CECinterview stated that they were informed of the results ofthe procedure in person (table EE). Twenty-seven percentreceived the results by telephone, 13 percent by mail, and9 percent never were notified of the results. Many of thewomen who were not notified volunteered that lack ofnotification was specified as signi&ing no problems.

Being told results in person was more common amongwomen 65 years of age and over than among youngerwomen, while telephone notification was more frequently

23

Table EE. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by method ofcommunication of resuits of iaat mammogram, according to race and age: United Statea, 1987

Method of communication

Never Face By ByRace and age Totaf told to face telephone mall

All races2

40years and over . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4E-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7e-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80-84years . . . . . . . . . . . . . . . . . . . . . . . . . . . .85yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . .

40 years and ove~Crude . . . . . . .Age adjusted.

4C+54years. . .55-64years . . . . .65-74years. . .75 years and over .

40 years and over:Crude . . . . . . .Agead]usted. . .

40-54years . . . . .55-64years . . . . .65-74years. . . .75 years and over

White

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . ,.

. . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . ,,. . . . . . . . . . . . . . . . . . . . . . .

Black

. . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

100.0lm.o100,0IGO.o1(K).O103.0100.0100.0100.0100.0100.0103,0103.0100.0

100.0100.0

100.0100.0100.0100,0

100.0103.0

Ico.o100.0Ico.o100.0

9,0

8.56.6

12.76.1

11.010.611.59.28.0

10.9*5.5*3.6*7.9*9.O

9,39.2

9.210.4

9.8*5.7

*6.7*5.O

*2.8*17.O


45.7

44.660.042.440.639.039.536.351.650.852.956.957.452.480.0

44.145.4

42.937.249.757.4

63.869.7

61.054.766.6

+100.0

27.1

29.626.329.933.227.728,326.823.624.522.120.021.8

*21 .2*8.3

12.8

12.912.49,8

17.215.914.917.19.6

10.7*7.6

9.6*I 0.8*1 0.3

*2.8

28,5 12.727.5 12.4

31.1 12.629.4 16,024.8 9.720.6 10.1

13.3 11.911.7 9.2

*16.4 *13.9*12.8 *13,4

*5,4 *3.4

llncludesother,unkm.vn, andwmbinaticmofmetiwds.‘Includesotherracesrmtslmwnseparately.

reported by younger women. Even after adjustment for age,black women reported receiving results in person moreoften than white women (70 compared with 45 percent),who were more likely to have been notified by telephone(28 compared with 12 percent for black women). Theproportion of women who were informed of their mam-mography results by mail did not vary according to race,nor was there a consistent pattern by age.

The probability of being notified of mammographyresults in person was inversely related to income andeducation and showed geographic variation consistent withthe effects of socioeconomic status (table FF). Fifty-sevenpercent of women not living in MSA’S reported beingnotified in person, compared with 47 percent of thoseliving incentral cities and41 percent ofthose living outsidecentral cities of MSA’S. In terms of geographic region,personal notification was most often mentioned by womenliving in the South (53 percent) and least often mentionedby women residing in the West (41 percent) or Midwest(43 percent).

Of those women who had not had a mammogram inthe 3 years preceding the NHIS-CEC interview, the mainreason given was that it was not needed or that no problemshad been experienced. This rationale was reported by

24

48 percent of women 40 years of age and over (table GG).Twenty-nine percent of these women said that their doctorshad never suggested that they have a mammogram, and7 percent said they had “put it off.” Twelve percent re-ported other reasons, including cost (3 percent); lack ofinsurance coverage (less than 1 percent); no regular doc-tor, including not going to doctors at all (2 percent);embarrassment (less than 1 percent); fear, including fearof irradiation (2 percent); painful procedure (1 percent);and unpredictable results (less than 1 percent).

The proportion of women stating that they had notneeded to have a mammogram increased with age, from43 percent of women 40-54 years of age to 56 percent ofthose age 75 years and over, and was higher for white thanfor black women, 48 compared with 42 percent after ageadjustment. Black women were more likely than whitewomen to report that their doctors never su~ested ,mam-mography, 41 compared with 28 percent. Surprisingly, theproportion of women who stated that their doctors hadnever suggested they have a mammogram increased withincome, from 26 percent of women with family incomes ofless than $10,000 to 34 percent of those with family in-comes of $35,000 or more (table HH).

Table FF. Percent distribution of women 40 years of age and over who had a mammogram in the past 3 years by method ofcommunication of results of last mammogram, according to selected characteristics adjusted for race and age: United States, 1987

Methrxi of communicatknr

Never Face w ByCharacfertstk Tok# told 10 face telephone mail

Educational Level Percent distribution

Lessthan 12years . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 10.3 55.5 22.612yeam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.9100.0 8.5 45.3 27.7

Morethan 12years . . . . . . . . . . . . . . . . . . . . . . . . . .13.2

100.0 7.6 45.4 26.0 13.6

Family income

Lessthan $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 9.1 58.0 17.1$10,00G$19)999 . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10.3100.0 9.1 49.1 24.4

$20,0m$34,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . .12.3

100.0 8.2 49.1 27.2$35,0000rmore . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12.9100.0 8.0 39.3 29.6 15.3

Place of residenosz

MSA, central ctty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 9.6 47.4 24.8MSA, noncentral city . . . . . . . . . . . . . . . . . . . . . . . . .

13.5100.0 10.8 41.1 28.7

Not In MSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13.1

100.0 5.8 57.2 21.4 11.1

Geographic regionNortheast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 10.7 48.9 24.2Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11.6100.0 7.0 43.0 29.3

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14.3

100.0 5.7 53.1 25.2West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10.6100.0 13.6 41.0 26.4 12.5

llndudesother,unkrsjwn, Srkicombinstianof mat~s.2MSA = mstropolhsn statistical mea.

Tabie GG. Percent distribution ofwomen 40yearsofageand overwho hadno mammogram inthe past3years bymost importantreason for not having a mammogram, according to race andage: United States, 1987

Not needed Never suggested PutRace and age Total or no problemsq by doctor it on Othe$ Unknown

All races3

40years andover . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50-54years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6&84years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Cr-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6C-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .

White

40 years and over:Crude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

40 years and ovefiCrude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-54yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

100.0100.01Cir.o100.0Its).o100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

‘tixl.o100.01CHJ.O100.0

lc!a.o1Cn.o100.0100.0100.0IQ(LO

47.8

43.242.143.744.246.748.948.351.147.855.855.95S.851.454.4

48.348.4

43.348.751.757.2

41.941.8

38.751.244.4

*34.O


2e.o

30.532729.727.926.426.028.927.928.127.830.628.035.630.1

27.827.8

26.125.626.929.6

40.841.1

42.134.344.4

*44.7

6.5

8.48.6

10.06.47.87.38.44.35.8

●2.3*1.4*1.8*1.1

6.96.8

8.98.54.5

*1.4

*4. 1*3. 1

*6.6*1.4*0.6

12.1

14.113.913.614.713.112.813.611.213.0

8.65.46.4

*4.O*4.3

12.612.6

15.413.311.25.3

7.77.8

●7.5*8. 1*7.7*7.5

4.6

3.82.6

*3.O8.84.05.0

*2.75.55.45.66.6

*5.O*7.7

*I 1.2

4.44.4

3.23.95.76.4

5.56.0

*5.2*5.O*3.2

*13.8

i Incbdes ‘“did @ know I shculd.”

‘Includes cost, lack of Insursnca coverage, no regular dcctor, fear, etiamssmsnt, painful procedure, ad urprsdlctable results.‘%4udes other rffias Id ShOVM SePa@elY.

25

Table HH. Percent distribution of women 40 years of age and over who had no mammogram in the past 3 years by most importantreason for not having a mammogram, according to selected characteristics adjusted for race and age: United States, 1987

Not needed Never suggested PutGharacterMk Total or no problemsl by doctor It Orf 0ther2 Unknown

Educational level Percent ctietrlbutlon

27.130.530.0

60.346.1

3.77.26.4

11.113.011.8

7.63.23.7

Leesthan 12yeafe . . . . . . . . . . . . . . . . . . . . . . . . . . .12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Morethan 12yeafe . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0 46.0

Family income

Lessthan $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,003-$19,999. . .. . . . . . . . . . . . . . . . . . . . . . . . .$20,00CH$34,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . .$35,0000r more . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0100.0

45.849.7S0.640.7

26.027.529133.5

3.45.55.77.0

19.511.710.815.2

5.35.53.83.6

Place of rasidence3

MSA, central city . . . . . . . . . . . . . . . . . . . . . . . . . . . .MSA, noncentral cay . . . . . . . . . . . . . . . . . . . . . . . .Not In MSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29.729.529.7

100.0100.0100.0

46.546.948.1

4.67.36.4

12.712.310.0

4.44.15.7

Geographic region

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0100.0100.0100.0

48.344.447.454.5

30.032.129.323.1

6.37.77.23.1

10.811.311.314.8

4.54.54.74.5

1includes ‘-did d krww I should.”

‘Inchdescost,leck ofinsur~coverage, Mregulsrdccfor, fear, embarreswnent, pehfulprocedwe, anduqndlctable results.3f,4~A- ~,r~~lt~~tati~j~ala,e~

26

Progress note

Screening trends

Breast cancer screening has become more common inrecent years (119–121); however, breast cancer screeningprocedures continued to be underutilized in 1987. Resultsfrom a recent analysis of the 1987 (NHIS) suggest that theextensive underutilization of most screening proceduresmay be due largely to such psychosocial factors as lack ofknowledge or awareness of specific tests, noncognizance ofthe importance of screening in the absence of symptoms,not living where mammography is readily available, andpossible race or ethnic factors associated with educationand income resources available (122). These data alsoimply that a communication problem may exist betweenphysicians and patients; for example, while there are pub-lished guidelines for physicians regarding ages at which toinitiate mammographic screening and recommendationsfor periodicity based on empirical data, a number of womenreported never having been told they needed to obtain amammogram.

Data from previous National Health Interview Surveysare available to compare with the 1987 data. Pre-1987 datarepresent estimates obtained from questions differentlyworded than in 1987 and thus are not directly comparableto 1987 estimates. However, an analysis of the 1973 and1985 NHIS data performed by Makuc, Freid, and KIein-man (123) suggests that mammography and BPE’s haveincreased markedly for certain population subgroups (blackwomen, for example), while there has been little change inutilization rates for white women.

With reference to mammography, recent data from theBehavioral Risk Factor Surveillance System confirm thetrend toward increased usage (124), but these data, basedon a sample of women who saw a physician for routine carein the year preceding interview, are not comparable to noras accurate or representative as those ikom the 1987 NHIS.A recent Gallup survey indicated that 85 percent of women40 years of age and over were aware of mammography andthat 40 percent had ever received one (125). These esti-mates are comparable to findings of the 1987 NHIS-CEC.

In contrast, a recent telephone poll (126) found that94 percent of respondents were aware of mammogramsand that 54 percent had had a mammogram in the past.These figures are considerably higher than the 1987 NHISestimates, and need to be interpreted with respect to themethodological differences between personal interviews, as

used in the NHIS-CEC and Gallup poll, and a telephonesurvey. Another factor that may explain the discrepancy isthat the telephone survey data were collected in the lastquarter of 1987. Awareness and use of mammographyincreased sharply in that quarter (124), possibly as a resultof publicity concerning Nancy Reagan’s breast cancer. Be-cause the NHIS data were collected over the course of thefull 12 months, the effects of this publicity on NHISestimates were somewhat attenuated.

Legislative trends

Over the past 3 years State legislatures have acceler-ated efforts to mandate some form of cost sharing orprogram provision for the purpose of decreasing accessbarriers of cost in obtaining screening mammograms. Spe-cific aspects of legislation for preventive care vary markedlyamong the States. Legislative variations include differencesin ages for screening and periodicity of examinations, limi-tations on radiation dosage and equipment, differences inamount an insurer must pay or the professional charge, andtypes of insurance policies or plans that are affected.

Legislation addressing mammography exists at the na-tional and the State levels. The Medicare CatastrophicCoverage Act, which becomes effective in 1990, will pro-vide 80 percent coverage of the actual charge of a screen-ing mammogram, to a maximum of $50, for Medicarebeneficiaries (age 65 years and over, or disabled). As ofJuly 1989, 30 States had enacted some form of legislationrelated to breast cancer screening by mammography. Ofthese, 24 (Arkansas, Aizona, California, Colorado, Con-necticut, Florida, Iowa, Kansas, Maryland, Massachusetts,Michigan, Minnesota, New Hampshire, Nevada, New YorkNorth Dakot~ Oklahoma Pennsylvania, Rhode Island,Tennessee, Texas, Virginia, Washington, and West Vir-ginia) mandated some form of third-party payment forscreening. While the geographic pattern was less clear in1989 than in 1988, most States were located either in thenortheastern or southwestern sectors of the United States.

States with the most comprehensive legislation (Massa-chusetts, California, and Connecticut) mandate third-partycoverage by most health plans. The majority of these basetheir mandates on National Cancer Institute and AmericanCancer Society guidelines or they provide for annual mam-mograms. States providing for somewhat less comprehen-sive coverage (for example, Texas, Oklahoma, New

27

Hampshire, and Arizona) generally mandate what dosemammography should be used (for example, less than 1 radper breast), but they tend to be more restrictive withreference to types of policies or health plans affected andthe ages at which women may receive these benefits (45years and over in Oklahoma, for example). States that areleast comprehensive (for example, Illinois and Alaska) donot mandate insurance coverage, but they are increasingefforts to promote screening either by provision of fundsfor health education pamphlets or by setting up systems toprovide coverage at the State health level.

As new laws and related programs get underway, otherStates will undoubtedly adopt similar policies or modifytheir plans based on the experience of the States in theforefront of mandating coverage for preventive services. Itis clear that legislation is not the causal force leading toincreased mammography screening. The apparent trendtoward increased screening appears to have either precededor occurred conjointly with the movement toward legislat-ing third-party involvement in these services (118).

In summary, the data indicate that if breast cancerscreening is to become more than nominally utilized, sev-eral factors affecting use of these tests must be addressed.Physicians and the public must become more aware of theimportance of mammography in breast cancer mortalityreduction and the current availability of mammographyscreening, so that these procedures are requested or rec-ommended regularly. Second, because the data clearlyindicate that older women (60 years and over), while morelikely to have or get breast cancer, are less likely to receivescreening, programs directed toward increasing participa-tion of the elderly need to be increased. Third, becauseblack women, Hispanic women, and women of low socio-economic status are the least likely to know about theseprocedures and their benefits and to have access to thetesting facilities, health program planners and practitionersneed to focus on service delivery to these subgroups in thepopulation.

28

References

1. Stephenson MG, Levy AS, Sass NL, McCarvey WE. 1985NHIS findings: Nutrition knowledge and baseline data forweight loss objectives. Pub Health Rep 102(1):61-7. 1987.

2. Gillum RF. Overweight and obesity in black women: A reviewof published data from the National Center for Health Statis-tics. JAMA 79(8):865–71. 1987.

3. Schoenbom CA. Health habits of U.S. adults, 1985: The“Alameda 7“ revisited. Pub Health Rep 101(6):571-80. 1986.

4. Dawson DA. Trends in routine screening examinations. Am JPub Health 77(8):1004-5. 1987.

5. Bloom B. Use of selected preventive care procedures. Na-tional Center for Health Statistics. Vital Health Stat 10(157).1986.

6. Moss AJ, Wilder MH. Use of selected medical proceduresassociated with medical care: United States, 1973. NationalCenter for Health Statistics. Vital Health Stat 10(110). 1977.

7. Schoenbom CA, Marano M. Current estimates from the Na-tional Health Interview Survey United States, 1987. NationalCenter for Health Statistics. Vital Health Stat 10(166). 1988.

8. American Cancer Society. Cancer facts and figures– 1988.New York: American Cancer Society. 1988.

9. National Cancer Institute. 1987 annual cancer statistics re-view. NfH pub no 88-2789. Washingtorx Public Health Ser-vice. 1988.

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30

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32

Appendixes

Contents

I. Technical notes on methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Statistical designof theNHIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Collection andprocessing ofdata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35TheNationalHealth Interview Survey ofCancer Epidemiology and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Estimation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Types ofestimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Reliability of estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Age-race adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

IL Definitions ofcertain terms used in this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Sociodemographic terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Terms related to health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

111.Survey instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Appendix tables

I.

n.

m.

Iv.

v.

VI.

Age-sex-race classes used in poststratification for the 1987 National Health Interview Survey of CancerEpidemiology and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Estimated standard errors for selected base percents of all women 40 years of age and over by selectedcharacteristics: UnitedStates,1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Estimatedstandard errorsforselected basepercentsofwomen 40yearsofageand overwhohadabreast physicalexamination (BPE)in the past 3yearsby selected characteristics: UnitedStates,1987 . . . . . . . . . . . . . . . . . . . . . . 39Estimated standard errors for selected base percents ofwomen 40 years of age and over who had no breastphysical exwination @PE)intie past3years byselected characteristic* United States, 1987 . . . . . . . . . . . . . . . 40Estimated standard errors for selected base percents of women 40 years of age and over who had a mammogramin the past 3 years byselected characteristics: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Estimated standard errors for selected base percents of women 40 years of age and over who had nomammogram in the past 3 years by selected characteristics: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

33

Appendix ITechnical notes onmethods

Background

This report is one of a series of statistical reportspublished by the staff of the National Center for HealthStatistics (NCHS). It is based on information collectedfrom a nationwide sample of households included in theNational Health Interview Survey (NHIS). Data are ob-tained on the sociodemographic and health characteristicsof all family members and unrelated individuals living inthese households.

Field operations for the survey are conducted by theU.S. Bureau of the Census under specifications establishedby NCHS. The U.S. Bureau of the Census participates inthe survey planning, selects the sample, and conducts theinterviews. The data then are transmitted to NCHS forpreparation, processing, and analysis.

Summary reports and reports on special topics for eachyear’s data are prepared by the staff of the Division ofHealth Interview Statistics for publication in Series 10publications of NCHS. Data also are tabulated for otherreports published by NCHS staff and for use by otherorganizations and by researchers within and outside theGovernment. Since 1969, public use data tapes have beenprepared for each year of data collection.

The health characteristics described by NHIS estimatespertain only to the resident, civilian noninstitutionalizedpopulation of the United States living at the time of theinterview. The sample does not include persons residing innursing homes, members of the armed forces, institutional-ized persons, or U.S. nationals living abroad.

Statistical design of the NHIS

General design

The NHIS has been conducted continuously since1957. The sample design of the survey has undergonechanges following each decennial census. This periodicredesign of the NHIS sample allows the incorporation ofthe latest population information and statistical methodol-ogy into the survey design. The data presented in this reportwere collected using an NHIS sample design first used in1985. It is anticipated that this design will be used until1995.

The sample design of the NHIS follows a multistageprobability design that permits continuous sampling of the

civilian noninstitutionali.zed population residing in theUnited States. The survey is designed in such a way that thesample scheduled for each week is representative of thetarget population and the weekly samples are additive overtime. This design permits estimates for frequent events orfor large population groups to be produced from datacollected over a short period of time. Estimates for fre-quent events or for smaller population subgroups can beobtained from data collected over a longer period of time.The annual sample is designed so that tabulations can beprovided for each of the four major geographic regions.Because interviewing is done throughout the year, there isno seasonal bias for annual estimates. The continuous datacollection also has administrative and operational advan-tages because fieldwork can be handled on a continuingbasis with an experienced, stable staff.

Sample selection

The target population for the NHIS is the civiliannoninstitutionalized population residing in the UnitedStates. For the first stage of the sample design, the UnitedStates is considered a universe composed of approximately1,900 geographically defined primmy sampling units(PSU’S). A PSU consists of a county, small group ofcontiguous counties, or a metropolitan statistical area. ThePSU’S collectively cover the 50 States and the District ofColumbia. The 52 largest PSU’S in the universe are re-ferred to as self-representing PSU’S. The other PSU’S in theuniverse are clustered into 73 strata, and 2 sample PSU’Sare chosen from each stratum with probability proportionalto population size. The selection of two PSU’S per stratumallows more efficient variance estimation than was possibleunder the pre-1985 NHIS design in which only one PSUwas selected per stratum (127). The current procedureyields a total of 198 PSI-J’Sselected in the second stage.

Within a PSU, two types of second stage units, referredto as segments, are used: area segments and permit areasegments. Area segments are defined geographically andcontain an expected eight households. Permit area seg-ments cover geographical areas containing housing unitsbuilt after the 1980 census. The permit area segments aredefined using updated lists of building permits issuecl in thePSU since 1980 and contain an expected four households.

Within each segment, all occupied households aretargeted for interview. On occasion, a sample segment maycontain a large number of households. In this situation, the

34

households are subsampled to provide a manageable inter-viewer workload.

To increase the precision of estimates for black per-sons, differential sampling rates are applied in PSU’S con-taining betsveen 5 and 50 percent black population. Withinthose PSU’s, sampling rates for selection of segments areincreased in areas known to have the highest concentrationof black persons segment sampling rates are decreased inother areas within those PSU’S to ensure that the totalsample is the same size as it would have been withoutoversampling black persons.

The sample was designed so that a typical NHIS fullsample for the data collection years 1985 to 1995 willconsist of approximately 7,500 segments containing about59,000 assigned households. Of these households, an ex-pected 10,000 will be vacant, demolished, or occupied bypersons not in the target population of the survey. Theexpected sample of 49,000 occupied households will yield aprobability sample of about 127,000 persons.

The NHIS sample is designed so that it can serve as asample frame for other NCHS population-based surveys.Four national subdesigns, or panels, constitute the fullNHIS sample design. Each panel contains a representativesample of the U.S. civilian noninstitutionalized population.All four panels have identical sampling properties, and anycombination of panels defines a national design. Panelswere constructed to facilitate the linkage of the NHIS toother surveys and also to efficiently make large reductionsin the size of the sample by eliminating panels from thesurvey when budgetary constraints make this necessary.

In 1987, the NHIS sample consisted of 8,282 segmentscontaining 61,009 assigned households. Of the 49,569households eligible for interview, 47,240 households actu-ally were interviewed, resulting in a sample of 122,859persons.

Collection and processing of data

The NHIS questionnaire contains two major parts. Thefiist, the basic health and demographic component, consistsof topics that remain relatively unchanged from year toyear. Among these topics are the incidence of acute condi-tions, the prevalence of chronic conditions, persons limitedin activity due to chronic conditions, restriction in activitydue to impairment or health problems, and utilization ofhealth care services involving physician care and short-stayhospitalization. The second part, a special topics compo-nent, consists of additional topics that change from year toyear. Details of the special topics covered in the 1987 NHISfollow this general description of data collection and pro-cessing techniques.

Careful procedures are followed to assure the qualityof the data collected in the NHIS interview. Most house-holds in the sample are contacted by mail before theinterviewer arrives. Potential respondents are informed ofthe importance of the survey and assured that all informa-tion obtained in the interview will be held in strict confi-dence, Interviewers make repeated trips to a household

when a respondent is not found on the first visit. Thesuccess of these procedures is indicated by the responserate for the survey, which has been between 96 and98 percent over the years.

When contact is made, the interviewer attempts to haveall family members of the household 19 years and overpresent during the interview. When this is not possible,proxy responses for absent family members are accepted.In most situations, proxy respondents are used for personsunder 19 years of age. Persons 17 and 18 years of age mayrespond for themselves, however.

Interviewers undergo extensive training and retraining.The quality of their work is checked by means of periodicobservation and by reintewiew. Their work also is evalu-ated by statistical studies of the data they obtain in theirinterviews. A field edit is performed on all completedinterviews so that if there are any problems with theinformation on the questionnaire, respondents may berecontacted to solve the problem.

Completed questiomaires are sent from the U.S. Bu-reau of the Census field offices to NCHS for coding andediting. To ensure the accuracy of coding, a 5-percentsample of all questionnaires is recoded and keyed by othercoders. A 100-percent verification procedure is used ifcertain error tolerances are exceeded. Staff members of theDivision of Health Interview Statistics then edit files toremove impossible and inconsistent codes.

The interview, fieldwork and data processing proce-dures summarized above are described in detail in Series 1,No. 18 (128).

The National Health InterviewSurvey of Cancer Epidemiologyand Control

In generaJ, one adult 18 years of age or over wasrandomly chosen from each NHIS sample family to partic-ipate in the 1987 NHIS of Cancer Epidemiology andControl (NHIS-CEC). The procedure differed slightly infamilies falling into a special “Hispanic oversimple.” His-panic persons were oversampled in selected PSU’S in threeconsolidated metropolitan statistical areas (CMSA’S): theNew York- Northern New Jersey-Long Island, New York-New Jersey–Connecticut CMS~ the Chicago-Gaxy-LakeCounty, Illinois-Indiana-Wisconsin CMSA, and the Mia-mi-Fort Lauderdale, Florida CMSA. In the PSU’S selectedfor the oversimple, up to two additional sample personswere included in each Hispanic family, yielding an addi-tional 354 Hispanic respondents. In households where onlySpanish was spoken, interviews were conducted with the aidof a Spanish translation guide.

Self-response was required for the NHIS-CEC, andcallbacks were made as necessary. ‘ho questionnaires wereused for the survey-one for the Cancer EpidemiologyStudy (CES) and one for the Cancer Control Study (CCS).One-half of the sample was interviewed with each question-naire. Respondents were systematically assigned to one of

35

the two questionnaires at the time of sample selection. Atotal of 22,080 persons were intemiewed with the CESquestionnaire; 22,043 were interviewed with the CCS ques-tionnaire. The total of 44,123 interviewed persons repre-sents a response rate of approximately 86 percent.

The survey included a wide range of information re-lated to cancer, including questions on acculturation; med-ical care; food knowledge; cancer knowledge and attitudes;smoking and other tobacco use; occupational exposures;height and weight; food, vitamin, and mineral intake; cancerscreening behavior; reproduction; hormone use; family his-tory of cancer; cancer survival; and social relationships andactivities.

Estimation procedures

The complex, multistage probability sample utilized bythe NHIS must be reflected in the derivation of survey-based estimates. The estimates presented in this report arebased upon 1987 NHIS-CEC sample person countsweighted to produce national estimates. The weight foreach sample person is the product of five componentweightx

1.

2.

3.

4.

36

Probability of selection— The basic weight for eachperson is obtained by multiplying the reciprocals of theprobabilities of selection at each step of the desi~PSU, segment, and household.Household nonresponse adjustment wz”thinsegment— Inthe NHLS, interviews are completed in about96 percent of all eligible households. Because ofhousehold nonresponse, a weighting adjustment is re-quired. The nonresponse adjustment weight is a ratiowith the number of households in a sample segment asthe numerator and the number of households actuallyinterviewed in that segment as the denominator. Thisadjustment reduces bias in an estimate to the extentthat persons in the noninterviewed households have thesame characteristics as persons in interviewed house-holds in the same segment. For nonresponse by NHIS-CEC sample persons, an additional adjustment wasperformed.First-stage ratio adjustment— The weight for persons inthe non-self-representing PSU’S is ratio adjusted to the1980 population within four race-residence classes ofthe non-self-representing strata within each geographicregion.Adjustment for the probability of selection within house-hold—The weight for each NHIS-CEC sample personis multiplied by the within-family sampling weight,which is the inverse of the person’s probability ofselection within the family. The within-family samplingweight then is multiplied by 2 because each question-naire was administered in only 1 of every 2 samplefamilies. For example, in a family of four adults, thesample person had a 1 in 4 probability of selection.That person’s weight is multiplied by 4, then doubled.

5.

In the Hispanic oversimple, the within-family samplingweight is calculated using a more complex formula thattakes into account the number of eligibles and thedistribution of eligibles by Hispanic status.Poststrati.cation by age-sex-race— Within each of the 20age-sex-race cells shown in table I, a weight is con-structed each quarter to ratio adjust the first-stagepopulation estimates based on the NHIS to an indepen-dent estimate of the population of each cell. Theseindependent estimates are prepared by the U.S. Bu-reau of the Census and are updated quarterly.

The main effect of the ratio-estimating process is tomake the sample more closely representative of the target

Table L Age-sex-race claases used in poststratification for the1987 National Health Interview Survey of Cancer Epidemiologyand Control

Age

1&24 25-34 35-44 45-54 55 yearsRace and sex years years years years and over

Black

Male . . . . . . . . . . . . . . x x x x xFemale . . . . . . . . . . . . x x x x x

Olher than black

Male . . . . . . . . . . . . . . x x x x xFemale . . . . . . . . . . . . x x x x x

population by age, sex, race, and residence. The poststrati-fication adjustment helps to reduce the component of biasresulting from sampling frame undercoverage; further-more, this adjustment frequently reduces sampling vari-ance.

In some households responding to the basic health anddemographic component of the NHIS, there is nonmsponseto the special topics questionnaire. While the NHIS estima-tion procedures include no separate adjustment factor toreduce the bias due to this type of nonresponse, the post-stratification by age-sex-race also serves to reduce thenonresponse bias in estimates derived from the specialtopics sections, to the extent that nonrespondents to thespecial topics questionnaire are similar to respondents ineach poststratification adjustment cell.

Types of estimates

As noted previously, NHIS data are collected weekly,with each week’s sample representing the resident, civiliannoninstitutionalized population of the United States livingduring that week. The weekly samples are consolidated toproduce quarterly files, each consisting of data for 13weeks. Weights to adjust these data to represent the U.S.population are assigned to each of the four quarterly files.These quarterly files are later consolidated to produce theannual file, which is the basis of most tabulations of NHISdata.

For prevalence statistics such as those included in thisreport (for example, the percent of women who have everhad a mammogram), the annual estimates are derived bysumming the weighted quarterly files and dividing by 4.This division is necessary because each quarterly file hasbeen weighted to produce an estimate of the number ofpersons in the United States with a given characteristic.Summing the quarters and dividing by 4 in effect averagesthese quarterly results for the year. Thus the type ofprevalence estimate ordinarily derived from NHIS data isan annual average prevalence estimate.

In the NHIS-CEC, for which two separate question-naires were used, most of the questions were unique to oneor the other of the questionnaires. A few questions wereasked on both. For this report, in instances where data weredrawn from only one of the instruments, the estimationprocedures were those described above. For data related tobody weight, which were obtained on both questionnaires,estimates from the CES and the CCS were pooled. In thiscase, average annual estimates were derived by summingthe eight quarterly estimates (four from each of the twoquestionnaires) and dividing by 8.

Reliability of estimates

Because NHIS estimates are based on a sample, theymay differ somewhat from the figures that would have beenobtained if a complete census had been taken using thesame survey and processing procedures. There are twotypes of errors possible in an estimate based on a samplesurvey sampling and nonsampling errors. To the extentpossible, these types of errors are kept to a minimum bymethods built into the survey procedures and describedelsewhere (129). Although it is very difficult to measure theextent of bias in the NHIS, several studies have beenconducted to examine this problem (130-133).

Nonsampling errors

Interviewing process— Some types of information, suchas the number of days of restricted activity caused by amedical condition, can be obtained more accurately fromhousehold members than from any other source, becauseonly the persons directly concerned with the situation are ina position to report this information. However, there arelimits to the accuracy of diagnostic and other informationcollected in the household interviews. For diagnostic infor-mation, the household respondent can pass on to theinterviewer only the information the physician has given tothe family. For conditions not medically attended, diagnos-tic information is often no more than a description ofsymptoms. Further, a respondent might not answer a ques-tion in the intended manner because he or she has notproperly understood the question, has forgotten the event,does not know, or does not wish to divulge the answer.Regardless of the type of measure, all NHIS data areestimates of known reported morbidity, disability, and soforth.

Reference-period bias— NHIS estimates do not repre-sent a complete measure of any given topic during thespecified calendar period because data are not collected inthe interview for persons who died or became institutional-ized during the reference period. For many types of statis-tics collected in the survey, the reference period is the 2weeks prior to the interview week. For such a short period,the contribution by decedents to a total invento~ of condi-tions or services should be very small. However, the contri-bution by decedents during a long reference period, such as1 year, might be significant, especially within the older agegroups.

Rounding of numbers-h published tables, the figuresare rounded to the nearest thousand, although they are notnecessarily accurate to that detail. Derived statistics, suchas rates and percents, are computed after the estimates onwhich they are based are rounded to the nearest thousand.

Sampling errors

The standard error is the primary measure of samplingerror, that is, the variation that might occur by chancebecause only a sample of a population is surveyed. Thechances are about 68 in 100 that an estimate based on asample would differ from that obtained from a completecensus by less than the standard error. The chances areabout 95 in 100 that the difference between a sample-basedand census estimate would differ by less than twice thestandard error of the estimate and about 99 in 100 that itwould differ by less than a factor of 2.5.

Individual standard errors were not computed for eachestimate in this report because of the complexity of thereplication or linearization procedures required to estimatevariance when a complex, multistage sample design is used.Instead, standard errors were computed for a broad spec-trum of estimates. Regression techniques then were used toproduce equations whose parameters a and b can be usedto approximate standard errors for any estimate.

For each percentp included in this report, the standarderror of the percent can be estimated as

where b = 10,000 (as estimated by the regressionequations)

y = denominator for the percent

Tables II-VI, which provide denominators y for all per-cents, also present estimated standard errors for selectedpercents. Standard errors for percents not shown in thesetables can be estimated using the formula above or inter-polation techniques.

The denominators in tables lLVI are themselves pop-ulation estimates, because they are not simple counts ofpopulation within any of the 20 age-sex-race poststratifica-tion cells shown in table I. These population estimates werederived from the NHIS and may differ from official popu-lation estimates from other sources, such as those pub-lished in the U.S. Bureau of the Census reports (Series

37

Table IL Estimated standard errors for selected base percents of all women 40 years of age and over by selected characteristics:United States, 1987

Basepercent

1 5 10 15 20 25 30 35 40 45Estimated or or or or or or or or or or

CharacterLstk population 99 95 w 65 m 75 70 65 60 55 50

All racesl

40yeers and over. . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . .4Cr-44yeare . . . . . . . . . . . . . . .45-49 yeaffi . . . . . . . . . . . . . . .50-54 years . . . . . . . . . . . . . . .

S5-64yeare . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . .60-64years . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . .65-69yeam . . . . . . . . . . . . . . .70-74years, . . . . . . . . . . . . . .

75yeareandover . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . .60-84years . . . . . . . . . . . . . . .65yeersandover . . . . . . . . . . .

White

40 years and ovenCrude . . . . . . . . . . . . . . . . . . .Agaadjusted . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . .75yearsandover, . . . . . . . . . . . .

Black

40 yeare end ovenCrude . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . .5E-64years . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . .75yeareandover . . . . . . . . . . . . .

Educetlonal level

Lessthan 12yeare . . . . . . . . . . . .12years . . . . . . . . . . . . . . . . . . .Morethan 12years . . . . . . . . . . . .

Famllylncome

Lessthan$lO,OOO . . . . . . . . . . . . .$10,00C+$19,999 . . . . . . . . . . . .$20,001H.34,999 . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . .

Place of resldencez

MSA, cenlralcity, . . . . . . . . . . . .MSA, notcentralclty . . . . . . . . . . .Not InMSA . . . . . . . . . . . . . . . . .

Geographk region

Northeast . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . .west . . . . . . . . . . . . . . . . . . . . .

Numberinthousands Standard error of percent

47,676

19,5977,6646,3445,588

11,7495,6145,9359,6655,4364,2296,6653,4182,0061,239

41,87741,677

16,75710,3116,7156,094

4,8304,630

2,272i ,205

624529

15,11219,82712,877

6,39610,026Io,eel11,399

15,10021,09911,820

10,70511,42116,6169,076

0.1

0.20.40.40.40.30.40.40.30.40.50.40.50.70.9

0.20.2

0.20.30.30.4

0.50.5

0.70.91.11.4

0.30.20.3

‘0.30.30.30.3

0.30.20.3

0.30.30.20.3

0.3

0.50.60.90.90.60.90.90.70.91.10.61.21.52.0

0.30.3

0.50.70.70.9

1.01.0

1.42.02.43.0

0.60.50.6

0.60.70.70.6

0.60.50.6

0.70.60.50.7

0.4

0.71.11.21.30.90.51.21.21.31.51.21.62.127

0.50.5

0.70.91.01.2

1.41.4

2.02.73.34.1

0.60.70.8

1.00.90.90.9

0.80.70.9

0.90.90.71.0

0.5

0.61.31.41.51.01.51.51.11.51.71.41.92.53.2

0.60.6

0.91.11.21.4

1.61.6

2.43.33.94.9

0.90.61.0

1.21.11.11.1

0.90.61.0

1.11.10.91.2

0.6

0.91.41.61.71.21.71.61.31.71.91.522283.6

0.60.6

1.01.21.41.6

1.61.8

273.64.45.5

1.00.91.1

1.41.31.21.2

1,00.91.2

1.21.21.01.3

0.6

1.01.61.71.81.31.61.61.41.92.11.72.33.13.9

0.70.7

1.11.31.51.8

2.02.0

2.93.94.86.0

1.11.01.2

1.51.41.31.3

1.10.91.3

1.31.31.11.4

0.7

1.01.71.81.91.31.91.91.52.02.21.82.53.24.1

0.70.7

1.11.41.61.9

212.1

3.04.25.06.3

1.21.01.3

1.61.41.41.4

1.21.01.3

1.41.41.11.5

0.7

1.11.71.92.01.42.02.01.52.02.31.62.63.44.3

0.70.7

i .21.51.61.9

222.2

3.24.35.36.6

1.21.11.3

1.61.51.41.4

1.21,01.4

1.51.41.21,6

0.7

1.11.61.9211.42.0201.62.12.41.92.63.54.4

0.80.8

1.21.51.72.0

2.22,2

3.34.55.46,7

1.31.11.4

1.71.51.51.5

1,31,11.4

1.51.41.21.6

0.7

1.1‘1.82.02.11.52.12.01.62.12.41.92.73.54.5

0.80.8

1.21.51.72.0

2.32.3

3.34.55.56.6

1.31.11.4

1.71.61.51.5

1.31.11.4

1.51.51.21.7

0.7

1.11.82.02.11.52.12.11.62.12.41.92.73.54.5

0.60.6

1.21.61.720

2.32.3

3.34.65.56.9

1.31.11.4

1.71.61.51.5

1.31.11.5

1.51.51.21.7

i Includes other races not shown separately.2MSA - metropolitan statistical area.

38

Table Ill. Estimated standard errors for selected base percents of women 40 years of age and over who had a breast physicalexamination (BPE) in the past 3 years by selected characteristics: United States, 1987

Base percent

1 5 10 15 .20 25 30 35 40 45Estimated or or or or or or or or or or

Cher.4cterktic populatbn 99 95 m 85 60 75 70 &5 60 55 50

All racesl

40yearsand over . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . .45-49 years . . . . . . . . . . . . . . .50-54 years . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .55-56 years . . . . . . . . . . . . . . .60-64 years . . . . . . . . . . . . . . .

65-74 yeara . . . . . . . . . . . . . . . .65-69 years . . . . . . . . . . . . . . .70-74years . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . .80-64years . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . .

WhKe

40 years and ovenCrude . . . . . . . . . . . . . . . . . . .AgeadJustad . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . .

Black

40 yeara and ove~Crude . . . . . . . . . . . . . . . . . . .AgeadJusted . . . . . . . . . . . . . .

40-54years . . . . . . . . . . . . . . . .55-64vears . . . . . . . . . . . . . . . .65-74~ears . . . . . . . . . . . . . . . .75yeersandover . . . . . . . . . . . . .

Educational level

Lessthan 12years . . . . . . . . . . . .12years . . . . . . . . . . . . . . . . . . .Morethan 12years . . . . . . . . . . .

Family income

Lessthan$lO,OOO . . . . . . . . . . . . .$lo,oo&$19,9e8 . . . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . .

Place of resldencez

MSA,centraIcity . . . . . . . . . . . . .MSA,notcentrelcity . . . . . . . . . .NotIn MSA . . . . . . . . . . . . . . . .

Geographic region

Northeast . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . .west . . . . . . . . . . . . . . . . . . . . .

1Includes other races rid ?Jwwm *paratelY.2M3A = mairopo~ian statistical area.

Number in

30,527

14,2305,7604,4194,0527,5494,2423,3075,4713,2792,1e23,2771,7811,Ci)l

495

27,13227,132

12,2716,7475,0183,096

2,9502,950

1,626740422161

7,63513,294

9,306

4,2276,0187,6268,544

9,73514,104

6,666

6,5637,300

10,6915,952

Standard error of percent

0.2

0.30.40.50.50.40.50.50.40.50.70.50.71.01.4

0.20.2

0.30.40.40.6

0.60.6

0.81.21.52.5

0.40.30.3

0.50.40.40.3

0.30.30.4

0.40.40.30.4

0.4

0.60.91.01.10.81.11.20.91.21.51.21.62.23.1

0.40.4

0.60.61.01.2

1.31.3

1.72.53.45.4

0.80.60.7

1.10.90.80.7

0.70.60.6

0.80.60.70.9

0.5

0.81.31.41.51.11.51.61.31.72.01.72.23.04.3

0.60.6

0.91.21.31.7

1.71.7

2.43.54.67.5

1.10.81.0

1.51.21.11.0

1.00.81.2

1.21.10.91.2

0.6

0.91.51.71.61.31.72.01.52.02.42.02.73.65.1

0.70.7

1.01.41.62.0

2.12.1

2.64.25.56.9

1.31.01.2

1.71.51.31.2

1.11.01.4

1.41.31.11.5

0.7

1.11.71.92.01.51.92.21.72.22.72.23.04.05.7

0.60.6

1.11.51.823

2.32.3

3.14.66.2

10.0

1.41.11.3

1.91.61.41.4

1.31.11.5

1.61.51.21.6

0.8

1.11.82.12.21.62.12.41.92.42.92.43.24.36.2

0.80.6

1.21.71.925

2.52.5

3.45.06.7

10.8

1.51.21.4

2.11.61.81.5

1.41.21.7

1.71.61.31.8

0.8

1.21.92.22.31.72.22.52.02.53.12.53.44.66.5

0.90.9

1.31.82.02.6

2.72.7

3.65.37.1

11.4

1.61.31.5

2.21.91.71.6

1.51.21.8

1.81.71.41.9

0.9

1.32.02.32.41.72.32.62.02.63.22.63.64.86.8

0.90.9

1.41.6212.7

2.82.8

3.75.57.3

11.9

1.71.31.6

2.31.91.71.6

1.51.31.8

1.91.81.52.0

0.9

1.32,02.32.41.82.42.72.12.73.32.73.74.97.0

0.90.9

1.41.92.228

2.92.9

3.85.77.5

12.2

1.81.31.6

2.42.01.81.7

1.81.31.9

1.91.81.52.0

0.9

1.32.12.42.51.824272.12.73.42.73.75.07.1

1.01.0

1.41.92.22.8

2.92.9

3.95.87.7

12.4

1.81.41.6

2.42.01.81.7

1.61.31.9

1.91.81.52.0

0,9

1.32.12.42.51.8242.72.12.83.42.83.75.07.1

1.01.0

1.41.92.22.6

2.92.9

3.95.87.7

125

1.81.41.6

2.42.01.81.7

1.61.31.9

1.91.91.52.0

39

Table W. Estimated standard errors for seiected base percents of women 40 years of age and over who had no breast physicaiexamination (BPE) in the past 3 years by selected characteristics: United States, 1987

Base percerrf

1 5 10 15 20 25 30 35 40 45Estimated or or or or or or or

Charactertstlc

or or orpopulation 99 95 90 85 30 75 70 65 60 55 50

All fSG3Si

40yeare end over. . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . .40-44 years . . . . . . . . . . . . . . .45-49 yeats . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .55-59 years . . . . . . . . . . . . . . .60-64 yeare . . . . . . . . . . . . . . .

65-74 yeare . . . . . . . . . . . . . . . .65-89 years . . . . . . . . . . . . . . .70-74 yeers . . . . . . . . . . . . . . .

75yeare end over. . . . . . . . . . . . .75-79 years . . . . . . . . . . . . . . .80-64 years . . . . . . . . . . . . . . .85 years And over . . . . . . . . . .

White

40 years and ovenCrude . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . .55-84yeare . . . . . . . . . . . .65-74years . . . . . . . . . . . . .75yearsand over . . . . . . . . . . . . .

Black

40 yeare and ovecCrude . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . .

Educalionel level

Lessthen 12years . . . . . . . . . . .12yeare . . . . . . . . . . . . . . . . . . .Morethan 12yeare . . . . . . . . . . . .

Famllyincome

Lessthan$lO,OOO . . . . . . . . . . . . .$10,000-$19,999 . . . . . . . . . . . . .$20,00W$34,999. . . . . . . . . . . . .$35,0000rmore . . . . . . . . . . . . . .

Place of residence

MSA, centralctty . . . . . . . . . . . . .MSA, notcentralcity . . . . . . . .NotIn MSA . . . . . . . . . . . . . . .

Geographic region

Noriheeat . . . . . . . . . . . . . . . . . .Midwest. . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . .

Number inthousends Standard error of percent

10,630

3,4601,2781,216

8662,6151,2191,3962,5021,4991,1041,9531,037

526367

9,5049,504

3,0292,3282,3611,786

872872

288232189162

4,2574,2132,108

2,5762,5982,2031,706

3,1644,2433,223

2,3622,7853,5711.913

0.3

0.50.90.91.00.60.90.80.60.80.90.71.01.41.6

0.30.3

0.60.70.60.7

1.11.1

1.92.12.32.5

0.50.50.7

0.60.60.70.8

0.60.50.6

0.60.60.50.7

0.7

1.21.92.02.21.32.01.81.41.82.11.62.13.03.5

0.70.7

1.31.41,41,6

2.32.3

4.14.55.05.4

1.11.11.5

1.41.41.51.7

1.21.11.2

1.41.31.21.6

0.9

1.62.72.73.11.92.72,51,92,52.92.12.94.14.8

1.01.0

1.72.02.02.2

3.23.2

5.66.26.97,5

1.51.52.1

1.91.92.02.3

1.71.51.7

2.01.81.62.2

1.1

1.93.23.23.62.23.23.02.22.93.42.63.54.95.7

1.21.2

2.12.32.32.7

3.83.8

6.77.48.28.9

1.71.72.5

2.22.22.42.7

2.0i .72.0

2.32.11.92.6

1.2

2.23.53.64.12.53.63.42.53.33.82.93.95.56.4

1.3

1.3

2.32.62.63.0

4.34.3

7.58.39.29.9

1.91.92.8

2.52.52.73.1

2.21.92.2

2,62.42.12.9

1.3

2.33.83.94.42.73.93.72.73.54.13.14.36.07.0

1.41.4

2.52.82.83.2

4.64.6

8.19,0

10.010.8

2.12.13.0

2.72.72.93.3

2.42.12.4

2.82.62.33.1

1.4

2.54.14.24.72.84.23.92.83.74.43.34.56.37.4

1.51.5

2.63.03.03.4

4.94.9

8.59.5

10.511.4

2.22.23.2

2.92.83.13.5

2.62.22.6

3.02.72.43.3

1.5

2.64.24.34.92.94.34.03.03.94.53.44.76.67.7

1.51.5

2.73.13.13.6

5.15.1

8.99.9

11.011.9

2.32.33.3

3.03.03.23.6

2.72.32.7

3.12.92.53.4

1.5

2.64.34.45.03.04.44.13.04.04.73.54.86.77.9

1.61.6

2.83.23.23.7

5.25.2

9.110.211.312.2

2.42.43.4

3.13.03.33.7

2.82.42.7

3.22.92.63.5

l.~

2.74.4.4.5,

5.13.14.54.23.14.14.73.64.96.88.0

1.61.6

2.93.33.23.7

5.35.3

9.310.311.412.4

:3.4

3.13.13.43.8

2.82.42.6

3.23.02.63.6

1.5

2.74.44.55.13.14.54.23.14.74.83.64.96.98.0

1.61.6

293.33.33.7

5.45.4

9.310.411.512.4

2.42.43.4

3.13.13.43.8

2.62.42.8

3.33.02.63.6

.1Incbdes other races not shown separately,

2M8A - metropolitan statistical area,

40

Table V. Estimated standard errors for selected base percents of women 40 years of age and over who had a mammogram in the past3 years byselected characteristics: United States, 1987

Base psrcant

1 5 10 15 .20 25 30 3?5 40 45EstimateU or or or or or or or or or or

Characterkk populstlorr 99 95 90 85 80 75 70 65 60 55 50

All racesl

40yeare andover. . . . . . . . . . . . .

40-54 years . . . . . . . . . . . . . . . .40-44 yeara . . . . . . . . . . . . . . .45-49 yeara . . . . . . . . . . . . . . .50-54yeare . . . . . . . . . . . . . . .

55-64year3 . . . . . . . . . . . . . . . .55-59years . . . . . . . . . . . . . . .60-64yem . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . .65-69years . . . . . . . . . . . . . . .70-74years . . . . . . . . . . . . . . .

75yearaandover . . . . . . . . . . . . .75-79years . . . . . . . . . . . . . . .6C-64years . . . . . . . . . . . . . . .85yearsandover . . . . . . . . . . .

White

40 years and overCrude . . . . . . . . . . . . . . . . . . .AgeadJusted . . . . . . . . . . . . . .

40-54yeara, . . . . . . . . . . . . . . .55-64yeare . . . . . . . . . . . . . . . .65-74years . . . . . . . . . . . . . . . .75yeareandover . . . . . . . . . . . . .

Black

40 years and ovenCrude . . . . . . . . . . . . . . . . . . .Ageadjusted . . . . . . . . . . . . . .

40-54yeare . . . . . . . . . . . . . . . .55-64years . . . . . . . . . . . . . . . .65-74yeara . . . . . . . . . . . . . . . .75yearsandover . . . . . . . . . . . . .

Educatlonallevel

Lessthan 12years . . . . . . . . . . . .12yeara . . . . . . . . . . . . . . . . . . .Morelhan 12yeers . . . . . . . . . . . .

Family Income

Lessthan$lO,OOO . . . . . . . . . . . . .$10,000-$19,999 . . . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . . .$35,@.130rmore . . . . . . . . . . . . . .

Place of resldencez

MSA, cenlralcHy . . . . . . . . . . . . .MSA, notcentralcity . . . . . . . . . . .NotInMSA . . . . . . . . . . . . . . . . .

Gaographicregion

Northeast . . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . .

Numberinthousands

13,966

6,5642,4002,2161,9483,5842,0271,5572,6141,5911,0231,204

7672e2145

12,64712,647

5,8343,2062,4531,153

I,leir1,160

61035614943

2,6056,2444,659

1,5032,4363,6264,593

4,40)6,7922,774

2,9063,2S24,59e3,099


0.3

0.40.60.70.70.50.70.80.60.8

G1.1

E

0.30.3

0.40.60.60.9

0.90.9

1.31.72.64.8

0.60.40.5

0.80.60.50.5

0.50.40.6

0.60.50.50.6

0.6

0.91.41.51.61.21.51.71.31.72.22.02.54.05.7

0.60.6

0.91.21.42.0

2.02.0

263.65.6

10.5

1.30,81.0

1.81.41.11.0

1.00.81.3

1.31.21.01.2

0.8

1.21.92.0211.62.12.41.92.43.02.73.45.67.9

0.60.8

1.21.7

;:

2.82.8

3.65.07.8

14.5

1.81.21.4

24i .91.61.4

1.41.21.6

1.81.61.41.7

1.01.42.32.42.61.92.52.92.22.83.53.34.16.69.4

1.01.0

1.52.02.33,3

3.33.3

4.66.09.3

17.2

211.41.6

2.92.31.91.7

1.71.42.1

2.11.91.72.0

1.1

1.62.62.72.92.12.83.22.53.24.03.64.67.4

10.5

1.11.1

1.7222.63.7

3.73.7

5.16.7

10.419.3

2.41.61.8

3.32.62.11.9

1.91.52.4

2.32.21.92.3

1.2

1.72.82.93.1233.03.52.73.44.33.94.98.0

11.4

1.21.2

1.82.4284.0

4.04.0

5.57.2

11.220.9

2.61.72.0

3.52.8232.0

2.11.726

252.42.025

1.2

1.83.03.13.32.43.23.72.83.64.54.25.28.5

12.0

1.31.3

1.926294.3

4.34.3

5.97.7

11.9221

2.71.821

3.72.92.42.1

2.21.826

2.72.5212.6

1.3

1.93.13.23.42.53.43.83.03.84.74.35.46.8

125

1.31.3

2.02.73.04.4

4.44.4

6.18.0

12.423.0

2.81.92.2

3.93.12.52.2

2.31.82.9

2.82.62.22.7

1.3

1.93.23.33.52.63.43.93.03.94.84.55.69.1

12.9

1.41.4

2.02.73.14.6

4.54.5

6.38,2

12.723.6

2.92.02.2

4.03.12.623

2.31.92.9

292.72.32.8

1.3

1.93.23.33.62.63.54.03.13.94.94.55.79.2

13.1

1.41.4

2.12.83.24.6

4.64.6

6.48.3

12.924.0

3.02.02.3

4.13.22.62.3

2.41.93.0

2.9272.32.8

1.3

2.03.23.43.62.63.54.03.14.04.94.65.79.3

13.1

1.41.4

2.12.83.24.7

4.64.6

6.48.4

13.024.1

3.02.02.3

4.13.22.62.3

2.41.93.0

2.92.72.32.8

Ilffiludmothermes rmsr-mnseperately.‘MSA= mtro~~tan statis!lcal wea

41

Table V1. Estimated standard errors for selected base percents of women 40 years of age and over who had no mammogram in the past3 years by selected characteristics: United States, 1987

8ase percent

1 5 10 15 20 25 30 w 40 45Estimated or or or or or or or or or or

Characteristic population 99 95 90 85 80 75 70 65 60 55 50

All racesl

40years and over . . . . . . . . . . . . .

4C-54yeare . . . . . . . . . . . . . . . .40-44 yeare . . . . . . . . . . . . . . .4E-49years . . . . . . . . . . . . . . .50-54 yeare . . . . . . . . . . . . . . .

55-84 years . . . . . . . . . . . . . . . .55-59 yeare . . . . . . . . . . . . . . .60-64 years . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . .65-69 years . . . . . . . . . . . . . . .70-74 years . . . . . . . . . . . . . . .

75years and over . . . . . . . . . . . . .75-79 yeare . . . . . . . . . . . . . . .80-64 yeare . . . . . . . . . . . . . . .85years And over . . . . . . . . . . .

White

40 years and ovenCrude . . . . . . . . . . . . . . . . . . .Age adjusted . . . . . . . . . . . . . .

40-54 yeere . . . . . . . . . . . . . . . .55-64 years . . . . . . . . . . . . . . . .65-74 years . . . . . . . . . . . . . .75 years and over . . . . . . . . . . . . .

Black

40 years and ove~Crude . . . . . . . . . . . . . . . . . . .Age adjusted . . . . . . . . . . . . . .

40-54 yeare . . . . . . . . . . . . . . . .55-64 yeare . . . . . . . . . . . . . . .65-74 yeare . . . . . . . . . . . . . . . .75years And over . . . . . . . . . . . . .

Educational level

Lessthan 12yaars . . . . . . . . . . .12 years . . . . . . . . . . . . . . . . . . .Morethan 12yeare . . . . . . . . . . . .

Family income

Lessthan $10,000 . . . . . . . . . . . .$10,000-$19,999 . . . . . . . . . . . . .$20,000-$34,999 . . . . . . . . . . . . .$35,0000r more . . . . . . . . . . . . . .

Place of residence

MSA, cenlral city . . . . . . . . . . . . .MSA, noncentral city. . . . . . . . . . .Notin MSA . . . . . . . . . . . . . . . . .

Number in

25,499

10,7314,581

3,2132,9386,2883,3752,9135,2403,0722,168

3,2391,787

961491

22,82522,825

9,1725,7244,8653,084

2,2482,248

1,279496313159

7,34911,276

6.819

4,2435,7546,1345,874

7,65911,0566,764

5,8666,2728,6984,663


0.2

0.30.50.60.60.40.50.60.40.60.70.60.71.01.4

0.20.2

0.30.40.50.6

0.70.7

0.91.41.82.5

0.40.30.4

0.50.40.40.4

0.40.30.4

0.40.40.30.5

0.4

0.71.01.21.30.91.21.31.01.21.51.21.62.23.1

0.50.5

0.70.91.01.2

1.51.5

1.93.13.95.5

0.80.60.8

1.10.90.90.9

0.80.70.8

0.90.90.71.0

0.6

0.91,41,71.81.21.61.81.31,72.01.72.23.14.3

0.60.6

1.01.3i .41.7

2.02.0

2.74.35.47.5

1.10.91.1

1.51.31.21.2

1.10,91.2

1.21.21.01.4

0.7

1.11.72.02.11.41.92.11.62.024202.73.65.1

0.70.7

1.21.51.62.0

2.42.4

3.25.18.49.0

1.31.11.4

1.71.51.41.5

1.31.11.4

1.51.41.21.7

0.8

1.21.92.22.31.6222.31.72.32.72.23.04.15.7

0.80.8

1.31.71.82.3

2.72.7

3.55.77.1

10.0

1.51.21.5

1.91.71.61.7

1.41.21.5

1.71.61.41.9

0.9

1.32.02.42.51.72.42.51.92.52.92.43.24.46.2

0.90.9

1.41.82.02.5

2.92.9

3.86.17.7

10.9

1.61.31.7

2.11.8i .71.8

1.61.31.7

1.81.71.52.0

0.9

i .42.12.62.71.82.52.72.02.63,12.53.44.76.5

1.01.0

1.51.92.12.6

3.13.1

4.16.58.2

11.5

1.71.41.8

2.21.91.91.9

1.71.41.8

1.91.61.62.1

0.9

1.52.22.72.81.92.62.82.12.73.22.73.64.96.8

1.01.0

1.62.02.22.7

3.23.2

4.26.88.5

12.0

1.61.41.8

2.32.01.920

1.71.41.8

2.01.91.62.2

1.0

1.52.32.72.92.02.72.92.12.63.32.73.75.07.0

1.01.0

1.62.02.22.8

3.33.3

%6.6

12.3

1.61.51.9

2.42.02.02.0

1.81.51.9

2.02.01.72.3

1.0

1.52.3

2.82.92.02.72.92.22.83.42.83.75.17.1

1.01.0

1.62.12.32.8

3.33.3

4.47.18.9

12.5

1.81.51.9

2.42.12.02.1

1.81.51.9

2.12.01.72.3

1.0

1.52.32.82.92.02.72.92.22.93.42.83.75.17.1

1.01.0

1.72.12.32.9

3.33.3

4.47.18.9

125

1.81.51.9

2.42.12.02.1

1.81.51.9

2.12.01.72.3

Geographic region

Northeast . . . . . . . . . . . . . . . . .Midwest . . . . . . . . . . . . . . . . . . .South . . . . . . . . . . . . . . . . . . . .West . . . . . . . . . . . . . . . . . . . . .

1Includesotherracesnotshownseparately.‘MSA= metropolitanstatisticalarea.

42

P-20, P-25, and P-GO).The standard error for each of theseNHIS-based population figures x can be estimated as

SE(X) = &x2+bx

where a = O

}

(as estimated by theb = 10,000 equations)x = the population figure itself

Age-race adjustment

This report contains a number of tables presenting datathat have been adjusted for the effects of age or for age andrace, These adjusted estimates were derived by directstandardization:

For the figures adjusted for age alone (that is, theage-adjusted estimates for white women 40 years of ageand over and for black women 40 years of age and over),the following age categories of i were used: 40-44,45-49,50-54, 55-59, 60-64, 65-69,70-74, 75-79, 80-84, and 85years and over.

For the figures adjusted for age and race (that is, thosebroken down by education, income, place of residence, andgeographic region), the following age-race categories of iwere used: black, 40-54 years; black, 55–64 years; black,65–74 years; black, 75 years and over; nonblack, 40-54years; nonblack, 55–64 years; nonblack, 65–74 years; andnonblack, 75 years and over.

In the few instances in which the sample size did notpermit use of categories as narrow as those listed above,adjacent age categories were combined as required.

where p,dj= age or age-race adjusted percentpi = crude or unadjusted percent in category iw; = we]ghted female population in catego~ i

43

Appendix IIDefinitions of certainterms used in thisreport

Sociodemographic terms

Age—The age recorded for each person is the age atlast birthday. Age is recorded in single years and groupedfor presentation in tables.

Race-The population is divided into three racialgroups: “white,” “black,” and “all other.” “AH other”includes Aleut, Eskimo, or American Indian; Asian orPacific Islander; and any other races. Characterization ofrace is based on the respondent’s description of his or herracial background.

Education —The categories of educational status referto years of school completed. Only years completed inregular schools in which persons are given a formal educa-tion are included. A regular school is one that advances aperson toward an elementary or high school diploma or acollege, university, or professional school degree. Thuseducation in vocational, trade, or business schools outsidethe regular school system is not counted in determining thehighest grade of school completed.

Fami/y inconae-Each member of a family is classifiedaccording to the total income of the family of which he orshe is a member. Within the household, all persons relatedto each other by blood, marriage, or adoption constitute afamily. Unrelated individuals are classified according to

their own incomes. The income recorded is the total of allincome received in the 12-month period preceding theweek of interview. Income from all sources—for example,wages, salaries, rents from property, pensions, governmentpayments, and help from relatives–is included.

Place of residence-Place of residence is classified asinside or outside a metropolitan statistical area (MSA).Place of residence inside an MSA is further classified aseither central city or not central city.

The definition and titles of MSA’S are established by

the U.S. Office of Management and Budget with the adviceof the Federal Committee on Metropolitan StatisticalAreas. Generally speaking, an MSA consists of a county orgroup of counties containing at least one city (or twin cities)having a population of 50,000 or more plus adjacent coun-ties that are metropolitan in character and are economically

and socially integrated with the central city. In New En-gland, towns and cities rather than counties are the unitsused in defining MSA’S. There is no limit to the number ofadjacent counties included in the MSA as long as they are

integrated with the central city, nor is an MSA limited to asingle State; boundaries may cross State lines. The metro-politan population in this report is based on MSA’S asdefined in the 1980 census and does not include anysubsequent additions or changes.

Central city of an MSA—The largest city in an MSA isalways a central city. One or two additional cities may besecondary central cities in the MSA on the basis of either ofthe following criteria:

. The additional city or cities must have a population

one-third or more of that of the largest city and aminimum population of 25,000.

. The additional city or cities must have at least 250,000inhabitants.

Not central city of an MSA –This includes all of theMSA that is not part of the central city itself.

Not in MSA—This includes all other places in thecountry.

Geographic region —The States are grouped into four

geographic regions. These regions, which correspond tothose used by the U.S. Bureau of the Census, areas follows:

Region States included

Northeast Maine, Vermont, New Hampshire,Massachusetts, Connecticut, Rhode Island,New York, New Jersey, and Pennsylvania

Midwest Ohio, Illinois, Indiana, Michigan, Wisconsin,Minnesota, Iowa, Missouri, North Dakota,South Dakota, Nebraska, and Kansas

South Delaware, Maryland, District of Columbia,West Virginia, Virginia, Kentucky, Tennessee,North Carolina, South Carolina, Georgia,Florida, Alabama, Mississippi, Louisiana,Oklahoma, Arkansas, and Texas

West Washington, Oregon, California, Nevada,New Mexico, Arizona, Idaho, Utah,Colorado, Montana, Wyoming,Alaska, and Hawaii

44

Terms related to health

Relative weight—Relative weight is the ratio of anindividual’s self-reported weight to his or her desirableweight as established by the 1983 Metropolitan Life Insur-ance Company (MLIC) weight-for-height charts (134). Themidpoint of the medium frame category for a particularheight was used as the desirable weight for that height. TheMLIC standards were developed based on weight in indoorclothing and height with l-inch heek for men and 2-inchheels for women. The National Health Interview Survey(NHIS) asked respondents to report their heights andweights without shoes. The IWLIC standards were adjustedby subtracting 2 pounds from the midpoint of the mediumihrne category for both sexes, and by subtracting 1 inchfrom the height of men and 2 inches from the height ofwomen.

The MLIC desirable weight standards are based on themortality experience of a group of life insurance policyhold-ers. Because persons who obtain life insurance are notrepresentative of the general population, the appropriate-ness of these standards for some population subgroups isunknown (13S). The 1983 MLIC standards differ slightlyfrom the earlier published 1959 MLIC standards (136).

Both MLIC and NHIS data are based on self-reportedheight and weight. Self-reported height and weight dataproduce conservative estimates of the extent of overweightin the population, because heavier people tend to underre-port their weight, and shorter people tend to overreporttheir height (137).

A variety of measures of overweight status have beenused (138) in past research. A major source of data on theprevalence of overweight in the U.S. population is the 2ndNational Health and Nutrition Examination Survey(NHANES II). Data released from the NHANES II onoverweight status are computed using measured height andweight and expressed as body mass index, calculated asweight divided by height squared. Although not identical,the proportions of population defined as “20 percent ormore overweight” using the NHANES II body mass indexcutpoints and the 1983 MLIC standards are not substan-tially different (138).

Alcohol consumption —Level of alcohol consumptionreflects drinking patterns during the 12 months precedingthe NHIS interview. NHIS respondents were asked howoften they drank beer “during the past year or so”; howmany cans, bottles, or glasses they usually consumed ondays when they drank beer; and whether these portionswere small, medium, or large. The same set of threequestions was repeated for wine and for liquor.

For each of the three types of alcoholic beverages, thenumber of drinks consumed per year was calculated bymultiplying the number of days per year on which thebeverage was consumed by the usual number of drinksconsumed on those days. If either the number of days orusual number of drinks was unknown, the value for thenumber of drinks consumed per year was set to unknown aswell. Total number of alcoholic drinks consumed per yearwas calculated as the sum of the numbers of drinks per yearof beer, wine, and alcohol. An unknown value for any of thethree types of alcoholic beverage resulted in an overallunknown value.

The categories of alcohol consumption were set asfollows

. Abstainer or light drinker—O to 155 drinks per year(less than three drinks per week, on average)

. Moderate drinker—156 to 729 drinks per year (threedrinks per week to less than two drinks per day, onaverage)

● Heavy drinker—730 drinks per year or more (twodrinks per day or more, on average)

These categories roughly correspond to those that havebeen used in a number of studies of alcohol consumption(92-95); most of these other studies, however, have used amore sophisticated classification scheme that involved con-version to grams of ethanol on the basis of type of beverageconsumed and size of drink. The questions on alcoholconsumption in the NHIS-CEC were asked as part of aseries of questions on general food and beverage intak~ thedata collected on alcohol were not of sufficient detail topermit such detailed classification as has been used eke-where.

45

Appendix HISurvey instruments

$eation GG – REPRODUCTION AND HORMONE USEI

GG1 Referto sex1 1 ❑ MA ktion HHI

t 2 ❑ Femab /7)

Than iuti qumtions ●re ●bout pragnancy ●nd mproductlcm. /1❑ Yes

1 Y

1a. HmJnyou aver @wan bfrtftta ● Nv.bom inti?z ❑ No (2J

-___ ---. _------ .___ --__ ------- .----___ --__. -_---lb. How many Ik births havQ YOUhad? ;-------------------------------------------—-=

I — Number_ ------_ -—______________________________________ &----------------------------------------------

C. How old wara you whca your {first) child was born? =! _ Am (2)f

99 ❑ DK /id)----- _-_---— ___________________________________

& Wwa YO. 20 or wamwer. w old.rthan 20?*_____________________________________________

1 q

---—-1❑ 20 or yo.ng.r /2)

80

z ❑ Oldnr than 20 (?6)1

9 ~ DK {2)-----------------------------------------------

em Wera YLUIZ1h224, 2S to 29, 30t034, w 36 orokk?~_____________________________________________ --_-,

~([ I ❑ 21–24 4035+

2 ❑ 2S-29 sDOK1

3030-34

2a. [Mddss [that ~m8#ta”C~/tfllI.. X.S”CIWID, Have you ~02

●ver had ●y (oth.r) pregnadm thatIastdSIXmonthc I 7z Yesw mora? 2❑ No (GG2j

b. ti%-&k-&j-~<~&-6-&;ib-G-&iGLii;iii6i6-&~------- +---------------------------------------------e1

— Number-----------------------------------------------

C. I+OW old Wata you ●t tha am! of [that~na’lcylthafht ~------------;;;;G;;;---------------------------=of ihon prqnanck]?

99Q OK (2d)------------------------------------------------

d. Warn yOU20 or yOLlnfJSF,or oldar than 20?p---- -----------------------------------------

! EI ❑ 20 or younger IGG2)

1 2 ❑ Older than 201

9 ❑ DK (GG2)1------------------------------------------------

0. Wwo you 211024,26 to 29,30 to 34, or 3S or oldwr?+---------------------–-__--_-_-_--—---------

~n21-24 ●m25+ -EC11 2 ❑ 25-29 BDDK

3030-341

1

GG2 ROfar to le

&3 ❑ -yos,e i“ 1n (3)

I8 ❑ Othar (4)

1 I

3. Did you bmastfcad ●ny of your ch11dran7 I ~

3 El Ye,I

lDNo

da. How old wwa you whm your manstvual c@.. baaan? 1— A.3816)

~

I 00 ❑ Never isnstru,wd /7)

1 09❑ OK f4b)_---____---___-________-___--_-__- ___-------__ --:_______________________________________________,%__

b. V&YotIYOWUIOrfhisnlO, 10to12, 13tol15,0r160r I a Younwt thm 10I2010-12

13013-15 -1

I 4016+

1 9DDK

5. H=va your manmrual EYCI.S stop pad pwm.n.ntly? 1 ~

II ❑ YesI

1 2 ❑ No (CU

6W HOW old wam you whan they eomplmaly $topped? I

— AT@ /7)I S9 ❑ OK @3bJ

_______________________________________________

b. W.ra YW you.fmrthan 20,20 to 29,30 to 39,40 to 44, ~+_-,---- ---------------------------------------

45 to 49, SO 1054, or 66 or c.ldar? t ❑ Younger than 201 2 ❑ 20-29 .

1 3030-39

i4040-44

5 ❑ 45-49I1

En50-84

7056+I BOOK

7. [Did thay ●@Wss this] due to SIM9WY7 11 •1 Yes

78

46

Section GG - REPRODUCTION AND HORMONE USE – ContinuedI

8a. Have you ●ror had an oparation to ramove a lump from your ~ I ❑ Yes (8b)braaat that was found to ba NONCANCEROUS? I 2DN0

I

)

s ❑ Lumps removed that (9)were cancerous

stl DKL---------------

b. 'R;~-;;;y-&f-~;;-G~&;~-&;E;~;~;~~aT?------------l “-----------------------------m11

Numtmr of operations

iraDK1’-------------- .--------—— --------------------- -------------- --- —-----——— ---------------

C ● HOW old wero you when you had the (fbt] I IEEooarationt Age st first orwetion

199 CIDK -

1

Wa ●ra Intaroatad[n Iearnlng about tho relationship ~

batwaorr bhth control pills and health. 1 1•l Yes

I 2 ❑ No (GG3)

9. Have you war rraad bl~ oontroi PIIIs?I

10a. HOW okl war. you whan you started using birth I

control pills? I Age (1lJ99 ❑ IDK (70bJ

___________________________._______—--.-----L--—

b. Wara you younger than 25, or 25 or oldsr?—-------———-—--_ —_ — -------------

EI ❑ Younger then 25 (70c)

2n25+(10d)

sDDK (II)

----------—-- .------------— L-——---— -------- -.-----------— --——----------- ——-— -------

c. Warayou 180ryoungar,lS to21,0r22t024? I ❑ 18 or younger

I

}

EI2019–21 (11)

I 3022–24

I sOCIK

--------------------------------------------b------;-;;~2;-------------------------------& Wara you 25 to 29,30 to 34, or 35 or oldar?

2 ❑ 30-343c135+sDDK

11 Il. AItqCthar, about how long dld you taka birth control ~

P::?ml::la any braaks In uaaga that Iastad lass than

{}

I ❑ Days

~ 2❑ Months (GG3Ji 3 •l Years

1(GG3)

I 9990 DK (1 lb)

L----------- — --------------------------------- -------- —------—---------—-— ----------------

b. Was it baa than ayaar. or ● yaar or mora? I EI ❑ Leas than one year (GG3)I 2 •l One year or more (f ?c)

/ a tl DK (GG 3)

-—---— --------------------------------------- ‘L.--------------–-------—---------—---------- -—-c. Was k 3 yaars or lass, mom than 3 but lass thari 5, or U1

5 or mora yaars? 1❑ 3 yearaor [aaai 2 ❑ More than 3, less than 5 yaws1

I 3 ❑ 5 or more yearstI

DDDK

I 84

GG3 Refer to ageI I ❑ Under 40 (section HH)

I 2❑ 40 and over (12)I 1

12. Estrogorr 1sa fomalo hormona that may ba takan aftar ●I

1 ❑ Yes 95

hystoraotomy or during menopause. Have you avar Itaken ●strogan pills for ● ny raason?

2i3N0

}(section HH)

I sDDK1

[3tt. How old war. you when you startad using estrogan pills? I S6-SII Age (14)

1 EIBD DK (13b)

______________ -_----------------------------L---------------------------------------------b, Warayou yourrgarthan 20,20 to 23,30 to 39,40 to 44, I

45 to 49,50 to 54, or 55 or oldar?

~

1•l Younger than 20I

2❑ 20–29I 3❑ 30-39I

I 4040-445045–49

/ 6050–54

r7055+

1 9CIDK

I

47

Section GG – REPRODUCTION AND HORMONE USE – Continued

&. Altogether, IIbOti how long did you take estrogen pills?

–{ }

EI ❑ Days

Include ●ny breaks hi usage that lasted less than onamonth.

2 ❑ Months /15)Number 3 •l Years

000 ❑ Lessthan one month (75)

88E ❑ Other (Specify) y

I—(16)

I 9990 DK (74ML––––______________________________–––––_______ _____

b. 'w;:tii;;s7E~6;>;GC%;~j;~;&-k;;;F----------------; I❑ Lessthan oneyear (75} l-.l!E

I 2 ❑ One year or more (i4c)

9CIDK (75)

---------------------------.-------------------;---------------------------------------------- -----C. Wasit3years or Iess, morethan 3butlessthan5,0r T_l!E_

5 or more yearst1❑ 13yearaorless

2 ❑ More than 3, less than 5 years

3 •l 5 or mora years

9CIDK

5. What was the brend nama of the astrogerr pills? I =I

Brandrmme

❑ OK

otes

I n, 0.

Section HH - FAMILY HISTORY OF CANCER 3-4

Thesa naxt questions are about your natural or birth mother and father. Do not Includastep or ●dopthro parsnts.

Ask 1–2 for mother, then for father. MOTHER FATHER

I 5–B

1a. In what yaar waa your rmtural [mothar/fathsrl born? la. — Year — Year9999 ❑ D K 9999 ❑ DK

-.----------- .——— ——--. ------------- —-- ————.-——- —--—-— ------------- ----- -—------------------

b. Isyour [mother/fatharl still Ilving? b.s

1 •l Yea (2)

~..

1 ❑ Yes (2)

2 ❑ No (lc) 2 n No (fC)

9 ❑ DK (2) 9 ❑ DK (2)

7 ❑ Never knew natural mother(1 for fatherl

7 ❑ Naver knew natural father (3,J

-- —-- —-- —--- —-----------— -— ——————-— ——————.-——- ———----, -—---------- --—-. -—--— -— ——— —————----

c. At what agc did your [mother/father] dia?lo–l 1 m

c.Age Age

99 ❑ DK a9a DK

Za. Was your [motharlfatherl svm diagnosed by a doctor as 2a. I 12 @

having cmcar?1 ❑ Yea 1 ❑ Yes

2UN0

)

(1 for father) 2~N0

)

[3)9ci DK 9nDK

---------— --—------------------------—---— ----- ----—---—---—-—-—— -—-——b. What kind of cancer was it? b.

—- —------ —----------13-16 EEz

(2d) (2dJ

799 ❑ DK (2c) 79s ❑ DK (2c)----— -- —-- —--— ----- .-- —--- —------------- .--— ---—---—--—--—---—--——- ----- —-----— -—-----------

c. What part of the body was ●ffsctod? c.

H DK ❑ DK-- ——----________----— ---- —------ —------- ..-—. ---—————-——--——— ———— ————-------- —— --—---

d. Dd your [mother/fathar] have any other kind of cancar d.16 E

that was dlagnoaad by ● doctor?, ❑ Yes

}

, ❑ Yes

2 ❑ NO (2g) ~DNo

sUDK }s~DK ’29’

--- —--------------— -----------------——--—- ----- ------- _—-----—---— ---—- --——-—-- —----------- ---

e. Tha FIRST time [she/he] waa dtagrrosod with cancar, e. 000 ❑ Seine as 2b/c (2g)17-1s

00CI❑ Same es 2b/c [2g) =what kind of cancsr waa it?

(Zg) (29/

799 ❑ DK (2fJ ?9a ❑ DK (2f)-------— -—— —-------------—-- —------------— ----- -—-- —----------—— ------- -———-—--- . --—------------

f. What part of tha body was affactad? f.

❑ DK ❑ DK--------—----------------—---------—---- -—- ---- ——-—-— --------- ---—- ------- ——— ————-——-- ----

g. How old was Your [mothar/fathsr] when cancw was 9-20-21 b

first diagnosad by ● doctor? Age

}

Age

99 ❑ DK(1for father)

99 ❑ DK

Uotas

49

Section HH – FAMILY HISTORY OF CANCER – Continued

?ead to resporrdent: Now I’m going to ●sk about your sisters and brothers who have the aama natural or birthmother AND fathar aa you. Do not Include step, half, or adoptiv~ siatera and brothars.

OOD None lzGE

aa. How many sisters do you have, Includlng 3a.●ny that may hava dlad?

Skters990 DK

‘----------------------------------- ‘- ‘------------------”---------------------Eiib. How many brothars do You have, Including b. oo~ Noneany that may hava died?

Brothers

990 DK

/f “None” in 3a and 3b, skip to 9. 1❑ YesTzC

4. Hava any of your Cbrothara /(or} siatersl ever baan 4.}

zi3N0(9)

diagnosed by a doctor aa having cancer? 9UDK

Ts. Whatare tbfirst nameaofyour brotierS/(Or) SiSt@rS] 6.44

who had cancer?Name

Record each person in 8 separete column Sex: sex: NameI ❑ Mele I ❑ Male

Anyone else? 2 ❑ Female 2❑ Female

sDDK 9DDK

Ask 6– 8 for the first person listed in 5 before asking 6 – 8 4s-47 TEzfor the next person.

(6c)

6a. Whatkhtdo fcancard Id(rtamein5)hava? 6a.

— (6c)

7990 DK {6b) 7s9❑ DK (6b)————————____________________________ -.—- ________________________ ________________ ,______

b. What part of tha body was affected? b.

❑ DK ❑ DK------- —-------- —- ——— ———-------— —--- ---- ..-- —------ ———-— ——— ---- ----——————----—- ..-

C. Did Jnarrre in 5) have any other kind of canoer that was c. E1UYes 48 I ❑ Yeadiagnosed by a doctor? 2tl N0

}

ZDNO

9CIDK “~ 9nDK}

(7)

-.-- _-__ --- —---- _-_ ——— ——-— ——— ——— —--- -.-— .. — ---- — ----------- —___ ________________ ------d. The H Rsr tlma [ha/ahal was dlagrtoaed with cancar. d. 0000 Same as 6a/b (7) 4e-61 000 ❑ Same as 6a/b (7) e

what kind of cancar was it?

---– __–_________– ___________ _____ –____ –––___.:_(:_

(7)7aau DK (6e) 7s90 DK (6e)

____________________________________& What part of the body waa ●ffacted? e.

❑ DK ❑ DK

T. How oid was (nama in 5) when cancar was first 7. 162-63 -lzEzdiagnosed by a doctor? Age Age

se ❑ DK w ❑ DK

8ii. In what year was (name in 5) born? 8a.154-57 -El

— Year — Year

9999n DK s999❑ DK----- ——-— ——— ——----- ——— ———-—----. --— — --—- -. —---------- —— ---- —-—. ------ — —-------- ..-If known, mark without asking. 1❑ Yes W/l) 58 1 ❑ Yes (f%WJ E

b. IS (name in S)sti[i iiving? b. 2❑ No (8c) 2 ❑ NO (8(2)

90DK /HHIJ 9 !d DK (i-fHI)—————_______________________________ ____ _______ ___ __, -_ ___

cm At what age did (name in 5) die? c. 69-60 m!Age Age

99 ❑ DK 99 ❑ DK

61

HHI 1❑ Additional siblings (6)’T

Rafer to entries in 5. HH1 1 ❑ Additional siblings (,6)

2 ❑ No more siblings (9) 2 ❑ No more siblings (9)

Notes

50

Section HH – FAMILY HISTORY OF CANCER - Continued

Vead to respondent: Those quaatlosrs ●. ●bout your natural or birth ohildren. Do not includa any childran for whom you are an adoptivo,atap, or foatar parant.

OQU None123-24

aa. How many daughtare do you hsve, Including 9s. I●ny that may have died?

Daughters

990 DKI

—-------- ——-— ————- ——----— . ----- —---—- --- .- —- ——-— ——-- —___________________________b. How many sons do you have, inciuding ●ny b. son None Q

that may have died?Sons

990 DK

If “None” in 9a and 9b, sk;p to section ]1. 1 ❑ YesI 27

0. Havm ●ny of your children ever been diagnoaed 10.20No

}{15)

by ● doctor ●s having cancer? 9DDK

1. What ●ra the first namas of your chiidren who had 11,/2S–3S I 64-s1

csncsr?

Record eech person in a separate column sex Namesex:

Name

Anyone ●iee?I ❑ Male I ❑ Male

2 ❑ Femala36

2 ❑ Female 62

Ask 12– 14 for the first person fisted in 11 before asking ]37–39

12-14 for tha next person.

163-65

(12CI (12C]

242. What kind of cancer did (name in 11) have? 12a. 799 ❑ DK (Izb) 799 ❑ DK {t2b)—- —-------------- —--- —---- —- ——————--— --— --—————--—--—-------—- .—--—-— -___ —___________

b. What part of the body was affected? b.

❑ DK ❑ DK

------- —----- —-- —--------- ——— —------- -—- ------- — --—--—--- ----- ---- —- ——— —— —--—--—

C. DidJnmns h 11) have any othar kind of cancar that was c. 1•1 Yes 40 mdiagnoaad bys doctor?

1 ❑ Yes2DN0

}

2DN0

90 DK “3) )9 ❑ DK (13)

----- —- —— - —-- — ------ — -------------- —- --- --- — —--- —-------- -—-— .- —-- —- —— —________ ___

d. The FIRST tima ihe/ahel was diagnosed with cancar, d. 000❑ Sarnnaa12a/b (13) 4’-43 000❑ Sameas 12a/b (13)*9

what kind of csncer waa it?(13) (13)

788 ❑ DK (?28) 7aa ❑ DK i12e)—-- —-------------- —---- —---- —-—------ --- --—-----—--————--—-——— -— —____________________

a. Whet part of the body was dfaotad? e.

❑ DK ❑ DK

% How old was (neme in 1 l[when cancar was first 13. 144-46 ~

diagnosed by ● doctor? Age Age

a9 ❑ DK 9a ❑ DK

14a.I46-49 I 72-7a

— Year — Yeaf

d& in what year waa (neme in 71) born? 0890❑ DK 9999 ❑ DK----------- —-- —- ———---------- ————————--- . --------- —--—--- ----- - _ -- —_____________If this child in household, mark “Yes” box without , ❑ Yes H+2) 50 I ❑ Yes 0+/+2) -ECasking.

b. is (name in 17) stili living?b. z ❑ No (14ct z ❑ No (74c)

~ ❑ DK (HH2) ~ I_J DK (HH2)-- —--- —---------- ————------------ —---- --- ----------- ——-— ———--- __________________

C. At what ●ga did (name in 11) die? c. 61-62 EAge Age

ae ❑ DK 99 ❑ DK

I

IiH263 7s

Refer to entries in 71. HH2 1 ❑ Additional children (12) 1 ❑ Additional children (72)

2 ❑ No more children (15) 2 ❑ No more children (?5)

~otes

I

51

_ERT 88

3-4

Section HH – FAMILY HISTORY OF CANCER — Continued

15. HIM the natural [father/mother] of [any of your (other)chlldrardyour child] ever been diagnosod by a doctoras having cane.r?

16a. Wtmt ISthe [father’e/mother’s] name?

--------- ..________ —_———————_________b. 1sh8 eln 16a/ tfw [father/mothar] of ●ll your

(othelchildren?

I Ya. Whet kind of aartoardid (name in 768) have?

--- —————————————————_________________b. What part of tha body was ●ffected?

--- —___—_____________________________C. Did (name in 1 Ba[hava any other kind of cancer that

was diagnosed by ● doctor?

-_- ——________________________________d. Tha FIRST time Umfshs] was diagnosed with cancar,

what kind of cencor was it7

.——___________________________________

0. Whet part of the body was affected?

[s. How old waa (rrwneh 76a)when cencar was firstdiagnosed by a doctor7

I Sa. In what year waajnama in 76a) born?

_--- —-———____________________________If person in household, mark “Yes” without aakkrg.

b. la (name in 16a) still living?

-————————~___________________________c. At what age dld (name in 16a) die?

Zoa. HOW many children did you ●nd Iname in 16a) hevetogethar, including ●ny that may heva died?

_- ———-————___________________________b. HOW many of thasa children are sons and how many

are daughtsre7

—————————____________________________C. What are the childrarfa first names?

HH3 I Refer to 16b.

6.

—

Ea.

-.b.

7a,

.—.b.

--c,

--d.

.-.e.

B.

z—-b.

—-C.

—Oa.

--b.

.—-

C.

H:

1 ❑ Yes ----me213N0

}~ ❑ ~K (section Z/

Name-- ——— ——— —______________________________

1n YEIS EL

(?7C)799 ❑ DK (17b)——— —— — _____________________________________

❑ DK,------- —— — _____________________________

1 ❑ Yes E

2DN0

}go DK “8)

—————__________________________________000 ❑ Same as 17a/b (18) E

(18)Y99D DK (1 7e)

— Year

9999❑ DK——— ——__________________________________

E1 ❑ Yes (20)2 ❑ No (19c)

9 u DK (20)

,————————_______________________________iz32

Agee9 ❑ DK

No. of children

___________________________________________

No. of sonsE

No. of daughters=

____________________________________________

First name

First name

First name

First nsms

First nsme

First name

First nsme

first name

, ❑ “No” in 16b {15) E

9 ❑ “Yes” in 16b (sectionm

52

Section KK - HEIGHT, WEIGHT, RELATIONSHIPS, AND SOCIAL ACTIVITIES

1.I

About howtsll ara you without shoes? @-I Feet

IInches

t

2. M20ut how much do you weigh without shoes?/

~

IFounds

I

3. When you walghod the moat, how much did you I p3&

weigh (not including pregnancy)?I

IPounds

I

Thasa naxt questions are ●bout social ●ctivitks ●nd I ~relationships.

/— Friands

4a. (Not Including your hdmnd/wifal)Of all your friends, how many are them that you can talk i oon Noneto ●bout prlvata mattwa or can 0s11on for help? /-------- —--— --------------------------------- ----— --—-- —-—— __________________________

b. (Not Includlng your Ihusbend/wffe])tI E

How many rslativaa do you have that you can talk to●bout prhrata matters or can call on for help? i Relatives

WU Nons- .----- —____________________________________ ;–______If None in 4a and 4b, skip to 5.

I -----------------–-–------------------E

c. How many of thasa frlands and rdadvas do you see or l— Friends and relatives

talk to at least once a month?II ooa Noru

6a. How oftan do you participate in or attend group I &

meetlngc or activ[tiae, for exampla, social clubs, PTA, I

{

2❑ Week

●porthw ●vants, church groups or other community l— s ❑ Month

service groups? Tims.spar4 •l Yesr

1 NH Never--------------------------------------------------------------------------------------------- --b. HOW oftan do you go to church, tampla, or other Es2religious Scrvloas? I

I{

2 ❑ Week

3 ❑ Monthlimes per

4 •l YesrI w&! Never

Section BB - FOOD FREQUENCY - Continued1

k8. Pie? I

I

I {

I ❑ Day 16’3-69 Small, medium or large? 70

2 ❑ Week1—

Times par3 ❑ Month 1 ❑ Small4 ❑ Year 2 ❑ Medium (1 med. slice)

1 00W ❑ Leaa then 6 n year 3 ❑ Large

! or never (49)

1$). Doughnuts, COOIA8, cake or paatry? I

I

I {

I ❑ Day \71 -74 A ~dum .am[ng i. 1 76

2 ❑ Weekpiece or 3 cookies

] Timesper3 ❑ Month4 •1 Ymlr

I ❑ Small2 ❑ Medium (1 piece or 3 cookies)

0000 ❑ Leee than 6 a yeer 3 •l LargeI or never (50)

; O. Chocolate candy? I

I {

I ❑ Dey 176-79 ---TzE

2❑ Week;_____ 3 ❑ Month

I ❑ SmallI Times~r

d ❑ Year 2 ❑ Medium (1 oz.)3 ❑ Large

ooca❑ Lessthan 6 a yearI or never (5 f )

j 1. Sugar In coffee or tea or on cereal? I

I

I {

I ❑ Day 181-84 ~

2 ❑ WeekI 3 ❑ Month

1 0 SmallI Times per

4 El Year2 ❑ Medium (2 t6p.)3 ❑ Large

0000 ❑ Less then 6 e yearI or never (52)

j 2. Whole milk or drinks msde with whole milk, not including on1

I

I {

I ❑ Dey ]86-89 &

cereel? I’m going to ask ●bout 1%, 2% and skim miikseparately.

2 ❑ Week

l— 3 ❑ Month1 •l Small

Timasper4 •l Year

2 ❑ Medium [B oz. glessll3 ❑ Large

0000 H Less than 6 a yearI or never (53)

53. 2% miik or drinks made with 2% miik, mrt including on ceraal? ~

I

~{

1❑ Dey ]91 -s4 &

2 ❑ Waak 1 •l Small3 ❑ Month

meaper 2 ❑ Medium (8 oz. glass)4 El Year 3 ❑ Large

0000 ❑ Leas than 6 a yearor never (54)

64. Skim miik, 1% milk or buttermilk, not inciuding on camel? I

I

I {

I ❑ Day ]96-09 ---lZZI2 ❑ Week

I 3 ❑ Month1 ❑ Small

I Timesp.9r 2 ❑ Madium [8 oz. glaas)4 •l Year

3 ❑ Large0000 ❑ Leas than 8 a year

I or never (55)

S5. Milk or cream in coffee or tea? I

I

I {

I ❑ Day ]101-1 04

2 ❑ WeekI_ 3 ❑ Month

i ❑ SmallI Timesper

4 ❑ Year2 ❑ Medium (1 tbs.)3 ❑ Larga

0000 ❑ Leaathan 6 a yearI or never (56)

66. Soda or soft drinks with sugar? I

I

I

~{

1❑ Day ~lo8-1 0s ~

2 ❑ Week1 ❑ Smail

3 ❑ Monthlinesper 2 ❑ Medium (12 oz.)

/4 ❑ Yeer

3 ❑ Large

i0000❑ Leas than 8 a year

or never (57)

5711. During thn paat year or ●o, how often did you I 001t❑ Everyday/deily &

drink bear? I

I ‘{

2 ❑ Weak

/ Imesper 3 ❑ Month4 •l Yaer

00C0 ❑ Never (58).---------------------------————----————-------

b. On the days you drank bear, how many cans, bottles+----- ------------------------------------------- ----

w glasses did you drink?I Elk!!

I Number

89 ❑ DK-----------__----------------------____--------:_______________________________________________ ----c. Wem they small, medium, or large?

I 1❑ Small Cx2 ❑ Medium (12 oz.)

I3 ❑ Large (16 oz.)

Notes

54

“, -J.

Section BB – FOOD FREQUENCY - Continued 3-4

58a. During tho pa;t year or CO,how oftrm did you drink wine?1I s-a

0011❑ Everyday/daily

{

2 ❑ Week

3 ❑ Month‘rimas par 4 ❑ Yeer

0000 ❑ Never (59)---—— ____________ ~ ______________ :

b. On the days you drank wine, how many glasses did you drink? , m

/ Number

99 ❑ OK

-----------------------------------------------+_____________________________________________C. Were thay small, medium, or large? 1❑ Small

mI

2 ❑ Medium (1 med. wine glaas)I

3 ❑ large

bs%. During thopastyaarorso, howoftandid youdrinkliquor? I

I 001I ❑ Evarydey/daily

1I

I{

2 ❑ Weak

3 ❑ Monthi Tlmss par 4 •l Year

woo ❑ Never (F30J______________________________________________

b.’ Onthedaysyou dmnkliquor,h owmenydrinked idyouhave? ~- --------–-----------–-----------------------e

I Number

-----------------------------------------------l____________________________________________UBUDK

C. Warethaysmall, madium, orlarga? ICI Small -

{ 2D Medium(lshotl

3D Large

60a. Waethareevaraperiodinyourlifawhenyou drankfive 1❑ Yesor more drinke of any ●lcoholic bevoraga aimost averyday? 2DN0

}

(61)9nDK

-----------:------:----------------------------+-------------------------------------------- ––-b. Forhowlongdldthatpcrmdlast7

I

I

[ {

I ❑ Deys e

2 ❑ Weeks

Numbsr30 Months

4~ Years

/9999U DK

I61. Whanyouaatchickrmorotharpoultry,howoften doyoueetit / 1❑OftenOralways

withtheskin on?Wouidyou aayoften.sometimae, rarsdyor 2US~~etiMa~nevar? / 3 ❑ Rsrely

4 ❑ Ne”arI

O ❑ Don’t eat chicken or poultry,

~z. Whanyoueat redmemt, howoftendo youeatthafat?Would ~ 1 ❑ ofts~~relways ~

you eay often, eometimaa, rarely or naver? 1 2 ❑ SOmetimes

3 ❑ RarelyI

4H NeverI

o ❑ Don’t eet red meat

63a. Onmostweekdaya, howmany maalsdoyouusuelly on Lessthanones dayeataach day?

— MealseaDK

--------------------------------------------___+_______________________________________________b. Onmostweekdaya,howmanysnacks doyouusually o ❑ Less than one a day E

aateachday, includinganacka aftcrdinner? I

I— Snacks

9CIDK---— __________________________________________

C. 0nmo8t Saturdtsya or Sundaya, howmanymealsdo+----- --——— ____________________________________I on Less than oneadsy E

You usually eat aach day?I Meals

-------------___________________________-------~--________9_q_D_K________________d. OnmostSaturdayacrSundays, howmanysnacksdoyou on Lessthanone a dayI l_z!-

ueuaily eat aach day?I — Snacks

9UDK1

54. Inatypical week, howmany mealadoyou usually gatin 00❑ Lessthenone a week *

restaurants, cafeterias, or fast food placaa?— Meals

99ci DK

FJotes

J

,

i

i

55

,

Section S — CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued_——-.—. — —I

ja. Have YOUmm’ had a Pap smear where the results I I 43I ❑ Yes

were NOT normal? I 2DN0

}(s3)

9CIDK

---------_____.________.___________.------.--L--------------------------------------------T2T--

b. Becauseoftheabnormalresults, didyouhava 1 ❑ Yesany additional tests7 I

2DN0I 90 DK

——— —------- ———--—---------- ——----— —————------ &----- -—- ——--— —------------ —————— ——----— ————- ——--

c. Baoause of tha abnormal reaulta, did you have I 1 •l Yes

any surgery or othar traatmnnt?

---------------------------------------------:---------------------------------------------

______________________.____________._-------:i-_______E}r----___-----------------._~:

d. Did the [Pap smeadaddkionel testehurgery o?’othertmatmentl indicata that you had cancer?

e. When were you diagnosed as having cancar?

I

I

I {

47-60

1 ❑ Days ago

~L OR 2 ❑ Weeks sgo

ma. yeer 3 ❑ Months ago

4 ❑ Yesrs sgo

999n DKII

I --E

S3 ~8f~ft01C8d ff.I ❑ More than 3 years in lC or 1f (6)

I B ❑ Other (7)

I6. What in the most important reason why you have [never had a I

p5-56ooDProcrastinated/Put itoff

Pap smear/not had a Pap smaar in the past faw years]? 01❑ Had a hysterectomy’ (8)I

02❑ Didn’t know I shouldI 03 H Not needed/not necessary

I 040 Coattoomuch

OSU No insurance covarageI

oe ❑ Don’t go to doctorsI .37❑ Don’t have a doctor

1 08 D Not recommended by doctor/Dr. never said it was needed

09 ❑ Dr. said it wasn’t naededI

Ion Too embarrassing/ I t ❑ Haven’t hed any problems

I 12 ❑ Fear

aan OtherI

990 OKI

73S. Doyouhavamenstrualperlods?I

I ❑ Yes (8) z

I 2 ❑ NO (7b)I

3 ❑ Never had menstrual periods (7c)

__________________________________________-__}_____________________________________________ ---–b. Did they stop due to ●urgary? I

}

12XL1❑ Yes (8)2DN0

--___________--——-—-———-------______---..—_____ ;–––––––––.––-–––––.––-–---------––-–––––––..-C. Wasthlsduetosurgary? -EEC

I 1 ❑ Yes

2DN0I

8a. Doyouknow howtoexamlnayourown breaetsforlumps? I I 601❑ Yes

I 2 ❑ No (S4)

-———————————————————__—_———_——————-——--------

b. Abouthowoften doyouexambroyourbreastsforlumps?&-––– ———————--—-———-———————————————---------1I

I

I{

-E&2

——-

I ❑ Day

2 ❑ Week

3 l_’J MonthTimes per 4D Year

II ~00 ❑ NevarI EBBEl Other (Specify) ~

II

I awo DK_—— ——________________________________________

C. Whotaught youhowto axamina your breasts?;---–––_–—– ——_———_________________________________ .I 1❑ Doctor

I

I

1

I

I g

64

lo NWW 65

Mark all mentioned, do nor probe. l’d Other health professional 66

In l.aar”ed ina class/meeting 67

lo Read in a book, pamphlet, magazine, etc. 66

10 Television 69

lD Other fSpecify)~ 70

I

IKIDK 7% ]

56

Section S — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued8I

S4I-?L

I ❑ Under 40 (39)Refer to age. I 2 ❑ 40 and over (9)

$3a.Abreastphysicalexem h when the breast Is felt for lumps ~ 1❑ Yes@

by ● dootor or madicsl assistant. Have you war hoard of abraaat physical examination? I }

‘nNo (15)8DDK

.---— ---- —-__. ___ —- —--— --—- ———________--— -_b. Havs you ●ver had a breast physical axam?

#---–.___-–- ——-—--- __---- —- —-_ —-- ——---— -----1 I •l Yes E

! 2DN0 (f4}I 9CIDK (15)

__________________________________________________________________________________________C. When did you have your last braast physical exam? I

I

I

I{}

I ❑ Days ago E

;~19 —OR—2 ❑ Weaks ego /f 3 years ago or less (10)

mo. year 3 ❑ Months ago If more than 3 years ago {12]

4 •l Years ago

99s ❑ DK fWf)-------------------------------------------A--------------------------------------------- Z?ZF

d. Was it within the past year or a year or more ago? 1❑ Wthin past year (9e) E 82s ❑ DK (72)I

2 ❑ 1 year or more (9fJ________________._______________--_______---;_____________________________________________ ____

e. Was it lass than thraa months, or 3 or more months ego? I ❑ Lees than 3 months1P_i1 2 ❑ 3 or more months (10)

sDDK

-------------------------------------------4--------------------------------------------f. Was it 3 years ago or less, batwaerr three end 5 yaara, or 1❑ 3 years or less (10) E

5ormoreyears ago? I

I 12 ❑ Between 3 and 5 years

3 •l 5 or more years(?2)

/ 9EIDK

o. Wherewasthis examdone— In a doctor’s office, a clinic, 1

● hospital, or some other p[eca?I 1D Doctor’s office

2 ❑ ClinicI

3❑ HospitalI 8 ❑ Other place (Specify) ~

I

I anDK

1a. Oid you go for your last breast physicel ●xam because Iofahaalthproblem ?

1•l Yes&

I 2DN0

}(1 Tel

9UDK--__— _______________________________________

b. What was the problem?;_____ -_-___--—_____—— ________________________ ___

I ❑ Follow-up tests/treatment

I

I

I

I

E

87

1 IJ Soreness 88

Mark all mantioned, do not probe.1❑ Swelling ao

I ❑ Lumps 90

1 ❑ Pain 91

I ❑ Oischarge 92

I ❑ Complications related to breast feeding 9s

1❑ Unrelated medical problem 94

I ❑ Other 96

lDDK--—--— ______________________________________

c. How worn you told the rasults of the test — in person,+—–————–—–––—--–—–——-.---—-—_—_________________I 10lnpersOn &

ovarthatalephona, through the mail,orsome otherway?

2❑ Telephone

3 ❑ Through the mail

4 ❑ Combination of methods

S❑ Never told: meaning results normalI

6 ❑ Never told; DK if problem

I a ❑ other1

S5lE!Yes (?3)

~

Refer to 1 la. 2DN0

9DDK}

(12)

‘Za. HaveyouEVERhada breaatphysicaI exambaoause I 1EIYesof a health problem?

~

I 2DN0I

)sDDK ’13}

b. ~6;;k~;~h-e-~r~L6&2-------------------------------------------------------------------------------1❑ Follow-up tests/treatmant

II

I

II

E

100

1❑ Soreness 101

Mark 811mentioned, do not probe. lCISwelling 102

t ❑ Lumps 103

1 ❑ Pain 104

I ❑ Discharge 106

I ❑ Complications related to breast feeding 106I ❑ Unrelated medical problem 107

I ~ Other 108

IHDK 109I

57

rrr 70

Section S – CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued 3-4

Is~. Have you ever had a breast physical exam where the I 1❑ Yes

5

results were NOT normal? I2UN0

I 1(S6/tJa DK

——————————————----- —-—————————————.. ——b. Because of the abnormal reqrlts, did you have

.------i --------------------------------------------1❑ Yes r

any additional tests? I2Q No

I 9nDK——————————————--— ——————————————————————..———--- +-------

c. Because of the abnormal results, did you have ---;HV:;------------------------------=

any surgery or other treatment? I 2DN0

I enDK---------------------------------------------+---------------------------------------------

d. Did the [breast physical exam/additional testsknrrgery or 1 El Yesother treatmantl Indicata that you had cancer? I

2DN0

I 1(S6)sDDK

___________________________________________--+_____________________________________________ ----e. When were you diagnosed as having cmrcw? I

I

I

I {

II?_zlzI ❑ Daya ago

~H_- OR2 ❑ Weeks ago

mo. year 3 ❑ Months ago

4 ❑ Years ago

I 999 ❑ DKI mI

S6 Refer to 9C and 9f.I ❑ More than 3 years in 9C or 9f (74)

ISD Other (16)

I

la. Whatisthamoatimportantresson whyyouhave[neverhads ~breaat physical exem/not had a breast physical axam in the 00❑ Procrastinated/Put it off

past few ysarel by ● doctor or other health professional? I 01 ❑ Didn’t know I should

020 Not neededlnot nacassaryI03❑ Cost too much

I04❑ No insurance coverage

I os~ Don’t go to doctorsI

06❑ Don’t have a doctorI07❑ Not recommsndsd by doctor/Dr. newer said it was needed

IDe❑ Dr. said it waan’t needed

09❑ Too embarrassing

I o❑ Haven’t had any problems

11❑ Fear

12D Examine own breasts

LIEDOther

asa DK

dotes

Section S – CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued1 I .-

5a.

b.

c.

d.

e.

f.

HAND CARD S I

1A mammogram 1swhen max-ray is taken only of the breasts /by a machine that presaas ●gainst the braast whila thapictura ia taken. Have you ever haard of a mammogrem?

I

II

1 L Yeszfl No

}9nDK ’21) ‘

--- —________________________________________Have you ever had a mammogram?

;––––––––___ ----- —------------ —- ——-- .- ...--—----1 1lJYes E

/ 2c1No (20)I 9CDK (2?)

1

‘------------------------------------------- ;----------"----i:----:-ti;;y;:;;--------Whan dld you hsva your last mammogram?---—

IJ19 OR

i {}

2n Weeks agO If3 years ago or less (16)

mo. year 3 ❑ Months ago if more than 3 years ago (18)

4 G Years ago.1

----------------------------------__________i_______________________________ . _____________ ____

999~ DK (75d)

Was it within tha past ysar or ● yaar or more ago?I E

25-27

1 n Wtihin past year (75e) s Q DK (18)28

------––-–-_________________________-_-__-__:.-2 ❑ 1 year or more (15f)

Was it less than three months, or 3 or more months ago?------ —___________________ ___________________

I p Less than 3 months

)

F/ 2 ~ 3 or more months (16)

9CIDK--------------------------------------------+---- -------------------------------------- --- ----Wasit3years ●goorless,batwaan threeand5yaara, or I ❑ 3 years or lass (16) El.S or mora yaara ●go? 1

I)

2❑ BetWean 3 and 5 yearsI 3 •l 5 or more veara [18)II 9DDK - J

6. WItarawas thieteetdona -inadoctor'a offica, aclinic, ahospital, or soma othar place?

I I ~Doctor’soffiie @

I 2 El Clinic3~ Hospital

I 4 n Imaging center/x-ray laba❑ Other place (Specify) ~

I

I9DDKI

7tt. Didyougoforyour lastmammogram bacauseofa I

haalth problam?1❑ Yes

p

I7.

}‘No (17C)

eaDK

b.

c.

---______ —__________________________________ ~______________________ _______________________What waa tha problem? I I n Thickening

I

I E

33

1❑ Soraness 34Mark a\I mentioned, do not probe. 1❑ SweIling 35

I ❑ Lumps 36

1•l Pain 37

I ~ Discharge 38

1❑ Unrelated medical problem 39

1~ Other 4a

IDDK[-- ——------- —-- —-- —--- —--— ------ —-- —--— -—--—- ~--------- .-—- —________________________________ ____

How ware you told tha results of the tact — in person, Lover tha talaphona, through the ma[l, Or soma othar

1 1D In person

way? 2 ❑ Telephone, 3 ❑ Through the mailI

4 ❑ Combhration of methods

/ 6 ❑ Naver told; meaning results normala ~ Never told; DK if problema ❑ Othar1

I

S71❑ Yas (19) e

Refer to 17a. I 2DN01 9DDK }

(18)I

sa, Have YOUEVER had a mammogram baceusa of aI

health problem?I 1~ Yes 44

/ 20N0

}9UDK “g)

----- _—— __________________________________

b. What was tha problem?; ----–- ------- —____________________________________I 1❑ Thickening 46

Mark all mentioned, do not probe.1El Sorenass 4e1 •l Swalling 47

1❑ Lumps 48

1 !l Pain 49

I ❑ Discharge 50I I ❑ Unrelated madical problem 61

I ❑ OtherI 52

lDDK 63

59

Section S – CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued1

ga. Have you ever had a mammogram where the I -DC1 ❑ Yes

results were NOT normal? I ZDNO

}(s8)

9CIDK

————_——_-------------------------—-———- - ..-——-—————-- ————————-———————-——————- ------ -..————b. Because of the abnormal results, did you have

-----1 •1 Yes UC

any additional tests? II z~ No

9CDK-— ——— ——----— -— ——— —--- ——— ——— ———-—----- +----- ----- ——------— ——---— —.. -- ————————-------—

c. Because of the abnormel results, did you have 1❑ YesI~

any surgery or other treatment? I 2DN0

I 9CIDK—---- —- ————--- ——-— ————--- ——— ————- —————— ——-— —-

d. Did the [mammogram/additional tests/surgery or other● ---_ —.-_ ---- ___________ -----— -___ -___ —– ________

1~ Yes lz!ztreatment] indicate that you had cancer? 2~N0

}90 DK ‘s8)———------ ——-—————-—.------- ———--———————————- \.______ –---____ :------------------------------ ----

e. When were you diagnosed as having cancer?

I{

wI ~ Days ago

~~ OR 2 ❑ Weeks ago

moo yeer a C Months sgo

4 E Years ago

II 999D DK

p

I &

S8 Refer to ? 5C and 15f.I ❑ More than 3 years in 15C or 15f (20)

II 8 n Other (Z I )I1

!O. What is the moat important reason wh y you have [never hed a I&

00❑ Procrastinated/Put it offmammogramhtot had a mammogram in the past few yeersl? ~ 01❑ Didn’t know I should

I 02P Nat neededhmt necessary

03G Cost too muchI040 No insurance coverage

050 Don’t go to doctors

os ❑ Oon’t have a doctor

I 07 ~ Not recommended by doctor/Dr. never said it was needed

08 ~ Dr. said it wasn’t needed

09 ~ Too embarrassingI 10U Haven’t had any problamsI

t I ❑ FaarI 12 ❑ Fear of radiation

I 13 G Painful procedure

14 ~ Unpredictable resultsI

86~ OtherI 99m OK

Votes

Vital and Health Statisticsseries descriptions

SERIES 1.

SERIES2.

SERIES 3.

SERIES 4.

SERIES 5.

SERIES 6.

SERIES 10.

SERIES 11.

SERIES 12.

SERIES 13.

SERIES 14

Programs and Collection Procedures—Reports descnblng

the general programs of the National Center for Health

Statlst!cs and its offices and divtslons and the data col-

lection methods used. They also include defln!tlons snd

other material necessary for understanding the data

Data Evaluation and Methods Research—Stud!es of new

statistical methodology mcludmg experimental tests of

new survey methods, studies of wtal statlst!cs collection

methods, new analytical techniques, objectwe evaluations

of rel!abdity of collected data, and contributions to

statistical theory. Studies also Include comparison of

U.S. methodology with those of other countries.

Analytical and Epidemiological Studies—Reports pre-

senting analytical or Interpretwe studies based on wtal

and health statistics, carrying the analysts further than

the expository types of reports In the other series.

Documents and Committee Reports-Final reports of

major committees concerned with wtal and health sta-

tistics and documents such as recommended model wtal

registration laws and revised birth and death certificates.

Comparative International Vital and Health Statistics

Reports-Analytical and descrvptwe reports comparing

U.S. vital and health statmtlcs with those of other countnes.

Cognition and Survey Measurement— Reports from the

National Laboratory for Collaborate Research In Cognk

tlon and Survey Measurement using methods of cognltwe

science to destgn, evaluate, and test survey Instruments.

Data From the National Health Interview Survey-Statis-

tics on Illness, accidental Injuries, ct]sablllty, use of hos-

pital, medical, dental, and other serwces, and other

health-related topics, all based on data collected In the

continuing national household Interview survey.

Data From the National Health Examination Survey and

the National Health and Nutrition Examination Survey—

Data from direct examlnat!on, testtng, and measurement

of national samples of the cwlllan nonlnstltutlona llzed

population provide the basw for (1) estimates of the

medtcally defined prevalence of speclftc diseases In the

United States and the distributions of the population

with respect to physical, physlologlcal, and psycho-

logical characteristics and (2) analysls of relationships

among the various measurements without reference to

an expllclt finite unwerse of persons.

Data From the Institutionalized Population Surveys-Dis-

continued m 1975. Reports from these surveys are m-

includedIn Series 13.

Data on Health Resources Utilization—Statistics on the

utilization of health manpower and fac!llt!es prov[dlng

long-term care, ambulatory care, hospital care, and family

planning services.

Data on Health Resources: Manpower and Facilities—

Statistics on the numbers, geographic dlstr!but!on, and

characteristics of health resources Includlng physlclans,

dentists, nurses, other health occupations. hospitals,

nursing homes, and outpatient facilities.

SERIES 15

SERIES 16

SERIES 20

SERIES 21

SERIES 22

SERIES 23

SERIES 24.

Data From Special Surveys-Statistics on health and

health-related topics collected in special surveys that

are not a parf of the contmumg data systems of the

Natlonai Center for Health Statistics.

Compilations of Advance Data From Vital and Health

Statistics—These reports provide early release of data

from the National Center for Health Statistics’ health and

demographic surveys, Many of these releases are followed

by detsllad reports m the Vital and Health Statwtics

Series.

Data on Mortality-Various statistics on mortality other

than as Included !n regular annual or monthly reports.

Special analyses by cause of death, age, and other demo-

graphic variables; geographic and time series analyses;

and statistics on characteristics of deaths not availablefrom the vital records based on sample surveys of those

records.

Data on Natality, Marriage, and Divorce—Var!ous sta-

tistics on natallty, marriage, and dworce other than as

Included In regular annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses: studies of fertility; and statistics on

characteristics of births not ava[lable from the vital

records based on sample surveys of those records.

Data From the National Mortality and NataIity Surveys—

D]scontlnued ]n 1975. Reports from these sample surveys

based on vital records are Included in Series 20 and 21,

respectively.

Data From the National Survey of Family Growth—

Statwtlcs on ferwllty, family formation and dissolution,

family plannlng, and related maternal and infant health

topics derwed from a periodic survey of a nationwide

probability sample of women 15-44 years of age.

Compilations of Data on Natality, Mortality, Marriage,Divorce, and Induced Termination of Pregnancy—

Advance reports of births, deaths, marriages, and divorces

are based on final data from the Nattonal Vital Statistics

System and are published annually as supplements to the

Monthly Vital Statlstlcs Report (MVSR). These reports are

followed by the publ!catlon of detaded data in Vital Statis-

tics of the United States annual volumes. Other reports

Including Induced terminations of pregnancy issued peri-

odically as supplements to the MVSR provide selected

flndlngs based on data from the National Vital Statistics

System and may be followed by detailed reports in Vital

and Health Statlst!cs Sertes.

For answers to questions about thw repoti or for a list of titles of

reports published In these series, contact

Sclentlfic and Technical Information Branch

Nat!onal Center for Health Statistics

Centers for Disease Control

Publlc Health Service

Hyattswlle, Md. 20782

301 –436–8500

U.S. DEPARTMENT OF HEALTH ANDHUMAN SERVICES

Public Health ServiceCenters for Disease ControlNational Center for Health Statistics3700 East-West HighwayHyattsville, Maryland 20782

OFFICIAL BUSINESSPENALTY FOR PRIVATE USE, $300

BULK RATEPOSTAGE & FEES PAID

PHS/NCHSPERMIT NO. G-281

DHHS Publication No. (PHS) 90-1500, Series 10, No. 172

Vital and Health Statistics; Series 10, No. 172 (1/90) 10: Data From the National Health Interview...

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Transcript of Vital and Health Statistics; Series 10, No. 172 (1/90) 10: Data From the National Health Interview...