Breast cancer is the most common cancer and the second leading cause of cancer death among U.S. women [1]. In 2019, an estimated 268,600 new cases of invasive breast cancer and 62,930 new cases of non-invasive breast cancer were diagnosed in women in the U.S.; also, an estimated 41,760 women are expected to die from breast cancer [2]. Previous evidence suggested that the decrease in incidence and mortality rate was partially due to the extensive use of preventive mammograms, which offer early detection and treatment of breast cancer [3, 4]. The latest American Cancer Society breast cancer screening guidelines recommend that “women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so; women ages 45-54 should have yearly mammograms; and women ages 55 and older should switch to mammograms every 2 years or can continue yearly screening” [5]. However, getting recommended mammograms is one of the unmet health care among female caregivers [6]. Approximately 23.5% of female caregivers never received a mammogram, particularly [7, 8]. Notably, the difference in mammogram use behaviors between caregivers and non-caregivers is understudied.
Previous studies have reported relevant factors to mammogram use in both caregivers and non-caregiver. For example, age-related trends in mammogram use were observed in both caregivers and non-caregivers in previous studies [3, 9, 10, 11]. After 45 years of age, older women were more likely than younger women to have mammograms [9, 12]. Also, cancer beliefs played a critical role in using mammograms. Cancer-related fear was common, which significantly impacted women's mammograms use [15]. Caregivers tended to be more familiar with cancer than non-caregivers [13, 14, 15, 16, 17]. However, non-caregivers seemed to be more attentive to cancer-related self-care and perceive a higher risk of breast cancer than caregivers, which leads to mammograms use [16]. People who have family cancer history, and caregivers of cancer survivors have increased odds in receiving mammograms [18, 19]. In addition, depression is a risk factor for mammography underuse in general populations [20]. Women who are depressed are less likely to receive screening, and female caregivers are at risk of depression due to the heavy caregiver burden [20, 21].
Regarding caregiver-specific factors to mammography screening, previous studies showed mixed or limited results. For example, caregiver burden was identified as one of the barriers to screening [22, 23]. The authors proposed that caregivers who have caregiver procrastination and high burden may lead to less frequent breast examinations [23]; however, another study found no significant association [2]. Also, caregivers of cancer patients generally had an increased likelihood of receiving cancer preventive screenings [23, 24]. An increase of likelihood may be due to the high supply of cancer information from medical professionals, leading to increased awareness of preventive screenings [24]. In addition, financial matter was an aspect impacting mammography recipients [15]. However, no income-related disparities in mammography use have been observed between caregivers and non-caregivers in previous literature.
By using the Andersen’s Behavioral Model of Health Services Use [25], our study compared mammogram screening behaviors between caregivers and non-caregivers to examine (1) the levels of mammogram receipt, (2) the role of caregiving factors, and (3) the role of cancer beliefs on mammogram screening of caregivers and non-caregivers. The hypotheses were:
1 The likelihood of using a mammogram would differently associate with predisposing factors (age, education, and beliefs about cancer) between caregivers and non-caregivers.
2 The likelihood of using a mammogram would differently associate with enabling factors (income, confidence about getting health information, and caregiving burden) between caregivers and non-caregivers.
3 The likelihood of using a mammogram would differently associate with need factors (general health, depression, and family cancer history) between caregivers and non-caregivers.