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BACKGROUND: To explore contextual effects and to test for interactions, this study examined how breast cancer stage at diagnosis among U.S. women related to individual- and county-level (contextual) variables associated with access to health care and socioeconomic status. METHODS: Individual-level incidence data were obtained from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology and End-Results (SEER) program. The county of residence of women with diagnosed breast cancer (n = 217,299) was used to link NPCR and SEER data with county-level measures of health care access from the 2004 Area Resource File (ARF). In addition to individual-level covariates such as age, race, and Hispanic ethnicity, we examined county-level covariates (residence in a Health Professional Shortage Area, urban/rural residence; race/ethnicity; and number of health centers/clinics, mammography screening centers, primary care physicians, and obstetrician-gynecologists per 100,000 female population or per 1000 square miles) as predictors of stage of breast cancer at diagnosis. RESULTS: Both individual-level and contextual variables are associated with later stage of breast cancer at diagnosis. Black women and women of "other race" had higher odds of receiving a diagnosis of regional or distant stage breast cancer (P <0.0001 and P = 0.02). With adjustment for age, Hispanics were more likely to receive a diagnosis of later stage breast cancer than non-Hispanics (P <0.0.001). Women living in areas with a higher proportion of black women had greater odds of receiving a diagnosis of regional or late stage breast cancer compared with women living in areas with the lowest proportion of black women. The same was noted for women living in areas with intermediate proportions of Hispanic women (age-adjusted odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92-0.97]. Other important contextual variables associated with stage at diagnosis included the percentage of persons living below the poverty level and the number of office-based physicians per 100,000 women. Women living in counties with a higher proportion of persons living below the poverty level or fewer office-based physicians were more likely to receive a diagnosis of later stage breast cancer than those living in other counties (P < 0.001). In multivariable analysis, residence in areas with a higher proportion of non-Hispanic black women modified the associations of age and Hispanic ethnicity with later stage breast cancer (P = 0.0159 and P = 0.0002, respectively). CONCLUSIONS: This study found that county-level contextual variables related to the availability and accessibility of health care providers and health services can affect the timeliness of breast cancer diagnosis. This information could help public health officials develop interventions to reduce the burden of breast cancer among U.S. women.

OBJECTIVE: We examined how predisposing, enabling and reinforcing factors influence mammography referrals by primary care physicians (PCPs). METHODS: Using the 2001-2003 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys, we identified visits to office (n=8,756) and outpatient (n=17,067) PCPs by women≥40 without breast symptoms or breast cancer. We examined mammography referrals by predisposing (age, race, ethnicity, education, chronic problem), enabling (income, payer, visits within 12 months, time with physician), and reinforcing factors (physician age, gender, specialty/clinic, PCP status, region, MSA, solo/group practice). Gender, specialty, physician age, time with physician and solo/group were only in NAMCS. Clinic type was only in NHAMCS. We fitted logistic regression models adjusted for all factors and year. RESULTS: Office-based referrals were more likely during visits: for preventive or chronic care; with private payer vs self/uninsured; by women with no visit within 12 months vs≥3; lasting≥15 minutes; to female PCPs; to PCPs aged ≥45; to gynecologists. Outpatient referrals were more likely during visits: by Hispanics; for preventive or chronic care; by women with no visit within 12 months; to one's own PCP; to gynecologic clinics; in the Northeast or Midwest. CONCLUSIONS: Reinforcing factors, in addition to predisposing and enabling factors, are associated with mammography referral. Interventions to increase referrals should consider provider factors and aspects of the healthcare environment, and recognize differences between settings. Efforts to facilitate referrals during chronic care visits or outpatient visits to non-PCP providers may provide opportunities to increase screening. Efforts are needed to ensure that uninsured women are receiving appropriate referrals.