Breast cancer in a county hospital population: Impact of breast screening on stage of presentation

Background: Indigent patients in a county hospital setting typically present with breast cancer at a later stage than do patients in the private sector. In the early 1980s, 50% of all breast cancers diagnosed in our county hospital were stages III and IV. This contrasted markedly with the findings of an American College of Surgeons study, which showed <15% of breast cancers diagnosed as stages III and IV. Methods: Recognizing this disparity, we instituted a breast screening project in the county teaching hospital targeted at women who routinely received medical care in the county hospital clinics. Between 1985 and 1992, 14,567 mammograms were performed. Results: Two hundred eighty-nine breast biopsies were performed and 76 cancers were identified (26%). Ninety-five patients advised to have surgical consultation for biopsy declined further evaluation. The stage distribution of cancers diagnosed was as follows: stage 0, 20%; stage I, 43%; stage II, 28%; stage III, 8%; and stage IV, 1%. This compares favorably with National Cancer Data Base statistics for 1988. In contrast, symptomatic nonscreened patients diagnosed at the county hospital in 1992 presented at a significantly more advanced stage: stage 0, 1%; stage I, 14%; stage II, 45%; stage III, 26%; and stage IV, 13%. Conclusions: Mammographic screening has lowered the stage of cancers diagnosed in the screened indigent population. However, a significant percentage of patients are presenting to our hospital with stage III and IV disease. Problems identified in the screening project included noncompliance with recommendations for follow-up of abnormal studies and noncompliance with appointments. In order to broaden the impact of our breast screening project, we have instituted outreach programs with community-based clinics and the American Cancer Society.