The Role of Physicians in Mammography Referral for Older Caribbean Women in Canada

Ilene Hyman, PhD; Mony Singh, BA; Farah Ahmad, MBBS, MPH; Marta Meana, PhD; Usha George, PhD; Lilian M. Wells, PhD; Donna Stewart, MD, DPsych

Disclosures
In This Article

Abstract and Introduction

Background: Despite the fact that the proportion of immigrant and minority women who consult a general practitioner about their health is similar to that of their Canadian-born counterparts, studies suggest that they are less likely to be screened for breast cancer. This study examines physician characteristics associated with mammography referral and perceived barriers to mammography among family physicians serving the Caribbean community of Toronto.
Methods: The study consisted of a mail-back family physician survey.
Results: Among the 64 physicians who responded to the survey, over half reported that they were "very likely" to refer women for mammography during a regular preventive check-up. Among physician variables, only the amount of time spent on patient education was significantly associated with the likelihood of referral. Regarding perceived barriers, for male physicians, patient refusal and intervention causing patient discomfort were significantly associated with referral. For female physicians, only forgetting to provide service was identified as a significant barrier to referral.
Interpretation: An increased emphasis on patient education may help to increase screening referral among all physicians. Gender differences in perceived barriers to referral suggest that the gender of the physician is of major importance to the Caribbean community.

Breast cancer is one of the most common causes of cancer among older women in Canada[1]; often, it can be detected at an early stage by mammography.[2,3] Many studies have highlighted the role of the physicians in determining whether a woman, especially an older woman, follows through with making an appointment, shows up, and undergoes the examination.[4,5,6] Despite the fact that the proportion of immigrant and minority women in Canada who consult a general practitioner about their health each year is similar to that of their Canadian-born counterparts,[7,8] national and provincial surveys suggest that they are less likely to be screened for breast cancer. Among Caribbean women in particular, studies suggest that older women (aged 50-69 years) are less likely to be screened for both breast and cervical cancer compared with the general population.[9,10,11,12,13,14,15] It is unclear why this is the case, but one area worthy of investigation in this population is physician referrals for mammography.

Physician variables associated with screening practice include gender,[16,17,18,19] age,[18,20,21] knowledge and attitudes toward screening,[22] preventive orientation,[23,24] and physician-perceived barriers such as "no reminder system" (ie, forgetfulness) and "priority must be given to presenting problem."[25] Among the studies that have examined physician gender, higher rates of screening and referral have been reported for female compared with male physicians.[18,19,26,27,28,29,30] However, it is unclear whether these differences can be explained by differences in physician or practice characteristics, such as number of patients seen per week and perceived barriers, or by higher rates of patient refusal when screening is performed or recommended by male doctors. Research suggests that female physicians are less likely to encounter patient reluctance in discussing gender-sensitive issues,[31,32] and this may indirectly influence the likelihood of mammography referral.

The specific objectives of this study were to determine physician characteristics associated with mammography referral and perceived barriers to mammography among family physicians serving the Caribbean community of Toronto. Particular attention was placed on the identification of gender differences in mammography referral and perceptions of barriers.

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