Research article
Breast and Cervical Cancer Screening: Specific Effects of Depression and Obesity

https://doi.org/10.1016/j.amepre.2009.10.039Get rights and content

Background

Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them.

Purpose

This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening.

Methods

A stratified sampling design was used to recruit women aged 40–65 years with information on BMI from an integrated health plan in Washington State in 2003–2005. A telephone survey included the Patient Health Questionnaire–9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged ≥51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests.

Results

In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model.

Conclusions

Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Introduction

Cancer is one of the leading causes of death among women worldwide.1 For cancers of the breast, cervix, and colon (three of the five leading causes of death by cancer worldwide), regular screening can reduce mortality.2, 3, 4 Unfortunately, screening participation is variable,5, 6 even in health systems with adequate resources.7 Emerging evidence links both obesity and depression with a lower likelihood of cancer screening. A recent systematic review8 of research on obesity and screening for cancer of the breast (ten studies) and cervix (14 studies) found the most consistent associations between cervical cancer screening and increasing BMI.

Findings have varied in the smaller number of studies that examined the relationship between cancer screening and depressive symptoms. One study9 found low rates of screening for breast but not cervical cancer, and two others10, 11 found low rates of breast cancer screening among women with depressive symptoms. One of these studies linked mood disorders with high severity, including depression (but not those that were less severe), to low screening rates for breast cancer.11 Conversely, another study did not link psychological distress to breast cancer screening.12 In addition, a study reported that younger depressed women were more likely, and older depressed women (aged ≥40 years) less likely, to report recent screening for cervical cancer, compared with nondepressed women.13

Lower rates of screening participation associated with obesity and depression are remarkable because both conditions are associated with increased use of medical services in general, for example, outpatient primary care and specialty care visits.14, 15, 16 This suggests that obesity and depression may affect patients' attitudes (e.g., body dissatisfaction) or providers' attitudes toward screening rather than reducing opportunities for screening to occur.

Few previous studies have considered screening for both breast and cervical cancer. None has examined the joint contributions of depression and obesity. Given the strong association between depression and obesity,17, 18 it is essential to examine their joint and separate effects on screening participation. This study was designed to examine associations of obesity and depression with receipt of breast and cervical cancer screening among women aged 40–65 years enrolled in a prepaid health plan with mailed screening reminders. It was hypothesized that depression and obesity would have specific associations with each type of cancer screening.

Section snippets

Setting

Women aged 40–65 years were recruited from Group Health Cooperative (GHC), an integrated prepaid health plan serving more than 500,000 members in the Pacific Northwest. During the study period, all women aged ≥40 years received mailed reminders for cervical cancer screening and all women aged ≥50 years received mailed reminders for breast cancer screening. Reminder intervals depended on personal risk and screening history, with a maximum interval of 2 years for breast cancer screening and 3

Unadjusted Associations Among Depression, Obesity, and Receiving Screening

Lower education, smoking, and depressive symptoms were associated with fewer Paps and mammograms received (Table 1). Increasing age, body dissatisfaction, and obesity were associated with fewer Paps only, whereas white and non-Hispanic race/ethnicity and never being married were associated with less mammography.

Among nondepressed women, the proportion of women receiving a Pap was 87% for non-obese women and 77% for obese women (Table 2). Among depressed women, 76% received a Pap whether or not

Discussion

To our knowledge, this study is the first to evaluate the relative contributions of both depression and obesity to both breast and cervical cancer screening in an insured population that received screening reminders. In a large population-based sample of middle-aged women, unadjusted analyses find that obesity and depression are each associated with low rates of cervical cancer screening, and depression is associated with low rates of breast cancer screening. Specific, distinct associations

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