ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 3, NO. 3 ✦ MAY/JUNE 2005
Breast and Cervical Cancer Screening:
Impact of Health Insurance Status,
Ethnicity, and Nativity of Latinas
PURPOSE Although rates of cancer screening for Latinas are lower than for non-
Latina whites, little is known about how insurance status, ethnicity, and nativity
interact to infl uence these disparities. Using a large statewide database, our study
examined the relationship between breast and cervical cancer screening rates and
socioeconomic and health insurance status among foreign-born Latinas, US-born
Latinas, and non-Latina whites in California.
METHODS Data from the1998 California Women’s Health Survey (CWHS) were
analyzed (n = 3,340) using multiple logistic regression models. Utilization rates
of mammography, clinical breast examinations, and Papanicolaou (Pap) smear
screening among foreign-born Latinas, US-born Latinas, and non-Latina whites
were the outcome measures.
RESULTS Foreign-born Latinas had the highest rates of never receiving mammog-
raphy, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively)
compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina
whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors,
foreign-born Latinas were more likely to report mammography use in the previ-
ous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of
health insurance coverage was the strongest independent predictor of low utiliza-
tion rates for mammography (odds ratio [OR] = 2.05; 95% confi dence interval
[CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90)
and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.)
CONCLUSIONS Breast and cervical cancer screening rates vary by ethnicity and
nativity, with foreign-born Latinas experiencing the highest rates of never being
screened. After accounting for socioeconomic factors, differences by ethnicity and
nativity are reversed or eliminated. Lack of health insurance coverage remains the
strongest predictor of cancer screening underutilization.
Ann Fam Med 2005;3:235-241. DOI: 10.1370/afm.291.
ment, and worse breast cancer survival outcomes.4,5 Latinas also experience
twice the incidence of cervical cancer compared with non-Latina whites.6
These disparities stem in part from infrequent screening practices for these
cancers. Previous studies suggest that Latinas face added challenges in
gaining access to needed preventive health services compared with non-
Latina whites because they are less educated,7-9 have lower incomes,7-9
have lower rates of health insurance coverage,9-14 and have limited English
profi ciency.15 Studies that examined utilization of cancer screening services
by nativity suggest that immigrants are less likely to receive a Papanicolaou
ancer is the second leading cause of death in the United States.1
Tragically, Latinas in the United States have greater proportions
of later stage breast cancer diagnoses,2-3 later initiation of treat-
Michael A. Rodríguez, MD, MPH1
Lisa M. Ward, MD, MScPH2
Eliseo J. Pérez-Stable, MD3
1Department of Family Medicine at the
David Geffen School of Medicine, University
of California, Los Angeles, Los Angeles, Calif
2Department of Obstetrics and Gynecology,
Center for Women’s Health, University of
California, Davis, Sacramento, Calif
3Division of General Internal Medicine,
Department of Medicine, Medical Effective-
ness Research Center for Diverse Popula-
tions, Center for Aging in Diverse Com-
munities, Comprehensive Cancer Center,
University of California, San Francisco,
San Francisco, Calif
Confl icts of interest: none reported
Michael A. Rodríguez, MD
David Geffen School of Medicine at UCLA
Oppenheimer Tower, Suite 1800
10880 Wilshire Blvd
Los Angeles, CA 90024
ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 3, NO. 3 ✦ MAY/JUNE 2005
LATINAS AND CANCER SCREENING
7. Calle EE, Flanders WD, Thun MJ, Martin LM. Demographic predic-
tors of mammography and Pap smear screening in US women. Am J
Public Health. 1993;83:53-60.
8. Frazier EL, Jiles RB, Mayberry R. Use of screening mammography
and clinical breast examinations among Black, Hispanic, and White
women. Prev Med. 1996;25:118-125.
9. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohammed ML. Use of
cancer screening practices by Hispanic women: analyses by sub-
group. Prev Med. 1999;29:466-477.
10. Kaplan RM, Navarro AM, Castro FG, et al. Increased use of mam-
mography among Hispanic women: baseline results from the NCI
Cooperative Group on Cancer Prevention in Hispanic Communities.
Am J Prev Med. 1996;12:467-471.
11. Coughlin SS, Uhler RJ. Breast and cervical cancer screening practices
among Hispanic women in the United States and Puerto Rico, 1998-
1999. Prev Med. 2002;34:242-251.
12. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Who gets
screened for cervical and breast cancer? Results from a new national
survey. Arch Intern Med. 1988;148:1177-1181.
13. Himmelstein DU, Woolhandler S. Care denied: US residents who
are unable to obtain needed medical services. Am J Public Health.
14. Selvin E, Brett KM. Breast and cervical cancer screening: sociodemo-
graphic predictors among Whites, Blacks, and Hispanic women. Am J
Public Health. 2003;93:618-623.
15. Ramirez AG, Talavera GA, Villarreal R, et al. Breast cancer screening
in regional Hispanic populations. Health Educ Res. 2000;15:559-568.
16. Chavez LR, Hubbel FA, Mishra SI, Burciaga Valdez R. The infl uence
of fatalism on self-reported use of Papanicolaou smears. Am J Prev
17. Hubbel FA, Waitzkin H, Mishra SI, Dombrink J, Chavez LR. Access to
medical care for documented and undocumented Latinos in a South-
ern California county. West J Med. 1991;154:414-417.
18. Pérez-Stable EJ, Otero-Sabogal R, Sabogal F, McPhee SJ, Hiatt RA.
Self-reported use of cancer screening tests among Latinos and Anglos
in a prepaid health plan. Arch Intern Med. 1994;154:1073-1081.
19. Goel MS, Wee CC, McCarthy EP, Davis RB, Ngo-Metzger Q, Phillips, RS.
Racial and ethnic disparities in cancer screening: the importance of for-
eign birth as a barrier to care. J Gen Intern Med. 2003;18:1028-1035.
20. Hiatt RA, Pasick RJ, Stewart S, et al. Community-based cancer
screening for underserved women; design and baseline fi ndings
from the Breast and Cervical Cancer Intervention Study. Prev Med.
21. Ramirez AG, Suarez L, Laufman L, Barroso C, Chalela P. Hispanic
women’s breast and cervical cancer knowledge, attitudes, and screen-
ing behaviors. Am J Health Promot. 2000;14:292-300.
22. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic
Disparities in Healthcare. Washington, DC: National Academies Press;
23. Martin LM, Calle EE, Wingo PA, Heath CW. Comparison of
mammography and Pap test use from 1987 and 1992 National
Health Interview Surveys: are we closing the gaps? Am J Prev Med.
24. Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM.
Unmet health needs of uninsured adults in the United States. JAMA.
25. Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R.
Progress in cancer screening over a decade: results of cancer screen-
ing from the 1987, 1992, and 1998 National Health Interview Sur-
veys. J Natl Cancer Inst. 2001;93:1704-1713.
26. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to
care, and use of preventive services by Hispanics: fi ndings from
HHANES 1982-84. Am J Public Health. 1990;80:11-19.
27. Suarez L. Pap smear and mammogram screening in Mexican-
American Women: the effects of acculturation. Am J Public Health.
28. Singh GK, Siahpush M. All-cause and cause-specifi c mortality of
immigrants and native-born in the United States. Am J Public Health.
29. Weinick RM, Jacobs EA, Stone LC, Ortega AN, Burstin H. Hispanic
healthcare disparities: challenging the myth of a monolithic Hispanic
population. Med Care. 2004;42:313-320.
30. Buekens P, Notzon F, Kotelchuck M, Wilcox A. Why do Mexican
Americans give birth to few low--birth-weight babies? Am J Epidemiol.
31. Fuentes-Affl ick E, Hessol NA, Perez-Stable EJ. Maternal birthplace,
ethnicity, and low birth-weight in California. Arch Pediatr Adolesc Med.
32. Borraya EA, Guarnaccia CA, Differences in Mexican-born and U.S.-
born women on Mexican descent regarding factors related to breast
cancer screening behaviors. Health Care Women Int. 2000;21:599-613.
33. Johnson HP & Hayes JM. The demographics of mortality in Califor-
nia. Calif Counts Pop Trends Profi les. 2004;5:1-18.
34. Hiatt RA, Pérez-Stable EJ, Quesenberry C, Sabogal F, Otero-Sabogal
R, McPhee SJ. Agreement between self-reported early cancer detec-
tion practices and medical audits among Hispanic and non-Hispanic
white health plan members in Northern California. Prev Med.
35. McPhee SJ, Nguyen TT, Shema SJ, Nguyen B, Somkin C, Vo P, Pasick
R. Validation of recall of breast and cervical cancer screening by
women in an ethnically diverse population. Prev Med. 2002;35:463-