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Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

  • Alex J. Mitchell (a1), Isabel Espirito Santo Pereira (a2), Motahare Yadegarfar (a2), Shingai Pepereke (a2), Vongai Mugadza (a2) and Brendon Stubbs (a3)...

There is a higher mortality rate due to cancer in people with mental illness and previous work suggests suboptimal medical care in this population. It remains unclear if this extends to breast cancer population screening.


To conduct a systematic review and meta-analysis to establish if women with a mental health condition are less likely to receive mammography screening compared with those without mental ill health.


Major electronic databases were searched from inception until February 2014. We calculated odds ratios (OR) with a random effects meta-analysis comparing mammography screening rates among women with and without a mental illness. Results were stratified according to primary diagnosis including any mental illness, mood disorders, depression, severe mental illness (SMI), distress and anxiety.


We identified 24 publications reporting breast cancer screening practices in women with mental illness (n = 715 705). An additional 5 studies investigating screening for those with distress (n = 21 491) but no diagnosis of mental disorder were identified. The pooled meta-analysis showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66–0.77), mood disorders (OR = 0.83, 95% CI 0.76–0.90) and particularly SMI (OR = 0.54, 95% CI 0.45–0.65). No disparity was evident among women with distress alone.


Rates of mammography screening are lower in women with mental illness, particularly women with SMI, and this is not explained by the presence of emotional distress. Disparities in medical care due to mental illness clearly extend into preventive population screening.

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Corresponding author
Dr Alex J. Mitchell, Department of Psycho-oncology, Cancer and Molecular Medicine, University of Leicester, Leicester LE1 5WW, UK. Email:
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1 Thornicroft, G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry 2011; 199: 441–2.
2 De Hert, M, Correll, CU, Bobes, J, Cetkovich-Bakmas, M, Cohen, D, Asai, I, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011; 10: 5277.
3 De Hert, M, Cohen, D, Bobes, J, Cetkovich-Bakmas, M, Leucht, S, Ndetei, DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011; 10: 138–51.
5 Lawrence, D, Hancock, KJ, Kisely, S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013; 346: f2539.
6 Nielsen, RE, Uggerby, AS, Jensen, SOW, McGrath, JJ. Increasing mortality gap for patients diagnosed with schizophrenia over the last three decades – a Danish nationwide study from 1980 to 2010. Schizophr Res 2013; 146: 22–7.
7 Stubbs, B, De Hert, M, Sepehry, AA, Correll, C, Mitchell, A, Soundy, A, et al. A meta-analysis of prevalence estimates and moderators of low bone mass in people with schizophrenia. Acta Psychiatr Scand 2014 (doi: 10.1111/acps.12313).
8 Mitchell, AJ, Malone, D, Doebbeling, CC. Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies. Br J Psychiatry 2009; 194: 491–9.
9 Lord, O, Malone, D, Mitchell, AJ. Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis. Gen Hosp Psychiatry 2010; 32: 519–43.
10 Mitchell, AJ, Lawrence, D. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. Br J Psychiatry 2011; 198: 434–41.
11 Aggarwal, A, Pandurangi, A, Smith, W. Disparities in breast and cervical cancer screening in women with mental illness: a systematic literature review. Am J Prevent Med 2013; 44: 392–8.
12 O'Rourke, RW, Diggs, BS, Spight, DH, Robinson, J, Elder, KA, Andrus, J, et al. Psychiatric illness delays diagnosis of esophageal cancer. Dis Esophagus 2008; 21: 416–21.
13 Baillargeon, J, Kuo, YF, Lin, YL, Raji, MA, Singh, A, Goodwin, JS. Effect of mental disorders on diagnosis, treatment, and survival of older adults with colon cancer. J Am Geriatr Soc 2011; 59: 1268–73.
14 World Health Organization. Cancer Control: Early Detection. Knowledge Into Action. WHO Guide for Effective Programmes. WHO, 2007 (
15 Centers for Disease Control and Prevention. Vital signs: breast cancer screening among women aged 50–74 years –United States, 2008. MMWR Morb Mortal Wkly Rep 2010; 59; 813–6
16 Smith, RA. International programs for the detection of breast cancer. Salud Publica Mex 2011; 53: 394404.
17 US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151: 716–26.
18 Duffy, SW, Tabar, L, Olsen, AH, Vitak, B, Allgood, PC, Chen, THH, et al. Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England. J Med Screen 2010; 17: 2530.
19 Marmot, MG, Altman, DG, Cameron, DA, Dewar, JA, Thompson, SG, Wilcox, M. The benefits and harms of breast cancer screening: an independent review. Br J Cancer 2013; 108: 2205–40.
20 Cancer Research, UK. Breast Cancer Screening Benefits and Harms (
21 Hendrick, RE, Smith, RA, Rutledge, JH, Smart, CR. Benefit of screening mammography in women aged 40–49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr 1997; 8792.
22 Kerlikowske, K, Grady, D, Ernster, V. Benefit of mammography screening in women ages 40–49 years: current evidence from randomized controlled trials. Cancer 1995; 76: 1679–81.
23 Magnus, MC, Ping, M, Shen, MM, Bourgeois, J, Magnus, JH. Effectiveness of mammography screening in reducing breast cancer mortality in women aged 39–49 years: a meta-analysis. J Womens Health (Larchmt) 2011; 20: 845–52.
24 Gotzsche, PC, Jorgensen, KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013; 6: CD001877.
25 Osborn, DPJ, Levy, G, Nazareth, I, Petersen, I, Islam, A, King, MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007; 64: 242–49.
26 Musuuza, JS, Sherman, ME, Knudsen, KJ, Sweeney, HA, Tyler, CV, Koroukian, SM. Analyzing excess mortality from cancer among individuals with mental illness. Cancer 2013; 119: 2469–76.
27 Kisely, S, Crowe, E, Lawrence, D. Cancer-related mortality in people with mental illness. JAMA Psychiatry 2013; 70: 209–17.
28 Ji, J, Sundquist, K, Ning, Y, Kendler, KS, Sundquist, J, Chen, X. Incidence of cancer in patients with schizophrenia and their first-degree relatives: a population-based study in Sweden. Schizophr Bull 2013; 39: 527–36.
29 Stroup, DF, Berlin, JA, Morton, SC, Olkin, I, Williamson, GD, Rennie, D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–12.
30 Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: 16.
31 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn, revised) (DSM-IV-TR). APA, 2000.
32 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders – Diagnostic Criteria for Research. WHO, 1993.
33 Sullivan, SG, Glasson, EJ, Hussain, R, Petterson, BA, Slack-Smith, LM, Montgomery, PD, et al. Breast cancer and the uptake of mammography screening services by women with intellectual disabilities. Prevent Med 2003; 37: 507–12.
34 Wells, G, Shea, B, O'Connell, D, Peterson, JEA. The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses (
35 Zhang, J, Yu, KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998; 280: 1690–1.
36 Higgins, JPT, Thompson, SG, Deeks, JJ, Altman, DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–60.
37 DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–88.
38 Egger, M, Davey Smith, G, Schneider, M, Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–34.
39 Begg, CB, Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088–101.
40 Baumeister, H, Harter, M. Prevalence of mental disorders based on general population surveys. Soc Psychiatry Psychiatr Epidemiol 2007; 42: 537–46.
41 Wittchen, HU, Jacobi, F. Size and burden of mental disorders in Europe – a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol 2005; 15: 357–76.
42 Carney, CP, Jones, LE. The influence of type and severity of mental illness on receipt of screening mammography. J Gen Intern Med 2006; 21: 1097–104.
43 Chochinov, HM, Martens, PJ, Prior, HJ, Fransoo, R, Burland, E. Does a diagnosis of schizophrenia reduce rates of mammography screening? A Manitoba population-based study. Schizophr Res 2009; 113: 95100.
44 Druss, BG, Rosenheck, RA, Desai, MM, Perlin, JB. Quality of preventive medical care for patients with mental disorders. Med Care 2002; 40: 129–36.
45 Lindamer, LA, Buse, DC, Auslander, L, Unutzer, J, Bartels, SJ, Jeste, DV. A comparison of gynecological variables and service use among older women with and without schizophrenia. Psychiatr Serv 2003; 54: 902–4.
46 Werneke, U, Horn, O, Maryon-Davis, A, Wessely, S, Donnan, S, McPherson, K. Uptake of screening for breast cancer in patients with mental health problems. J Epidemiol Commun Health 2006; 60: 600–5.
47 Iezzoni, LI, McCarthy, EP, Davis, RB, Harris-David, L, O'Day, B. Use of screening and preventive services among women with disabilities. Am J Med Qual 2001; 16: 135–44.
48 Druss, BG, Rask, K, Katon, WJ. Major depression, depression treatment and quality of primary medical care. Gen Hosp Psychiatry 2008; 30: 20–5.
49 Green, CA, Pope, CR. Depressive symptoms, health promotion, and health risk behaviors. Am J Health Promot 2000; 15: 2934.
50 Patten, SB, Williams, JVA, Lavorato, DH, Eliasziw, M. The effect of major depression on participation in preventive health care activities. BMC Public Health 2009; 9: 87.
51 Peytremann-Bridevaux, I, Voellinger, R, Santos-Eggimann, B. Healthcare and preventive services utilization of elderly Europeans with depressive symptoms. J Affect Disord 2008; 105: 247–52.
52 Pirraglia, PA, Sanyal, P, Singer, DE, Ferris, TG. Depressive symptom burden as a barrier to screening for breast and cervical cancers. J Womens Health (Larchmt) 2004; 13: 731–8.
53 Stecker, T, Fortney, JC, Prajapati, S. How depression influences the receipt of primary care services among women: a propensity score analysis. J Womens Health (Larchmt) 2007; 16: 198205.
54 Masterson, EA, Hopenhayn, C, Christian, WJ. Self-reported mental health status and recent mammography screening. J Womens Health (Larchmt) 2010; 19: 1569–76.
55 Ludman, EJ, Ichikawa, LE, Simon, GE, Rohde, P, Arterburn, D, Operskalski, BH, et al. Breast and cervical cancer screening: specific effects of depression and obesity. Am J Prevent Med 2010; 38: 303–10.
56 Vigod, S, Kurdyak, P, Stewart, D, Gnam, W, Goering, P. Depressive symptoms as a determinant of breast and cervical cancer screening in women: a population-based study in Ontario, Canada. Arch Womens Ment Health 2011; 14: 159–68.
57 Aggarwal, A, Freund, K, Sato, A, Adams-Campbell, LL, Lopez, AM, Lessin, LS, et al. Are depressive symptoms associated with cancer screening and cancer stage at diagnosis among postmenopausal women? The Women's Health Initiative observational cohort. J Womens Health (Larchmt) 2008; 17: 1353–61.
58 Blackwell, DL, Martinez, ME, Gentleman, JF. Women's compliance with public health guidelines for mammograms and Pap tests in Canada and the United States: an analysis of data from the Joint Canada/United States Survey of Health. Womens Health Issues 2008; 18: 8599.
59 Kempe, KL, Larson, RS, Shetterley, S, Wilkinson, A. Breast cancer screening in an insured population: whom are we missing? Perm J 2013; 17: 3844.
60 Schwartz, MD, Taylor, KL, Willard, KS. Prospective association between distress and mammography utilization among women with a family history of breast cancer. J Behav Med 2003; 26: 105.
61 Thorpe, JM, Kalinowski, CT, Patterson, ME, Sleath, BL. Psychological distress as a barrier to preventive care in community-dwelling elderly in the United States. Med Care 2006; 44: 187–91.
62 Leiferman, JA, Pheley, AM. The effect of mental distress on women's preventive health behaviors. Am J Health Promot 2006; 20: 196–9.
63 Lasser, KE, Zeytinoglu, H, Miller, E, Becker, AE, Hermann, RC, Bor, DH. Do women who screen positive for mental disorders in primary care have lower mammography rates? Gen Hosp Psychiatry 2003; 25: 214–6.
64 Yee, EFT, White, R, Lee, SJ, Washington, DL, Yano, EM, Murata, G, et al. Mental illness: is there an association with cancer screening among women veterans? Womens Health Issues 2011; 21: S195202.
65 Koroukian, SM, Bakaki, PM, Golchin, N, Tyler, C, Loue, S. Mental illness and use of screening mammography among Medicaid beneficiaries. Am J Prevent Med 2012; 42: 606–9.
66 Health and Social Care Information Centre. Breast Cancer Screening Program in England. HSCIC, 2013 (
67 Perini, G, Grigoletti, L, Hanife, B, Biggeri, A, Tansella, M, Amaddeo, F. Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study. Soc Psychiatry Psychiatr Epidemiol 2014; 49: 693701.
68 Osborn, DP, Baio, G, Walters, K, Petersen, I, Limburg, H, Raine, R, et al. Inequalities in the provision of cardiovascular screening to people with severe mental illnesses in primary care: cohort study in the United Kingdom THIN Primary Care Database 2000–2007. Schizophr Res 2011; 129: 104–10.
69 Roberts, L, Roalfe, A, Wilson, S, Lester, H. Physical health care of patients with schizophrenia in primary care: a comparative study. Family Pract 2007; 24: 3440.
70 Mitchell, AJ, Hardy, SA. Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Psychiatr Serv 2013; 64: 1060–3.
71 Mitchell, AJ, Lord, O, Malone, D. Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis. Br J Psychiatry 2012; 201: 435–43.
72 Ng, DM, Jeffery, RW. Relationships between perceived stress and health behaviors in a sample of working adults. Health Psychol 2003; 22: 638–42.
73 O'Donnell, S, Goldstein, B, DiMatteo, MR, Fox, SA, John, CR, Obrzut, JE. Adherence to mammography and colorectal cancer screening in women 50–80 years of age: the role of psychological distress. Womens Health Iss 2010; 20: 343–9.
74 Kotwal, AA, Schumm, P, Mohile, SG, Dale, W. The influence of stress, depression, and anxiety on PSA screening rates in a nationally representative sample. Med Care 2012; 50: 1037–44.
75 Consedine, NS, Morgenstern, AH, Kudadjie-Gyamfi, E, Magai, C, Neugut, AI. Prostate cancer screening behavior in men from seven ethnic groups: the fear factor. Cancer Epidemiol Biomarkers Prev 2006; 15: 228–37.
76 Hardy, S, Gray, R. Is the use of an invitation letter effective in prompting patients with severe mental illness to attend a primary care physical health check? Prim Health Care Res Dev 2012; 13: 347–52.
77 Kahn, LS, Fox, CH, Krause-Kelly, J, Berdine, DE, Cadzow, RB. Identifying barriers and facilitating factors to improve screening mammography rates in women diagnosed with mental illness and substance use disorders. Women Health 2005; 42: 111–26.
78 Mitchell, AJ, Selmes, T. Why don't patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treatment 2007; 13: 423–34.
79 Legg, JS, Clement, DG, White, KR. Are women with self-reported cognitive limitation at risk for underutilization of mammography? J Health Care Poor Underserved. 2004; 15: 688702.
80 Temitope, B, Daniel, A, Ademola, A. A survey of physicians’ attitudes and practices to screening mammography in Osogbo & Ibadan, South-West Nigeria. Internet Journal of Radiology 2006; 6: 1.
81 Miller, E, Lasser, KE, Becker, AE. Breast and cervical cancer screening for women with mental illness: patient and provider perspectives on improving linkages between primary care and mental health. Arch Womens Ment Health 2007; 10: 189–97.
82 Friedman, LC, Puryear, LJ, Moore, A, Green, CE. Breast and colorectal cancer screening among low-income women with psychiatric disorders. Psychooncology 2005; 14: 786–91.
83 Starfield, B, Leiyu, S, Macinko, J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457502.
84 Lester, HE, Soroham, H, Tritter, JQ. Patients’ and health professionals’ views on primary care for people with serious mental illness: focus group study. BMJ 2005; 330: 1122–6.
85 Jorgensen, KJ, Gotzsche, PC. Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ 2009; 339: b2587.
86 Miller, AB, Wall, C, Baines, CJ, Sun, P, To, T, Narod, SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 2014; 348: g366.
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Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

  • Alex J. Mitchell (a1), Isabel Espirito Santo Pereira (a2), Motahare Yadegarfar (a2), Shingai Pepereke (a2), Vongai Mugadza (a2) and Brendon Stubbs (a3)...
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