The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women

Main Article Content

Sage Kim Yamile Molina Anne Elizabeth Glassgow Jenny Guadamuz Elizabeth Calhoun


Background:  Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result.  One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics.  Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined.  The current study examine the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics.  


Methods:  We examined data from a total of 1,696 randomized patients from a randomized controlled trial, “the Patient Navigation in Medically Underserved Areas” study that explored the effect of navigation on breast health outcomes.  We categorized participants’ neighborhoods into three categories and compared the effect of navigation between these neighborhood types.


Results:  Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods.  Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods. 


Conclusion:  Patient navigation interventions improve timely follow-up of abnormal mammogram.  Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services.  Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods.  Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms.  Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.  

Article Details

How to Cite
KIM, Sage et al. The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women. Medical Research Archives, [S.l.], n. 3, may 2015. ISSN 2375-1924. Available at: <>. Date accessed: 19 july 2024.
breast cancer; health disparity; follow-up; neighborhood effects
Research Articles



1. National Cancer Institute. SEER Cancer Statistics Review, 1975-2007. Bethesda, MD: National Cancer Institute; 2010. Available at:

2. Surveillance epidemiology and end results (SEER). SEER stat fact sheets: breast; 2013. National Cancer Institute, Bethesda, MD: 2013. Accessed on: Available at:

3. Illinois Department of Public Health. Cancer Mortality by Race, Illinois, 1986-2006; 2009.

4. Gerend MA, Pai M. Social Determinants of Black-White Disparities in Breast Cancer Mortality: A Review. Cancer Epidemiology, Biomarkers & Prevention. 2008;17(11):2913-2923.

5. Malin Fair A, Wujckik D, Lin J-MS, Zheng W, Egan K, Grau A, et al. Psychosocial determinants of mammography follow-up after receipt of abnormal mammography results in medically underserved women. Journal of Health Care for the Poor and Underserved. 2010;21(1 Suppl):71–94.

6. Buseman S, Mouchawar J, Calonge N, Byer T. Mammography screening matters for young women with breast carcinoma: evidence of downstaging among 42–49-year-old women with a history of previous mammography screening. Cancer. 2003;97(2):352–358.

7. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, et al. Effects of health insurance and race on early detection of cancer. Journal of the National Cancer Institute. 1999;91(16):1409–1415.

8. Mandelblatt J, Howard A, Kemer J, Zauber A, Bumetu W. Determinants of late stage diagnosis of breast cancer and cervical cancer: the impact of age, race, social class, and hospital type. American Journal of Public Health. 1991;81(5):646–649.

9. Mundt AJ, Connell PP, Campbell T, Hwang JH, Rotmensch J, Waggoner S. Race and clinical outcomes in patients with carcinoma of the uterine cervix treated with radiation therapy. Gynecologic Oncology. 1998;71(2):151–158.

10. Grisby P, Hall-Daniels L, Baker S, Perez C. Comparison of clinical outcomes in black and white women treated with radiotherapy for cervical carcinoma. Gynecol Oncol. 2000;79:357–361.

11. Wang F, McLafferty S, Escamilla V, Luo L. Late-Stage Breast Cancer Diagnosis and Health Care Access in Illinois. Prof Geogr. 2008;60(1):54-69.

12. Eley JW, Hill HA, Chen VW, Austin DF, Wesley MN, Muss HB, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. 1994;272(12):947-54.

13. Cross CK, Harris J, Recht A. Race, socioeconomic status, and breast carcinoma in the U.S: what have we learned from clinical studies. Cancer. 2002;95(9):1988-99.

14. American Cancer Society. Cancer Facts & Figures 2009. Atlanta, GA: American Cancer Society; 2009.

15. Albano J, Ward E, Jemal A, Anderson R, Cokkinides V, Murray T, et al. Cancer Mortality in the United States by Education Level and Race. Journal of the National Cancer Institute. 2007;99(18):1384-1394.

16. Smith-Bindman R, Miglioretti DL, Lurie N, al. e. Does utilization of screening mammography explain racial and ethnic differences in breast cancer? Ann Intern Med. 2006;144(8):541–553.

17. Press R, Carrasquillo O, Sciacca RR, Giardina E-GV. Racial/Ethnic Disparities in Time to Follow-Up after an Abnormal Mammogram. Journal of Women's Health. 2008;17(6):923-930.

18. Adams SA, Smith ER, Hardin J, Das IP, Fulton J, Hebert JR. Racial Differences in Follow-up of Abnormal Mammography Findings Among Economically Disadvantaged Women. Cancer. 2009;115(24):5788-5797.

19. Markossian TW, Darnell JS, Calhoun EA. Follow-Up and Timeliness After an Abnormal Cancer Screening Among Underserved, Urban Women in a Patient Navigation Program. Cancer Epidemiology, Biomarkers & Prevention. 2012;21(10):1691-1699.

20. Gorin S, Heck J, Cheng B, Smith S. Delays in breast cancer diagnosis and treatment by racial/ethnic group. Arch Intern Med. 2006;166(20):2244-2252.

21. Rojas M, Mandelblatt J, Cagney K, Kerner J, Freeman H. Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem. Ethn Health. 1996;1(3):221-228.

22. McCarthy B, Yood M, Janz N, Boohaker E, Ward R, Johnson C. Evaluation of factors potentially associated with inadequate follow-up of mammographic abnormalities. Cancer. 1996;77:2070–2076.

23. Williams D, Tortu S, Thomson J. Factors associated with delays to diagnosis and treatment of breast cancer in women in a Louisiana urban safety net hospital. Women Health. 2010;50(8):705-718.

24. Strzelczyk J, Dignan M. Disparities in adherence to recommended follow-up on screening mammography: interaction of sociodemographic factors. Ethn Dis. 2002;12:77-86.

25. Yabroff K, Breen N, Vernon S, Meissner H, Freedman A, Ballard-Barbash R. What Factors Are Associated with Diagnostic Follow-Up after Abnormal Mammograms? Findings from a U.S. National Survey. Cancer Epidemiol Biomarkers Prev. 2004;13(5):723-732.

26. Krieger N, Chen JT, Waterman PD, Soobader MJ, Subramanian SV, R. C. Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter?: the public health disparities geocoding project. Am J Epidemiol. 2002;156:471-482.

27. Roux AVD, Mair C. Neighborhoods and health. Annals of the New York Acadamy of Sciences. 2010;1186:125-145.

28. Lochner K, Kawachi I, Brennan R, Buka S. Social capital and neighborhood mortality rates in Chicago. Social Science & Medicine. 2003;56:1797–1805.

29. Kawachi I, Berkman LF. Neighborhoods and health. Oxford ; New York: Oxford University Press; 2003.

30. Kirby J. Poor people, poor places, and access to health care in the US. Soc Forces. 2008;87(1):325-355.

31. Schultz W. Racial and spatial relations as fundamental determinants of health in Detroit. Milbank. 2002;80(4):54-56.

32. Dailey AB, Kasl SV, Holford TR, Calvocoressi L, Jones BA. Neighborhood-Level Socioeconomic Predictors of Nonadherence to Mammography Screening Guidelines. Cancer Epidemiology Biomarkers and Prevention. 2007;16(11):2293-2303.

33. Rosenberg L, Wise LA, Palmer JR, Horton NJ, Adams-Campbell LL. A Multilevel Study of Socioeconomic Predictors of Regular Mammography Use Among African-American Women. Cancer Epidemiology Biomarkers and Prevention. 2005;14(11):2628-2633.

34. Jones BA, Dailey A, Calvocoressi L, Reams K, Kasl SV, Lee C, et al. Inadequate Follow-up of Abnormal Screening Mammograms: Findings From the Race Differences in Screening Mammography Process Study (United States). Cancer Causes and Control. 2005;16:809-821.

35. Burack RC, Simon MS, Stano M, George J, Coombs J. Follow-Up Among Women with an Abnormal Mammogram in an HMO: Is It Timely, Complete, and Efficient? American Journal of Managed Care. 2000;6(10):1102-1113.

36. Caplan LS, May DS, Richardson LC. Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 1991-1995. American Journal of Public Health. 2000;90(1).

37. Chang SW, Kerlikowske K, Nápoles-Springer AM, Posner SF, Sickles EA, Pérez-Stable EJ. Racial differences in timeliness of follow-up after abnormal screening mammography. Cancer. 1996;78(7):1398-1402.

38. McCarthy BD, Yood U, Boohaker EA, Ward RE, Rebner M, Johnson CC. Inadequate follow-up of abnormal mammograms. American Journal of Preventive Medicine. 1996;12(4):252-288.

39. Yabroff KR, Washington KS, Leader A, Neilson E, Mandelblatt JS. Is the Promise of Cancer-Screening Programs Being Compromised? Quality of Follow-Up Care after Abnormal Screening Results. Medical Care Research and Review. 2003;60(3):294-331.

40. Galster G. On the nature of the neighbourhood. Urban Studies. 2001;38(12):2111-2124.

41. Kothari A, Birch S. Individual and regional determinants of mammography uptake. Can J Public Health. 2004;95:290-294.

42. Schootman M, Jeffe D, Baker E, Walker M. Effect of area poverty rate on cancer screening across US communities. J Epidemiol Community Health. 2006;60:202–207.

43. Litaker D, Tomolo A. Association of contextual factors and breast cancer screening: finding new targets to promote early detection. J Womens Health. 2007;16:36-45.

44. Phillips K, Kerlikowske K, Baker L, Chang S, Brown M. Factors associated with women's adherence to mammography screening guidelines. Health Serv Res. 1998;33:29–53.

45. Zenk S, Tarlov E, Sun J. Spatial equity in facilities providing low- or no-fee screening mammography in Chicago neighborhoods. J Urban Health. 2006;83:195–210.

46. Plascak JJ, Llanos AA, Pennell ML, Weier RC, Paskett ED. Neighborhood and Geographic Factors Associated with Diagnostic Resolution After an Abnormal Breast or Cervical Cancer Screening Test Among Women Enrolled in a Patient Navigator Program. Cancer Epidemiology, Biomarkers & Prevention. 2014;23.

47. Lopez RP, H. Patricia H. Obesity, physical activity, and the urban environment: public health research needs. Environmental Health: A Global Access Science Source. 2006;5:25-10.

48. Pastor Jr M, Sadd JL, Morello-Frosch R. Waiting to Inhale: The Demographics of Toxic Air Release Facilities in 21st-Century California. Social Science Quarterly (Wiley-Blackwell). 2004;85(2):420-440.

49. Heinrich KM, Rebecca EL, Regan GR, Reese-Smith JY, Howard HH, Haddock CK, et al. How Does the Built Environment Relate to Body Mass Index and Obesity Prevalence Among Public Housing Residents? American Journal of Health Promotion. 2008;22(3):187-194.

50. Cohen L, Chávez V, Chehimi S. Prevention is primary: strategies for community well-being. San Francisco, CA: Jossey-Bass; 2010.

51. Jennifer S. Haas, Craig C. Earle, John E. Orav, Phyllis Brawarsky, Marie Keohane, Bridge A. Neville, et al. Racial Segregation and Disparities in Breast Cancer Care and Mortality. Cancer. 2008 113(8):2166–2172.

52. Dajun Dai. Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health Place. 2010;16(5):1038–1052.

53. Harper S LJ, Meersman SC, Breen N, Davis WW, Reichman MC,. Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987-2005). Cancer Epidemiol Biomarkers Prev. 2009;18(1):121-131.

54. Laia Bécares, Richard Shaw, James Nazroo, Mai Stafford, Christo Albor, Karl Atkin, et al. Ethnic Density Effects on Physical Morbidity, Mortality, and Health Behaviors: A Systematic Review of the Literature. American Journal of Public Health. 2012;102(12):e33-e66.

55. J. Boydell JvO, K. McKenzie, J. Allardyce, R. Goel, R.G. McCreadie, R.M. Murray. Incidence of schizophrenia in ethnic minorities in London: Ecological study into interactions with environment. British Medical Journal. 2001;323(7325):1336–1338.

56. Cochrane R, Bal SS. Ethnic density is unrelated to incidence of schizophrenia. British Journal of Psychiatry. 1988;153:363–366.

57. Kate E. Pickett, Richard G. Wilkinson. People like us: ethnic group density effects on health. Ethnicity & Health. 2008;13(4):321-334.

58. Laia Bécares, James Nazroo, Mai Stafford. The buffering effects of ethnic density on experienced racism and health. Health & Place. 2009;15(3):700–708.

59. Klassen AC, Washington C. How does social integration influence breast cancer control among urban African-American women? Results from a cross-sectional survey. BMC Women's Health. 2008;8(4).

60. Allen JD, Stoddard AM, Sorensen G. Do Social Network Characteristics Predict Mammography Screening Practices? Health Education & Behavior. 2008;35(6):763-776.

61. Warner ET, Gomez SL. Impact of Neighborhood Racial Composition and Metropolitan Residential Segregation on Disparities in Breast Cancer Stage at Diagnosis and Survival Between Black and White Women in California. Journal of Community Health. 2010;35:398-408.

62. Consedine N, Magai C, Krivoshekova Y, Ryzewicz L, Neugut A. Fear, anxiety, worry, and breast cancer screening behavior: A critical review. Cancer Epidemiology, Biomarkers & Prevention. 2004;13:501-510.

63. Magai C, Consedine N, Conway F, Neugut A, Culver C. Diversity Matters: Unique populations of women and breat cancer screening. Cancer. 2004;100(11):2300-2307.

64. Taplin SH, Yabroff KR, Zapka J. A Multilevel Research Perspective on Cancer Care Delivery: The Example of Follow-Up to An Abnormal Mammogram. Cancer Epidemiology, Biomarkers & Prevention. 2012;21(10):1709-1715.

65. Battaglia TA, Roloff K, Posner MA, Freund KM. Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention. Cancer. 2007;109(2):359-367.

66. Percac-Lima S, Cronin PR, Ryan DP, Chabner BA, Daly EA, Kimball AB. Patient Navigation Based on Predictive Modeling Decreases No-Show Rates in Cancer Care. Cancer. 2015;121(4).

67. Percac-Lima S, Ashburner JM, Bond B, Oo SA, Atlas SJ. Decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. Journal of General Internal Medicine. 2013;28(11):1463-1468.

68. Wells KJ, Battaglia TA, Dudley DJ, Garcia R, Greene A, Calhoun E, et al. Patient Navigation: State of the Art, or Is It Science? Cancer. 2008;113(8):1999-2010.

69. Paskett ED, Harrop PJ, Wells KJ. Patient Navigation: An Update on the State of the Science. A Cancer Journal for Clinicians. 2011;61(4):237-249.

70. Gabitova G, Burke NJ. Improving healthcare empowerment through breast cancer patient navigation: a mixed methods evaluation in a safety-net setting. BMC Health Services Research. 2014;14.

71. Korber SF, Padula C, Gray J, Powell M. A breast navigator program: barriers, enhancers, and nursing interventions. Oncology Nursing Forum. 2011;38(1):44-50.

72. Pedersen AE, Hack TF, McClement SE, Taylor-Brown J. An exploration of the patient navigator role: perspectives of younger women with breast cancer. Oncology Nursing Forum. 2014;41(1):77-88.

73. Gotlib Conn L, Hammond Mobilio M, Rotstein OD, Blacker S. Cancer patient experience with navigation service in an urban hospital setting: A qualitative study. European Journal of Cancer Care. 2014;24(1):1-9.

74. Campbell C, Craig J. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncology Nursing Forum. 2010;37:61-68.

75. Dohan D, Schrag D. Using navigators to improve care of underserved patients: Current practices and approaches. Cancer. 2005;104(4):848-855.

76. Peek ME, Han JH. Disparities in Screening Mammography: Current Status, Interventions, and Implications. Journal of General Internal Medicine. 2004;19:184-194.

77. Phillips CE, Rothstein JD, Beaver K, Sherman BJ, Freund KM, Battaglia TA. Patient navigation to increase mammography screening among inner city women. Journal of General Internal Medicine. 2011;26(2):123-129.

78. Robie L, Alexandru D, Bota DA. The use of patient navigators to improve cancer care for Hispanic patients. Clinical Medicine Insights: Oncology. 2011;5:1-7.

79. Balleyguier C, Ayadi S, Van Nguyen K, Vanel D, Dromain C, Sigal R. BIRADS classification in mammography. European Journal of Radiology. 2007;61(2):192–194.

80. US Department of Health & Human Services. The HHS poverty guidelines for the remainder of 2010. US Department of Health & Human Services, Washington, DC: 2010. Accessed on: Available at:

81. Sampson R, Wilson WJ. Toward a theory of race, crime, and urban inequality. In: Hagan J, Ruth P, editors. Crime and Inequality. Stanford, CA: Stanford University Press; 1995. p. 37-56.

82. Sampson R, Raudenbush S, Earls F. Neighborhoods and violent crime: A multilevel study of collective efficacy. Science. 1997;277(15):918-924.

83. Skrondal A, Rabe-Hesketh S. Latent variable modelling: A survey. Scandinavian Journal of Statistics. 2007;34:712-745.

84. Schootman M, Jeff DB, Gillanders WE, Yan Y, Jenkins B, Aft R. Geographic clustering of adequate diagnostic follow-up after abnormal screening results for breast cancer among low-income women in Missouri. Ann Epidemiol. 2007 17(9):704-712.

85. Nancy Tian, J Gaines Wilson, F Benjamin Zhan. Spatial association of racial/ethnic disparities between late-stage diagnosis and mortality for female breast cancer: where to intervene? Int J Health Geogr. 2011;10:1-9.

86. Russell E, Kramer MR, Cooper HLF, Thompson WW, Arrio KRJ. Residential Racial Composition, Spatial Access to Care, and Breast Cancer Mortality among Women in Georgia. Journal of Urban Health. 2011;88(6):1117-1129.

87. Christopher M. Masi, Louise C. Hawkley, Z. Harry Piotrowski, Kate E. Pickett. Neighborhood economic disadvantage, violent crime, group density, and pregnancy outcomes in a diverse, urban population. Social Science & Medicine. 2007;65(12): 2440–2457.

88. Kate E. Pickett, James W. Collins Jr, Christopher M. Masi, Wilkinson RG. The effects of racial density and income incongruity on pregnancy outcomes. Social Science & Medicine. 2005;60(10):2229–2238.

89. Massey D, Eggers M. The ecology of inequality: Minorities and the concentration of poverty, 1970-1980. American Journal of Sociology. 1990;95(5):1153-1188.

90. Ruby Mendenhall, Stefanie DeLuca, Greg Duncan. Neighborhood resources, racial segregation, and economic mobility: Results from the Gautreaux program Social Science Research. 2006;35(4):892–923.

91. US Department of Health & Human Services. What are Federally qualified health centers (FQHCs)? US Department of Health & Human Services,, Washington, DC: 2015. Accessed on: Available at: