Original article Longitudinal Patterns of Breast Cancer Screening: Mammography, Clinical, and Breast Self-Examinations in a Rural and Urban Setting Janni Leung, BHS a, * , Samantha McKenzie, PhD a , Jennifer Martin, PhD b , Annette Dobson, PhD a , Deirdre McLaughlin, PhD a a School of Population Health, University of Queensland, Australia b School of Medicine, University of Queensland, Australia Article history: Received 7 June 2013; Received in revised form 12 November 2013; Accepted 12 November 2013 abstract Background: We identified breast screening patterns over time and patterns among women residing in rural and urban areas by sociodemographic factors. Methods: This study employs a longitudinal design over 9 years from 2001 on 11,200 women aged 50 to 55 from the Australian Longitudinal Study on Women’s Health. Area of residence was defined in accordance with the accessibility remoteness index of Australia Plus. Breast screening measures included mammography utilization, clinical breast ex aminations (CBE), and breast self examinations (BSE). Findings: Most women had a mammogram in the past 2 years in combination with CBE or BSE or both. Despite poorer access to mammography services, women residing in rural areas had similar mammography screening rates to their urban counterparts. Women residing in rural areas were less likely to have CBEs, but more likely to conduct BSEs. The breast screening behaviors were generally consistent over time. Conclusions: The poorer breast cancer survival among rural women is unlikely to be explained by differences in mammography service use. A substantial proportion of the population may be experiencing overscreening by con ducting all three types of breast screening. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. Breast cancer is the most prevalent cancer in women in the world and it is one of the few cancers for which population screening technologies are available (World Health Organization, 2012). Cancer screening aims to detect diseases at an early stage in symptom free populations. The most widely used method for breast cancer screening is mammography. Additional forms of breast cancer screening are clinical breast examinations (CBE) and breast self examination (BSE). CBE involves a physical ex amination of the breasts by a doctor or a nurse to check for signs of abnormality, such as lumps. BSE is the physical examination of the breasts that women can conduct on themselves. Most developed countries, such as the United States and Australia, have population breast cancer screening programs targeting women over 50 years of age who are encouraged to have mammograms every 2 years. Public health organizations and physicians suggest CBE to be conducted annually and BSE monthly (National Breast Cancer Foundation, 2012). Breast cancer mortality rates have been found to be higher in women residing in rural areas compared with women in urban areas, despite the higher incidence observed in urban areas (Dey et al., 2010; Hall, Holman, Sheiner, & Hendrie, 2004; Krzyzak et al., 2010; Minelli et al., 2007; Mitchell et al., 2006; Wilkinson & Cameron, 2004). Because screening contributes to early detection of cancer can lead to a better chance of survival (Harris, Yeatts, & Kinsinger, 2011), a plausible hypothesis for the higher mortality rate is that women residing in rural areas may be less likely to use breast screening services. Some studies have shown that the use of both mammography and CBE services are lower among the rural population (Coughlin, Thompson, Hall, Logan, & Uhler, 2002; Doescher & Jackson, 2009; Husaini et al., 2005; Jackson et al., 2009; Maxwell, Bancej, & Snider, 2001; McDonald & Sherman, 2010; Mitchell et al., 2006; Polasek et al., 2007; Siahpush & Singh, 2002; Stamenic & Strnad, 2011), * Correspondence to: Janni Leung, University of Queensland, School of Pop- ulation Health, Herston Rd, Herston, Brisbane, Queensland, 4006. Phone: þ61433655335; fax: þ61733655540. E-mail address: j.leung1@uq.edu.au (J. Leung). www.whijournal.com 1049-3867/$ - see front matter Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.11.005 Women's Health Issues 24-1 (2014) e139–e146