The Effect of Physicians’ Bias and Beliefs about Recommending Breast Cancer Screening to their Patients

Research Article

J Fam Med. 2016; 3(8): 1081.

The Effect of Physicians’ Bias and Beliefs about Recommending Breast Cancer Screening to their Patients

Soffer M*, Cohen M and Azaiza F

School of Social Work and the Center for Rehabilitation Research, School of Social Faculty of Social Welfare & Health Sciences, University of Haifa, Israel

*Corresponding author: Soffer M, School of Social Work and the Center for Rehabilitation Research, School of Social Faculty of Social Welfare & Health Sciences, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, Haifa 3498838, Israel

Received: August 22, 2016; Accepted: September 19, 2016; Published: September 23, 2016


Receiving physicians' recommendations to undergo screening was found to be given less often to patients from low income or ethnic minority groups. One of the factors accounting for discriminatory healthcare is physician’s bias.

This study examined physicians’ beliefs regarding cancer, barriers to screening among women, and physicians' bias in relation to recommending and discussing breast cancer screening with their patients.

A random sample (cluster sampling) of 146 Arab physicians who serve the Arab population was drawn. Pathways among the study variables were examined by Structural equation modeling (SEM).

The results show that the majority of physicians recommend regular examinations to average-risk women. However, recommending CBE to young women was relatively low. The models for predicting recommending mammography and CBE, and discussing screening with patients demonstrated good fit indices. Physicians’ bias mediated the associations of years of seniority as a physician and gender with recommending mammography, recommending CBE, and discussing screening. Traditional beliefs served as a mediator between years of seniority as a physician and discussing screening.

Because of their significant role in breast cancer screening, physicians' bias and traditional beliefs about cancer need to be addressed and eliminated. Efforts to debunk physicians' bias should particularly target less experienced physicians and male physicians.

Keywords: Screening for breast cancer; Recommending and discussing screening; Traditional beliefs; Barriers to screening; Physicians’ bias


Breast cancer is the second leading cause of death, due to cancer incidence among women in Western countries [1]. Surviving breast cancer greatly depends on its detection at an early stage [2]. Although regular mammography screening has recently been questioned - due to high over-diagnosis and false-positive rates [3] - systematic screening programs, especially for average-risk women aged fifty and over, have been shown to significantly increase early detection and reduce mortality [2]. However, young women are often diagnosed at a more advanced stage than older women, due to a lack of efficient screening procedures for young women; as a result, they have worse survival rates [4].

Current Israeli guidelines for average-risk women aged 50-74 and above for early detection practice, stipulate regular mammography testing once every two years [5]. In addition, women from the age of 20 are advised to undergo a yearly clinical breast examination (CBE) and increase breast awareness (BA) to become more familiar with their breasts and learn to notice when changes occur in them [5], although these examinations have not proven efficient [6]. However, attending CBE may create awareness about the importance of screening, and creates an opportunity for physicians to discuss screening importance.

The Arab population in Israel is an ethnic minority, constituting about 20% of the Israeli population. This population consists of several religious groups: 83% Muslims, 8% Christians, 8% Druze, and 1% other [7]. Although this population is currently experiencing modernization processes, it is still, to a large extent, a traditional and religious society [8,9]. The incidence of breast cancer is considerably lower among Arab women than among Jewish women in Israel and women in Western countries, but Arab women are more likely to be diagnosed at a more advanced stage of the disease [10]. In addition, research shows that young Arab women are at a higher risk to develop breast cancer at an early age than Jewish women in Israel or women in Western countries [11]. This tendency towards a later diagnosis was suggested to be attributed to the significantly lower incidence of screening for the early detection of breast cancer [12], and is related to social and cultural screening barriers [8,13-15]. Due to the provision and promotion of the free-of-charge screening system and major efforts on the part of the Israeli health services and the Israel Cancer Society, since 2014 the majority of Arab women aged 50 and over has undergone a mammography screening at least once, thus decreasing the gap in screening rates with the Jewish population [16]. However, the adherence rate to the mammography schedule (undergoing mammography every two years), and of CBE for younger women, is still low among Arab women [15,17]. Thus, further research is necessary to identify factors that impede regular screening.

Lower attendance of mammography, as well as other screening behaviors, was also found among women from ethnic or traditional groups in Western countries [18-20]. Studies have identified several factors that affect disparities in screening tests for breast cancer among different ethnic or traditional groups in Western countries [18,21,22], and among Arab women in Israel [9,13-15,23-25]. Patient-related factors include low socio-economic status; high perceived barriers to screening, such as the fear of radiation or pain; and low perceived benefits of screening (reviewed in [9]). Healthcare system-related factors consisted of language barriers and geographic distance [13,23,26]. Recent studies have identified additional barriers to screening in women from traditional societies such as the Latinas in the USA [21], and Jewish ultra-Orthodox [27] and Arab women in Israel [24,28,29]. These findings reflect cultural and religious perceptions about cancer, health, and fate [9].

Provider-level factors were found to play a significant role in ethnic and racial healthcare disparities [30]. Considerable research suggests that physicians play an important role in their patients’ screening attendance [31,32], particularly patients from ethnic minority groups [13,33,34]. Imparting information, recommending screening or reminding patients about specific screenings, and most importantly, discussing the advantages as well as women’s barriers to screening have all proved to be the main predictors for mammography completion in studies conducted in both the US and Israel [13,35].

However, it was also found that physicians’ recommendations tend to be given less often to patients from low income or ethnic minority groups [13,34,36]. Moreover, studies on women from different backgrounds in Israel, including Muslim and Christian Arab women, showed that, according to the women’s self-reports, physicians recommend mammography less to Arab women than to Jewish ones. When controlling for demographic factors, recommendation receipt was a strong predictor of mammography and CBE adherence [13-15,23].

Studies have identified several factors related to whether or not physicians recommend or discuss breast cancer screening with their patients. These factors are related to physicians’ personal characteristics, such as gender, age, and seniority [37,38], and the socio-demographic characteristics of their patients, such as education, language, ethnicity, and co-morbidities [34,39,40]. Nevertheless, only a few studies examined the effect of physicians’ own beliefs on their recommendation patterns. A few studies suggested that physicians seem to be influenced, regarding their decision to recommend or not recommend mammography, by their own beliefs and attitudes regarding breast cancer and screening [40,41]. These attitudes stem from the general perception of cancer as a stigmatized illness [42,43].

Physicians were also found to be less likely to recommend screening examinations to women who the physicians believe would not be receptive to the advice or would not be able to appear for mammography because of costs, accessibility barriers or considerations related to modesty [44,45]. This phenomenon, coined "physician bias," was defined as a case whereby "a personal characteristic of a patient seeking medical advice or treatment appears to have influenced a physician's clinical treatment of the patient" [46,p. 195]. Research has shown that physicians’ bias promotes discriminatory healthcare [47]. Moreover, bias among healthcare personnel was also found to have an independent effect on health disparities [30,48]. It is important to mention that biases are not always conscious; nonetheless, both explicit and implicit biases produce discrimination [49].

In light of the lacuna in both theory and research regarding the factors that affect physicians’ recommending or discussing screening advantages and barriers for the early detection of breast cancer, the present study will first assess the frequency of recommending mammography to women aged 50 and older, recommending CBE to patients aged 20-50, and discussing screening with patients who do not undergo screening. Next, the study will assess the role of physicians’ gender, seniority, and personal beliefs regarding cancer; physicians’ perceptions of their female patients’ barriers to screening; and the role of physicians' bias on recommending mammography and CBE, and on discussing screening advantages and barriers with their patients (Figure 1).