{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T18:09:56Z","timestamp":1789150196472,"version":"build-2803163510"},"reference-count":51,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T00:00:00Z","timestamp":1789084800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Program of Cancer Registries","award":["NU58DP007164"],"award-info":[{"award-number":["NU58DP007164"]}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["P50GM133807 and S21MD001830"],"award-info":[{"award-number":["P50GM133807 and S21MD001830"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Breast cancer is the most common cancer among women globally. Early detection using mammography is crucial for improving outcomes and reducing aggressive treatment. Factors such as age, comorbidities, insurance coverage, and mental health conditions may influence screening behavior. Limited research exists on the relationship between mental health and breast cancer screening in Puerto Rico. This study examines factors associated with early detection among women aged 50 and older diagnosed with breast cancer and coexisting anxiety or affective disorder.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study using data from the Puerto Rico Central Cancer Registry linked with the Health Insurance Linkage Database. Multivariable logistic regression was used to estimate adjusted odds ratios (AOR) to describe the relationship between having anxiety or affective disorder with the use of mammography and the stage at diagnosis. Cox proportional hazards model was used to assess the association between mental health diagnosis and risk of death, respectively.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 4,708 eligible women, 376 (8.0%) had an anxiety or affective disorder. Overall, 90.0% received a mammogram within 24 months prior to diagnosis, and 35.1% were diagnosed at a late stage. Women with anxiety or affective disorder were 57.0% more likely to have undergone screening (AOR 1.57, 95% confidence interval [CI]: 1.01\u20132.43; p\u2009=\u20090.046). These disorders were not significantly associated with cancer stage at diagnosis (AOR 0.86, 95% CI 0.68\u20131.09; p\u2009=\u20090.208) and did not increase the risk of death within 5 years (Adjusted Hazard Ratio [AHR] 1.01, 95% CI: 0.76\u20131.35; p\u2009=\u20090.094).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In our study, anxiety or affective disorders were associated with increased mammography use but not with earlier cancer stages. Further research is needed on severe mental illness and the bidirectional relationship between cancer and mental health.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0357375","type":"journal-article","created":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T17:37:57Z","timestamp":1789148277000},"page":"e0357375","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["The impact of anxiety and affective disorders on breast cancer screening in women in Puerto Rico"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-4091-4104","authenticated-orcid":true,"given":"Marjorie","family":"V\u00e1zquez-Rold\u00e1n","sequence":"first","affiliation":[{"name":"University of Puerto Rico Comprehensive Cancer Center","place":["San Juan, Puerto Rico"],"department":["Division of Cancer Control and Population Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0134-9947","authenticated-orcid":true,"given":"Karen J.","family":"Ortiz-Ortiz","sequence":"additional","affiliation":[{"name":"University of Puerto Rico Comprehensive Cancer Center","place":["San Juan, Puerto Rico"],"department":["Division of Cancer Control and Population Sciences"]},{"name":"Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico","place":["San Juan, Puerto Rico"],"department":["Department of Health Services Administration"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liza I.","family":"Mill\u00e1n-P\u00e9rez","sequence":"additional","affiliation":[{"name":"Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico","place":["San Juan, Puerto Rico"],"department":["Department of Health Services Administration"]},{"name":"Auxiliary Secretariat for Public Health Surveillance & Protection","place":["San Juan, Puerto Rico"],"department":["Puerto Rico Department of Health"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-5363-7299","authenticated-orcid":true,"given":"Axel","family":"Gierbolini-Berm\u00fadez","sequence":"additional","affiliation":[{"name":"University of Puerto Rico Comprehensive Cancer Center","place":["San Juan, Puerto Rico"],"department":["Division of Cancer Control and Population Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"R\u00edos-Motta","sequence":"additional","affiliation":[{"name":"Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico","place":["San Juan, Puerto Rico"],"department":["Department of Health Services Administration"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,11]]},"reference":[{"issue":"1","key":"pone.0357375.ref001","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1007\/s10549-017-4399-x","article-title":"Diagnosis and treatment delays among elderly breast cancer patients with pre-existing mental illness","volume":"166","author":"K Iglay","year":"2017","journal-title":"Breast Cancer Res Treat"},{"issue":"6","key":"pone.0357375.ref002","first-page":"1661","article-title":"Assessment of Depression and Anxiety in Breast Cancer Patients: Prevalence and Associated Factors","volume":"19","author":"K Tsaras","year":"2018","journal-title":"Asian Pac J Cancer Prev"},{"issue":"6","key":"pone.0357375.ref003","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1016\/j.genhosppsych.2015.06.003","article-title":"Cancer survival in the context of mental illness: a national cohort study","volume":"37","author":"R Cunningham","year":"2015","journal-title":"Gen Hosp Psychiatry"},{"issue":"02","key":"pone.0357375.ref004","doi-asserted-by":"crossref","first-page":"66","DOI":"10.4236\/health.2012.42012","article-title":"An epidemiological study on delay in treatment initiation of cancer patients","volume":"04","author":"AK Dwivedi","year":"2012","journal-title":"Health"},{"issue":"10","key":"pone.0357375.ref005","doi-asserted-by":"crossref","first-page":"1097","DOI":"10.1111\/j.1525-1497.2006.00565.x","article-title":"The influence of type and severity of mental illness on receipt of screening mammography","volume":"21","author":"CP Carney","year":"2006","journal-title":"J Gen Intern Med"},{"key":"pone.0357375.ref006","doi-asserted-by":"crossref","first-page":"112801","DOI":"10.1016\/j.psychres.2020.112801","article-title":"Excess mortality from breast cancer in female breast cancer patients with severe mental illness","volume":"286","author":"AJ Ahlgr\u00e9n-Rimpil\u00e4inen","year":"2020","journal-title":"Psychiatry Res"},{"issue":"8","key":"pone.0357375.ref007","doi-asserted-by":"crossref","first-page":"547","DOI":"10.7326\/M18-2147","article-title":"Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians","volume":"170","author":"Clinical Guidelines Committee of the American College of P","year":"2019","journal-title":"Ann Intern Med"},{"key":"pone.0357375.ref008","article-title":"Clinical Diagnosis and Management of Breast Cancer","author":"ES McDonald","year":"2016","journal-title":"J Nucl Med"},{"issue":"1","key":"pone.0357375.ref009","article-title":"Practice bulletin number 179: Breast cancer risk assessment and screening in average-risk women","volume":"130","year":"2017","journal-title":"Obstet Gynecol"},{"issue":"9","key":"pone.0357375.ref010","doi-asserted-by":"crossref","first-page":"822","DOI":"10.1016\/j.puhe.2013.03.006","article-title":"Inequalities in uptake of breast cancer screening in Spain: analysis of a cross-sectional national survey","volume":"127","author":"R Mart\u00edn-L\u00f3pez","year":"2013","journal-title":"Public Health"},{"issue":"6","key":"pone.0357375.ref011","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1634\/theoncologist.2011-0469","article-title":"The effect of age on delay in diagnosis and stage of breast cancer","volume":"17","author":"AH Partridge","year":"2012","journal-title":"Oncologist"},{"issue":"4","key":"pone.0357375.ref012","doi-asserted-by":"crossref","first-page":"279","DOI":"10.7326\/M15-2886","article-title":"Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement","volume":"164","author":"AL Siu","year":"2016","journal-title":"Ann Intern Med"},{"issue":"50","key":"pone.0357375.ref013","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000009125","article-title":"Disparities in quality of cancer care: The role of health insurance and population demographics","volume":"96","author":"A Parikh-Patel","year":"2017","journal-title":"Medicine (Baltimore)"},{"issue":"6","key":"pone.0357375.ref014","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1002\/cncr.33330","article-title":"Relationship between insurance status and outcomes for patients with breast cancer in Missouri","volume":"127","author":"JL Berrian","year":"2021","journal-title":"Cancer"},{"issue":"1","key":"pone.0357375.ref015","doi-asserted-by":"crossref","first-page":"5421","DOI":"10.1038\/s41598-021-84996-y","article-title":"Dynamic changes in marital status and survival in women with breast cancer: a population-based study","volume":"11","author":"W Ding","year":"2021","journal-title":"Sci Rep"},{"issue":"12","key":"pone.0357375.ref016","doi-asserted-by":"crossref","first-page":"1378","DOI":"10.1634\/theoncologist.2015-0110","article-title":"Distance as a Barrier to Cancer Diagnosis and Treatment: Review of the Literature","volume":"20","author":"M Ambroggi","year":"2015","journal-title":"Oncologist"},{"issue":"3","key":"pone.0357375.ref017","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1093\/jnci\/djac217","article-title":"Changes in geographic accessibility to mammography by state and rural-urban status, United States, 2006-2022","volume":"115","author":"D Wiese","year":"2023","journal-title":"J Natl Cancer Inst"},{"issue":"3","key":"pone.0357375.ref018","first-page":"3063","article-title":"Rural-urban difference in female breast cancer diagnosis in Missouri","volume":"15","author":"F Williams","year":"2015","journal-title":"Rural Remote Health"},{"issue":"1","key":"pone.0357375.ref019","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1159\/000338393","article-title":"Tumor markers in clinical practice: a review focusing on common solid cancers","volume":"22","author":"MJ Duffy","year":"2013","journal-title":"Med Princ Pract"},{"issue":"2","key":"pone.0357375.ref020","article-title":"High-Intensity End-of-Life Care Among Patients With GI Cancer in Puerto Rico: A Population-Based Study","volume":"17","author":"KJ Ortiz-Ortiz","year":"2021","journal-title":"JCO Oncol Pract"},{"issue":"5","key":"pone.0357375.ref021","article-title":"Effects of type of health insurance coverage on colorectal cancer survival in Puerto Rico: a population-based study","volume":"9","author":"KJ Ortiz-Ortiz","year":"2014","journal-title":"PLoS One"},{"issue":"6","key":"pone.0357375.ref022","first-page":"542","article-title":"Health insurance status and cancer stage at diagnosis and survival in the United States","volume":"72","author":"J Zhao","year":"2022","journal-title":"CA Cancer J Clin"},{"issue":"9","key":"pone.0357375.ref023","doi-asserted-by":"crossref","first-page":"1375","DOI":"10.1038\/bjc.2015.355","article-title":"The impact of patient comorbidity on cancer stage at diagnosis","volume":"113","author":"J Gurney","year":"2015","journal-title":"Br J Cancer"},{"issue":"2","key":"pone.0357375.ref024","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1097\/00005650-200502000-00006","article-title":"Comorbidity as a predictor of stage of illness for patients with breast cancer","volume":"43","author":"ST Fleming","year":"2005","journal-title":"Med Care"},{"issue":"1","key":"pone.0357375.ref025","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1016\/j.whi.2014.09.001","article-title":"Serious psychological distress as a barrier to cancer screening among women","volume":"25","author":"X Xiang","year":"2015","journal-title":"Womens Health Issues"},{"key":"pone.0357375.ref026","article-title":"Mental illness: is there an association with cancer screening among women veterans?","volume":"21","author":"EFT Yee","year":"2011","journal-title":"Womens Health Issues"},{"issue":"6","key":"pone.0357375.ref027","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1192\/bjp.bp.114.147629","article-title":"Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake","volume":"205","author":"AJ Mitchell","year":"2014","journal-title":"Br J Psychiatry"},{"issue":"1","key":"pone.0357375.ref028","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/S2215-0366(19)30414-6","article-title":"Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4\u2008717\u2008839 people","volume":"7","author":"M Solmi","year":"2020","journal-title":"Lancet Psychiatry"},{"issue":"3","key":"pone.0357375.ref029","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.surg.2012.06.010","article-title":"The effect of depression on stage at diagnosis, treatment, and survival in pancreatic adenocarcinoma","volume":"152","author":"CA Boyd","year":"2012","journal-title":"Surgery"},{"key":"pone.0357375.ref030","unstructured":"Dattani S. How are mental illnesses defined?. https:\/\/ourworldindata.org. 2023."},{"key":"pone.0357375.ref031","unstructured":"Observatorio de Salud Mental y Adicci\u00f3n de Puerto Rico. https:\/\/observatorio.assmca.pr.gov\/. 2025."},{"issue":"3","key":"pone.0357375.ref032","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1007\/s00127-019-01653-6","article-title":"A comparison of the prevalence of psychiatric disorders in Puerto Rico with the United States and the Puerto Rican population of the United States","volume":"54","author":"G Canino","year":"2019","journal-title":"Soc Psychiatry Psychiatr Epidemiol"},{"key":"pone.0357375.ref033","unstructured":"Serrano-Rodriguez RRA, Nimsay. Puerto Rico Behavioral Risk Surveillance System Trends Report 2011-2021. 2021."},{"issue":"9","key":"pone.0357375.ref034","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph21091237","article-title":"Hispanic cancer survivors exposed to multiple natural disasters: pre-post-disaster changes in anxiety, depression, PTSD, perceived stress, and physical symptom burden","volume":"21","author":"EM Castro-Figueroa","year":"2024","journal-title":"Int J Environ Res Public Health"},{"issue":"2","key":"pone.0357375.ref035","doi-asserted-by":"crossref","first-page":"475","DOI":"10.3390\/nursrep11020044","article-title":"Brief report: Hispanic patients\u2019 trajectory of cancer symptom burden, depression, anxiety, and quality of life","volume":"11","author":"EM Castro-Figueroa","year":"2021","journal-title":"Nurs Rep"},{"key":"pone.0357375.ref036","article-title":"C\u00e1ncer en Puerto Rico, 2016-2020","author":"CRS-R Torres-Cintr\u00f3n","year":"2023","journal-title":"San Juan: Puerto Rico Central Cancer Registry"},{"issue":"5","key":"pone.0357375.ref037","doi-asserted-by":"crossref","first-page":"441","DOI":"10.4097\/kja.19183","article-title":"Survival analysis: part II - applied clinical data analysis","volume":"72","author":"J In","year":"2019","journal-title":"Korean J Anesthesiol"},{"issue":"14","key":"pone.0357375.ref038","doi-asserted-by":"crossref","first-page":"3252","DOI":"10.1002\/cncr.25857","article-title":"Comorbidities and mammography use interact to explain racial\/ethnic disparities in breast cancer stage at diagnosis","volume":"117","author":"S Yasmeen","year":"2011","journal-title":"Cancer"},{"issue":"1","key":"pone.0357375.ref039","article-title":"A cohort study on mental disorders, stage of cancer at diagnosis and subsequent survival","volume":"4","author":"C-K Chang","year":"2014","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0357375.ref040","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1021\/acsenvironau.2c00012","article-title":"Cancer and Ongoing Climate Change: Who Are the Most Affected?","volume":"3","author":"P Yu","year":"2022","journal-title":"ACS Environ Au"},{"key":"pone.0357375.ref041","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1016\/j.jad.2012.03.025","article-title":"Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age","volume":"141","author":"W Linden","year":"2012","journal-title":"J Affect Disord"},{"issue":"2","key":"pone.0357375.ref042","doi-asserted-by":"crossref","first-page":"48","DOI":"10.7812\/TPP\/14-241","article-title":"Breast cancer survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations","volume":"19","author":"BI Bodai","year":"2015","journal-title":"Perm J"},{"issue":"4","key":"pone.0357375.ref043","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1016\/j.genhosppsych.2013.03.017","article-title":"Course of depression, mental health service utilization and treatment preferences in women receiving chemotherapy for breast cancer","volume":"35","author":"JC Reece","year":"2013","journal-title":"Gen Hosp Psychiatry"},{"issue":"7","key":"pone.0357375.ref044","doi-asserted-by":"crossref","first-page":"964","DOI":"10.1093\/geront\/gnac082","article-title":"Aging and the Left Behind: Puerto Rico and Its Unconventional Rapid Aging","volume":"62","author":"A Matos-Moreno","year":"2022","journal-title":"Gerontologist"},{"issue":"4","key":"pone.0357375.ref045","doi-asserted-by":"crossref","first-page":"715","DOI":"10.3390\/epidemiologia5040050","article-title":"How Physician-Insurance Contracting Contributes to the Medical Exodus and Access to Ophthalmic Care in Puerto Rico","volume":"5","author":"L Al-Attar","year":"2024","journal-title":"Epidemiologia (Basel)"},{"key":"pone.0357375.ref046","volume-title":"Analisis del entorno de prestaci\u00f3n de servicios oncol\u00f3gicos en Puerto Rico","author":"C Cabrera-Bonet","year":"2022"},{"issue":"3","key":"pone.0357375.ref047","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1245\/s10434-012-2558-1","article-title":"Patient and process factors associated with late-stage breast cancer diagnosis in Safety-Net patients: a pilot prospective study","volume":"20","author":"OM Fayanju","year":"2013","journal-title":"Ann Surg Oncol"},{"issue":"1","key":"pone.0357375.ref048","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1186\/s12905-021-01293-6","article-title":"Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan","volume":"21","author":"S Saeed","year":"2021","journal-title":"BMC Womens Health"},{"issue":"3","key":"pone.0357375.ref049","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1001\/jama.2018.19323","article-title":"Breast Cancer Treatment: A Review","volume":"321","author":"AG Waks","year":"2019","journal-title":"Jama"},{"issue":"4","key":"pone.0357375.ref050","first-page":"395","article-title":"Secondary analysis research","volume":"10","author":"RJ Wickham","year":"2019","journal-title":"J Adv Pract Oncol"},{"issue":"1","key":"pone.0357375.ref051","doi-asserted-by":"crossref","first-page":"11","DOI":"10.2174\/1874944500902010011","article-title":"The Use of Claims Data in Healthcare Research","volume":"2","author":"K Ferver","year":"2009","journal-title":"TOPHJ"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0357375","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T17:38:06Z","timestamp":1789148286000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0357375"}},"subtitle":[],"editor":[{"given":"Daniele Ugo","family":"Tari","sequence":"first","affiliation":[{"name":"Local Health Authority Caserta: Azienda Sanitaria Locale Caserta","place":["ITALY"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,9,11]]},"references-count":51,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,11]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0357375","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,11]]}}}