Insights into Breast Cancer Disparities

1
Insights into Breast Cancer Disparities

• Melissa Cole
• Graduate Research Assistant

2
Outline

• Purpose of the Research
• Breast Cancer Disparities Data
• Past Research
• What We Already Know
• Detection
• Barriers
• Getting around barriers
• CDCs National Breast and Cervical Cancer Early
  Detection Program
• Current Research Questions
• Role of Health Educators
• Discussion Questions

3
About Me

• B.S. in Health May 2006
• Community Health Option
• Currently working toward M.S. in Health Education
• Interest in breast cancer, prenatal, and
  pregnancy-related issues

4
Purpose of Research

• Breast cancer is a very treatable disease,
  particularly when its caught early (Dr. Carol
  Lee, professor at Yale University School of
  Medicine and head of American College of
  Radiologys breast imaging commission)
• Implications for more diligentscreening
  practices, especially focusing on high-risk
  populations

Source HealthDay News. (2006). Digital
mammography boosts chances of spotting
malignancies. accessed November 1, 2006.
Available at http//www.nlm.nih.gov/medlineplus/n
ews/fullstory_40348.html
5
Top 10 Causes of Death for Women in the United
States
Source CDC. (2006). Statistics. accessed
November 10, 2006. Available at
http//www.cdc.gov/cancer/breast/statistics/
6
Female Breast CancerSEER Incidence Rates by Race
and Ethnicity, US, 1994-2003
Rates are per 100,000 and are age-adjusted to the
2000 U.S. standard population. Source CDC.
(2006). Comparing Breast Cancer by Race and
Ethnicity. accessed November 10, 2006.
Available at http//www.cdc.gov/cancer/breast/sta
tistics/race.htm
7
Female Breast CancerU.S. Death Rates by Race and
Ethnicity, 1950-2003
1980s- The United States began campaign to
eradicate breast cancer Pink Ribbon
Campaign Rates are per 100,000 and are
age-adjusted to the 2000 U.S. standard
population. Source CDC. (2006). Comparing
Breast Cancer by Race and Ethnicity. accessed
November 10, 2006. Available at
http//www.cdc.gov/cancer/breast/statistics/race.h
tm
8
Percent of U.S. Women Who Develop Breast Cancer
Over 10-, 20-, and 30-Year Intervals According to
Their Current Age, 2001-2003
Source CDC. (2006). Risk of Breast Cancer By
Age. accessed November 10, 2006. Available at
http//www.cdc.gov/cancer/breast/statistics/age.ht
m
9
Percent of U.S. Women Who Die from Breast Cancer
Over 10-, 20-, and 30-Year Intervals According to
Their Current Age, 2001-2003
Source CDC. (2006). Risk of Breast Cancer By
Age. accessed November 10, 2006. Available at
http//www.cdc.gov/cancer/breast/statistics/age.ht
m
10
Female Breast Cancer Incidence Rates, by State,
2003
Rates are per 100,000 and are age-adjusted to the
2000 U.S. standard population. Source CDC.
(2006). Comparing breast cancer in different
U.S. states. accessed November 10, 2006.
Available at http//www.cdc.gov/cancer/breast/sta
tistics/state.htm
11
Female Breast Cancer Death Rates, by State, 2003
Rates are per 100,000 and are age-adjusted to the
2000 U.S. standard population. Source CDC.
(2006). Comparing breast cancer in different
U.S. states. accessed November 10, 2006.
Available at http//www.cdc.gov/cancer/breast/sta
tistics/state.htm
12
Age-adjusted Cancer Death Rates and 95
Confidence Intervals by Primary Site and Race
and Ethnicity, United States, 2002 (per
100,000) Source CDC. (2006). United States
cancer statistics 2002 incidence and mortality.
accessed October 30, 2006. Available at
http//www.cdc.gov/cancer/npcr/uscs/index.htm
13
Breast Cancer in Men

• Signs and symptoms similar to women
• Risk factors
• Genetic (5-10), radiation exposure, Klinefelter
  syndrome, exposure to estrogen, liver disease,
  excess weight, and excessive use of alcohol

Source Mayo Clinic. (2006). Mens Health, Male
Breast Cancer. accessed November 14, 2006.
Available at http//www.mayoclinic.com/health/mal
e-breast-cancer/DS00661/DSECTION4
14
Past Research

• Hereditary and environmental factors could
  contribute to more severe breast cancers,
  especially among African American women
• Large, advanced-stage tumors and lymph
  node-involved tumors more likely to be diagnosed
  in African Americans than any other group
• Inadequate use of mammography?

Source Newman, L.A., K.A. Griffith, I. Jatoi,
M.S. Simon, J.P. Crowe, and G.A. Colditz.
(2006). Meta-analysis of survival in African
American and White American patients with breast
cancer Ethnicity compared with socioeconomic
status. Journal of Clinical Oncology, 24(9)
1342-1347 Smith-Bindman, R., D.L. Miglioretti,
N. Lurie, L. Abraham, R.B. Barbash, J.
Strzelczyk, M. Dignan, W.E. Barlow, C.M. Beasley,
and K. Kerlikowske. (2006). Does utilization of
screening mammography explain racial and ethnic
differences in breast cancer? Annals of Internal
Medicine, 144(8) 541-552.
15
Past Research (continued)

• Possible link to being overweight and developing
  breast cancer after menopause
• Physical activity associated with a 10-25
  reduction in risk (ACS)
• Circulates hormones
• Alcohol may contribute
• Regular consumption along with decreased
  consumption of vitamin folate

Source ACS. (2006). Lifestyle vs. breast
cancer. accessed on November 1, 2006.
Available at http//www.cancer.org/docroot/NWS/co
ntent/NWS_1_1x_Lifestyle_vs_Breast_Cancer.asp
16
Detection

• Self Breast Exam
• Begin by age 20
• Capable of feeling lump and visual changes
• Clinical Breast Exam
• Begin by age 20
• Capable of feeling lump and visual changes
• Mammogram
• Begin by age 40
• Capable of detecting before lump can be felt

17
Barriers

• Cost of exam (monetary)
• Cost of exam (time)
• Work, family, travel
• Fear of diagnosis
• Potential cost of future treatment (monetary and
  time)
• Fear of pain from mammogram
• Also cultural, psychosocial
• Barriers have the potential to delay detection
  and therefore treatment

Source National Breast Cancer Awareness Month.
(2006). Know the Facts about Early Detection.
accessed on October 9, 2006. Available at
http//www.nbcam.com/aboutBC_earlyDetection.cfm
Guidry, J.J., P. Matthews-Juarez, V.A.
Copeland. (2003). Barriers to breast cancer
control for African-American women. CANCER
Supplement, 97(1) 318-323.
18
Addressing the Barriers

• Cost (monetary)
• Private insurance, Medicare, and Medicaid should
  cover screenings and treatments
• Some hospitals offer payment plans
• Free or low cost mammograms may be available
  (CDC)
• Fear of diagnosis and fear of mammogram
• Education

19
2000 and 2002 Behavioral Risk Factor Surveillance
System (BRFSS) and 2000 U.S. Census Data, 35
metropolitan statistical areas (MSAs) Source
CDC. (2005). MMWR breast cancer screening and
socioeconomic status 35 metropolitan areas,
2000 and 2002. accessed November 10, 2006.
Available at http//www.cdc.gov/MMWR/preview/mmwr
html/mm5439a2.htm
20
2000 and 2002 Behavioral Risk Factor Surveillance
System (BRFSS) and 2000 U.S. Census Data, 35
metropolitan statistical areas (MSAs) Source
CDC. (2005). MMWR breast cancer screening and
socioeconomic status 35 metropolitan areas,
2000 and 2002. accessed November 10, 2006.
Available at http//www.cdc.gov/MMWR/preview/mmwr
html/mm5439a2.htm
21
2000 and 2002 Behavioral Risk Factor Surveillance
System (BRFSS) and 2000 U.S. Census Data, 35
metropolitan statistical areas (MSAs) Source
CDC. (2005). MMWR breast cancer screening and
socioeconomic status 35 metropolitan areas,
2000 and 2002. accessed November 10, 2006.
Available at http//www.cdc.gov/MMWR/preview/mmwr
html/mm5439a2.htm
22
2000 and 2002 Behavioral Risk Factor Surveillance
System (BRFSS) and 2000 U.S. Census Data, 35
metropolitan statistical areas (MSAs) Source
CDC. (2005). MMWR breast cancer screening and
socioeconomic status 35 metropolitan areas,
2000 and 2002. accessed November 10, 2006.
Available at http//www.cdc.gov/MMWR/preview/mmwr
html/mm5439a2.htm
23
2000 and 2002 Behavioral Risk Factor Surveillance
System (BRFSS) and 2000 U.S. Census Data, 35
metropolitan statistical areas (MSAs) Source
CDC. (2005). MMWR breast cancer screening and
socioeconomic status 35 metropolitan areas,
2000 and 2002. accessed November 10, 2006.
Available at http//www.cdc.gov/MMWR/preview/mmwr
html/mm5439a2.htm
24
National Breast and Cervical Cancer Early
Detection Program

• Congress passed the Breast and Cervical Cancer
  Mortality Prevention Act in 1990
• CDC program for low-income, uninsured, and
  underserved women
• 7-10 of US women are eligible
• Must be at or below 250 federal poverty level
  and between ages 40-64 for breast screenings

Source The National Breast and Cervical Cancer
Early Detection Program 1991-2002 National
Report, CDC
25
Source The National Breast and Cervical Cancer
Early Detection Program 1991-2002 National
Report, CDC
26
Most women 65 years and older not served through
program because of eligibility for Medicare Part
B coverage Source The National Breast and
Cervical Cancer Early Detection Program
1991-2002 National Report, CDC
27
Source The National Breast and Cervical Cancer
Early Detection Program 1991-2002 National
Report, CDC
28
NBCCEDP

• From 1991 to 2002
• 1,175,759 women have received 2,038,118
  mammograms
• 9,956 cases of breast cancer were diagnosed
• Available in all 50 states, 4 U.S. territories,
  the District of Columbia, and 13 American
  Indian/Alaskan Native tribes or organizations

Source The National Breast and Cervical Cancer
Early Detection Program 1991-2002 National
Report, CDC
29
Current Research Questions

• Is the study population representative of the
  entire population?
• Was the pattern of mammography use over time
  evaluated or just the interval between two
  mammograms?
• Was the data from medical records or
  self-reports? Was the data extraction consistent
  for all study participants?

Source Smith-Bindman, R., D.L. Miglioretti, N.
Lurie, L. Abraham, R.B. Barbash, J. Strzelczyk,
M. Dignan, W.E. Barlow, C.M. Beasley, and K.
Kerlikowske. (2006). Does utilization of
screening mammography explain racial and ethnic
differences in breast cancer? Annals of Internal
Medicine, 144(8) 541-552.
30
Current Research Questions (Continued)

• Should breast cancer treatments be tailored to
  individuals?
• Tamoxifen genetic profiles, antidepressants
• Does red meat increase risk of breast cancer?
• Women eating 1 ½ servings per day twice as likely
  to develop hormone receptor-positive breast
  cancer
• Black women have genetic disadvantage?
• More likely to have estrogen-receptor negative
  tumors and high-grade tumors with low survival
  rates

Source Health Day News. (2006). Black womens
genes may spur deadlier breast cancer. accessed
November 14, 2006. Available at
http//www.healthday.com/view.cfm?id535601
Health Day News. (2006). Breast cancer drugs not
one-size-fits-all. accessed November 1, 2006.
Available at http//www.nlm.nih.gov/medlineplus/n
ews/fullstory_40404.html and Reinberg, S. (2006).
Health Day News. Red meat may boost breast
cancer risk. accessed November 14, 2006.
Available at http//www.healthday.com/view.cfm?id
536057
31
Implications for Health Educators

• In regard to mammography programs
• Intensify efforts to increase the number of
  women utilizing this potentially life-saving
  test (Jazieh and Buncher).
• Cancer education programs should look at
• many levels that address the fundamental,
  causative issues contributing to the myriad of
  health disparities, i.e. access, health
  insurance, transportation, MD referral, lack of
  time, fear, fatalism and lack of knowledge
  (Hurd, Muti, Erwin, and Womack).

Source Jazieh, A.R. and C.R. Buncher. (2002).
Racial and age-related disparities in obtaining
screening mammography Results of a statewide
database. Southern Medical Journal, 95(10)
1145-1147. and Hurd, T.C., P. Muti, D.O. Erwin,
and S. Womack. (2003). An evaluation of the
integration of non-traditional learning tools
into a community-based breast and cervical cancer
education program The witness project of
Buffalo. BMC Cancer, 3 1-8.
32
Research Questions

• Two areas need to be addressed
• Lack of early detection
• Educate on importance of overcoming barriers and
  getting screened early
• Aggressive forms of breast cancer
• Provide race/ethnicity specific education to
  approach the different populations
• Health educators play a key role in addressing
  both

33
Role of Lay Health Advisors in Health Education

• Social network strategy
• Individuals are influenced by groups that provide
  social identity
• Source of comfort
• Individuals trust them
• Serve as cultural brokers
• Language, religious beliefs, social/ethnic
  characteristics

Source Earp, J.L., C.I. Viadro, A.A. Vincus, M.
Altpeter, L. Mayne, E. Eng. (1997). Lay health
advisors A strategy for getting the word out
about breast cancer. Health Education and
Behavior, 24(4) 432-451.
34
Role of Lay Health Advisors in Health Education

• Earp, J.A., E. Eng, M.S. OMalley, M. Altpeter,
  G. Rauscher, L. Mayne, H.F. Mathews, K.S. Lynch,
  B. Qaqish. (2002). Increasing use of
  mammography among older, rural African American
  women Results from a community trial. American
  Journal of Public Health, 92(4) 646-654.
• L. Suarez. (2000). Social networks and cancer
  screenings in four U.S. Hispanic groups. American
  Journal of Preventive Medicine, 19(1) 47-52.
• Hiatt, R.A., R.J. Pasick, S. Stewart, J. Bloom,
  P. Davis, P. Gardiner, M. Johnston, J. Luce, K.
  Schorr, W. Brunner, F. Stroud. (2001).
  Community-based cancer screening for underserved
  women Design and baseline findings from the
  breast and cervical cancer intervention study.
  Preventive Medicine, 33(3) 190-203.

35
Discussion Questions

• What role do health educators play in breast
  cancer awareness and prevention?
• What are the ethical implications of performing
  the research?
• How can we change the lifestyle and environmental
  factors that play a role in hormone
  receptor-positive breast cancer?
• Can more effective detection methods be
  developed?
• How can we increase screening rates?
• Will there ever be a time when disparities in
  breast cancer incidence and death are not a
  factor?

36
References

• ACS. (2006). Lifestyle vs. breast cancer.
  accessed on November 1, 2006. Available at
  http//www.cancer.org/docroot/NWS/content/NWS_1_1x
  _Lifestyle_vs_Breast_Cancer.asp
• CDC. (2006). Comparing Breast Cancer by Race and
  Ethnicity. accessed November 10, 2006.
  Available at http//www.cdc.gov/cancer/breast/sta
  tistics/race.htm
• CDC. (2006). Comparing breast cancer in
  different U.S. states. accessed November 10,
  2006. Available at http//www.cdc.gov/cancer/bre
  ast/statistics/state.htm
• CDC. (2005). MMWR breast cancer screening and
  socioeconomic status 35 metropolitan areas,
  2000 and 2002. accessed November 10, 2006.
  Available at http//www.cdc.gov/MMWR/preview/mmwr
  html/mm5439a2.htm
• CDC. (2006). Risk of Breast Cancer By Age.
  accessed November 10, 2006. Available at
  http//www.cdc.gov/cancer/breast/statistics/age.ht
  m
• CDC. (2006). United States cancer statistics
  2002 incidence and mortality. accessed October
  30, 2006. Available at http//www.cdc.gov/cancer
  /npcr/uscs/index.htm
• Earp, J.L., C.I. Viadro, A.A. Vincus, M.
  Altpeter, L. Mayne, E. Eng. (1997). Lay health
  advisors A strategy for getting the word out
  about breast cancer. Health Education and
  Behavior, 24(4) 432-451.
• Guidry, J.J., P. Matthews-Juarez, V.A.
  Copeland. (2003). Barriers to breast cancer
  control for African-American women. CANCER
  Supplement, 97(1) 318-323.
• Health Day News. (2006). Black womens genes may
  spur deadlier breast cancer. accessed November
  14, 2006. Available at http//www.healthday.com/
  view.cfm?id535601
• Health Day News. (2006). Breast cancer drugs not
  one-size-fits-all. accessed November 1, 2006.
  Available at http//www.nlm.nih.gov/medlineplus/n
  ews/fullstory_40404.html
• Health Day News. (2006). Digital mammography
  boosts chances of spotting malignancies.
  accessed November 1, 2006. Available at
  http//www.nlm.nih.gov/medlineplus/news/fullstory_
  40348.html
• Mayo Clinic. (2006). Mens Health, Male Breast
  Cancer. accessed November 14, 2006. Available
  at http//www.mayoclinic.com/health/male-breast-c
  ancer/DS00661/DSECTION4
• Newman, L.A., K.A. Griffith, I. Jatoi, M.S.
  Simon, J.P. Crowe, and G.A. Colditz. (2006).
  Meta-analysis of survival in African American
  and White American patients with breast cancer
  Ethnicity compared with socioeconomic status.
  Journal of Clinical Oncology, 24(9) 1342-1347.
• Reinberg, S. (2006). Health Day News. Red meat
  may boost breast cancer risk. accessed
  November 14, 2006. Available at
  http//www.healthday.com/view.cfm?id536057
• Ryerson, A.B., V.B. Benard, and A.C. Major.
  (2002). National breast and cervical cancer
  early detection program 1991-2002 national
  report. CDC
• Smith-Bindman, R., D.L. Miglioretti, N. Lurie, L.
  Abraham, R.B. Barbash, J. Strzelczyk, M. Dignan,
  W.E. Barlow, C.M. Beasley, and K. Kerlikowske.
  (2006). Does utilization of screening mammography
  explain racial and ethnic differences in breast
  cancer? Annals of Internal Medicine, 144(8)
  541-552.