Breast cancer prevention and control among the medically underserved

Decision making for breast cancer prevention among women at elevated risk

Several medical management approaches have been shown to be effective in preventing breast cancer and detecting it early among women at elevated risk: 1) prophylactic mastectomy; 2) prophylactic oophorectomy; 3) chemoprevention; and 4) enhanced screening routines. To varying extents, however, these approaches are substantially underused relative to clinical practice recommendations. This article reviews the existing research on the uptake of these prevention approaches, the characteristics of women who are likely to use various methods, and the decision-making processes that underlie the differing choices of women. It also highlights important areas for future research, detailing the types of studies that are particularly needed in four key areas: documenting women's perspectives on their own perceptions of risk and prevention decisions; explicit comparisons of available prevention pathways and their likely health effects; the psychological, interpersonal, and social processes of prevention decision making; and the dynamics of subgroup variation. Ultimately, this research could support the development of interventions that more fully empower women to make informed and values-consistent decisions, and to move towards favorable health outcomes.

Survival Benefits of Treatment Access Among Underserved Breast Cancer Patients Diagnosed Through the Texas Breast and Cervical Cancer Services Program

PURPOSE

The Texas Breast and Cervical Cancer Services (BCCS) program was established to address socioeconomic disparities in breast and cervical cancer screening and survival. This study examined the impact of the program on treatment and survival of breast cancer patients.

METHODS

A retrospective analysis was performed using the Texas Cancer Registry data linked to the BCCS program data. The sample consisted of 40- to 64-year-old women screened and diagnosed with breast cancer through the BCCS program (participants) and similar women living in low socioeconomic status census tracts and diagnosed outside the program (comparison group) during 1995-2008. Regular screeners among the participants were also compared with the comparison group.

RESULTS

Participants had lower rates of breast surgery and higher rates of chemotherapy as compared with the comparison group. Participants undergoing surgery had higher rates of mastectomy (as compared with breast-conserving surgery) and lower rates of adjuvant radiation therapy. Unadjusted survival rates were similar between the participants and the comparison group, and higher among regular screeners, which was primarily driven by stage at diagnosis. Adjusted survival rates were similar between the 3 groups.

CONCLUSIONS

Although there are differences in the types of treatment provided to the participants and the comparison group, there is no evidence of guideline noncompliance or stage-inappropriate treatment provision in either of the groups. Despite being diagnosed with a more advanced stage, the participants had similar unadjusted and adjusted survival rates as the comparison group. Access to timely treatment improved survival and brought the underserved participants on par with the comparison group.

Breast cancer stage at diagnosis among medically underserved women screened through the Texas Breast and Cervical Cancer Services

The Texas Breast and Cervical Cancer Services (BCCS) program was established to address the socioeconomic disparities in stage at diagnosis and outcomes among breast cancer patients. This study examines the impact of Texas BCCS on stage at diagnosis among low socioeconomic status (SES) breast cancer patients. This is a retrospective analysis of women aged 40-64 years who were screened and diagnosed with breast cancer through the Texas BCCS program (participants) as compared with similar women living in low-SES census tracts and diagnosed outside the program (comparison group) during 1995-2008. Incident cases among the participants were compared with the comparison group as well. Stage at diagnosis was also analyzed separately for the years 1995-2002 and 2003-2008 in order to estimate the effect of BCCS-related Medicaid expansion in 2002. Over the study period of 1995-2008, BCCS participants had a 1.23 (P value<0.0001) times higher odds, and BCCS incident cases had 40% (P value<0.0001) lower odds of advanced stage at diagnosis as compared with the comparison group. A statistically significant difference in stage at diagnosis between the participants and the comparison group only existed for the 2003-2008 (post-Medicaid) period (odds ratio: 1.39, P value<0.0001). Texas BCCS program acts as a source of diagnosis and treatment access to many suspected cancer cases, especially since the 2002 Medicaid expansion, leading to more advanced stage at diagnosis among the BCCS cases as compared with other low-SES cases. Significant expansion of the program to serve a higher proportion of the eligible population is needed to achieve its goals as a screening program.

"Why take it if you don't have anything?" breast cancer risk perceptions and prevention choices at a public hospital

BACKGROUND

Despite advances in breast cancer risk assessment and risk reduction technologies, little is still known about how high-risk women make sense of their risk and assess prevention options, particularly among minority and low-income women. Qualitative methods explore the complex meanings and logics of risk and prevention that quantitative approaches overlook.

OBJECTIVE

This study examined how women attending a high risk breast cancer clinic at a public hospital conceptualize their breast cancer risk and think about the prevention options available to them.

METHODS

Semi-structured interviews were used to gather data from 33 high-risk women (75% African American) between May and August 2004. Interview transcripts were analyzed for recurrent themes and patterns.

RESULTS

Despite general awareness of their objective risk status, many women in this study reported they did not feel "high risk" because they lacked signs and symptoms of cancer. Risk was described as an experienced acute problem rather than a statistical possibility. Women also frequently stated that thinking about cancer might cause it to happen and so it is better not to "dwell on it." While screening was welcomed, women were generally skeptical about primary prevention. In particular, preventive therapies were perceived to cause problems and were only acceptable as treatment options for a disease.

CONCLUSIONS

The body of ideas about risk and prevention expressed by this population differ from the medical model. These findings have implications for risk perception research as well as for the efficacy of risk communication and prevention counseling in clinical contexts.

Factors that affect breast cancer treatment: underserved and minority populations

Breast cancer treatment in underserved populations continues to deviate from established guidelines. Significant barriers persist at the system, physician, and patient levels that ultimately may affect survival adversely. Successful strategies to reduce the disparities must be developed to improve outcomes in this population of women.

A Feasibility Study of the Evaluation of the Florida Breast Cancer Early Detection Program Using the Statewide Cancer Registry

In Florida, a Center for Disease Control and Prevention (CDC)-funded initiative of the Florida Department of Health has targeted socio-economically disadvantaged women for breast and cervical cancer screening. Since 1995, over 12,000 women aged 50-64, within 200% of the federally defined poverty level, with no health insurance, and living in metropolitan catchment areas in Florida, have been screened by the Florida Breast and Cervical Cancer Early Detection Program (BCCEDP). This was a matched cohort cross-sectional analysis of a cohort study of Florida women with breast cancer using the Florida incident cancer registry, the Florida Cancer Data System (FCDS). The study evaluated the hypothesis that there would be no difference in the stage at diagnosis between breast cancer cases in the BCCEDP-screening program and breast cancer cases not diagnosed in the screening program. After linking the BCCEDP records with the FCDS, BCCEDP-screened cases were matched on gender, age, race, ethnicity, and other variables with five groups of FCDS breast cancer cases not screened by BCCEDP to control for demographic and socio-economic factors. Breast cancer cases diagnosed in BCCEDP were significantly more likely to be diagnosed at later stage than non-BCCEDP breast cancer cases in the five matched groups. The BCCEDP is not purely a screening program since it also caters to symptomatic women in the indigent population, therefore these finding were expected. In fact, 71% of the BCCEDP cases were symptomatic at the time of screening/diagnosis and 53% were late-stage diagnosed. These findings show that BCCEDP is indeed servicing its targeted population of medically under-served and symptomatic women in Florida. Furthermore, despite limitations, this study illustrates the potential collaboration between cancer registries and breast cancer screening programs for quality control purposes.

Psychological adjustment among African American breast cancer patients: one-year follow-up results of a randomized psychoeducational group intervention

The effectiveness of support group interventions for cancer patients has been established among White patients but has been virtually unstudied among minority patients. The current study represents the 1st randomized support group intervention targeted to African American women with breast cancer. Participants (N = 73) with nonmetastatic breast cancer were randomly assigned to an 8-week group intervention or an assessment-only control condition At 12 months, the intervention resulted in improved mood as well as improved general and cancer-specific psychological functioning among women with greater baseline distress or lower income. Subsequent research is needed to address effective methods of enrolling and following women with fewer psychosocial and financial resources, as they were the most likely to benefit from this particular intervention.

Mammography screening and differences in stage of disease by race/ethnicity

OBJECTIVES

We examined the effect of routine screening on breast cancer staging by race/ethnicity.

METHODS

We used a 1990 to 1998 mammography database (N = 5182) of metropolitan Denver, Colo, women to examine each racial/ethnic cohort's incident cancer cases (n = 1902) and tumor stage distribution given similar patterns of routine screening use.

RESULTS

Regardless of race/ethnicity, women participating in routine screenings had earlier-stage disease by 5 to 13 percentage points. After control for possible confounding factors, White women were more likely to have early-stage disease compared with Black and Hispanic women.

CONCLUSIONS

Lack of screening coverage in certain racial/ethnic populations has often been cited as a reason for tumor stage differences at detection. In this study, correcting for screening did not completely reduce stage differentials among Black and Hispanic women.

What factors hinder women of color from obtaining preventive health care?

This commentary examines how women of color fare on the use of preventive care. Logistic regression models of women's use of preventive care were computed with data from the 1994 Commonwealth Fund Minority Health Survey. It was found that having a regular doctor was the most consistent predictor of the use of preventive care, irrespective of the women's racial/ethnic background, socioeconomic circumstances, or place of residence. These findings reinforce the importance of physicians in the delivery of preventive care. Suggestions for improving the use of preventive services by women of color are provided.

The identified needs of ethnic minority groups with cancer within the community: a review of the literature

The literature suggests that healthcare provision for ethnic minority groups is poorer than for the majority population. The intention of this paper is to review the literature available on healthcare provision for ethnic minority groups to see if this is the case for those with cancer. The introduction in the UK of monitoring of ethnic origins in the general population and healthcare service is recent and means that there are few data available. At present, cancer mortality is lower among ethnic minority groups than the majority population in the UK, which may partly be explained by a younger than average age within the ethnic minority groups and the fact that some members of ethnic groups retire to their country of origin. However, the mortality rates are expected to increase as the population ages. Breast and lung cancers are the most common cancers among ethnic minority groups in the UK. Traditional intervention strategies have been aimed at the majority white population and have not taken into account the needs identified by the ethnic communities themselves. Intervention strategies include advice on stopping smoking and chewing tobacco, increasing use of screening services by ethnic minority groups, targeted health promotion messages and education on cancer specifically for these groups. More data are required on cancer among ethnic minority groups in the UK. There are many similarities in the use of cancer services between ethnic minority groups and individuals with lower socioeconomic status in the UK.

An assessment of delays in obtaining definitive breast cancer treatment in Southern Italy

Female population is medically underserved in Southern Italy (in comparison with other Italian regions). In a recent systematic review of published studies, delays of 3-6 months between symptom onset and treatment have been clearly associated with lower survival rates for breast cancer patients. The aim of this study was to examine breast cancer delays in medically underserved patients in Southern Italy, in order to recognize their determinating factors so as to provide women with a better opportunity for survival. The variables examined were age, education, symptom status at first presentation: symptomatic and asymptomatic, date of first symptom presentation, date of first consultation with a health provider, consulted provider, tumor size and nodal status, according to the pTNM system. Time intervals were categorized into: < 1 month, 1-3 months and > 3 months for patient and medical delay; 1-3 months, 3-6 months, > 6 months for overall delay. Patient delay was associated with education: a higher risk was found for women with < or = 5 years school attendance (OR = 3.3, 95%, CI 2.0-5.6). Medical delay was seen to be associated with the professional figure: significant differences were found between senologists (oncologist exclusively dedicated to breast cancer) and other specialists (OR 3.5, 95%, CI 1.5-8.4). Age and symptomatic presentation were found to be high risk factors. Concerning tumor size in overall delay in cases > 2 cm had OR values were of 2.4 (95%, CI 1.5-3.7). In conclusion our study suggests that diagnostic delay is associated with medically underserved status and can be reduced by educating younger and less educated women, as suggested in other studies and by providing training programs for members in the medical profession.

Holes in the safety net? Assessing the effects of targeted benefits upon the health care utilization of poor New Zealanders

This paper examines the issue of targeting primary health-care benefits in favour of low-income recipients and other high users of health care. Specifically we examine the New Zealand case where, despite the introduction of such benefits in 1992, financial barriers appear to remain a significant determinant of utilization. We address this issue through a case study conducted in the city of Christchurch. Through a survey-based research design, we seek to determine the extent to which price barriers remain important by comparing patient utilization of a free community health clinic (n = 202) with a low-income control sample of patients who continue to use conventional (for New Zealand) fee-for-service providers (n = 148). We found that a large proportion of respondents delayed seeking care because of cost. Further, for respondents using the fee-for-service providers, levels of use were not related to need, whereas at the free clinic there was an inverse relationship between income and consultation rates. We conclude that if a universality of benefits is not possible, then there is a need for better targeting of primary care benefits. We believe there is a danger in such initiatives being evaluated primarily in terms of their validity as funding mechanisms, rather than in terms of their success in meeting the health-care needs of the disdavantaged.