Improved Access
Benign Breast Disease, Biopsy and Cancer Preventive Self-Care
Jacqueline O'Connor, Ph.D.
University of California, Davis
The rates of benign breast disease indicate that a substantial number of pre- and post-menopausal women have experienced the discovery, biopsy, and diagnosis of benign (i.e., non-cancerous) breast disease—a sequence of events that our research team refer to collectively as a breast health crisis. The limited psychological research to date supports the idea that these experiences constitute a stressful life event, and for some, a life crisis. Our multidisci-plinary research team proposes to conduct a longitudinal study of psychological and behavioral processes in breast self-care following biopsy and diagnosis of benign breast disease. The goal of this study is to identify the most important elements of the psychological self-appraisal system that regulates preventive breast self-care, and to describe the dynamic relations among those elements that predict continuity and discontinuity in self care following an acute threat to breast health. (We define self-care in terms of all three components of cancer screening behavior: performing breast self-examination, obtaining a mammogram, and having a clinical breast examination.)
There is evidence from previous research that self-care routines may be disrupted in the aftermath of a breast health crisis, although to date there are no published long-term follow-up studies to assess patterns of stability or change following a benign breast diagnosis. In addition, although some types of benign breast disease have been associated with an increased risk of breast cancer, many women with a history of benign breast disease do not comply with recommended guidelines for breast self-examination, screening mammography, and clinical breast examinations.
We plan to prospectively monitor breast health knowledge, beliefs, and behaviors in approximately 200 women who have recently undergone investigative medical procedures including breast biopsy, for benign breast disease , as well as a large control sample of approximately 300 women, for the entire duration of the 3-year study period. Data collection will include measures of stress and coping through a breast health crisis; breast cancer knowledge, beliefs, and attitudes; personal appraisal of susceptibility, breast cancer-related anxiety, and efficacy regarding self-care practices; and interval tracking of breast self-care behaviors.
The significance of this project in terms of the Breast Cancer Research Program's emphasis on early detection is that the occurrence of a benign breast disease may present an opportunity for positive intervention related to subsequent breast self-care , or may, on the other hand, overwhelm a woman's coping resources, leaving her feeling vulnerable, powerless, and unmotivated to adopt or continue preventive self-care. Therefore, the study we propose of psychological and behavioral processes in breast self-care in the presence - and absence - of a benign breast disease history can make a valuable contribution to our understanding of important aspects of personal behavior that affect early detection, and through such understanding to help achieve the broader goal of reducing the human and economic costs of breast cancer among all women.
Group Intervention For Women at High Risk for Breast Cancer
David K. Wellisch, Ph.D.
University of California, Los Angeles
This study is a group intervention for women at high risk for breast cancer. It addresses the Breast Cancer Research Program's priority issue involving improved access for underserved populations, specifically women at a high risk of developing breast cancer. Thus far, no viable group interventions have been developed for this population. The purpose of this study is to identify and develop a multidisci-plinary and multispecialty organizational model of service delivery by defining the content and characteristics of the best group model to increase education, prevent the development of psychological symptoms and problems, and increase adaptation and coping to the threat these women live with daily. A special effort will be made to recruit minority women, since to date, most work in this area has been on Caucasian women. The study additionally addresses the psychosocial and behavioral consequences of elevated genetic risk for breast cancer.
Specific aims of the project include: (1) to test the viability of the group model in terms of content, interest, effectiveness, attendance, and optimal participant mix; (2) to test the feasibility of the group model in terms of decreasing the participants' adverse psychological and behavioral symptomatology; (3) to test the feasibility of the group model in terms of increasing knowledge of nutrition and its relationship to increased cancer risk; (4) to test the feasibility of the group model to facilitate a more realistic assessment of personal cancer risk; (5) to test the feasibility of the group model in terms of increasing knowledge of positive coping methods; and (6) to test the feasibility of the group model in reduction of grief symptoms.
If this group model proves feasible, it will be possible to shift focus to long-tem retention of high risk women in appropriate clinics and other settings which would promote earlier detection and diagnosis, thus reducing mortality and morbidity from this disease.
Effects of Stress and Support on Delay in Cancer Treatment
Karyn L. Angell, Ph.D.
Stanford University
This project is a direct attempt to identify behavioral and social barriers to the early detection of breast cancer. Women recently diagnosed with primary breast cancer will be interviewed in an effort to understand the roles of both life stress and social support on their initial cancer treatment-seeking decisions. While it is fairly clear why women with more financial resources may take advantage of medical intervention sooner than women who live in poverty, it is less clear how a woman who is juggling a shaky marriage, caring for an ailing parent, or worrying about a teenager on drugs may be influenced by these factors when making decisions about her own medical care. A woman's social network may also influence how she chooses medical care upon discovery of potential cancer symptoms.
Sixty women with biopsy-confirmed breast carcinoma without distant metasteses (i.e., Stage I-III breast cancer) will be recruited within six months of their diagnoses through their oncology clinics. The women will be interviewed in their homes by trained clinical interviewers about the year preceding their cancer diagnosis. The interview is designed to tap 10 major areas of life experiences. The interview forms the basis for standardized ratings on a social stress rating system which provides an assessment of the degree of stress arising from different life circumstances. The women will also be asked to complete questionnaires assessing the presence and effectiveness of any social support network they identify. The onset of any symptom or health change preceding the breast cancer diagnosis will be carefully documented during the interview, and actual dates of initial treatment will be confirmed through a chart review.
We hypothesize that the time between the onset of first cancer symptoms and the date of first cancer care will be affected by the experience of severe life events and the type of social support available during the year prior to diagnosis. We anticipate a buffering effect of social support on stress such that women who experience severe stress but who also report strong supportive networks will be less affected than women whose severe stress occurs in the absence of social support or in the context of a social network which is critical in nature. Knowledge about the influences of stress and social support on care-seeking behavior will provide important information for interventions aimed at getting women into treatment sooner, possibly leading to better prognoses and potentially lowering breast cancer mortality rates.
Race/Ethnicity and Late Stage Breast Cancer
David J. Delgado, Ph.D., M.P.H.
University of Southern California
Over 20 million Hispanics live in the United States, and more than 50% of them live in California. Between 1974 and 1991, over 50,000 cases of breast cancer have been diagnosed in Los Angeles White and Hispanic women, making it an issue of extreme importance. Breast cancer accounts for the largest number of incident cases among all ethnic groups in Los Angeles. With the L.A. Hispanic population age distribution reflecting that of third world countries, the issue of age and its impact in early breast cancer detection for the Hispanic population is also important to examine. Incidence rates for racial/ethnic groups have been published, but fail to account for socioeconomic status. Incidence rates by stage-of-diagnosis, socioeconomic status, age, and race/ethnicity are not readily available.
The State of California's Breast Cancer Early Detection Program specifically targets women of lower socioeconomic status and minority racial/ethnic groups in order to improve breast cancer survival and reduce stage-at-diagnosis. In order to measure the progress and success of this program, and other similar programs attempting to encourage earlier screening, appropriate baseline data will be needed. In particular, it will be important to be able to confidently examine changes in stage-of-diagnosis over time for subgroups of the population defined by race/ethnicity, age and socioeconomic status. One of the major contributions of this research will be to use various sophisticated statistical techniques (empirical bayes and constrained empirical bayes methodology) to provide reliable incidence rates calculated for these sub-populations. This type of methodology will help examine the incidence of late-staged breast cancer as it relates to socioeconomic status, race/ethnicity, and time period, after adjusting for age. Finally, this methodology will help in studying the combination of all of the above variables in order to better understand the potential impact of early detection interventions. This study can provide a geographically-defined baseline, of stage-specific incidence rates from which future calculations of late stage-of-diagnosis can be compared.
We will examine our data for all of Los Angeles, dividing the County for analysis purpose into 86 Medical Service Study Areas (MSSAs) to be targeted for analysis. The results will enable policy makers and community service agencies to target the worst MSSAs with programs for the early detection of breast cancer. We will identify these MSSAs of extreme poverty, and estimate baseline information about the incidence of late-staged diagnosis on a Racial/Ethnic and Age-specific basis. Not only should our analysis help to focus future health education/outreach interventions, but will also offer a baseline from which to evaluate the effectiveness of these programs in the future.
False-Positive Mammograms: A Barrier to Annual Screening?
Phillip Gardiner, Dr.P.H.
Northern California Cancer Center
This research proposes to measure the extent and assess the psychological and behavioral impacts of false-positive mammography results among underserved African American women. Studies continue to show that African American women have a lower incidence of breast cancer but a disproportionately high rate of mortality from this disease compared to white women. Late stage diagnosis has been one of the main factors cited for this disparity. Evidence suggests that even though African American women have increased use of initial mammography screening, they may not adhere to recommended annual screening over time. Additionally, the low incidence of breast cancer, combined with greater use of initial screening is expected to yield numerous false-positive results among African American women. Due to the problems poor women encounter in trying to obtain medical care, it is the hypothesis of this study that the experience of a false-positive mammogram combined with all that is involved in resolving the abnormality is a deterrent to subsequent screening, and thus may be a factor in disproportionate mortality among African American women.
This study seeks to (1) analyze the distribution of false-positive mammography results across racial/ethnic groups of underserved women; (2) establish the positive predictive value (PPV) of the BCCCP mammography screening (PPV is the likelihood that an abnormal mammogram has actually detected cancer); (3) assess the relationship between false-positive results and subsequent screening practices; and (4) identify the psychological and behavioral impact of false-positives in African American women.
Using data from the State of California's Breast and Cervical Cancer Control Program (BCCCP), a cross-sectional analysis (i.e. assessment of data at one point in time) will compare rates of false positive mammograms across race/ethnic groups for the period 1992 to 1997. Second, a cohort study of BCCCP participants who have had false positive mammograms will be followed up for a period of three years to assess the relationship of the false-positive and subsequent screening. Third, a telephone interview of 100 African American women who had a false-positive and a matched sample of 100 whose results were normal will be conducted to compare the attitudes, intentions, and behaviors of these two groups and to further illuminate the potential impact of the result on routine screening.
Innovative interventions directed at populations most at risk for false-positives can improve and expand the early detection of breast cancer. This intervention can lay the basis for the development of educational material about false-positive mammography screening. Better informed and educated women can improve and expand their cancer screening practices. Research that addresses the racial disparity in breast cancer mortality can be instrumental in reducing human toll and misery from this disease.
Impact of Physician Attitudes on Mammography Screening Rates
Miriam Komaromy, M.D.
University of California, San Francisco
This project examines the possible role of physician attitudes and practice style in explaining the observed racial-ethnic and socio-economic differences in breast cancer screening and early detection rates. The goals of this study are to determine whether individual physicians differ in their attitude toward breast cancer screening or the likelihood that they would recommend breast cancer screening in minority and poor patients compared with wealthier, non-minority patients. Understanding physicians' role, if any, in contributing to disparity in breast cancer screening rates will allow us to design interventions to improve access to breast cancer screening and reduce breast cancer morbidity and mortality for poor and minority women.
There will be two major components to this study. The first is a series of focus groups with California physicians who provide primary care for women. In the focus groups we will explore how physician attitudes and practice style may vary when physicians are evaluating patients of different racial-ethnic or socio-economic backgrounds. We will perform eight focus groups with 8-10 physicians. The second study component will be a survey of a random sample of 720 California primary care physicians, sampled so as to increase the representation of physicians practicing in areas with large numbers of poor and minority patients. The survey will reflect the physician attitudes and practice styles revealed during the focus groups, and will be used to test the generalizability of these findings. It will also assess the relationship of physician attitudes regarding breast cancer screening in poor and minority populations, and physicians' knowledge and usual practice with regard to breast cancer screening. Finally the survey will include a measure of physicians' degree of cultural sensitivity, i.e. their attitudes toward the care for minority patients and degree of competence in caring for special problems of minority patients. Results will be analyzed to determine the frequency with which physicians perceive they are less able to communicate adequately about breast cancer screening with poor and minority patients, and the reasons for and consequences of communication barriers. We will also compare the frequency with which physicians who care for large poor and minority populations report that they recommend mammography with the frequency reported by physicians who care for few poor and minority patients.
Results will be used to design targeted educational interventions for physicians to improve their cross-cultural communication skills, and reinforce the awareness of the need for breast cancer screening in poor and minority patients.
Understanding Breast Cancer Screening in Filipino Women
Annette E. Maxwell, Dr. P.H.
University of California, Los Angeles
A recent case control study suggests that the risk of breast cancer among Asian women (including Filipino women) may be as high as or even higher than that of White women. Asian women frequently have been excluded from breast cancer research, and the few studies that have included Asian-American women show that they have the lowest screening rates among all ethnic groups. These considerations, coupled with the fact that Asians are the fastest growing ethnic group in California, create an urgent need for interventions to increase screening. However, at the present time, any intervention efforts will certainly be hampered by a woefully inadequate understanding of breast cancer screening behaviors among Asian-American women. The proposed study attempts to provide this information for women of Filipino descent as a first step in the design of an effective, culturally appropriate intervention program.
The purpose of this proposal is to gather detailed information on factors that affect breast cancer screening in Filipino women 50 years of age and older residing in Los Angeles County. Information will be obtained from focus groups and face-to-face interviews with women of this target group. This study will: (1) conduct semi-structured interviews with key informants in Asian American communities in Los Angeles County regarding breast cancer screening among women of Filipino descent; (2) conduct focus groups with Filipino women to explore attitudes and beliefs regarding breast cancer screening, barriers to screening and how to successfully overcome these barriers; (3) develop, translate and pilot test a survey to collect detailed information on breast cancer screening and correlates in Filipino women; and (4) administer the survey to 200 women 50 years of age and older residing in Los Angeles County.
Results of this study will be used to formulate recommendations for strategies to increase breast cancer screening among Filipino women 50 years of age and older.
Promoting Early Detection of Breast Cancer Among Vietnamese
Stephen J. McPhee, M.D.
University of California, San Francisco
This proposal seeks to increase the access to early breast cancer detection services of Vietnamese women-members of a poor, under-insured, and rapidly growing racial and ethnic minority in California. Previous studies by the investigators demonstrate that Vietnamese women underutilize breast cancer screening: they are both less likely to report ever having had clinical breast examination (CBE) and mammography, and are more frequently overdue for these procedures than women in the general U.S. population. The research will employ interventions to reduce cultural and economic barriers to accessing services for the early detection of breast cancer and will target both Vietnamese consumers and physicians.
The study will test the effect of a coordinated set of interventions on breast cancer screening rates of Vietnamese women. Study plans were guided by the theoretical assumptions that women are more likely to be screened if their knowledge, attitudes, and intentions are concordant with preventive behavior, and if such behavior is modeled and socially reinforced. The efforts to improve women's self-efficacy in making breast cancer screening appointments and in navigating through the health care system and the use of volunteers recruited from the community will be based on accepted concepts of social learning theory. The interventions will incorporate four sets of activities. First, a neighborhood approach will establish a storefront operation to: (a) provide counseling, appointment-making assistance, and referrals to free breast cancer screening services; (b) sponsor a Vietnamese-language breast health-line, and encourage participation in community coalitions, small group meetings, educational contests, and annual health fairs; and (c) to recruit volunteers. Second, materials will be distributed encompassing previously-developed, Vietnamese-language breast screening educational materials, including printed brochures, posters, calendars, and a videotape. Third, a Vietnamese-language media campaign will be initiated including both print media (newspaper articles and advertisements) and electronic media (paid television advertisements and television broadcast of the videotapes). Fourth, a Vietnamese physician intervention will include in-office distribution of educational materials, annual Continuing Medical Education sessions, and involvement in health fairs. Data analysis will use appropriate techniques to test our hypotheses.
Knowledge gained in this intervention will be valuable to other programs aimed at this population, and the general approach used could be adapted for other ethnic groups. Success here would contribute to the ultimate goal of reducing the human and economic costs of breast cancer in California.
How Women Decide to Seek Evaluation of Breast Symptoms
Noreen Facione, Ph.D.
University of California, San Francisco
This project focuses on earlier detection of breast cancer for the women of California by examining women's decisions of whether and when to seek an evaluation of a potential breast cancer symptom. Seeking a provider evaluation of a self-discovered breast symptom (often referred to as “help seeking” in the literature) is an important factor in early case-finding. In the majority of breast cancer cases, and particularly those in women of African American and Latina cultural heritage, the symptoms of breast cancer are discovered by the women themselves. Current breast symptoms, perceptions of the consequences of delay, gender related constraints, access to services, prior utilization habits, fatalistic beliefs about breast cancer, and religiousness explained 46% of the variance in help seeking intention in a sample of 352 African American women in a previous investigation. This study will re-examine these variables and three others (perceptions of racism, breast cancer symptom knowledge and decision-making style) for their predictive power to describe the intention to seek help promptly versus the intention to delay a provider evaluation for a self-discovered breast cancer symptom in a more culturally diverse sample. By identifying the factors that influence a woman's decision to seek or not seek an evaluation of her breast symptoms, this project's long-term goal is to identify women at risk for more advanced breast cancer at diagnosis related to delays in help seeking.
