Health Policy and Health Services: Better Serving
If research findings are going to lead to action and change, gathering information that will be important for policy makers at the national, state, and local level is vital. Research in this area is aimed at developing strategies to serve women more effectively by investigating the organizational and sociopolitical context of breast cancer prevention, detection, and treatment.
The CBCRP funds research aimed at making the health care system more responsive to the needs of women with breast cancer and better at preventing the disease. We're looking for ways to reduce waste and increase access to breast cancer care. We also encourage research on actions that will reduce inequalities in access to prevention and treatment among California's geographically and ethnically diverse population. The CBCRP encourages more research in the health policy and health services area.
Research Conclusions
Race/Ethnicity, Socioeconomic Status, and Breast Cancer.
William Wright, Ph.D., at the Public Health Institute, Berkeley, investigated the relationship between race/ ethnicity and socioeconomic status and how likely it is that a woman's breast cancer will be detected early, when treatment is most effective. Dr. Wright used innovative statistical methods to analyze data from California's statewide cancer registry and the Women's Health Survey, an annual telephone survey that collects information on health practices on a random sample of California women. Dr. Wright found that the higher a woman's socioeconomic status, the more likely it is that her breast cancer will be diagnosed at an early stage. This is most true for Hispanic women, followed by African American, then white, then Asian women. This trend is especially true if cases of carcinoma in situ (a precancerous condition of the breast) are counted as part of the category of early stage at diagnosis. The research team also found that high socioeconomic status is related to several known breast cancer risk factors. Women of higher socioeconomic status give birth to a lower number of babies, which raises breast cancer risk. To a lesser extent, women of high socioeconomic status are older at the birth of their first babies, which also raises the risk of breast cancer. Women of high socioeconomic status, on average, have a low body mass index, which lowers the risk of breast cancer. Dr. Wright has also shown that because the 2000 US Census allowed people to select more than one race on their census forms, researchers will not be able to obtain accurate estimates of the population of various races in the state. This means the California Cancer Registry may not be able to calculate breast cancer rates by race in 2000 and beyond, or monitor trends in breast cancer by ethnicity.
Does a Peer Navigator Improve Quality of Life at Diagnosis?
Women with breast cancer say they have the greatest need for counseling when they are newly diagnosed. Many women don't seek formal counseling services because they feel overwhelmed, are unfamiliar with available resources, or are concerned about stigma in seeking counseling. David Spiegel, M.D., of Stanford University, collaborated with Caroline Bliss-Isberg, Ph.D., of the community organization WomenCARE, in Santa Cruz, to evaluate the effectiveness of matching women who have just learned they have breast cancer with trained volunteer breast cancer survivors (peer navigators). Each navigator and woman with cancer make at least one contact a week for three months. The relationships can be renewed by mutual agreement every three months. In this preliminary study, the research team matched 42 newly-diagnosed women with peer navigators. The team found that women matched with a navigator maintain their quality of life and actually improve in some areas. The more empathic and effective the navigator, the better the quality of life for the recently-diagnosed woman. However, more successful navigators showed some trauma and depression symptoms, although most navigators reported high quality of life and low stress levels. The CBCRP is funding a 3-year expansion of this research. A well-designed peer counseling program could cut the human and economic costs of breast cancer in California by increasing newly-diagnosed women's knowledge about strategies for making medical decisions and knowledge about other helpful resources. Based on this pilot study, the researchers urge organizations providing peer counseling for women with breast cancer to provide training, supervision, and support for their volunteers.
Research in Progress
Geographic Variation in Breast Cancer Stage at Diagnosis.
Women whose breast cancer is diagnosed at the earliest stage, before it has spread to surrounding tissue or to distant sites in the body, have a better chance of surviving. Among California counties, the percentage of breast cancer patients who are diagnosed at this early stage ranges from 40% to 71%. Pamela Davidson, Ph.D., at the University of California, Los Angeles, is investigating how community-level factors, such as the health care delivery system, influence the stage at which a woman's breast cancer is diagnosed. During the first year, the team has collected data from a variety of databases that track cancer cases, from the federal census, and from sources of information on the health care system. One goal of this research is data-driven recommendations for communitylevel interventions to raise the percentage of women whose breast cancer is diagnosed at an early stage.
Return to Work After Breast Cancer Surgery.
Diane R. Estrin, of the Women's Cancer Resource Center, a Berkeley community organization, and Rani B. Eversley, Ph.D., of the University of California, San Francisco, are looking at what helps—and what hinders—women returning to work after breast cancer surgery. They will interview 588 women from various ethnic groups, 6 and 12 months after surgery. So far, they have developed and tested their questionnaire and are translating it into Spanish and Cantonese. Next year, they will enroll women in the study. The researchers hope to have an impact on employer policies regarding return to work and also on disability benefit eligibility for breast cancer survivors.
Determinants of Receiving Breast Cancer Treatment in the Underserved.
Low-income and less-educated women are more likely to be diagnosed with advanced breast cancer, less likely to receive standard treatment, and less likely to survive 5 years, compared to breast cancer patients from the general population. Rose Maly, Ph.D., of the University of California, Los Angeles, will survey 230 low-income breast cancer patients, survey their health care providers, and analyze their medical records. The goal is to identify factors in the patients' lives (for example, lack of transportation) or in the health care system (for example, problems with doctorpatient interactions) that could be changed to reduce the suffering and death in this vulnerable population. So far, the research team has begun identifying and enrolling patients, developed questionnaires for patients and health care providers, and held focus groups to identify relevant questions for the questionnaires. The team hopes to use the results to directly improve care for this population of women.
Research Initiated in 2002
Impact of Breast Cancer and Its Therapy on Osteoporosis.
After women go through menopause, their bones can become weaker and smaller, which puts them at risk for osteoporosis. Carolyn Crandall, M.D., at the University of California, Los Angeles, is investigating whether having had breast cancer affects the risk of osteoporosis. She will also investigate whether levels of hormones in the blood can predict the rate at which breast cancer survivors lose bone mass.
African American Women and Breast Cancer: What Works?
African American women are less likely than other American women to be diagnosed with breast cancer, but those who have the disease are more likely to die from it. Lack of access to care is one factor, but not the whole story. Carol Somkin, Ph.D., at the Kaiser Foundation Research Institute, Oakland, and Priscilla Banks, M.S., at the African American Advisory Committee on Cancer, Hayward, are investigating what aspects of health care settings and interactions with health care providers promote or inhibit culturally-sensitive care for African American women.
