in Women ages Whitney Stilwell Health 240: Section 002 Clemson University

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1 Predisposing, Enabling, and Reinforcing Factors for Mammography Breast Cancer Screenings in Women ages Whitney Stilwell Health 240: Section 002 Clemson University 1

2 Introduction Breast Cancer screenings in women ages is a growing concern in our world today. Breast cancer is a disease that continues to become more prevalent in women and it is starting at a younger age. Many women don t understand the importance of early detection in breast cancer specifically and don t realize the impact a cancer screening could have on their lives. There are a few different types of breast cancer screening tests. There is a self- exam where a woman uses her hands to check her breasts for lumps, changes in size or shape of your breast, or any other changes in the breast or underarm. You can also have a clinical breast exam where a doctor or nurse checks for lumps or changes in breast size. The final form of screening is a mammogram and this is an X- ray of the breast. Mammograms are the best method to detect breast cancer early, which makes it easier to treat, and having a regular mammogram can lower the risk of dying from breast cancer. (Screening for breast cancer, 2009) According to the Susan G. Komen foundation, women ages should have a clinical breast exam at least every 3 years. However they don t recommend mammograms until women reach the age of 40. This is different from the National Cancer institute because they don t provide any recommendations for women ages Some women are at a higher risk of developing breast cancer and they may need to be screened more than once a year. The factors that greatly increase breast cancer risk are: a mutation in the BRCA1 or BRCA2 gene, strong family history of breast cancer, personal history of breast cancer, radiation treatment to the chest area during childhood, and a mutation in the TP53 or 2

3 PTEN genes. ACS and NCCN recommend yearly screenings with mammography plus MRI for women who have these high risk factors. ("Breast cancer screening," 2012) Scientists are trying to have a better understanding of which cancers develop in which group of people. There is a higher risk associated with women who have genetic history of breast cancer however it does not mean that you will for sure be diagnosed. The New York Times recently published an article that states the incidence of advanced breast cancer among younger women, ages 25-39, may have increased slightly over the last three decades. The study was published in The Journal of the American Medical Association; found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 in That s more than 800 per year in 2009, which may seem small but researchers say it s worrisome because it involves cancer (Grady, 2013). As of now, researchers are advising young women to go to the doctor quickly if they notice any change in breast tissue, especially lumps. However, Dr. Johnson says that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. Breast cancer is not as common in younger women ages 20-34, however when it does happen, the disease tends to me more deadly than in older women and they aren t sure why that is (Grady, 2013). From , only 6.5% of the breast cancers were diagnosed in women under the age of 40 and 21% were diagnosed before the age of 50. (Hankey, 1994). There were approximately 2,747,459 women alive with breast cancer as of January 1, 2009, according to SEER, Surveillance Epidemiology and End Results. Between the years of , the age adjusted incidence rate was per 100,000 women per year; 9.9% 3

4 of these cases were between the ages of 35 and 44 and 22.5% between 45 and 54 (Howlader, 2012). Studies show that mammography screening reduces breast cancer mortality by 15% for women aged years and radiation exposure from mammography is low (Nelson, 2009). In a recent study done in 2011, women ages that were screened regularly are at a 29% lower risk of dying from breast cancer (Hellquist, 2011). According to the American Breast Cancer Foundation, women diagnosed with breast cancer in its earliest stages actually have a five- year survival rate of over 98%. If nothing else, this is a prime example of the benefits of screening and early detection of breast cancer. The American Cancer Society recommends women age 40 and older should have mammograms once a year as long as they are in good health and they should feel comfortable about the benefits that come from early detection of breast cancer (American cancer society, 2013). Age- standardized breast cancer incidence rates were calculated using data from the surveillance, epidemiology, and end results 18 registries from 2000 to 2009, for 677,774 female breast cancer patients aged 20 and above. Since 2004, incidence rates in women aged years significantly increased for most racial/ethnic groups. The localized breast cancer incidence significantly increased in non- Hispanic blacks (APC = 1.3%, p = 0.004) and Asians (APC = 1.2%, p = 0.03). ER positive breast cancer significantly increased in almost all age/race sub- groups after 2005, while ER- negative breast cancer decreased in most sub- groups. Recently the incidence of breast cancer appears to be increasing in certain subgroups, including ER- positive, early- stage breast cancers, in particular among non- Hispanic blacks and Asian/Pacific Islanders (Hou, 2013). 4

5 Screening for breast cancer falls under many of the Healthy People 2020 objectives including access to health services, cancer, health communication and health information technology. This falls into these categories because getting screened is a health service that deals with cancer so this should be a first priority of health preventative strategies. Breast cancer screenings are the number one way to detect breast cancer early so it can be treated quickly and efficiently and women need to understand this to take precautious measures. Predisposing factors A predisposing factor is a factor that comes before the behavior, such as knowledge, attitude, beliefs, values, and confidence or motivation. There are many positive and negative predisposing factors that influence women s opinions about being screened for breast cancer. The main reason women choose not to have mammographies is that they believe the disease wouldn t affect them. Cancer is a scary disease that most people feel they are incapable of getting therefore it is unnecessary for them to get tested. Because of this it is so important for health professionals to inform the public about the prevalence of breast cancer in women and how they can detect it early. On the opposite spectrum there are women who are at very high risk for breast cancer and because of this they know the risks of not being screened. Finally, there are women who are afraid of false positives. According to the American cancer society, mammograms can miss some cancers but they may also lead to follow up findings that are not cancer ("American cancer society," 2013). Being diagnosed with a false positive can be traumatizing to a patient. Some patients go through surgery just to realize that it was a benign tumor, this is a negative predisposing factor because it keeps women from being screened because they are afraid. A positive 5

6 predisposing factor is public health education. Within the last decade breast cancer awareness has increased tremendously. There are multiple fundraiser walk including Relay for Life and Susan G. Komen, Race for the Cure. There are commercials, t- shirts, and billboards that are promoting breast cancer screenings and educating women of their risks. A recent study shows that differences in attitudes and perceptions related to breast cancer screenings explain why some women choose mammographies or no screening. The study was done with six different focus groups that included 34 women, 15 who used opportunistic screening and 19 who used no screening. Perceptions, attitudes and knowledge differed between the two groups and women who were in the screening group perceived a high susceptibility to breast cancer and they visited their gynecologist regularly. The group that used no screening had very high- or low- perceived susceptibility to breast cancer and expressed negative opinions of mammograms. In conclusion, they realized that general practitioners and gynecologists are in a unique position to provide individual messages to their patients to improve participation in mammograms (Ferrat, 2013). Enabling Factors Enabling factors are antecedents that facilitate behavior change such as teaching skills, providing a service, or tracking process. A big enabling factor in women being screened for breast cancer is the type of insurance they have and this can be positive or negative. Women who don t have any health insurance or have limited health insurance might not be in a financial position to have a mammogram, much less pay for the cancer treatment. If 6

7 that s the case this will keep them from being screened regardless of if they have the desire to. A study was recently done at the University of Illinois at Chicago where they looked at the relationship between socioeconomic status and potentially missed detection with screenings. Of 149 mammograms that were originally read as nonmalignant, 46% of them had a potentially detectable lesion and PMD was greater among patients with incomes below $30,000, less education, and lacking private health insurance (Rauscher, 2013). Figure 1: Mammography Rates of women in the US in 2012 (American Cancer Society, 2012) A final positive enabling factor is that mammograms are noninvasive and tend to be a quick and easy procedure and they are only recommended once a year for most women. They are easy to schedule around your work or family schedules and more times than not, the results are normal and that s the only procedure necessary. Women are more likely to be screened if it doesn t take up too much of their time. 7

8 Reinforcing Factors Lastly, reinforcing factors are factors that provide a reward or feedback for behavior, such as interaction with family, friends, or health professionals. The fact that the community promotes screening is a huge reinforcing factor because it allows awareness to travel faster. Detecting breast cancer early reduces the risk of having it metastasize to different parts of the body, which can increase your chance of survival. The more health promotion the better. A negative reinforcing factor may be that they don t know anyone who has been diagnosed with breast cancer so they are less likely to feel a burden to be screened. If nobody in their family or none of their peers have been diagnosed some women might not feel like cancer could happen to them. They could have peers telling them that screening is unnecessary because their scans have all been normal. Peer pressure is a strong influential factor in anything we do and that includes health behaviors like cancer screenings. The university of Mexico conducted a study looking at social determinants of breast cancer screening in urban primary care practices. They found that important promoters of screening behavior included social- level factors such as hope, family interaction, and social support (Mishra, 2012). Supporting Theories The Health Belief Model is one of the most widely used and broadest of health behavior theories. This is an expectancy theory where behavior is generally viewed as related to the subject value of the outcome and the subjective expectation that an action will achieve the outcome (Glanz, 2002). The key constructs in this theory are perceived barriers, perceived 8

9 severity, perceived susceptibility and perceived benefits. The total benefit of partaking in a behavior is the perceived benefits minus the perceived barriers. The risk of a health behavior is perceived susceptibility and perceived severity and both of these thing lead into prediction, which is the likelihood of an individual participating in the behavior. Perceived barriers are the most powerful single predictor across multiple studies and behaviors and these are the barriers that are between a woman and being screened. Perceived benefits are the benefits women feel they are gaining by being screened for breast cancer. Perceived severity is the least powerful predictor overall but this severe women believe the outcome of the screening to be. Finally, perceived susceptibility is the level at which women believe their screening will be positive for breast cancer, in other words, do they feel they are actually susceptible to getting this disease. According to a study done in Lexington, KY, mammography adherence was about 60%, meaning that only 60% of women actually followed the screening guidelines recommended for breast cancer. Women who were not contemplating being screened were significantly less likely to perceive themselves to be at risk of getting breast cancer. Women who had more barriers to mammography perceived less benefit from having a mammogram (Hatcher- Keller, 2013). This shows the correlation between benefits and barriers. The women who had more barriers perceived the benefit to be less. This study was done regarding mammography screening among women visiting the emergency department for nonurgent care. They looked at women who used the emergency department as a medical home and the purpose of this study was to look at the differences in beliefs regarding mammography screening. They administered scales of risk, benefits, and barriers to a sample of 110 women who had presented to the emergency 9

10 department of a public hospital or were seated in the ED waiting room. They also collected sociodemographic information and stage of readiness (Hatcher- Keller, 2013). Transtheoretical model has four main constructs: stages of change, decisional balance, self- efficacy, and processes of change. In 2006, Sharp Health Plan conducted a campaign to increase mammography screening for at- risk female members and there was a survey that was based on the Transtheoretical Model of Change which was designed to assess members behavioral stage and barriers to breast cancer screening. The campaign consisted of mailing each participant an information mammography postcard with an appointment tracker. The participants then received a phone call reminder about their mammography appointment. After the campaign, 70% of SHP members sought mammography screening while 30% remained nonadherent. SHP conducted a survey to better understand members barriers to breast cancer screening. The main construct this intervention examined was the stages of change. They were looking at whether women had changed their views on breast cancer screening and how to change their perceived barriers. They stages of change are precontemplation, contemplation, preparation, action, and maintenance. The purpose of this study was to help women progress through the stages of change by sending them post card and telephone reminders about their appointment. They found that the top three barriers identified were: mammogram is not a priority, knowledge deficit, and they had a bad experience in the past. This study also uses some constructs from the health belief model and looking at perceived barriers involved with breast cancer screening. After seeing the common barriers involved with breast 10

11 cancer screening the SHP can use this information to develop more tailored interventions and to increase the rate of breast cancer screenings for their member population (Parkington, 2009). From this point, they can look at where women may be in the stages of change and what kind of interventions they can implement to help them move forward towards participating an mammography. Theory of planned behavior is a theory about the link between attitudes and behavior. In 2005 a study was done to examine the consistency of beliefs and intentions toward follow up attendance at breast cancer screening using the Theory of Planned Behavior. The goal of the study was to examine whether and how cognitions changed throughout the program. A total of 2,657 women filled out a baseline questionnaire 2 months after being invited for their initial mammogram. Their attendance data in a second and third screening were recorded and a follow up questionnaire was collected in four parts: once right before and after the second screening and before and shortly after the third screening round. They found that there were only minor changes in belief and intentions. Throughout the course of the program women s opinions about their appointments remained positive and even some women became more convinced that they were susceptible to getting breast cancer and that participating in mammography screening was beneficial to them. This is tied directly to the theory of planned behavior because as women s attitude and knowledge about breast cancer increased, their attendance to mammograms increased as well because they put higher value on being screened. In conclusion, the study found that in organized breast cancer screening; beliefs and intentions remain positive and rather stable (Drossaert, 2005). The theory of planned behavior is used in conjunction with theory of reasoned action and together they look at attitudes towards behavior, subjective norms, 11

12 and perceived behavioral control and their relationship towards the behavior. The theory of planned behavior is a combination of control beliefs (resources) and perceived power (weighted) combined into the perceived behavioral control. This study did a good job looking at women s attitudes about their mammograms and whether or not they continued to pursue screenings based off of their attitudes. Suggestions for Intervention According to a study done in 2012 in Wollongong, Australia, perceived behavior control emerged as the most important variable in predicting the target behavior. Because of this, an effective intervention would be to use upward communication between women. The intervention would begin with women age and they would be educated on breast cancer and the benefits of being screened. Women will be assigned to either a control or experimental condition and the experimental group formed intention intervention plans about initiating conversation with other women about having a mammogram. This intervention would be beneficial because it would start with women who aren t affected by breast cancer yet but they will be educated early so when it becomes important to their health they will take action. It will also help influence older women to get screened because it will be a more personal account if someone in their family, mainly a daughter, is influencing them to make healthier choices. In the study done by the University of Wollongong, they found that those who formed intention interventions were more likely to engage in the target communication behavior, but the intervention was most likely effective for those who reported low levels of intention at baseline (Browne, 2012). 12

13 More Important Less Important More Changeable Knowledge about breast cancer, belief about severity/susceptibility Breast self exam, Financial situation, Family support Less Changeable Family members with breast cancer, health care provider, access to health care, age Family health history Genetics Fig. 2: Importance and Changeability of predisposing, enabling, and reinforcing factors Importance is when the factor occurs frequently, is strongly associated with the behavior, and it is empirically shows to be in the casual pathway. Changeability means that it is reasonable to expect a change in the factor based on health promotion programs or interventions. Knowledge about breast cancer and belief about severity and susceptibility are more changeable and more important because studies have shown that women who were educated were more likely to have a mammogram done (Ferrat, 2013) (Hatcher- Keller, 2013). Also, according to a recent 13

14 study, women who received a tailored print reminder were more likely to follow through with their scheduled appointment (Ishikawa, Hiraai, Fukuyoshi, Yonekura & Harada, 2011). Health care providers and access to health care are more important factors of screening but less changeable because 68% of uninsured women are not being screened for breast cancer (American Cancer Society, 2012) and it is difficult for someone to change health care providers. Education for young women needs to begin in high school. Majority of high schools require students take at least one year of health and that is where education should start. If young women begin to believe that breast cancer screening is important at a young age, it is more likely to affect their beliefs when they are older. Once girls get to college the intervention will be put to use. Family practitioners and university doctors should continue to talk to young women about the risks of breast cancer and the benefits of being screened. Then they will be given ways to talk to their older relatives about mammograms and hopefully influence their attitudes towards being screened. This intervention has a large emotional tie to it, which could allow it to be very effective because if daughters are pleading with their mothers to be screened, mothers are more likely to listen to them. This intervention focuses on women s belief and knowledge, which are two of the more important factors and more changeable factors (Drossaert, 2005) (Hatcher- Keller, 2013). If women have more knowledge about the impacts of early detection of breast cancer they are more likely to take early precautions. Also, beliefs and attitudes can often change. As more research becomes available and more resources are shared, women s negative opinions are more likely to become positive (Drossaert, 2005) (Parkington, 2009). 14

15 References American Cancer Society. (2012). Mammography Statistics [Web Graphic]. American cancer society recommendations for early breast cancer detection in women without breast symptoms. (2013, February 06). Retrieved from Breast self-exam. (2013, February 25). Retrieved from Breast cancer screening recommendations for women at average risk. (2012, July 24). Retrieved from Browne, J.L., Chan, AY. (2012). Using the theory of planned behavior and implementation intentions to predict and facilitate upward family communication about mammography. (2012 ). Psychol Health, 12(760), doi: / Drossaert, C., Boer, H., Seydel E.R (2005). Women's opinions about attending for breast cancer screening: stability of cognitive determinants during three rounds of screening. 10(Pt 1): Ferrat, E., Le Breton, J., Djassibel, M., Veerabudun, K., Brixi, Z., Attali, C., Renard, V. (2013). Understanding barriers to organized breast cancer screening in France: women's perceptions, attitudes, and knowledge. Family Practice, doi: PMID: Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons. 15

16 Grady, D. (2013, Febrary 26). Study sees more breast cancer at young age. New York Times, p. A13. Hankey, B. F., Miller, B., Curtis, R., & Kosary, C. (1994). Trends in breast cancer in younger women in contrast to older women. Journal of the National Cancer Institute Monographs, (16), Hatcher- Keller, J., Rayens, M.K., Dignam, M., Schoenberg, N., Allison, P (2013). Beliefs regarding mammography screening among women visiting the emergency department for nonurgent care. Journal of Emergency Nursing. S (13) Hellquist BN, Duffy SW, Abdsaleh S, et al. (2011) Effectiveness of population- based service screening with mammography for women ages 40 to 49 years: evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort. Cancer. 117(4):714-22, Hou, N., Hou, D (2013). A trend analysis of breast cancer incidence rates in the United States from 2000 to 2009 shows a recent increase. Breast Cancer Research and Treatment, 138(2): Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD, based on November 2011 SEER data submission, posted to the SEER web site, Ishikawa, Y., Hiraai, K., Fukuyoshi, J., Yonekura, A., & Harada, K. (2011). Cost- effectiveness of a tailored intervention designed to increase breast cancer screening among a non- adherent population: a randomized controlled trial. BMC Public Health, doi: / Mishra, S., DeForge, B., Barnet, B., Ntiri, S., Grant, L (2012). Social determinants of breast cancer screening in urban primary care practices: a community- engaged formative study. Womens Health Issues, 22(5):e doi: /j.whi

17 Nelson, HD., Tyne, K., Naik, A., Bougatsos, C., Chan, BK., Humphrey, L (2009) Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality. 151(10):727-37, W Parkington, S., Faine, N., Nguyen, MC., Lowry, MT., Virginkar, PA. (2009). Barriers to breast cancer screening in a managed care population. Managed Care. 18(4):34-45 Rauscher, G., Khan, JA., Berbaum, ML., Conant, EF (2013). Potentially missed detection with screening mammography: does the quality of radiologist's interpretation vary by patient socioeconomic advantage/disadvantage? Annals of Epidemiology, 23(4):210-4 doi: /j.annepidem