Running Head: BREAST CANCER MORTALITY

Transcription

1 Running Head: BREAST CANCER MORTALITY Breast Cancer Mortality Among African American Women Patsy Montana Maxim Kent State University Health Disparities-PH Course Instructor: Dr. Tina Bhargava

2 BREAST CANCER MORTALITY 2 Introduction Breast cancer is the most common cancer in women and the second leading cause of cancer deaths among women in the United States (World Health Organization, 2013). The World Health Organization (2013) estimated that in 2011, 508,000 women died due to breast cancer. In 2009, over 300,000 African American women died from breast cancer (Healthy People, 2014). Breast cancer survival rates vary significantly depending on which stage a patient is diagnosed in. According to the American Cancer Society (2014), women with stage 0-I breast cancer have a nearly 100% survival rate, stage II have a 93% rate, stage III have a 72% rate, and stage IV have a 22% survival rate. Breast cancer death rates are rapidly decreasing among white women; however, this trend is not the same for African American women. According to the American Cancer Society s Report, 1 in 9 African American women will develop breast cancer and 1 in 31 will die from breast cancer. This is compared to white women, where 1 in 8 women will develop breast cancer (higher prevalence) yet only 1 in 37 will die from breast cancer (lower mortality). African American women have the highest breast cancer mortality rates of all racial and ethnic groups; being 40% more likely to die of breast cancer than white women (Centers for Disease Control and Prevention, 2012). In 2010, 51% of African American women reported having a mammogram within the past year; compared to 52% of white women. Despite the similar screening rates, breast cancer is more often detected at a more advanced stage in African American women than in white women (ACS, ).

3 BREAST CANCER MORTALITY 3 Several factors contribute to the disparity in breast cancer mortality in African American women compared to white women. Contributing factors may include differences in socioeconomic status, access to healthcare, lifestyle choices and biology. Another factor is lack of timely follow-up of suspicious mammogram results. In addition, public policies involving breast cancer have been changing, primarily surrounding how often insurance companies will pay for screening, such as mammograms. Discussion Determinants Individual/Interpersonal An important individual determinant of this disparity is the utilization of healthcare services. The way a woman feels about healthcare and the perceived severity that influences whether she feels she needs to receive treatment or follow-up care, greatly impacts the time she will allow to pass before making a follow-up appointment. According to the American Cancer Society ( ), African American women had longer intervals between suspicious mammograms and lack of timely follow-up. African American women also have a greater difficulty scheduling follow-up appointments than white women do, which in turn negatively influences an African American woman s behavior and feelings towards the healthcare system (Caplan et al). The longer a woman waits, or is forced to wait, delays diagnosis and treatment of breast cancer and could lead to the cancer metastasizing, making the woman s risk of mortality to increase (Caplan et al). Another individual determinant is whether a woman utilizes self-screening methods. According to the World Health Organization (2013), early detection is a cornerstone of breast cancer early detection in order to improve outcomes. One method of early detection is early diagnosis or awareness of signs and symptoms. The second

4 BREAST CANCER MORTALITY 4 early detection method is self-screening, both for symptomatic and asymptomatic individuals (WHO, 2013). African American women reported less utilization of selfexaminations compared to white women (ACS, ). These methods can detect a change in a woman s breast, giving them reason to see their physician and possibly diagnosis breast cancer in an earlier stage. The earlier stage that breast cancer is detected the higher survival rate a woman will in turn have (ACS, ). An individual s weight is directly associated with developing breast cancer. According to the ACS ( ), individuals who are overweight or obese have an increased risk for cancer recurrence and decreased the likelihood of survival. One-half of all African American adults are considered obese and 77% of African American adults are considered overweight; overweight and obesity are more common among African American women and girls than white women and girls (ACS, ), making them more vulnerable to breast cancer incidence and mortality. The way in which a physician responds to certain patients, based on the type of insurance they have or their socioeconomic status, affects the amount and quality of care a patient receives. In a study done by Polacek et al (2007), physicians were less likely to suggest breast-conserving surgery with radiation to African American women and more likely to suggest mastectomy surgery, which can be disfiguring. The same study suggests that African American women who do receive breast-conserving surgery are less likely to receive radiation therapy. When the same treatment was used to treat an African American woman and a white woman they showed similar survival outcomes (Chu et al, 2003).

5 BREAST CANCER MORTALITY 5 Determinants Organizational/Community The geographic region in which the woman lives affects poor access to healthcare. Breast cancer screening and treatment are difficult when physicians and hospitals are not accessible in certain geographic areas where economically deprived populations live, where African American women primarily live (Lacey, 1993). African American women are more likely to have to work more than one job or not be able to take off work to go to the doctor, increasing the time before she is diagnosed. Less frequent doctor visits for preventive and follow-up care are associated with higher rates of breast cancer mortality (ACS, ). Furthermore, the Centers for Disease Control and Prevention (2014), reported that African American women are more likely to live in neighborhoods in which they will be exposed to carcinogens. These neighborhoods that are primarily composed of ethnic and racial minorities are more likely to be located near places where carcinogens are generated. African Americans are consequently more likely to be exposed to carcinogens, putting them at a higher risk of cancers and in particular women to breast cancer (CDC, 2014). Determinants - Policy Policy determinants that affect breast cancer mortality are the public policies that have been recently changing and the number of uninsured citizens in the United States. Unfortunately, the United States has 47 million uninsured Americans (pre-the Affordable Care Act) and 6.8 million of those uninsured are African Americans (U.S. Department of Health and Human Services, 2014). National recommendations involving breast cancer screenings have been changing, primarily surrounding how often insurance companies

6 BREAST CANCER MORTALITY 6 should pay for mammography screenings. African American women are more likely to develop breast cancer at a younger age (CDC, 2014), but from an economic standpoint, the age at which mammograms are considered cost effective begins at age 40 (CDC, 2014). This leaves African American women with several more years that breast cancer could begin to develop and possibly metastasize before receiving a mammogram. If someone is not insured they cannot take advantage of the new preventative services that insurance companies are now required to offer under standard plans. The lack of preventative care leads to higher rates of mortality from breast cancer (CDC, 2014). Healthcare reforms made to the Affordable Care Act that began on August 1, 2012, include BRCA gene counseling for women at higher risk and breast cancer mammography screenings every 1 to 2 years for women over 40 (HHS, 2014). By insurance plans considering BRCA gene testing preventive and covering those at high risk, women can take action and know if they will develop breast cancer at some point in their life. African American women are at a higher risk of developing breast cancer under 45 years of age, making this policy change regarding what age screening begins very crucial (ACS, 2014). Analytical Framework - Theory Risk exposure theory is an ideal way to describe disparities that exist relating to breast cancer. Risk exposure theory states that a higher prevalence of risk in segregated minority population areas lead to a higher prevalence of a certain disease. These risks can include environmental, such as exposure to carcinogens, to social risks, such as recommendations for care based on race. Ethnic and racial minorities are typically those that live in neighborhoods that are not easily accessible to good jobs,

7 BREAST CANCER MORTALITY 7 schools, doctors, or stores that sell healthy good. These neighborhoods are also more likely to be exposed to carcinogens, putting residents at a higher risk of cancers. Analytical Framework Social Justice Perspective Poverty and low socioeconomic status have been associated with lack of resources, information, and knowledge in regards to breast cancer mortality because if women do not have the proper information about the severity of a health problem then they cannot take it seriously enough to get treated. Also, if a woman is in poverty she is more likely to not have health insurance and even with insurance, medical procedures are often too costly for many individuals to receive. If more jobs, both higher paying and minimum wage, offered health insurance then African American women would be more likely to have access to insurance and get the screening they need. Even with the new healthcare reforms, many Americans are either uneducated on the matter or are still having a difficult time paying for health insurance. The problem with health insurance is that many Americans only use it if they are sick; they don t utilize preventive care, as they should. Furthermore, breast cancer is often asymptomatic or the only symptom is a mass that they would only discover if they utilize self-examination screening methods. Reducing carcinogens that people are exposed to would greatly impact the health of the general population. Being exposed to high levels of carcinogens is not only harmful to individual s overall health but in particular can increase the amount of cancers. Air quality control is something that will improve the people who live and work in those areas health but might also promote physical activity if people feel more comfortable being outside. Feeling more comfortable outside could help reduce breast

8 BREAST CANCER MORTALITY 8 cancer mortality because not only will exposure to carcinogens not be a problem but also they can maintain a healthy weight. African American women are more likely to live in neighborhoods that are exposed to carcinogens and are more likely to work in jobs where air quality is compromised or they are exposed to carcinogens at work. This could be a result of being born into a lower social economic status. And a a result of the vicious cycle occurring, it is nearly impossible to move up a social class and escape the effects of the vicious cycle. Analytical Framework Ecological Approach A multi-level ecological approach to addressing breast cancer mortality disparities would be to start at a policy level, which the Affordable Care Act has done. From there, education interventions done at a community level need to be done in order to facilitate access to the resources that are being made available by the ACA. Even now with current healthcare reforms, many Americans do not understand the reforms that were made or know the regulations that have been implemented. Informing people of resources they can receive is crucial in this situation. Public Health Interventions One intervention to address this disparity focused on women younger than 40 years to an effort to increase understanding or breast cancer and the utilization of preventive services. in the intervention consisted of 4-week sessions through in-class and asynchronous learning-centered environments tailored to African American women, aged 20 to 39 years, at 2-year and 4-year postsecondary schools and culturally relevant community-based organizations (Doughty, 2012).

9 BREAST CANCER MORTALITY 9 Results showed that the intervention increased understanding of breast cancer in African American women in a classroom environment (p<.039) and in an online environment (p<.05). The study compared ages 20 to 29 and 30 to 39, finding high agreement and no statistically significant difference related to age about the use of preventive services, importance of preventive services, and tailoring preventive services for younger women. The intervention demonstrated that the implementation of an evidence-based breast cancer intervention that improved understanding of breast cancer in this race/ethnicity was successful. It demonstrated that there is a strong need to improve preventive services through the integration of evidence-based educational interventions targeting African American women prior to age 40 (Doughty, 2012). African American women have been a difficult group to reach through conventional breast cancer intervention programs; so one community-based intervention targeted beauty salons. The intervention aimed to increase breast cancer screening awareness and provide a referral or free breast cancer screening, or both, for African American women ages 50 and older. The interventions provided breast cancer prevention information that is culturally sensitive and relevant, using a familiar setting, i.e. four local beauty salons, and provided access to free breast cancer screening for approximately 125 women. The intervention delivered breast cancer education through print and electronic media such as videos. The project addressed the public health and community need to reach older African American women who were not being reached through conventional means (Forte, 1995). The intervention used short evaluation surveys as one means of evaluating its effectiveness. Short surveys were completed by each participant, in person, at the salon

10 BREAST CANCER MORTALITY 10 or by telephone for those women who viewed the electronic media videos at other sites. Many intervention programs have been implemented in a variety of venues but this was the first to use beauty salons. The clientele at these particular salons is more than 90 percent African Americans. By using a familiar place the women felt comfortable and trusting. They found that beast cancer prevention pamphlets were a feasible option. They also found that by showing the video where African American women already exchange information and socialize, they are more likely to understand and accept the benefit of mammography (Forte, 1995). The two interventions focused on African American women and aimed to increase understanding of breast cancer screening. The first intervention used in-class and asynchronous learning-centered environments, while the second intervention used videos and pamphlets at beauty salons. Both interventions focused on African American women younger than 40 years of age, when women should begin thinking of breast cancer screening. Even though both interventions focused to increase understanding, the first was more of an educational setting and the other was at a social setting. The first aimed at increasing utilization of preventive services in order to reduce mortality. The second aimed at helping women understand and trust physicians in order to receive mammography screenings. Conclusion There are several disparities that exist between African American and white women in regards to breast cancer and breast cancer mortality. The disparity begins with the racial divide between African American and white women, starting with socioeconomic status and resulting in a disparity of breast cancer mortality. An

11 BREAST CANCER MORTALITY 11 individual s behavior directly affects their health. If that individual does not have healthcare coverage or the money to receive services then they will almost always be retrospectively responding to health concerns. And this method of healthcare response can be fatal when dealing with breast cancer.

12 BREAST CANCER MORTALITY 12 References American Cancer Society. ( ). Cancer Facts & Figures for African Americans. Retrieved from Caplan LS, Helzlsouer KJ, Shapiro S, Wesley MN, Edwards BK. Reasons for delay in breast cancer diagnosis. Prev Med 1996;25: Centers for Disease Control and Prevention. (2012). Differences in Screening, Follow- Up, and Treatment. Breast Cancer Disparities. Retrieved from Centers for Disease Control and Prevention. (2014). Factors that Contribute to Health Disparites in Cancer. Retrieved from Chu KC, Lamar CA, Freeman HP. Racial disparities in breast carcinoma survival rates: separating factors that affect diagnosis from factors that affect treatment. Cancer 2003;97: Doughty, M.J. (September, 2013). An applied research intervention: breast cancer and preventive services in African American women. 14(5): doi: / Epub 2012 Nov 19. Retrieved from Forte, D.A. (April, 1995). Community-based breast cancer intervention program for older African American women in beauty salons. 110(2): Retrieved from

13 BREAST CANCER MORTALITY 13 Freeman HP, Chu KC. Determinants of cancer disparities: barriers to cancer screening, diagnosis, and treatment. Surg Oncol Clin N Am 2005;14: Gerend, M.A., Pai, M. (November, 2008). Social determinants of Black-White disparities in breast cancer mortality: a review. 17(11): doi: / EP Retrieved from Newman, L.A. (July, 2014). Breast cancer disparities: high-risk breast cancer and African ancestry Doi: /j.soc Retrieved from Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision-making among U.S. women. Patient Educ Couns 2007;65: Sturtz, L.A., Melley, J., Mamula, K., Shriver, C.D., Ellsworth, R.E. (2013). Outcome disparities in African American women with triple negative breast cancer: a comparison of epidemiological and molecular factors between African American and Caucasian women with triple negative breast cancer. BMC Cancer. 14:62. doi: / Retrieved from U.S. Department of Health and Human Services. (2014). The Affordable Care Act and African Americans. Retrieved from World Health Organization. (2013). Global Health Estimates. Breast cancer: prevention and control. Retrieved from

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