Mark Manning, PhD Karmanos Cancer Institute/Wayne State School of Medicine

Mark Manning, PhD Karmanos Cancer Institute/Wayne State School of Medicine Michigan Cancer Consortium 11.4.15

Co-PI Kristen Purrington, PhD Co-Investigators Terrance Albrecht, PhD Neb Duric, PhD Funding Karmanos Cancer Institute - Strategic Research Initiative Grant KCC Imaging Department Sharon Helmer, MD Julie Shultz, MD Zeynep Yilmaz-Saab, MD Sandra Ziaja Dave Winstrand MDCSS Fawn Vigneau Patricia Arballo-Spong Ron Shore Study staff Stephanie Ferrante Gina Polsinelli Epidemiology Research Core Julie Ruterbusch Behavioral and Field Research Core Mark Wojda Danielle Swift Heatherlun Uphold Mary Smith Rachel Stawis-Ungar Stephanie Stone

Retrospective Study Effects of racial group membership and breast density classification on breast cancer and breast density knowledge and perceptions Prospective Study Effects of racial group membership on psychological responses to breast density notification.

Do women s racial group membership and breast density influence: Breast cancer risk knowledge Breast density knowledge Reports of physicians communication about breast density Breast cancer worry Breast cancer risk perception

Recruited from women previously screened at KCI (2014) for whom we had breast density BI-RADS classification Participants Eligibility: AA or EA No prior breast cancer Upper and lower quartiles of PD 193 AA women (62%); 118 EA women (34%) Mean age 58.64 (8.14)

Education* AA EA High School 40 (21%) 12 (10%) Higher Education 108 (56%) 67 (57%) Graduate or Prof Degree 44 (23%) 39 (33%) Marital Status** Married or Partnered 54 (28%) 74 (63%) Separated, Divorced or Widowed 79 (42%) 28 (24%) Single; Never Married 57 (30%) 15 (13%) Household Income** Mean: ~$45,000 Mean:~$80,000 * = p <.05; ** = p <.01

AA EA Total BI-RADS BD Category** Dense Breasts** a (Entirely Fatty) 44 (23%) 13 (11%) 57 (18%) b (Scattered Density) 111 (58%) 59 (50%) 170 (55%) c (Heterogeneously Dense) 33 (17%) 43 (36%) 76 (25%) d (Extremely Dense) 4 (2%) 3 (3%) 7 (2%) No 155 (81%) 72 (61%) 227 (73%) Yes 37 (19%) 46 (39%) 83 (27%) More EA women classified as having dense breasts

Indicated whether they thought each of 15 factors (e.g., age, family history, breast density, etc.) decreases, doesn't affect, or increases women's risk of breast cancer *. Score = Proportion answered correctly M =.59 (SD =.17) 2 (Race) by 2 (Density) by 3(Education) ANOVA: Main effect of race: F 1,292 = 26.81, p <.001, η 2 =.08 Mean AA =.53; Mean EA =.69 Main effect of education: F 2,292 = 4.85, p <.01, η 2 =.03 Mean HS =.53; Mean HE =.63; Mean GP =.67 Three-way interaction: F 2,292 = 3.17, p <.05, η 2 =.02 * McMenamin et al., (2005)

African Americans European Americans 0.90 0.90 BC Risk Knowledge 0.80 0.70 0.60 0.50 0.40 0.30 Non-Dense Dense BC Risk Knowledge 0.80 0.70 0.60 0.50 0.40 0.30 Non-Dense Dense 0.20 0.20 High School Higher Ed Grad/Prof Degree High School Higher Ed Grad/Prof Degree Education level: F 2,181 = 17.04, p <.001, η 2 =.16 Breast density: F 1,111 = 4.78, p <.05, η 2 =.04 Take home: AA with dense breast not more likely to know more about BC risk; EA with dense breasts are more likely to know more about BC risk.

Do you know what breast density is? 1 ( never heard about it) to 5 (know exactly what it is) M = 3.23 (SD = 1.25) Most women had least heard about it 2 (Race) by 2 (Density) by 3(Education) ANOVA: Race: F 1,291 = 19.34, p <.001, η 2 =.06 Mean AA = 2.84; Mean EA = 3.83 Education: F 2,291 = 6.26, p <.01, η 2 =.04 Mean HS = 2.73; Mean HE = 3.46; Mean GP = 3.82 Three-way interaction: F 2,291 = 2.22, p =.11, η 2 =.02

African Americans European Americans 5.000 5.000 BD Knowledge 4.000 3.000 2.000 1.000 Non-Dense Dense BD Knowledge 4.000 3.000 2.000 1.000 Non-Dense Dense 0.000 0.000 High School Higher Ed Grad/Prof Degree High School Higher Ed Grad/Prof Degree Education level: F 2,183 = 10.59, Breast density by Education: p <.001, η 2 =.10 F 2,108 = 1.06, p <.05, η 2 =.07 Take home: AA with dense breast not more likely to report knowing what BD is; EA with dense breasts are more likely to report knowing what BD is (except highest education category).

Have any of your previous health providers told you that you have dense breasts? Yes = 28% Of those, only 43% actually had dense breasts! 21% of those who did not have dense breasts also indicated their physicians told them so ** = p <.01; * = p <.05

Log-Odds S.E. Odds-Ratios Constant -1.06* 0.44 0.35 African American -0.80* 0.34 0.45 Having dense breasts 1.05** 0.40 2.86 Interaction (AfAm by BD) -0.46 0.59 0.63 Higher Ed vs. HS 0.54 0.42 1.72 Grad/Prof vs. HS -0.06 0.48 0.94 ** = p <.01; * = p <.05 Take home: Controlling for whether or not one has dense breasts, AA still less likely to report having been told about BD. 27% of AA with dense breasts (and 18% without) report having been told by their HCP. χ 2 = 1.69, ns 57% of EA with dense breasts (and 32% without) report having been told by their HCP. χ 2 = 6.89, p <.01

How often do you worry about breast cancer Range: 1 (not at all) to 5 (all the time) M = 2.51 (SD = 1.02) 2 (Race) by 2 (Density) Race: F 1,302 = 7.54, p<.01, η 2 =.02 Mean AA = 2.37; Mean EA = 2.73 AA women worry less about breast cancer

On a scale of 0% to 100%,...how likely are you to get breast cancer in your lifetime? M = 35.65 (SD = 24.47) 2 (Race) by 2 (Density) ANOVA: Race: F 1,242 = 8.82, p <.01, η 2 =.04 Mean AA = 29.17; Mean EA = 39.59 Density: F 1,242 = 4.38, p <.05, η 2 =.02 Not Dense = 38.06; Dense = 30.71 Race by Density: F 1,242 = 2.65, p =.10, η 2 =.01

45 40 AA: Lower perception of BC risk 35 BC Risk Perception 30 25 Non-Dense Dense Dense breast: Lower perception of BC risk 20 15 10 Black or African American White or Caucasian American Due to differences in risk perception among AA

What are psychological reactions to BD notification? Are there between race differences in psychological reactions? How are those psychological reactions related to relevant behavioral intentions (i.e., talking to HCP about BD)? Are there between race differences in the effects of psychological reactions?

Recruit women 2 3 weeks after they received BD notifications Participants Eligibility: Dense breasts BI-RADS assessment 0 (inconclusive), 1 (negative) or 2 (benign) Preliminary data: 89 AA women (56%); 71 EA women (44%) 25% of AA women vs. 61% of EA women indicated knowing their BD before receiving notification. χ2(1) = 20.56, p <.001.

AA EA Age* 53.49 57.75 Education* High School 19% 6% Higher Educaton 56% 48% Graduate Degree 25% 46% Marital Status* Married of Partnered 40% 68% Separated, Widowed or Divorced 31% 27% Single, Never Married 30% 6% Household Income* Mean: ~ $40000 Mean (~ $80000)

3 Confusion items Since learning that I have dense breasts, I have been confused about my own risk of being diagnosed with breast cancer. I know exactly what to do now that I learned that I have dense breasts. (R) Learning that I have dense breasts is very confusing to a woman like me. Range (1 5) (α =.70) M = 2.96 (0.90): No between-race difference

I have no idea whether it places me at greater risk or simply can make it more difficult to detect breast cancer. What is Dense breast I don't know if there is a link between dense breasts and breast cancer. I actually did not read the report until I got the questionnaire I only saw the words normal. I will discuss the finding with my doctor... The report did not indicate the level of my breast density. I understand there are 4 levels. The report was also confusing to my primary physician who is not sure what other tests I should have in addition to or in place of the mammogram.

Breast Cancer Worry: How often do you worry about breast cancer? Range: 1 (not at all) 4 (quite a lot) No between-race difference (ANOVA) Mean AA = 2.46; MeanEA = 2.59

How anxious do you get when you think about how dense your own breasts are? (1 10) 6 5 4 3 2 AA EA 1 0 BD Anxiety* F 1,112 = 3.53, p =.06 *N = 62: AA, 52: EA

Psychological consequences of learning BD* Over the last week how often have you experienced the following because of thoughts and feelings about your breast density? Negative Consequences Physical (e.g., Had trouble sleeping) Emotional (e.g., Been unhappy or depressed) Social (e.g., Found yourself taking things out on other people) Range, 1 4 (4 being more negative consequences) *adapted from Cockburn et al., (1992).

Negative Psychological Consequences 1.6 1.54 1.5 1.48 1.42 1.4 1.3 1.24 AA EA 1.2 1.1 1.12 1.16 1.0 Physical Social Emotional Fs 1,152 8.13, ps <.01

Psychological consequences of learning BD* Over the last week how often have you experienced the following because of thoughts and feelings about your breast density? Positive Consequences Physical (e.g., Feeling more able to meet your home and/or work responsibilities ) Emotional (e.g., Feeling more relaxed ) Social (e.g., Getting on better with those around you ) Range, 1 4 (4 being more positive consequences) *adapted from Cockburn et al., (1992).

Positive Psychological Consequences 2.6 2.46 2.4 2.2 2.07 2.0 1.8 1.6 1.84 1.95 AA EA 1.4 1.37 1.34 1.2 1.0 Physical Social Emotional F 1,149 150 15.30, ps <.001

Among women who received breast density notification: No between-race difference in breast cancer worry (likely due to mammogram BI-RADS assessment?) AA report more extreme psychological reactions (positive and negative) related to thinking about breast density

2 items I intend to talk to my doctor (i.e., primary care, ob/gyn, etc.) about the notification regarding the density of my breasts within the next three months. I have decided that I will talk to my doctor (i.e., primary care, ob/gyn, etc.) about the notification regarding the density of my breasts within the next three months. Range (1-7) α =.62; r =.45

Intentions to Talk to HCP 5.4 5.3 5.2 5.1 5.0 AA EA 4.9 4.8 4.7 p <.10

Bivariate Correlations AA EA Confusion.10.28 * BC Worry.18.33 ** BD Anxiety -.05.39 ** NPC - Physical -.06.25 * NPC - Social -.04.21 NPC - Emotional -.04.28 * PPC - Physical.04.12 PPC - Social.08.13 PPC - Emotional -.11.16 GBMM -.22 @.04 = p <.10; @ = p =.05; * = p <.05; ** = p <.01

12-item scale measuring racial-group based mistrust in medical system (i.e., institutions and professions). 7-point agreement scale; higher values= greater mistrust Doctors and health care workers sometimes hide information from patients who belong to my ethnic group. People of my ethnic group should be suspicious of modern medicine. Mean AA = 3.07; Mean EA = 1.86; F 1,151 = 77.81, p <.001.

AA Standardized Estimate EA Standardized Estimate Knew Breast Density -0.05 0.12 PPC - Physical 0.47* -0.41 PPC - Emotional 0.24-0.08 PPC - Social -0.69** 0.50 NPC - Physical -0.18 0.31 NPC - Social 0.06-0.26 NPC - Emotional 0.09-0.01 BD Anxiety -0.06 0.29* BC Worry 0.09 0.15 GBMM -0.27* -0.02 Confusion 0.05 0.20 Age 0.17 0.34** Multi-Group Path Analyses * = p <.05; ** = p <.01

AA women less likely to know their own BD AA women less likely to report being told about BD by physicians AA women more anxious when notified about BD Anxiety doesn t translate to behavioral intentions for AA as it does for EA women Mistrust in medical system among AA attenuates intentions to talk to physicians about BD notification Implications for behavior? AA women with dense breasts might be less likely to request and receive supplemental breast cancer screening Good: Less potentially unnecessary testing among screen negative AA women with dense breasts. Bad: Miss more cancers not detected by mammograms among screen negative AA women with dense breasts

Does BD notification cause anxiety? Does that anxiety lead to more supplemental screening among women with no other BC risk factors? What interventions are effective for women who receive BD notifications? Reduce anxiety Supplemental screening to appropriate women BETWEEN-RACE DIFFERENCES? Where are those differences coming from? Race as a proxy for underlying socio-cultural differences (medical mistrust, cultural values, income; education, etc.)