Social/Behavioral Research on Earlier Detection
Research Project Awards
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: 1) provide counseling, appointment-making assistance, and referrals to free breast cancer screening services; 2) sponsor a Vietnamese-language breast health-line and encourage participation in community coalitions, small group meetings, educational contests, and annual health fairs; and 3) to recruit volunteers. Second, materials will be distributed encompassing previously-developed, Vietnameselanguage 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.
Innovative Developmental and Exploratory Awards (IDEAs)
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 (Ziegler, Hoover, Pike et al., 1993). 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.
New Investigator Awards
- False-Positive Mammograms: A Barrier to Annual Screening? – Phillip Gardiner, Dr.P.H. Northern California Cancer Center
- How Women Decide to Seek Evaluation of Breast Symptoms – Noreen C. Facione, Ph.D. University of California, San Francisco
- Impact of Physician Attitudes on Mammography Screening Rates – Miriam Komaromy, M.D. University of California, San Francisco
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 at 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 (Breast and Cervical Cancer Control Program) mammo-graphy 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 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.
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 decision 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.
Using multiple methods, this community based study will take a culture-specific approach to the study of help seeking for breast cancer symptoms in San Francisco Bay area women. Study participants will be stratified to span income, education and age. Targeting community organizations will purposefully recruit Latinas and African American women (over-represented in women with advanced breast cancer at diagnosis). The inclusion of non-Latina white women in the study will allow the examination of the generalizability of factors identified as significant for delaying help seeking across cultures. This investigation will provided valuable information for interventions designed to influence decision-making regarding prompt help seeking for self-discovered breast symptoms that may signal the presence of breast cancer.
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.
Postdoctoral Fellowship Awards
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 metastases (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 ex- periences. 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 careseeking 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.
