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UT Austin nursing study brings better health care to Texas by improving breast cancer screening rates among African American women

Breast cancer remains a serious public health challenge in the United States with more than 175,000 new cases and 43,000 associated deaths estimated for 1999. It is the most common type of cancer among American women, accounting for one of every three cancers diagnosed in the United States. And even though great strides have been made in scientific knowledge about the disease, the exact cause of breast cancer still eludes researchers.

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AUSTIN, Texas—Breast cancer remains a serious public health challenge in the United States with more than 175,000 new cases and 43,000 associated deaths estimated for 1999. It is the most common type of cancer among American women, accounting for one of every three cancers diagnosed in the United States. And even though great strides have been made in scientific knowledge about the disease, the exact cause of breast cancer still eludes researchers.

Research studies document that the challenge of the disease is greater among African American women who have increased breast cancer mortality compared with white women. Higher death rates for African American women are attributed to later stage of disease progress at diagnosis or a greater likelihood of a more aggressive tumor that is harder to treat. Moreover, the five-year survival rates for breast cancer are lower for African American women at 70 percent compared to 85 percent five-year survival rates for white women. Increased participation in routine mammography screening with subsequent detection and treatment of the disease at an early stage offer the best opportunity for decreasing mortality and improving survival.

School of Nursing Project:In an effort to encourage African American women in Texas to participate in early breast cancer detection and follow-up services, a research project was launched in 1998 at the UT Austin School of Nursing. The community-based focus of this project is derived from the model developed for the Community Women’s Wellness Center under the direction of Dr. Susan Grobe at the School of Nursing.

One of the factors influencing the discrepancy in survival rates between races is the variation in socioeconomic status that affects access to medical care and therefore early diagnosis and treatment. Many African American women often delay seeking health care, and breast cancer is often diagnosed in later stages than is the case for white women. Studies indicate that women of lower socioeconomic status groups are less likely than women of higher socioeconomic status groups to participate in screening and early detection programs. Thus lower socioeconomic women are diagnosed when the disease is in its later and more severe stages and have higher rates of death from breast cancer than higher socioeconomic women.

Efforts to reduce breast cancer mortality focus on early detection of the disease through the use of the screening measures, clinical breast examination, breast self-examination and mammography. For the past twenty years extensive research has been collected on behavioral and community-based intervention programs throughout the United States to promote breast cancer screening. Although the benefits of screening for breast cancer are well documented, many women, particularly poor, medically under-served, and ethnic minority, do not participate in screening programs. They are kept away by barriers such as high cost, lack of awareness of the need for screening, and fear of breast cancer. On the whole, ethnic minority women are less likely to have heard of mammography.

This pattern holds true in Texas where screening rates are not as high as they should be for African American women. In Texas 11,300 new cases of breast cancer expect to be diagnosed in 1999, and 1,000 of these will be among African American women highlighting the need to screen these women.

African American Outreach Project:Developing effective community-based intervention strategies to reduce the burden of an illness related to breast cancer in African American women is a challenge. This is particularly true when one attempts to develop models of intervention in cancer screening for the medically under-served and ethnic minorities who often are poor.

The work that I have begun with my colleagues in the School of Nursing focuses on the development, implementation and evaluation of a community-based model to increase the numbers of African American women screened for breast cancer in Texas, especially those who are poor and under-served. Community-based models differ from the traditional medical model. The traditional medical model has its general focus on the biological issues surrounding a disease. Community-based models include the roles that various community groups and health beliefs play in the development of illness and health seeking behaviors. An emphasis is placed on culture and the social environment.

A community-based model incorporates strategies to reduce the burden of breast cancer among African Americans and other high-risk groups with the development of specifically targeted and culturally sensitive interventions to encourage women’s participation in breast cancer screening. The African American women’s breast cancer screening outreach project in the School of Nursing represents a culturally sensitive intervention. It is a five-year pilot project funded by the Texas Cancer Council. The first two to three years include a period of refinement and development, and years four and five include full implementation and evaluation.

The primary purpose of this project is to develop, implement, refine, and evaluate a culturally sensitive community-based model to enhance African American women’s participation in early detection and follow-up services for breast cancer in three specific communities in Texas. The model involves the use of outreach/case manager coordinators, the development of site community and professional advisory committees, and the development of community coalitions to promote education and awareness within the specific communities. The model is being implemented in Houston, Dallas, and Tyler. According to the Texas Cancer Data Center, these targeted areas represent the estimated source of 70 percent of breast cancers that will be diagnosed in African American women in Texas.

The project focuses on implementing this model through numerous activities designed to (1) build the infrastructure of the project (2) select community organizations to serve as sites for the project; (3) provide technical advice and training on culturally sensitive outreach and case management strategies to the sites; (4) evaluate the project to determine its effectiveness; and (5) disseminate information on the model and the outcomes. The desired outcome is that the community-based model can be transferred to other communities for use throughout the state.

To date, progress has been made in the first two areas. The infrastructure is being developed. As part of the infrastructure an overall project advisory committee has been established to help plan and support project activities comprised of members from the Texas Cancer Council, the American Cancer Society, the Susan G. Komen Foundation, the Texas Department of Health, and representatives from the participating communities. The sites have been identified. In Dallas the site is the Parkland Health & Hospital System, Community Oriented Primary Care Clinic. In Houston, the Harris County Hospital District is the site and in Tyler the University of Texas Health Center at Tyler/National Black Leadership Initiative is the site.

Outreach case managers have been hired in each location to coordinate site activities and conduct comprehensive needs assessments. Community coalitions are being established in each community to support and promote breast cancer screening. An understanding of the factors that influence breast cancer incidence and early detection in this population is necessary to conduct comprehensive needs assessment in each of the communities. These will provide information on demographics, breast cancer screening activities, and profiles of other services available in the targeted areas.

In order to plan effective outreach interventions to increase African American womenïs use of breast cancer screening services, particularly mammography, it is imperative that information is obtained about their specific knowledge and beliefs concerning this issue. This also necessitates an understanding of the traditional and non-traditional places frequented by African American women that may become a source of obtaining health information, in other words, beauty shops and churches. As part of the needs assessment a questionnaire has been developed to identify and describe barriers to mammography screening among African American women. The tool, entitled “Why We Don’t Get Breast Cancer X-rays (mammograms),” will be used to obtain information from that population’s attitudes and beliefs about breast cancer screening and mammography. Focus groups will also be conducted to provide information necessary to develop culturally appropriate outreach strategies to encourage women to be screened.

Conclusion:Information about cancer risks and the benefits of prevention must be effectively communicated to all Texans. Primary prevention of cancer seeks to help people have the knowledge, skills, and resources they need to reduce their risks of developing cancer. Secondary prevention of cancer seeks to help people identify cancers in their earliest stages when cure is attainable. The African American breast cancer screening outreach project at the UT Austin School of Nursing provides tools to help African American women improve access to health care, increase their knowledge about breast cancer, and encourage the adoption and continuation of breast cancer screening practices.