Breast cancer screening and mortality disparities in African-American women

Breast Cancer Treatment

Breast cancer is not an illness which can be cured with medication, it is a fatal disease. If not detected at an early stage it is incurable. A famous Chinese proverb states "We cannot control the wind, but we have the power to adjust its sails"; in the same manner, we cannot prevent breast cancer, but it is in our power to take appropriate measures to reduce its fatality. Annual mammography screening is one of the ways to detect this disease at an early stage. Doctors recommend women to get it done at least once in a year. Despite all this, African-American women do not give much attention to this. Cancer screening, spreading awareness about its side effects and health related issues are concepts alien to these women. Such an attitude constitutes a major obstacle in the way of dealing with this disease. This article attempts to identify the liaison between social, psychological and cultural factors affecting women's ability to accept the bitter truth of life. This study takes into account even the tiniest details of this syndrome, starting with its side effects to making it curable in some way. This topic has proved to be quite famous amongst researchers who explored almost all possible areas, including the individual's reaction to dealing with the different challenges of life, most appropriate procedures for cancer screening and constituents of Health Belief Model (HBM) (Ries et al., 2002).

Background

The fatal disease of breast cancer prevails throughout the world. Approach of women regarding the existence of this disease varies in each region and this affects the mortality rates of the particular region. For example, research work highlighted an incompatible relationship between the fatality and prevalence rates of African-American women when compared to Caucasian-American women. Although frequency of this disease amongst Caucasian-American women is higher, the death rates of African-American women surpass the other (Ries et al., 2002) This inconsistency was first identified in 1976, and since then it has been reported frequently in various population-based surveys conducted by Surveillance, Epidemiology and End Results (SEER) program (Ries et al., 2003). This research also revealed that African-American women are more prone to the inception of this disease.

Studies show that low prevalence rates are inconsistent with the high fatality rates of African-American women. There is no reasonable explanation for this discrepancy. An attempt has been made to arrive to a rational conclusion by mentioning the advanced stage distribution amongst African-American women, but the actual question remains unanswered (Ries et al., 2002-03).

Contraceptives and Steroid Hormone (CASH) study focuses on the prevalence of breast cancer disease among African-American women. Although the factors behind high prevalence rates have been discussed, the study failed to establish the exact reasons for their existence (Mayberry, 1992; 1994).

Mayberry and Stoddard-Wright (1992) further investigated the CASH study to ascertain that the familial and gynecological factors affected the prevalence rates in a different way. The analysis was based on various breast cancer cases (a total of 3,934 Caucasian-American women, and around 490 African-American women) and its preventive measures (a total of 3,901 Caucasian-American women, and a total of 485 African-American women). The different factors taken into consideration include surgical menopause, family history and age at menarche. Family history had a greater effect on African-American women as compared to Caucasian-American women. This is evident from facts which state that the existence of breast cancer amongst first and second degree family history for African-American (odds ratios, 1.61 and 1.71, respectively) is greater than that of Caucasian-American women (odds ratio, 2.16 for first-degree relatives, and 1.44 for second-degree relatives). Along with this, African-American women have been noted to have an early age for start of menstrual cycle. Study reveals that this also increases breast cancer risk but fails to deduce a logical reason for this statement (Bernstein et al., 2003).

Another study relates the frequency of this disease with its age of inception and the resulting conclusions are worth having a look at (Ries et al., 2002; 2003). Theory indicates that the possibility of getting diagnosed with this fatal disease increases with age. Research contradicts with this point as the prevalence rate is higher for those African-American women who are younger than 45. Rates for Caucasian-American women in this age group are low on the other hand. Fifth decade is the meeting point for both ethnicities as prevalence rates are almost equal, but it does not last long. For women over the age of 50, the relationship graph takes a U-turn. Now, prevalence rates for Caucasian-American women are higher than those of African-American women. This relationship is also evident in numerical terms. According to statistics, only 20% of Caucasian-American women get diagnosed with this disease under the age of 50, whereas the percentage for African-American women is around 30-40% (National Cancer Data Base, 2004).

Regardless of the details and statistical facts, this is an observable fact that cannot be relied upon. This is because the notion was first introduced in 1960s (Krieger, 1990) and SEER program was initiated in 1970s. SEER program is the most deep-rooted and authentic program for the maintenance of cancer-based data in U.S.

The research conducted by Pathak and colleagues (2000) is amongst the researchers who took an initiative to explore the details behind the occurrence of breast cancer at an early age. This study builds a relationship between the postpartum period and premenopausal breast cancer risk. The study was based on an analysis that indicated that African-American women experienced child bearing at an early stage which results in breast cancer risk. Palmer and colleagues (2003) further contribute to these details by stating an interesting fact in The Black Women's Health Study. They identified a twofold connection between pregnancy and breast cancer risk. Early pregnancy increases breast cancer risk before the age of 45, but reduces the same risk when a woman crosses the age limit of 45 years.

Another factor for breast cancer is postmenopausal obesity (Colditz, 2000). In the non-existence of ovarian function, estrogen levels increase as a result of fatty tissue metabolism of adrenal gland steroids. This factor has been exploited by Flegal and colleagues (2003) who scrutinized the Third National Health and Nutrition Examination Survey (NHANES III) and identified that the ratio of obese women (body mass > 30) amongst African-American women under the age of 40 was more than 50%, and the ratio of overweight women within the same age group was more than 80%. The reasons behind this relationship are still undiscovered however. Although researchers have identified physical inactivity, and inappropriate intake of micro nutrients amongst the factors that lead to high risk of breast cancer, logical justification is still missing (Forshee, 2003). On the contrary, the prevalence rates in the postmenstrual age group are significantly lower for these women.

In spite of the innumerous efforts to avert this disease, the occurrence rates have taken an increasing trend since 1980s (American Cancer Society [ACS], 2005). Along with this, the inconsistencies between incidental and mortality rates for African-American and white women continue to rise. Based on the extensive research work, ACS anticipated that around 211,240 women in U.S. will be diagnosed with this disease and from this around 40,410 will lose their lives.

As mentioned earlier, the occurrence rate for African-American women is lower than that for Caucasian-American women (119.9 per 100,000 compared with 141.7 per 100,000), however, fatality rate for the same is higher. (35.4 per 100,000 compared with 26.4 per 100,000) (ACS) Although the actual reasons behind this inconsistency have not been documented, researchers have proposed a few in an attempt to resolve the query. These reasons include lack of awareness about cancer and the fact that it is curable, ineffective communication, lack of financial support and limited access to health care (Paskett et al., 2004; Schwartz, Crossley-May, Vigneau, Brown, & Banerjee, 2003; Smedley, Stith, & Nelson, 2003).

Problem Statement

Breast cancer is the top ranked disease amongst women (American Cancer Society, 2006a). Besides being the most popular form of cancer, it is also the major contributor to high ratio of cancer related deaths in U.S.. Following the increasing prevalence rates, it is projected that 212,910 women will be diagnosed with breast cancer in 2006, with 6,290 women in North Carolina (American Cancer Society, 2006a). The prediction for breast cancers started from 2005, and in the first year of prediction, 250 women were expected to be diagnosed with this syndrome (Central Cancer Registry & American Cancer Society, 2005).

Once a woman is diagnosed with cancer, the first question to consider is whether it is fatal or not. The answer lies in the stage at which cancer is detected. The disease is curable if detected at an early stage. This is evident from the fact that the ratio for endurance is 98% for those women whose cancer was diagnosed at an early stage as compared to 26% for those women whose cancer reached the advanced stage (American Cancer Society, 2005a). Research has revealed that African-American women mostly become victims of advanced stage cancer increasing the death rates for this demographic (Ghafoor et al., 2003; Li, Malone, & Daling, 2003). Once remedy for prevention of cancer was mentioned earlier, i.e. annual mammography screening. But when should a woman start the cycle of annual mammography screening. According to the extensive research work, annual screening should start at the age of 40 to reduce fatality rates (American Cancer Society, 2006b).

Work of HBM was concerned with different aspects of mammography screening. The first step was to identify the reasons behind women's attitude towards cancer screening. Therefore, a sample of women was selected to fill a questionnaire. The sample represented groups of women in favor of screening and women who oppose this. Results were concluded using relationships between different variables of HBM. Along with this, multivariable regression models were used to identify factors affecting social support and other constituents of the HBM model.

Purpose

This article intends to make a connection between social, psychological and cultural factors that have an impact on African-American women and their attitude to cancer treatment and annual screening. After establishing the factors, the next step is to explore the concept of annual mammography screening from every possible aspect. In order to achieve the main purpose, research work has been based on a variety of factors which can be changed according to different situations in order to arrive at a logical and reasonable conclusion. The factors include cancer fatalism, dispositional optimism, social support, perception of general health, components of HBM and mammography in the past year (Trochim, 2006).

This study was initiated with a survey conducted amongst older African-American women to discover the driving force behind their attitude to cancer screening and treatment. The area of focus was South Carolina and women under the age of 50 were encouraged to participate in this activity.

Assistance was provided by local hospitals and housing authorities who generated a list of low income houses and an estimate of the number of old women residing in that area. Housing unit managers invited women to participate after explaining the reason behind the study and coordinated with participants to arrange focus group sessions in these houses.

The session started with an opening speech about the objectives of the research work, and a formal and written approval was obtained from all participants. A questionnaire was distributed amongst the group containing two open ended questions. The questions were planned to incarcerate the extent to which women have accepted this bitter truth of life and their motivation levels to deal with the biggest challenge of life. It was also concerned about the way in which women prefer to receive such information. After the questionnaires were filled, participants were given details about cancer, cancer screening and locations at which they can get access to free mammograms.

Significance of the Study

Researchers have put in a lot of effort and hard work in order to reveal answers to the unanswered questions, and these efforts have been acknowledged widely. Works of various researchers have been compiled in this article to provide a complete picture of breast cancer, its hazards, treatment and its preventive measures. As the article focuses on African-American women, it helps to enhance knowledge about cancer treatment in that region. Also, it serves as the starting point for healthcare practitioners who can improvise community health programs targeted for African-American women to make them more effective. Nonetheless, the article is a valuable addition to the existing data on cancer treatment and annual screening among African-American women (Trochim, 2006).

Conceptual or Theoretical Framework

This framework deals with the walls surrounded around the concept of screening that prevent women from entering inside. These obstacles include conveyance issues resulting from cost and transportation issues, not having access to health care facilities and insufficient information about cancer screening and its treatment. The most powerful obstacle in the way to improvement is perception of women who believe that the disease is incurable and a thing to be ashamed of, because people start looking at you with sympathy and regret (Jernigan, Trauth, Neal-Ferguson, & Cartier-Ulrich, 2001; Powe, 2001; Shankar, Selvin, & Alberg, 2002).

In today's world, people are so busy with their own lives that the disease of cancer and its risk of occurrence are normally overlooked by women. As a result, cancer screening is undertaken only when it is predicted. Therefore, it takes a crisis orientation approach rather than a prevention orientation approach (Shankar et al., 2002) Now, mammography screening is a requirement recommended by doctors when cancer is predicted and not part of normal health care routine as it should be (Powe, 2001). For it to be part of normal health care routine, it should be encouraged by health care providers, explaining to people that it does not mean something bad, but this is just a safety measure. Unfortunately, health care providers also ignore the need for annual screening which leaves the impression that it is just a waste of time and money. (Davis, Emerson, & Husaini, 2005; Lukwago et al., 2003; Powe, 2001)

Fatalism can be defined as a resignation to fate. Cancer fatalism is the principle that cancer is incurable and death is waiting for you ahead. With this belief in mind, women do not adopt a positive attitude towards mammography screening. Cancer fatalism is not a bud; it is a well grown tree having strong roots beneath. The idea of cancer fatalism emerges from the side effects of cancer and past experiences of cancer patients losing their lives in the process. Cancer patients go through a mixed feeling of helplessness and pain and feel that there is nothing good left for them in life (Powe, 1995b). With the passage of time, the roots are getting stronger and the idea of cancer fatalism is getting more and more popular amongst African-American women (Powe, 1995a; Powe & Finnic, 2003; Skinner, Champion, Menon, & Seshadri, 2002). Women over the age of 50 who come from a low income background are more affected by this principle as they do not have sufficient resources to gain access to knowledge about this disease and its treatment (Powe, 2001; Powe & Finnic; Powe & Weinrich, 1999).

On the contrary, even older women can promote cancer screening if they have adequate knowledge about the disease and if they know someone who has been diagnosed with this illness, regardless of the fact that he survived or not (Jernigan et al., 2001). Along with this, nature of a woman in general also influences the outcome. A pessimistic woman who only thinks about the worst outcomes will never be motivated about the mammography screening, as compared to an optimistic woman who always picks out the good things from every decision (Clarke, Lovegrove, Williams, & Machperson, 2000).

This article uses the HBM model to identify the reasons behind different attitudes of people. For example, some women perceive mammography screening as a health care procedure while others perceive it to be a punishment from God (Clarke et al., 2000). HBM model is based on an assumption that decision regarding health promotion is entirely dependent on the individual's perception of that particular disease.

This specific perception is based on an individual's knowledge about the disease and its effects on personal lives and health of that person. In order to promote precautionary measures, it is necessary that the positivity should take over the negative factors associated with these measures. HBM revolves around health behavior and the paradigm of HBM incorporates all kind of factors starting with social and economic factors to warning signs of illness and recommendation by health care professionals. In the last 10-15 years, the entire focus has been on African-American women and a variety of experiments have been conducted to analyze an individual's behavior and attitude towards cancer screening (Clarke et al., 2000; Gasalberti, 2002; Thomas-Vadaparampil, Champion, Miller, Menon, & Skinner, 2003).

Definitions of important terms

Breast Cancer - Breast Cancer is a famous non-skin cancer that is usually produced in the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk) of breast. Men and women both can be victims of this disease; however, the frequency of breast cancer amongst males is significantly low (Ries et al., 2003).

Breast conservation therapy or breast-conserving therapy

Breast cancer is no longer incurable. Among the many discoveries of science, there are a few methods to cure breast cancer by eradicating that particular tissue without affecting any other part of the breast. Therapy involves removing lymph nodes under the arm after which radiation therapy is given to the patient. In medical terminology this therapy has been given various names such as lumpectomy, segmental excision, limited breast surgery, or tylectomy (Ries et al., 2003).

Breast Self-Exam (BSE)

This is another method to detect breast cancer at an early stage. Women over the age of 20 check their own breasts for any swelling or doubtful changes just before or after the menstrual cycle. This period is selected for examination as any unnatural changes can be highlighted in this period (Ries et al., 2003).

Invasive Cancer

Cancer develops in tissue in any part of the body and if not cured at that stage, it will flow down to other parts of the body too. Invasive cancer is one that has not been detected at an early stage and as a result has reached other parts of the body too (Ries et al., 2003).

Breast cancer screening

A health care method recommended for even those women who have not come across any indications for this disease (Ries et al., 2003).

Health Disparities

Inconsistencies between the prevalence and fatality rates among different ethnicities of United States have been highlighted above. If the whole phenomenon is to be summarized in one word then that would be health disparities (Ries et al., 2003).

Incidence

The underlying concept is similar to that of prevalence. It can be defined as the frequency of a particular disease among people of same age group (Ries et al., 2003).

Mammography

A special form of x-ray designed to detect breast cancer at an early stage, even before the warning signs start showing indicating the existence of breast cancer. This is the reason that annual mammography screening is recommended for women above the age of 40. On the other hand, diagnostic mammography reveals breast masses and causes of breast cancer which will help the doctor in his treatment (Ries et al., 2003).

Mortality

It represents number of deaths due to any disease (Ries et al., 2003).

Prevalence

It shows the number of people diagnosed with the particular disease at a certain time (Ries et al., 2003).

Assumptions

Every research is based on certain assumptions. These assumptions reduce its credibility but are essential to reach to a logical conclusion. For example, in this article the researcher has presumed that the extent to which African-American women are equipped with information about breast cancer is constant, and all women are keen to add their knowledge. In this regard, the important thing to consider is the reliability of the underlying data of this research. This is because even the tiniest doubt can make the research unreliable. Assumptions go hand in hand with any research work. The success of project depends on the dependability of data, sample being representative of the total population and impartial attitude of Author. In this article, the approach of researcher has been consistent throughout the study. Same questionnaires were forwarded to all participants; therefore, we have some surety over the sincerity of answers given and the research cannot be condemned by others (Trochim, 2006).

Scope, Limitations and Delimitations

Scope refers to the extent to which a topic will be analyzed, for example this article was mainly concerned with identifying a relationship between social, cultural and psychological factors that can influence women's attitude towards breast cancer and annual screening. Furthermore, like any other research work this article also had certain limitations. Sample selected consisted of women residing in low income houses and within the age limit of 50-98. There is a risk that this sample fails to represent the target population. However, this limitation has been overcome by the stance taken by researcher. The sample was selected considering the purpose of study (Trochim, 2006). As the objective of research was to identify factors affecting women's attitude towards prevention and early detection of breast cancer, the target population was confined to certain group of people. As the focus has been on African-American women, the surveys were conducted in United States.

The article has highlighted the different obstacles in the way of cancer treatment which along with lack of financial and social support can adversely affect the phenomenon of annual mammography screening. Along with this, HBM also plays an important role in analyzing the different aspects of mammography screening.

Chapter Summary

Summing up, the objective of the research was to examine the relationship between socio-economic and cultural factors that can influence cancer treatment and its prevention. As a result all factors have been scrutinized in detail. These factors include cancer fatalism, dispositional optimism, individual's perception towards health care procedures and components of HBM.

A cross sectional research was designed for the purpose, that is, data at a certain point of time was selected for the purpose of examination. The surveys were conducted in South Carolina and a sample of 198 African-American women was selected. These women were within the age limit of 50 and belonged to low income families. Questionnaires were forwarded to these participants and results will be concluded using correlate variables and multi-variable regression models.