As investigations into the breast tumor biology of black women intensify, advocates of early detection are stepping up efforts to create culturally sensitive breast cancer screening programs for African-American women that guide them beyond early detection to diagnosis and treatment.
Incidence and mortality rates have always formed the rationale behind the creation of breast cancer detection programs for African-American women. Recent data from the National Cancer Institutes Surveillance, Epidemiology, and End Results Program indicate the age-adjusted incidence rate of breast cancer in black women is 99.3 per 100,000 population compared with 113.2 for white women.
Yet when blacks breast tumors are diagnosed, 51% of the cancer cases are detected in their localized stage, compared with 63% for white women. Overall, African-American women are more likely to die of breast cancer than are white women; black womens mortality rates attributable to breast neoplasms31.4 per 100,000 populationexceed those of white women by about 22%. Black womens mortality rates due to breast cancer surpass those of other ethnic minorities as well, including Asian and Pacific Islanders, American Indians, and Hispanics.
Disparities like these have propelled breast cancer advocates to argue for African-American women to have better access to breast cancer screening.
"I think weve made a lot of strides over the past 20 years regarding screening mammography for African-American women," said Roshan Bastani, Ph.D., associate professor of health services and associate director of the Division of Cancer Prevention and Control Research at the University of California at Los Angeles.
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Bastani ascribed these gains to health behavior research and federal screening programs for low-income minority women that laid the groundwork for grassroots advocacy groups to make breast cancer "a visible disease." Despite steady increases in black womens mammography use during the 1980s and 1990s, their mortality rates from breast cancer have remained constant.
"There are non-health care barriers to getting health care," explained Nancy Krieger, Ph.D., associate professor in the Department of Health and Social Behavior at the Harvard School of Public Health, Cambridge, Mass. Krieger noted that institutional racism, poverty, cultural differences, and lack of transportation and adequate childcare often hinder black women from receiving appropriate screening and treatment for breast cancer.
"I think reaching a community is really difficult," observed Ruby T. Senie, Ph.D., professor of clinical public health in the Divisions of Sociomedical Sciences and Epidemiology at Columbia University Joseph L. Mailman School of Public Health, New York.
"Just having a screening facility is not enough," Senie said. "We need to be culturally aware of what prompts some women to come forward and be screened and what keeps them away." Often, she said, African-American women are distrustful of breast cancer screening and the clinical setting in general.
"You cant just tell people they have to be screened, especially if the women havent been educated about mammography, how the machine works, and what the procedure is," Senie continued.
In an effort to decrease the diseases deleterious effect on African-American women, public health initiatives focusing on broader social, cultural, economic, and political factors affecting womens health are trying to equalize the disparate screening and treatment outcomes black women encounter.
One organization taking black women beyond breast cancer screening is the Breast Examination Center of Harlem, New York. Founded in 1979 and now an outreach program of Memorial Sloan-Kettering Cancer Center, New York, the state-of-the-art facility offers community outreach, free gynecologic and breast examinations, a childrens play area, and a bilingual staff. It averages 10,000 patient visits per year primarily from black and Hispanic women.
Community outreach is the first task on the centers agenda, said Diana Godfrey, program director at BECH. After women are screened, those with abnormal findings are referred to a patient navigator, who then arranges follow-up procedures, such as needle aspiration and biopsy, at nearby medical centers. North General Hospital and Harlem Hospital Center in New York both work in tandem with BECH and utilize patient navigation to diagnose and treat breast cancer patients.
Focus on Patients
Throughout the entire process, the navigators do not lose sight of the patient. "Were responsible for her," noted Godfrey, who said navigators require tremendous patience because of their intense involvement in the details of womens medical decisions and complex hospital procedures.
"Patients need navigation, particularly when they are poor," explained Harold P. Freeman, M.D., president and chief executive officer of North General Hospital and BECHs medical director since its inception. Freeman is also the chairman of the Presidents Cancer Panel.
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Going Where the Women Are
Whereas BECH attracts women to its screening facility, the Columbia University Breast Cancer Screening Partnership seeks out black and Hispanic women throughout Harlem, at times holding workshops in hair and nail salons. This federally and state-funded program, which began in 1989, has been at Columbia since 1997 and targets women through motivational breast and cervical cancer screening programs. Karen Schmitt, R.N., director of the partnership, said the program uses African-American and Hispanic breast cancer survivors as peer educators to show women that survival after breast cancer is possible.
Women are either screened in one of the partnerships two mobile mammography units or referred to Harlem Hospital Center or Columbia-Presbyterian Medical Center for screening and follow up.
Schmitt believes the partnerships personalization of health care and cultural sensitivity have contributed to blacks seeking earlier breast health care. Compared with previous years, said Schmitt, the partnership sees more localized cases of breast cancer.
Federal screening programs like the partnership do not receive funding for subsequent cancer treatment and are forced to turn to outside support. For now, this fills the gap in treatment, said Schmitt, "to ensure that follow-up is done quickly and well."
Last month, however, President Clinton put forth a 5-year, $220 million plan to treat women under Medicaid whose breast and cervical cancers are diagnosed via federally supported early detection programs. Citing that uninsured women receive "inadequate care or no care at all," Clinton said the proposal would see women through their entire cancer treatment and supportive care.
Such plans may hold promise for African-American women, for whom breast cancer screening is but one aspect of their health care. "If women are receiving poor health care for breast cancer," said Bastani, "chances are they are receiving poor health care in general."
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