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Breaking down barriers:
Increasing screening mammography in African-American women
Christine F. Legler, PA-C, MS
Ms. Legler is Program Director, School of Physician Assistant Studies,
at Pacific University, Forest Grove, Ore.
Breast cancer in African-American
women tends to be diagnosed late, and death rates are surprisingly high. Successful
strategies that increase breast cancer screening among low-income and poorly
educated African-American women incorporate culturally appropriate, community-based
strategies.
African-American women have the highest mortality rate from breast cancer despite
having the second highest incidence of the disease. White women, by comparison,
have the highest overall incidence of breast cancer, but they have the second-highest
death rate. Between 1990 and 1998, breast cancer deaths decreased for whites
by 2.5% per year but were unchanged for African-American women.1
The disease tends to strike African-American women at younger ages than it does
white women, but it is often diagnosed at a later stage.2 This article
explores some of the possible reasons for the higher death rate among African-American
women with breast cancer by evaluating socioeconomic factors, access to health
care, cultural issues, and other barriers to the early detection of breast cancer.
Demographics of the disease
The incidence of breast cancer in African-American women is 121.7 per 100,000,
and the death rate from the disease is 35.9 per 100,000.1 Compare
these numbers with those for white women, who have an incidence of 140.8 per
100,000 and a death rate of 27.2 per 100,000. The data clearly show that while
white women have a higher incidence of breast cancer, African-American women
have a significantly higher overall death rate.1
Identifying barriers to screening: Socioeconomic status and cultural beliefs
US census data from March 2003 on poverty rates, unemployment, and marriage
in the African-American and white populations show that the overall poverty
rate for African-American women is 25%, twice that of white women, and that
26% of African-American women older than 65 years live in poverty compared to
10% for whites.3 In addition, African-American women have higher
rates of unemployment compared to white women.
The Kaiser Permanente Council on Diversity handbook addresses health care issues
for African-Americans. It notes that blacks could interpret impersonal or hasty
treatment by nonblack health care providers as racist. A prior negative experience
with the health care system may create communication barriers and a sense of
mistrust toward health care providers, which can result in a delay in seeking
care for medical problems or in failure to follow medical treatment plans. In
addition, many African-Americans believe in fatalism and the inevitability of
the development of diseases such as cancer, which may also be a factor in why
patients do not seek cancer screening services.2
Locks and Boateng categorized the African-American view of the cause of illness
as natural or unnatural.4 Natural causes include improper diet and
eating habits or exposure to cold air; an unnatural cause is God’s punishment
for improper behavior. Mental illness is attributed to a lack of spiritual balance,
and genetic disorders are God’s will. African-Americans are likely to use
both folk and medical treatments for illness. Folk remedies include teas, herbs,
warm medicated compresses, and cotton balls in the nose to protect against cold
winds. In addition, some African-Americans in rural areas practice magic or
voodoo.4 Because many believe in the power of community healers through
the use of folk remedies and spiritual ceremonies, health care providers need
to be aware of the patient’s beliefs and, if possible, to provide treatment
regimens that allow for the use of folk remedies. In addition, African-Americans
generally rely on the extended family, the community, and local churches for
support. These resources can be very helpful for a patient with a significant
medical problem such as breast cancer.5
Rajaram and Rashidi found that strategies developed to encourage women to participate
in cancer screening programs must understand and incorporate their cultural
beliefs.6 The researchers discussed the role of culture as an explanatory
model for minority women obtaining breast cancer screening. Their review of
studies showed that some African-American women believe that physical abuse
of the breast from domestic violence can cause breast cancer, and these women
may be reluctant to obtain mammography screening because it would reveal the
existence of such violence. Other women feel that compression of the breast
during screening mammography increases the chance of developing breast cancer.
Social and economic factors—such as the lack of health insurance, transportation
problems, the lack of child care, or the inability to take time off from work—may
also affect a woman’s ability to seek medical care and preventive screening
services. In addition, prior negative experience with the health care system
and providers can also affect a minority woman’s willingness to seek preventive
services. Because social networks are important within the African-American
community, the beliefs of the woman’s family or community concerning breast
cancer have an effect on the woman’s knowledge of breast cancer and the
value of mammography.6
Overcoming barriers to screening
Because breast cancer is a significant health issue for women, one goal of
Healthy People 2010 is to increase the percentage of women aged 40 years and
older who have a mammogram every 2 years to 70%.7 Achieving this
goal will require intervention strategies that meet the needs of the different
minority populations, including African-American women. The following studies
summarize effective strategies that have been developed and implemented.
Bernstein and coworkers studied ways to increase utilization of mammography
services by older minority women, who have a low rate of screening mammography.8
In their study of 151 culturally diverse women between the ages of 50 and 90
years, the researchers found that 95% of the women knew that early diagnosis
of breast cancer increased the chance of survival and 90% agreed that mammography
was a good screening procedure. Only one third, however, knew that older women
are at greater risk for developing the disease or that early detection and treatment
are associated with a 95% survival rate. Only 30% of the study participants
felt they were at risk for breast cancer, and 65% had never had a mammogram.
The study participants identified fear of the results (46%) and transportation
problems (38%) as the primary barriers to obtaining a mammogram.
In addition, the women in the study participated in education sessions conducted
by culturally competent peer educators who acknowledged the patient as having
responsibility for her own life, encouraged the patient to freely discuss her
beliefs concerning mammography, and provided facts about breast cancer and mammography
screening services. As a result, 69% of the women who participated in these
discussions kept their appointments for a screening mammogram and 77% of those
who missed the appointment rescheduled.8 Although this study involved
a small sample, it shows the power of appropriately designed educational programs
that include educators trained to understand and respect the cultural barriers
within different minority communities that may affect a woman’s decision
to obtain mammography.
Using data about mammogram use from the 1998 National Health Interview Survey,
for which 41,000 households in the United States were interviewed about their
health, Selvin and Brett found that educational level and income are important
issues that must be included in any intervention strategy.9 The study
also showed that the strongest predictor of whether a woman obtained cancer
screening services was having a regular source of health care; women who had
such a source were four times more likely to obtain these screening services.
In addition, the researchers found that because both African-American and Hispanic
women are less likely than white women to have health insurance or be able to
afford health care, they are less likely to obtain cancer screening services.
The researchers did note an increase in mammography rates among both African-American
and white women who were covered by Medicaid or Medicare, which have breast
cancer screening programs that target these women. Another significant issue
is the low rate of cancer screening services among women from all races and
socioeconomic levels who are also smokers.9
This study shows clearly the importance of targeting programs that encourage
women–especially those who are low income and uninsured–to obtain
cancer screening services. It also demonstrated that women who smoke are less
like to obtain cancer screening services and that clinicians should be aware
of this factor.
Evaluating the effect of age and race on mammography screening, Rawl and coworkers
identified four possible barriers to screening: time, radiation exposure, scheduling,
and not understanding the benefit of screening.10 Time was more a
problem for older African-American women than for younger women, and older women
expressed more concern about the radiation exposure. Remembering to schedule
an appointment was very problematic for older women, who also had a lower rate
of seeing the benefit of mammography. Women from all ages and races reported
that the most common reason for not getting a mammogram was pain from the mammogram.10
The researchers concluded that age, race, and perceived barriers and benefits
of mammography affect a woman’s decision to obtain a mammogram and must
be considered when developing intervention strategies for different populations.
Cole and colleagues evaluated the relationship between mammography screening
rates and four beliefs about mammography: early detection improves breast cancer
outcome; mammography is painful; it causes breast cancer; and it is dangerous.11
Forty-six percent of the 407 women studied were African-American. The 82% of
women studied who believed that early detection was a means to improve breast
cancer outcome had a twofold higher incidence of obtaining mammograms. Results
were inconclusive that belief that mammography was painful or dangerous affected
mammography rates. The belief that mammography causes breast cancer had a negative
affect in screening rates among all groups. The study also showed that lower-educated
and minority women were less likely to obtain mammography screening services.
Thompson and colleagues found that family history–mother, sister, grandmother,
aunt, cousin having breast cancer—was a factor in whether a woman obtained
a mammogram. This finding supports the findings of other research indicating
that women in lower socioeconomic groups may not feel they are at risk for breast
cancer. Many women in the study believed that compression of the breast during
mammography could cause breast cancer and also identified the lack of courtesy
of the mammography technicians as a barrier to having a repeat test. Many women
indicated that most of their information about breast cancer and mammography
was obtained from television talk shows, which prompted the researchers to conclude
that the development of a video using a talk show format could be an effective
teaching technique for this population. The study also shows the importance
of developing different strategies for educating women from different subgroups
of women within the African-American community.12
Breast cancer issues
Women from all ethnic groups have similar concerns about the effects of breast
cancer on their lives, particularly quality of life and sexuality. In a focus
study of African-American women who had breast cancer, Wilmoth and Sanders identified
additional concerns among this patient population—including finding prostheses
and wigs that match skin color and hair texture, keloid formation at the surgical
scar, and the need for culturally specific support groups—and identified churches
as an important source of support.13 African-American women who had
breast cancer identified the urgent need to develop culturally appropriate educational
programs about the early detection and treatment of breast cancer specifically
for African-American women.
The participants were appreciative that this study was conducted by a multiethnic
group who listened to the needs of African-American women with breast cancer,
and they stressed that health care providers and nurses need to be aware of
these issues in order to provide culturally appropriate care and support programs.
This important study begins to address issues for African-American women with
breast cancer. Appropriate counseling and support services that include African-American
breast cancer survivors must be developed and implemented within the community
to increase the rates of African-American women who obtain breast cancer screening
and early treatment.
To examine why the survival rates for African-American women with breast cancer
are lower than for other groups, Boyer-Chammard and coworkers evaluated data
from 12,409 women with a diagnosis of invasive breast cancer in the California
Cancer Reporting System.14 Unadjusted survival rates showed that
non-Hispanic whites had an overall 2-year survival rate of 88% and a 5-year
survival rate of 70%, compared to 77% and 48%, respectively, in African-Americans.
The data also indicated an increased mortality risk for blacks compared to non-Hispanic
whites who had disease staged at diagnosis as localized or regional, but there
was no mortality difference in those who had distant disease. More black and
Hispanic patients were younger than 50 years at the time of diagnosis, compared
to non-Hispanic whites, raising the question of whether the risk of developing
breast cancer is greater in younger African-American and Hispanic women than
in whites. Since 43% of black women with breast cancer were younger than 50
years at the time of diagnosis and their disease was not detected at an early
stage, mammography screening for this population should be a priority. Where
a patient receives treatment for her cancer may also be a factor in survival
rates of minority women.14
One approach
The National Breast and Cervical Cancer Early
Detection Program (NBCCEDP) was established by Congress in 1991 and is administered
by the CDC. The program was developed to help low-income, uninsured, and underserved
women gain access to breast and cervical cancer screening by supporting public
and provider education, quality assurance, surveillance, and evaluation activities
needed to achieve maximum utilization of the screening, diagnostic, and case
management services funded by the program. The program provides breast and cervical
cancer screening services, referrals, diagnostic follow-up, and case management.15
Despite this program and others like it, deaths from breast cancer
in African-American women remain higher than for other groups,
reinforcing the need to expand breast cancer education and screening programs
for this population. In addition, the high incidence and death rates suggest
the need for research into whether the disease has a different pathophysiology
in African-American women that causes it to manifest earlier
in life with greater mortality and morbidity.
Conclusion
Clearly, breast cancer is a significant health problem for African American
women. Strategies to encourage participation in cancer screening programs must
incorporate the population’s cultural beliefs and address the socioeconomic
factors that are barriers to obtaining screening mammograms; namely, lack of
health insurance, transportation problems, lack of child care, and the inability
to take time off from work. A past negative experience with the health care
system may create communication barriers and lack of trust toward health care
providers that could result in a delay in seeking care for medical problems
or failure to follow medical treatment plans.
Successful intervention programs include the use of culturally competent peer
educators who acknowledge that the patient has responsibility for her own life
and health, encourage the patient to discuss her concerns about mammography,
and provide facts about breast cancer and mammography screening services. A
regular source of health care has been identified as the best predictor of whether
a woman obtains a mammogram on the provider’s recommendation. The fact
that smokers of all ethnicities have low rates of cancer screening underscores
the need to develop interventions that target subpopulations of African-American
women.
Because the overall survival rate for localized breast cancer
is 97%, it is essential to increase the number of African-American women who
seek early and regular mammography services; programs such as the NBCCEDP are
a good start and should be continued.
. Clearly, education programs that target African-American women–particularly
those who are low income and less educated–are essential and should be
culturally appropriate. Integrating these education programs into existing community
programs such as those run by churches may be advantageous. In addition, African-American
women with breast cancer want to participate in such programs and should be
included in planning outreach activities.
REFERENCES
1. National Cancer Institute News Center. Cancer Health
Disparities. Available at: http://www.cancer.gov/newscenter/healthdisparities
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2. Kaiser Permanente National Diversity Council. A Provider’s
Handbook on Culturally Competent Care for African Americans. Kaiser Permanente;
1999.
3. US Census Bureau. U.S. Census. Available at: http://www.census.gov
. Accessed October 28, 2003.
4. Locks S, Boateng L. Black/African Americans. In:
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Francisco, Calif: UCSF Nursing Pr; 1996.
5. Spector RE. Cultural Diversity in Health and Illness.
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7. Healthy People 2010: Objectives for Improving Health.
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aged 40 years and older who have received a mammogram within the preceding 2
years. Available at: http://www.healthypeople.gov . Accessed October 28, 2003.
8. Bernstein J, Mutschler P, Bernstein E. Keeping mammography
referral appointments: motivation, health beliefs, and access barriers experienced
by older minority women. J Midwifery Womens Health. 2000;45:308-313.
9. Selvin E, Brett KM. Breast and cervical cancer screening:
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Public Health. 2003;93:618-623.
10. Rawl SM, Campion VL, Menon U, Foster JL. The impact of
age and race on mammography practices. Health C Women Int. 2000;21:583-597.
11. Cole SR, Bryant CA, McDermott RJ, et al. Beliefs and mammography
screening. Am J Prev Med. 1997;13:439-443.
12. Thompson B, Montano DE, Mahloch J, et al. Attitudes and
beliefs toward mammography among women using an urban public hospital. J
Health Care Poor Underserved. 1997;8(2):186-201.
13. Wilmoth MC, Sanders LD. Accept me for myself: African American
women’s issues after breast cancer. Oncol Nurs Forum. 2001;28:875-879.
14. Boyer-Chammard A, Taylor TH, Anton-Culver H. Survival differences
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15. Centers for Disease Control.—The National Breast and
Cervical Cancer Early Detection Program. Available at: http://www.cdc.gov/cancer/nbccedp/index.htm
. Accessed October 28, 2003.
Breast cancer resources
Agency for Healthcare Research and Quality
www.ahrq.gov
American Breast Cancer Foundation
www.abcf.org
American Cancer Society
www.cancer.org
National Alliance of Breast Cancer Organizations
www.nabco.org
National Breast and Cervical Cancer Early Detection
www.cdc.gov/cancer/nbcced
National Institutes of Health Clinical Trails
www.nci.nih.gov
Susan G. Komen Breast Cancer Foundation
www.komen.org/grants
U.S. Preventive Services Task Force
www.ahcpr.gov/clinic/3rduspstf/breastcancer/brcanrr.htm
Christine Legler. Breaking down barriers: Increasing mammography in African-American women. JAAPA January 2004;17:Web.
Copyright © 2004, Advanstar/Medical Economics Healthcare Communications at Montvale, NJ 07645-1742. All rights reserved.
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