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Finding Answers:
Disparities Research for Change
Interventions to Enhance Breast
Cancer Screening, Diagnosis, and
Treatment Among Racial and
Ethnic Minority Women
Christopher Masi, MD, PhD
Dionne Blackman, MD
Monica Peek, MD, MPH
University of Chicago
American Cancer Society’s Bridging the Health Care Divide
New Orleans, Louisiana
April 19, 2007
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Racial/Ethnic Disparities in Breast
Cancer Incidence & Mortality, 2000-2003
Mortality
140
35
120
30
100
25
Per 100,000
Per 100,000
Incidence
80
60
20
15
40
10
20
5
0
0
White
AI/AN
Black
Hispanic
API
White
AI/AN
Black
Hispanic
API
Ries et al. SEER Cancer Statistics Review, 2006
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Racial/Ethnic Disparities in 5-Year Breast
Cancer Survival and Risk of Death, 1992-2000
Cause-Specific Survival
90
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
85
80
75
70
65
White
AI/AN
Adjusted Relative Risk of Death
Black
Hispanic
API
White
AI/AN
Black
Hispanic
API
Jemal et al. Cancer 2004;101(1):3-27
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Goal
 To review the literature and determine
which clinic-based initiatives most
effectively enhance breast cancer
screening, diagnosis, and treatment
among racial and ethnic minority women
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Method
 MeSH terms from the following categories:
– Breast neoplasm
– Study design
– Racial/ethnic minorities
 Databases:
– Medline
– Cochrane
– CINAHL
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Method
 Inclusion criteria
– RCT or CCT
– Published 1986-2005
– Clinic-based
– Study population > 50% minority or
 results analyzed by race if population < 50%
minority
 Primary and secondary reviewer
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Conceptual Model
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Results
 215 unique citations
 154 eligible for full review
 42 interventions
– screening (36)
– diagnosis (5)
– treatment (2)
 Intervention targets
– patients (20)
– patients & providers (18)
– providers (4)
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Screening
 I. Patient-targeted Interventions
– Reminder-based
 More successful at increasing mammography among women
with higher educational attainment and previous
mammography
– Culturally sensitive
 Increased mammography and breast self exams among
Hispanic and Black women
– Multifaceted
 Increased mammography regardless of race, ethnicity,
education, income
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Screening
 II. Patient- & Provider-targeted
Interventions
– Reminder-based
 More effective at increasing mammography than
patient-targeted interventions alone
 Effective even after out-of-pocket mammography
cost removed
 More impact on mammography than on clinical
breast exam
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Diagnosis
Patient-targeted Case Management
– Minimal Model
 Outreach, planning, referral
 Increased adherence to subspecialty appointments
– Coordination Model
 Above plus advocacy, casework, reassessment
 Increased adherence to subspecialty appointments
– Sociomedical Model
 Above plus assistance with housing, work, food security,
substance use, domestic violence, & mental health services
 Increased biopsy rate and shortened time to biopsy
 Increased adherence to subspecialty appointments
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Treatment
Patient-targeted Case Management
– Sociomedical Model
 1st treatment within 30 days (62% vs. 40% ) (ns)
 Median time to treatment (24 days vs. 29 days) (ns)
Ell et al. Cancer Practice 2002;10(3):130-138
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Treatment
Patient-targeted Case Management
– Sociomedical Model
 Breast conserving surgery (28.6% vs 18.7%) (p=.031)
 Radiation therapy (36% vs. 19%) (p=.003)
 Breast reconstruction (9.3% vs. 2.6%) (p=.054)
 Normal arm function (93% vs 84%) (p=.037)
Goodwin et al. Journal of the American Geriatric Society 2003;51:1252-1259
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
National Breast and Cervical
Cancer Early Detection Program
(NBCCEDP)
 Federal program which funds breast and
cervical cancer screening and diagnostic
testing among uninsured and
underinsured women
 $192 million budget in 20021
 292,601 mammograms in 20021
1Ryerson
& Major. National Breast and Cervical Cancer Early Detection Program: 1991-2002 National Report. 2005
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
National Breast and Cervical
Cancer Early Detection Program
(NBCCEDP)
 In 2003, 42% of uninsured women
reported having had mammography in
previous two years1
 With 6.7 million uninsured women
between the ages of 40-64 years, ~3.9
million women are eligible for NBCCEDPfinanced mammography2
1Nat
Center for Health Statistics Health, United States, 2005
2DeNavas-Walt
et al. Income, Poverty, and Health Insurance 2005
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Breast and Cervical Cancer
Prevention and Treatment Act
(BCCPTA) of 2000
 Women diagnosed through NBCCEDP can
receive treatment through the BCCPTA, a
federal program which permits states to extend
Medicaid benefits to uninsured women
regardless of income or assets.
 Focus group study in 2003 revealed knowledge
of BCCPTA is limited1
 Increased publicity re. BCCPTA may lead to
increased mammography among low-income
women1
Kenney et al. Hearing Their Voices, Kaiser Family Foundation, 2004
1
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Conclusions
 Causes of racial & ethnic disparities in breast
cancer mortality are several and include barriers
to screening, diagnosis, and treatment
 Multi-faceted interventions are the most effective
at increasing mammography among women with
lower incomes, lower education, or language
barriers
 More research is needed regarding interventions
to improve treatment among racial/ethnic
minority women
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Conclusions
 With the large number of uninsured Americans,
the NBCCEDP and BCCPTA provide much
needed support for breast cancer screening &
treatment
 In the absence of substantive health insurance
reform, additional resources should be
dedicated to NBCCEDP, BCCPTA, and to
interventions which address the range of
barriers faced by racial & ethnic minority women
A National Program of the Robert Wood Johnson Foundation at the University of Chicago
Finding Answers:
Disparities Research for Change
Acknowledgments





Dionne Blackman, MD
Monica Peek, MD, MPH
Elbert Huang, MD
Marshall Chin, MD, MPH
Jeroan Allison, MD, MS
– Special Issue Editor, Medical Care Research
& Review. See October 2007 issue for the
paper re. this study.
A National Program of the Robert Wood Johnson Foundation at the University of Chicago