Journal of Community Health Vol. 16, No. 5, October 1991
A BREAST CANCER SCREENING PROGRAM IN A COMMUNITY HOSPITAL Max E. Dodds, MD; Sharon L. Dowd, MD; Mary Mitchell-Beren, RN, MS; Mary Yarbrough; Kelly Choi, BS, BA
A B S T R A C T : Breast cancer screening continues to be underutilized in the United States. T h e National Cancer Institute has set a goal of increasing screening by the year 2000. T h e American Cancer Society wants to identify p r o g r a m s that target asymptomatic women and economically disadvantaged women. T h e purpose o f this study was to develop, implement and evaluate a comprehensive breast cancer screening p r o g r a m for women in a community setting. One case of infiltrating ductal carcinoma was detected from the 144 women who participated in the study. Following the educational component, the post test d e m o n s t r a t e d a significant increase (p 40,000 INSURANCE BC/BS Other None HMO Medicare/Medicaid
Number (n)
Percent(%)
97 42 5
67 29 4
16 45 43 40
11 31 30 28
86 44 14
59 31 10
68 41 23 8 4
47 28 16 6 3
33 29 22 15 11
30 26 20 14 10
38 37 31 18 17
27 26 22 13 12
67 28 28 11 10
47 19 19 8 7
244
JOURNAL OF COMMUNITY HEALTH
TABLE 2
Clinical Histories of the 144 Breast Cancer Screening Program Participants
AGE AGE AGE AGE AGE
AT AT AT AT AT
TIME OF STUDY MENSTRUATION FIRST BIRTH LAST BIRTH MENOPAUSE
SAW A PHYSICIAN Every year Longer than every 2 years Between 1-2 years Never USED BSE Yes No USED BSE Once/Month Several/Year Once/Year NOTICED CHANGES IN BREAST Yes No CHANGES OBSERVED IN BREAST Nodularity Fibryocystic Discoloration Dimpling Discharge Irregular Shape
Number of Women
Age Mean +_S.D.
144 144 109 109 33
41.2_+ 12.8 12.8 + 1.7 21.8+4.6 27.8+_5.2 45.2 +_6.9
Number
Percent (%)
81 39 19 5
56 27 13 4
87 57
60 40
50 21 16
58 24 18
58 86
40 60
19 14 8 6 6 5
33 24 14 10 10 9
Max E. Dodds, et al.
245
TABLE 3
Reported Risk Factors of 144 Breast Cancer Detection Participants
F A M I L I A L H I S T O R Y OF CA: Grandmother Aunt Mother Sister P R E V I O U S H I S T O R Y OF: Cystic Disease Uterus/Cervical Cancer Breast Cancer RISK FACTORS: Did not breast feed child(ren) High fat diet Birth control pill Surgical m e n o p a u s e T r e a t e d with DES
Number
Percent (%)
14 14 12 6
10 10 9 4
44 6 5
31
60 57 39 28
55 40 27 19
1
1
4 4
tered to the participants prior to the packet, nurse's educational presentation, and video. Each participant received a post test to determine the effectiveness of the breast cancer information presented. Each participant went to an examining room and was asked to demonstrate her ability to perform a BSE to an oncology nurse. The participants were asked several questions to determine demographic data, personal risk factors, and relevant medical history. Following the program, all the participants were given a satisfaction questionnaire regarding the program which asked if the clinic/doctor was pleasant; if their questions were answered; and if they benefited from the program more or less than they expected. The participants who received mammograms were given radiology questionnaires. RESULTS
One h u n d r e d and forty-four women participated in the breast cancer screening in the oncology d e p a r t m e n t at HMC. T h e demographic data are summarized in Table 1. T h e majority of the w o m e n in this study were Caucasian (67%), and had further education (58%) following high school. Twenty-seven percent of the women had a house-
246
JOURNAL OF COMMUNITY HEALTH
hold income less than $10,000 p e r year with 19 p e r c e n t o f the w o m e n having no insurance, a n d 7 percent having Medicare/Medicaid. T h e clinical histories are s u m m a r i z e d in Table 2. T h e m e a n age o f the w o m e n in this study was 41 years o f age with a range o f 21 to 80 years. T h e age range of the w o m e n at the time o f their first child was 15 to 37 years. T h e age range of the w o m e n at the time o f their last child was 18 to 37 years. Forty-seven o f the w o m e n r e p o r t e d using an oral contraceptive (BCP) with a range o f 1 to 17 years o f use. T h e m e a n n u m b e r of contraceptive use was 6.4 _+4.3 years. T h e r e p o r t e d risk factors of the participants are s u m m a r i z e d in Table 3. T h i r t y - t h r e e p e r c e n t o f the w o m e n r e p o r t e d a familial history of cancer. Forty p e r c e n t of the w o m e n r e p o r t e d using a high fat diet. T h e s u m m a r y o f the results o f the clinical examination, m a m m o g r a m s , a n d biopsies are p r e s e n t e d in Table 4. O n e h u n d r e d and seven w o m e n had a m a m m o g r a m following the clinical examination. Following a mamm o g r a m , one patient's clinical examination r e m a i n e d suspicious, a n d a biopsy was p e r f o r m e d which later showed an infiltrating ductal carcinoma. Eleven o f the w o m e n had biopsies with the following results: benign ( n = 5 ) , fibryocystic disease (n = 3), f i b r o a d e n o m a ( n = 1) and infiltrating ductal cancer (n = 1). T h e evaluation c o m p o n e n t s o f the BCSP are s u m m a r i z e d in "Fable 5. T h e r e was a significant increase (p < 0.001), using a d e p e n d e n t t-test analysis o f the ten questions, f r o m the pre to the post test regarding breast cancer awareness following the educational c o m p o n e n t o f the study. Following the nurse's presentation and viewing o f the breast film, 100 p e r c e n t of the w o m e n were able to d e m o n s t r a t e breast self-exam to an oncology nurse. T h e motivating factors which the w o m e n r e p o r t e d for participating in the study included: cancer concern a n d desire to know m o r e about cancer, n e e d for a clinical breast exam, physician's advice, desire to learn BSE, a n d wanting a m a m m o g r a m . T h e satisfaction questionnaire indicated that 100 percent of the w o m e n were pleased with the oncology clinical a n d physician, and 96 p e r c e n t were pleased with the radiological services. Most participants (94 percent) stated that they received m o r e than they initially expected f r o m the study.
DISCUSSION Breast cancer screening continues to be underutilized in the U n i t e d States? 10 Presently most third-party payers do not cover screen-
Max E. Dodds, et al.
247
TABLE 4 Results o f the Clinical Examinations, Mammograms and Biopsies
Number
Percent (%)
81 33 24 3 2 1 144
56 23 17 2 1 1 100
22
15
18
13
8 6 3 1 1
6 4 2 1 1
52 19 15 12 5 3 1 107
49 17 14 11 5 3 1 100
5 3 2 1 11
45 27 18 10 100
CLINICAL E X A M I N A T I O N S
Breast Negative Fibryocystic Nodules Thick Mastectomy Pigment Total
Axilla Nodules
Supraclavicular Nodules
Nipple Discharge Inverted Retracted Dimpled Keratinized mole MAMMOGRAMS Breast Fibrofatty Negative Dominant Mass Nodules Vascular Calcification Increased density Fibroadenoma Total BIOPSIES Benign Fibryocystic disease Fibroadenoma Infiltrating ductal cancer Total
248
JOURNAL
OF COMMUNITY HEALTH
TABLE 5
Evaluation C o m p o n e n t s of the Breast Cancer Detection Program BREAST AWARENESS MEAN T E S T SCORE
MOTIVATING FACTOR TO PARTICIPATE Knowledge/Concern Clinical Breast Exam Instructed to Go Learn BSE Mammogram SATISFACTION QUESTIONNAIRE Clinic/Doctor Pleasant Questions Answered X-Ray Pleasant Benefited More T h a n Expected from Program
PRE POST
7.0 8.8*
Number
Percent
55 36 24 22 7
38 25 17 15 5
144 142 103 135
100 99 96 94
*Significantly more points on the post test regarding cancer knowledge tbllowing the educational component of the study, p < 0.001 using dependent t-test,
ing procedures of asymptomatic individuals. Additionally, economically disadvantaged w o m e n who are asymptomatic are not able to pay the costs since they are not covered by Medicare/Medicaid. To increase the use of breast cancer screening, which is a valuable tool in the reduction of breast cancer mortality in women, '~ mechanisms which lower or remove the out-of-pocket payment barrier must be established. T h e results of this comprehensive study could help future prograins in bringing breast cancer screening to women in the community. T h e costs of screening for the disadvantaged women in this study were provided by a local grant. Additionally, the p r o g r a m served to heighten each woman's awareness of breast cancer through educational information and demonstration of breast self examination. Each woman received a clinical breast examination, and m a m m o g r a m s were provided. One interesting fact of the study was that the majority of the w o m e n who participated were not disadvantaged. However, the study was advertised and available which sheds new light on the scope of the problem of providing care to the economically disadvantaged in the United States. T h e focus of our next study will be to target this group
Max E. Dodds, et al.
249
through new recruitment means and evaluate the effectiveness of the different methods of recruitment. This information is essential to address the unmet cancer prevention and control needs of the disadvantaged. The national goal to reduce the morbidity and mortality of breast cancer can be accomplished since the technology has been developed to detect cancer at a curable stage in women of all ages. However before this goal can be reached, effective programs which include cancer education, prevention, and detection techniques must be provided to help disadvantaged and asymptomatic women in the community setting.
REFERENCES 1. Silverberg, E, and Lubera, JA, Cancer statistics of 1989. CA 39:3-20, 1989. 2. Dodd, GR, Fink, DJ, and Murphy, GP, Breast Cancer Detection and Community Practice: Executive Summary Report of a Workshop Cosponsored by the General Motors Cancer Research Foundation and the American Cancer Society. CA 39:227-229, 1989. 3. Cancer control objectives for the nation: 1985-2000. NCI Monogr 2:27-32, 1986. 4. Nationwide breast cancer detection emphasizing mammography, playing down breast self examinations, urged by participants at ACS workshop. Cl Ca Letter 12:1-4, 1989. 5. A summary of the American Cancer Society report to the nation: Cancer in the poor. CA 39:263-265, 1989. 6. Freeman, H, Cancer in the socioeconomically disadvantaged. CA 39:266-288, 1989. 7. Holleb, A, Cancer and poverty: A double tragedy. CA 39:261, 1989. 8. Howard, J, Using mammography for cancer control: an unrealized potential. CA 37:33-48, 1987. 9. Reeder, S, Berkanovic, E, and Marcus, AC, Breast cancer detection behavior among urban women. Public Health Rep 95:276-281, 1980. 10. Centers for Disease Control, Use of mammography for breast cancer screening: Rhode Island. M M W R 37:357-360, 1988. 11. Collette, HJA, Day, NE, Rombach, J J, et al., Evaluation of screening for breast cancer in a non-randomized study. Lancet 1: 1224-1226, 1984.
A BREAST CANCER SCREENING PROGRAM IN A COMMUNITY HOSPITAL Max E. Dodds, MD; Sharon L. Dowd, MD; Mary Mitchell-Beren, RN, MS; Mary Yarbrough; Kelly Choi, BS, BA
A B S T R A C T : Breast cancer screening continues to be underutilized in the United States. T h e National Cancer Institute has set a goal of increasing screening by the year 2000. T h e American Cancer Society wants to identify p r o g r a m s that target asymptomatic women and economically disadvantaged women. T h e purpose o f this study was to develop, implement and evaluate a comprehensive breast cancer screening p r o g r a m for women in a community setting. One case of infiltrating ductal carcinoma was detected from the 144 women who participated in the study. Following the educational component, the post test d e m o n s t r a t e d a significant increase (p 40,000 INSURANCE BC/BS Other None HMO Medicare/Medicaid
Number (n)
Percent(%)
97 42 5
67 29 4
16 45 43 40
11 31 30 28
86 44 14
59 31 10
68 41 23 8 4
47 28 16 6 3
33 29 22 15 11
30 26 20 14 10
38 37 31 18 17
27 26 22 13 12
67 28 28 11 10
47 19 19 8 7
244
JOURNAL OF COMMUNITY HEALTH
TABLE 2
Clinical Histories of the 144 Breast Cancer Screening Program Participants
AGE AGE AGE AGE AGE
AT AT AT AT AT
TIME OF STUDY MENSTRUATION FIRST BIRTH LAST BIRTH MENOPAUSE
SAW A PHYSICIAN Every year Longer than every 2 years Between 1-2 years Never USED BSE Yes No USED BSE Once/Month Several/Year Once/Year NOTICED CHANGES IN BREAST Yes No CHANGES OBSERVED IN BREAST Nodularity Fibryocystic Discoloration Dimpling Discharge Irregular Shape
Number of Women
Age Mean +_S.D.
144 144 109 109 33
41.2_+ 12.8 12.8 + 1.7 21.8+4.6 27.8+_5.2 45.2 +_6.9
Number
Percent (%)
81 39 19 5
56 27 13 4
87 57
60 40
50 21 16
58 24 18
58 86
40 60
19 14 8 6 6 5
33 24 14 10 10 9
Max E. Dodds, et al.
245
TABLE 3
Reported Risk Factors of 144 Breast Cancer Detection Participants
F A M I L I A L H I S T O R Y OF CA: Grandmother Aunt Mother Sister P R E V I O U S H I S T O R Y OF: Cystic Disease Uterus/Cervical Cancer Breast Cancer RISK FACTORS: Did not breast feed child(ren) High fat diet Birth control pill Surgical m e n o p a u s e T r e a t e d with DES
Number
Percent (%)
14 14 12 6
10 10 9 4
44 6 5
31
60 57 39 28
55 40 27 19
1
1
4 4
tered to the participants prior to the packet, nurse's educational presentation, and video. Each participant received a post test to determine the effectiveness of the breast cancer information presented. Each participant went to an examining room and was asked to demonstrate her ability to perform a BSE to an oncology nurse. The participants were asked several questions to determine demographic data, personal risk factors, and relevant medical history. Following the program, all the participants were given a satisfaction questionnaire regarding the program which asked if the clinic/doctor was pleasant; if their questions were answered; and if they benefited from the program more or less than they expected. The participants who received mammograms were given radiology questionnaires. RESULTS
One h u n d r e d and forty-four women participated in the breast cancer screening in the oncology d e p a r t m e n t at HMC. T h e demographic data are summarized in Table 1. T h e majority of the w o m e n in this study were Caucasian (67%), and had further education (58%) following high school. Twenty-seven percent of the women had a house-
246
JOURNAL OF COMMUNITY HEALTH
hold income less than $10,000 p e r year with 19 p e r c e n t o f the w o m e n having no insurance, a n d 7 percent having Medicare/Medicaid. T h e clinical histories are s u m m a r i z e d in Table 2. T h e m e a n age o f the w o m e n in this study was 41 years o f age with a range o f 21 to 80 years. T h e age range of the w o m e n at the time o f their first child was 15 to 37 years. T h e age range of the w o m e n at the time o f their last child was 18 to 37 years. Forty-seven o f the w o m e n r e p o r t e d using an oral contraceptive (BCP) with a range o f 1 to 17 years o f use. T h e m e a n n u m b e r of contraceptive use was 6.4 _+4.3 years. T h e r e p o r t e d risk factors of the participants are s u m m a r i z e d in Table 3. T h i r t y - t h r e e p e r c e n t o f the w o m e n r e p o r t e d a familial history of cancer. Forty p e r c e n t of the w o m e n r e p o r t e d using a high fat diet. T h e s u m m a r y o f the results o f the clinical examination, m a m m o g r a m s , a n d biopsies are p r e s e n t e d in Table 4. O n e h u n d r e d and seven w o m e n had a m a m m o g r a m following the clinical examination. Following a mamm o g r a m , one patient's clinical examination r e m a i n e d suspicious, a n d a biopsy was p e r f o r m e d which later showed an infiltrating ductal carcinoma. Eleven o f the w o m e n had biopsies with the following results: benign ( n = 5 ) , fibryocystic disease (n = 3), f i b r o a d e n o m a ( n = 1) and infiltrating ductal cancer (n = 1). T h e evaluation c o m p o n e n t s o f the BCSP are s u m m a r i z e d in "Fable 5. T h e r e was a significant increase (p < 0.001), using a d e p e n d e n t t-test analysis o f the ten questions, f r o m the pre to the post test regarding breast cancer awareness following the educational c o m p o n e n t o f the study. Following the nurse's presentation and viewing o f the breast film, 100 p e r c e n t of the w o m e n were able to d e m o n s t r a t e breast self-exam to an oncology nurse. T h e motivating factors which the w o m e n r e p o r t e d for participating in the study included: cancer concern a n d desire to know m o r e about cancer, n e e d for a clinical breast exam, physician's advice, desire to learn BSE, a n d wanting a m a m m o g r a m . T h e satisfaction questionnaire indicated that 100 percent of the w o m e n were pleased with the oncology clinical a n d physician, and 96 p e r c e n t were pleased with the radiological services. Most participants (94 percent) stated that they received m o r e than they initially expected f r o m the study.
DISCUSSION Breast cancer screening continues to be underutilized in the U n i t e d States? 10 Presently most third-party payers do not cover screen-
Max E. Dodds, et al.
247
TABLE 4 Results o f the Clinical Examinations, Mammograms and Biopsies
Number
Percent (%)
81 33 24 3 2 1 144
56 23 17 2 1 1 100
22
15
18
13
8 6 3 1 1
6 4 2 1 1
52 19 15 12 5 3 1 107
49 17 14 11 5 3 1 100
5 3 2 1 11
45 27 18 10 100
CLINICAL E X A M I N A T I O N S
Breast Negative Fibryocystic Nodules Thick Mastectomy Pigment Total
Axilla Nodules
Supraclavicular Nodules
Nipple Discharge Inverted Retracted Dimpled Keratinized mole MAMMOGRAMS Breast Fibrofatty Negative Dominant Mass Nodules Vascular Calcification Increased density Fibroadenoma Total BIOPSIES Benign Fibryocystic disease Fibroadenoma Infiltrating ductal cancer Total
248
JOURNAL
OF COMMUNITY HEALTH
TABLE 5
Evaluation C o m p o n e n t s of the Breast Cancer Detection Program BREAST AWARENESS MEAN T E S T SCORE
MOTIVATING FACTOR TO PARTICIPATE Knowledge/Concern Clinical Breast Exam Instructed to Go Learn BSE Mammogram SATISFACTION QUESTIONNAIRE Clinic/Doctor Pleasant Questions Answered X-Ray Pleasant Benefited More T h a n Expected from Program
PRE POST
7.0 8.8*
Number
Percent
55 36 24 22 7
38 25 17 15 5
144 142 103 135
100 99 96 94
*Significantly more points on the post test regarding cancer knowledge tbllowing the educational component of the study, p < 0.001 using dependent t-test,
ing procedures of asymptomatic individuals. Additionally, economically disadvantaged w o m e n who are asymptomatic are not able to pay the costs since they are not covered by Medicare/Medicaid. To increase the use of breast cancer screening, which is a valuable tool in the reduction of breast cancer mortality in women, '~ mechanisms which lower or remove the out-of-pocket payment barrier must be established. T h e results of this comprehensive study could help future prograins in bringing breast cancer screening to women in the community. T h e costs of screening for the disadvantaged women in this study were provided by a local grant. Additionally, the p r o g r a m served to heighten each woman's awareness of breast cancer through educational information and demonstration of breast self examination. Each woman received a clinical breast examination, and m a m m o g r a m s were provided. One interesting fact of the study was that the majority of the w o m e n who participated were not disadvantaged. However, the study was advertised and available which sheds new light on the scope of the problem of providing care to the economically disadvantaged in the United States. T h e focus of our next study will be to target this group
Max E. Dodds, et al.
249
through new recruitment means and evaluate the effectiveness of the different methods of recruitment. This information is essential to address the unmet cancer prevention and control needs of the disadvantaged. The national goal to reduce the morbidity and mortality of breast cancer can be accomplished since the technology has been developed to detect cancer at a curable stage in women of all ages. However before this goal can be reached, effective programs which include cancer education, prevention, and detection techniques must be provided to help disadvantaged and asymptomatic women in the community setting.
REFERENCES 1. Silverberg, E, and Lubera, JA, Cancer statistics of 1989. CA 39:3-20, 1989. 2. Dodd, GR, Fink, DJ, and Murphy, GP, Breast Cancer Detection and Community Practice: Executive Summary Report of a Workshop Cosponsored by the General Motors Cancer Research Foundation and the American Cancer Society. CA 39:227-229, 1989. 3. Cancer control objectives for the nation: 1985-2000. NCI Monogr 2:27-32, 1986. 4. Nationwide breast cancer detection emphasizing mammography, playing down breast self examinations, urged by participants at ACS workshop. Cl Ca Letter 12:1-4, 1989. 5. A summary of the American Cancer Society report to the nation: Cancer in the poor. CA 39:263-265, 1989. 6. Freeman, H, Cancer in the socioeconomically disadvantaged. CA 39:266-288, 1989. 7. Holleb, A, Cancer and poverty: A double tragedy. CA 39:261, 1989. 8. Howard, J, Using mammography for cancer control: an unrealized potential. CA 37:33-48, 1987. 9. Reeder, S, Berkanovic, E, and Marcus, AC, Breast cancer detection behavior among urban women. Public Health Rep 95:276-281, 1980. 10. Centers for Disease Control, Use of mammography for breast cancer screening: Rhode Island. M M W R 37:357-360, 1988. 11. Collette, HJA, Day, NE, Rombach, J J, et al., Evaluation of screening for breast cancer in a non-randomized study. Lancet 1: 1224-1226, 1984.
