Breast cancer screening in regional Hispanic populations

Addressing Data Aggregation and Data Inequity in Race and Ethnicity Reporting and the Impact on Breast Cancer Disparities

Collecting and reporting data on race and ethnicity is vital to understanding and addressing health disparities in the United States. These health disparities can include increased prevalence and severity of disease, poorer health outcomes, decreased access to healthcare, etc., in disadvantaged populations compared with advantaged groups. Without these data, researchers, administrators, public health practitioners, and policymakers are unable to identify the need for targeted interventions and assistance. When researching or reporting on race and ethnicity, typically broad racial categories are used. These include White or Caucasian, Black or African American, Asian American, Native Hawaiian or Other Pacific Islander, or American Indian and Alaska Native, as well as categories for ethnicity such as Latino or Hispanic or not Latino or Hispanic. These categories, defined by the Office of Management and Budget, are the minimum standards for collecting and reporting race and ethnicity data across federal agencies. Of note, these categories have not been updated since 1997. The lack of accurate and comprehensive data on marginalized racial and ethnic groups limits our understanding of and ability to address health disparities. This has implications for breast cancer outcomes in various populations in this country. In this paper, we examine the impact data inequity and the lack of data equity centered processes have in providing appropriate prevention and intervention efforts and resource allocations.

Disparities in Primary Breast Cancer Stage at Presentation Among Hispanic Subgroups

BACKGROUND

Although the United States (US) Hispanic population consists of diverse communities, prior breast cancer studies often analyze this group in aggregate. Our aim was to identify differences in breast cancer stage at presentation in the US population, with a particular focus on Hispanic subgroups.

METHODS

Data from the National Cancer Database (NCDB) from 2004 to 2017 were used to select women with primary breast cancer; individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression was used to create adjusted odds ratios (aORs) with 95% confidence intervals (CIs), with higher odds representing presentation at later-stage breast cancer. Subgroup analysis was conducted based on tumor receptor status.

RESULTS

Overall, among 2,282,691 women (5.2% Hispanic), Hispanic women were more likely to live in low-income and low-educational attainment neighborhoods, and were also more likely to be uninsured. Hispanic women were also more likely to present at later-stage primary breast cancer when compared with non-Hispanic White women (aOR 1.19, 95% CI 1.18-1.21; p < 0.01). Stage disparities were demonstrated when populations were disaggregated by country of origin, particularly for Mexican women (aOR 1.55, 95% CI 1.51-1.60; p < 0.01). Disparities worsened among both racial and country of origin subgroups in women with triple-negative disease.

CONCLUSION

Later breast cancer stage at presentation was observed among Hispanic populations when disaggregated by racial subgroup and country of origin. Socioeconomic disparities, as well as uncaptured disparities in access and/or differential care, may drive these observed differences. Future studies with disaggregated data are needed to characterize outcomes in Hispanic communities and develop targeted interventions.

A multi-theory model based analysis of correlates for initiating and sustaining mammography screening behavior among Hispanic American women in the United States

Background: Despite the known advantages of mammography, screening rates among Hispanic American women are lower compared to other ethnic groups. Therefore, this cross-sectional study aimed to explore correlates of mammography screening behavior among a sample of Hispanic women aged 45-54 years living in the United States using the multi-theory model (MTM). Methods: A 50-item web-based survey consisting of psychometrically valid tools based on MTM theoretical framework was administered through non-random sampling procedures using Qualtrics. Univariate, bivariate, and multivariate statistics were used to analyze the data. Results: Out of 370 participants, nearly 49% (n=189) reported not having a mammogram in the past two years. The mean age of the sample was 48.8±2.8 years. A greater proportion of participants who have had a mammogram reported having health insurance compared to those who have not had a mammogram (93.1% vs. 75.7%, P <0.001). Results of hierarchical regression suggest that all MTM constructs, including participatory dialogue, behavioral confidence, and changes in the physical environment explained 33.4% of variance in initiating mammography behavior among those who have not had a mammogram. Similarly, practice for change, emotional transformation, and changes in the social environment explained 53% of the variance in sustenance of the behavior change. Conclusion: Along with the MTM subscales, this study points to the important correlates such as health insurance and messaging by healthcare providers to promote the mammography seeking behavior among Hispanic women.

Mammography Screening Among Latinas: Does Gender and Ethnic Patient-Physician Concordance Matter?

Breast cancer is the most commonly diagnosed cancer among Latinas. Dominican women in particular have a higher lifetime risk of breast cancer than do other Latinas in the U.S. This study examines how gender, ethnic, and language concordance between providers and patients are associated with recent mammography screening for Latina immigrant women from the Dominican Republic. We conducted structured interviews, in Spanish, with 419 Dominican women aged 40 years or older living in New York City. Using bivariate analysis and logistic regressions, we tested whether patient-provider gender, ethnic, and language concordance was associated with recent mammography when controlling for demographic covariates, breast cancer screening knowledge, and self-rated health. Gender concordance predicted recent mammography after controlling for covariates (β = 0.13). Neither ethnic nor language concordance significantly predicted recent mammography. Our findings suggest that promotion of patient-provider gender concordance may help reduce health disparities among Latinos/as and other minority groups across the United States.

Disparities in Cardiovascular Disease Risk Among Hispanic Breast Cancer Survivors in a Population-Based Cohort

Background

Breast cancer is the leading cause of cancer death among Hispanic women. The aim of our study was to estimate cardiovascular disease (CVD) risk among Hispanic and non-Hispanic White (NHW) breast cancer survivors compared with their respective general population cohorts.

Methods

Cohorts of 17 469 breast cancer survivors (1774 Hispanic and 15 695 NHW) in the Utah Cancer Registry diagnosed between 1997 and 2016, and 65 866 women (6209 Hispanic and 59 657 NHW) from the general population in the Utah Population Database were identified. Cox proportional hazards models were used to estimate hazard ratios (HRs) for CVD.

Results

The risk of diseases of the circulatory system was higher in Hispanic than NHW breast cancer survivors 1-5 years after cancer diagnosis, in comparison with their respective general population cohorts (HR_Hispanic = 1.94, 99% confidence interval [CI] = 1.49 to 2.53; H_NHW = 1.38, 99% CI = 1.33 to 1.43; 2-sided P_{heterogeneity} = .01, respectively). Increased risks were observed for both Hispanic and NHW breast cancer survivors for diseases of the heart and the veins and lymphatics, compared with the general population cohorts. More than 5 years after cancer diagnosis, elevated risk of diseases of the veins and lymphatics persisted in both ethnicities. The CVD risk due to chemotherapy and hormone therapy was higher in Hispanic than NHW breast cancer survivors but did not differ for distant stage, higher baseline comorbidities, or baseline smoking.

Conclusions

We observed a risk difference for diseases of the circulatory system between Hispanic and NHW breast cancer survivors compared with their respective general population cohorts but only within the first 5 years of cancer diagnosis.

Hereditary Breast Cancer Risk Analysis in Uninsured Mexican-Origin Women Living in the U.S.–Mexico Border Region

Purpose:

This article describes the risk of hereditary breast cancer (HBC) in low-income Hispanic women living on the U.S.–Mexico border using the Pedigree Assessment Tool (PAT).

Method:

The PAT was administered as part of the El Paso and Hudspeth County Breast Cancer Education, Screening and NavigaTion program (BEST). Baseline data ( n = 1,966) from this program was used to analyze risk factors for HBC. Analysis was conducted to determine significant covariates associated with the presence of any PAT risk factors.

Results:

The PAT identified 17% (95% CI [15%, 19%]) of the women in the study as having some risk of HBC. Having had a mammogram within 3 years was significantly associated with having any PAT risk factors (odds ratio [OR] = 1.79, p = .006). Women who immigrated to the United States during childbearing age (OR = 0.610, p = .009) or during peri/menopause (OR = 0.637, p = .024) were significantly less likely to have any PAT risk factors.

Discussion:

The PAT instrument detected a substantial pool of women who may be at risk for HBC. A significant proportion of these women were not up to date mammogram.

Conclusions:

The PAT is an effective tool to identify women at risk for HBC and encourage regular screening.

African-American and Caribbean-Born Men's Perceptions of Prostate Cancer Fear and Facilitators for Screening Behavior: a Pilot Study

This study describes how a concurrent exploratory mixed methodology (CEMM) approach was used to investigate perceptions of prostate cancer (CaP) fear and facilitators of screening behavior in African-American (AA) and Caribbean-born (CB) black men for instrument development. A quantitative paper-based questionnaire was modified, adapted, and administered to participants from the Personal Integrative Model of Prostate Cancer Disparity Survey and the Powe Fatalism Inventory. Focus groups and individual interviews were conducted and analyzed using thematic analysis. Of the 31 participants, 17 (55%) were CB black men and 14 (45%) were AA men. CB black men reported significantly higher mean perception of CaP treatment scores compared to AA men (8.23 versus 6.14, p < 0.05). Overall, the focus group and interview data revealed highly interrelated key themes. These themes included perceived barriers to CaP screening (e.g., health-care affordability), misconceptions about CaP (e.g., limited knowledge), and misinformation about CaP (e.g., conflicting CaP screening information from health-care providers). Feeling responsible to make sure family members were taken care of and the role of a significant other were reported as motivation for visiting the doctor. As a result of the CEMM design, a reliable survey instrument was developed to measure CaP fear and facilitators for screening behavior within subpopulations of AA men, which is important because despite their shared genetic ancestry, AA and CB black males may have very different lifestyles.

[An analysis of breast cancer prevention in Brazil]

This research sets out to study the interrelationship between breast cancer prevention and the socioeconomic, demographic, behavioral, regional and health factors in determining the temporal frequency of tests for prevention by performing mammograms and breast exams in Brazil. Based on the information of the health supplement of the National Sampling Survey of Domiciles of 2008, a sample that includes only women over age 40 was created. To achieve the desired goal, the estimate of the ordered logit model is used to establish partial proportional odds, which revealed the main results as follows. Women with a good socioeconomic status, living in the more developed regions of the country, family structure including children, making a good self-assessment of health and having been diagnosed with some type of cancer in the past. This is the profile of women who are best at preventing breast cancer, both in relation to the demand for mammograms and to a greater demand for breast exam performed by a doctor or a nurse. The results also point to the fact that the majority of those interviewed had either had the tests in question within the previous year, or had never been exposed to such procedures.

Beyond the black box: a systematic review of breast, prostate, colorectal, and cervical screening among native and immigrant African-descent Caribbean populations

Cancer screening disparities between black and white groupings are well-documented. Less is known regarding African-descent subpopulations despite elevated risk, distinct cultural backgrounds, and increasing numbers of Caribbean migrants. A systematic search of Medline, Web of Science, PubMed and SCOPUS databases (1980-2012) identified 53 studies reporting rates of breast, prostate, cervical, and colorectal screening behavior among immigrant and non-immigrant Caribbean groups. Few studies were conducted within the Caribbean itself; most work is US-based, and the majority stem from Brooklyn, New York. In general, African-descent Caribbean populations screen for breast, prostate, colorectal, and cervical cancers less frequently than US-born African-Americans and at lower rates than recommendations and guidelines. Haitian immigrants, in particular, screen at very low frequencies. Both immigrant and non-immigrant African-descent Caribbean groups participate in screening less frequently than recommended. Studying screening among specific Caribbean groups of African-descent may yield data that both clarifies health disparities between US-born African-Americans and whites and illuminates the specific subpopulations at risk in these growing immigrant communities.

Breast cancer delay in Latinas: the role of cultural beliefs and acculturation

Cultural beliefs about breast cancer may act as a barrier to Latina women seeking preventive services or timely follow-up for breast symptoms regardless of access. This study examines the association between factors and breast cancer cultural beliefs and the extent to which cultural beliefs are associated with delays in breast cancer care. Participants who were Latina, ages 30-79, and had been diagnosed with a primary breast cancer were examined (n = 181). Interviews included a 15-item cultural beliefs scale spanning beliefs inconsistent with motivation to seek timely healthcare. Self-reported date of symptom discovery, date of first medical presentation, and date of first treatment were used to construct measures of prolonged patient, clinical, and total delay. Logistic regression with model-based standardization was used to estimate crude and confounder-adjusted prevalence differences for prolonged delay by number of cultural beliefs held. Women held a mean score of three cultural beliefs. The belief most commonly held was, "Faith in God can protect you from breast cancer" (48 %). Holding three or more cultural beliefs was associated with lower acculturation, lower socioeconomic status and less access to care (p < 0.01). After adjusting for age, education, income, acculturation, trust, and insurance, likelihood of prolonged total delay remained 21 percentage points higher in women who held a higher number cultural beliefs (p = 0.02). Cultural beliefs may predispose Latina women to prolong delays in seeking diagnosis and treatment for breast symptoms. Cultural beliefs represent a potential point of intervention to decrease delays among Latina breast cancer patients.

Correlates of Mammography Screening Among Hispanic Women Living in Lower Rio Grande Valley Farmworker Communities

Factors contributing to the underuse of mammography screening by female Hispanic farmworkers aged 50 years and older in the Lower Rio Grande Valley were determined through home-based, Spanish-language personal interviews ( N = 200). Questions covered adherence to screening mammography guidelines (mammogram within 2 years), healthcare access, sociodemographic characteristics, and theoretical constructs related to breast cancer screening in the literature. Multivariate findings indicated that adherent women were 3.6 times more likely to have health insurance. Self-efficacy for obtaining a mammogram and decisional balance were also significantly related to adherence; age, income, and education variables were not associated, perhaps because of restricted variation. Results indicate continuing efforts are needed to ensure that medically underserved migrant farmworker women have access to health care services. In addition, efforts to increase their self-efficacy in obtaining a mammogram and to counter negative attitudes and opinions by stressing the positive prognosis associated with early detection are warranted.

Disparities in Vision Loss Due to Cataracts in Hispanic Women in the United States

PURPOSE

To review the current literature on the prevalence of cataract in Hispanic females living in the United States.

METHODS

Review relevant literature on cataract, eye disease, and health practices of Hispanics living in the U.S.

RESULTS

Females comprise 64.5% of blind persons worldwide. Internationally, female gender is associated with lower awareness of cataract and other diseases of the eye and women are less likely to have cataract surgery than men in low- and middle-income countries.

CONCLUSION

Hispanic women receive disparate care compared to their male counterparts. The etiology of this is likely multifactorial but possible contributors include genetics, gender roles, and personal healthcare decisions. Interventions to address this disparity should be targeted, efficient, and sustainable.

Family and cultural influences on cervical cancer screening among immigrant Latinas in Miami-Dade County, USA

Cervical cancer disproportionately affects minorities, immigrants and low-income women in the USA, with disparities greatest among Latino immigrants. We examined barriers and facilitators to cervical cancer screening practices among a group of immigrant Latino women in Florida, USA. Between January and May 2013, six focus group discussions, involving 35 participants, were conducted among Hispanic women in Miami to explore their knowledge, beliefs about cervical cancer and facilitators and barriers to cervical cancer screening using a theoretical framework. The data showed that family support, especially from female relatives, was an important facilitator of screening and treatment. Women, however, reported prioritising family health over their own, and some expressed fatalistic beliefs about cancer. Major obstacles to receiving a Pap smear included fear that it might result in removal of the uterus, discomfort about being seen by a male doctor and concern that testing might stigmatise them as being sexually promiscuous or having a sexually transmitted disease. Targeted education on cancer and prevention is critically needed in this population. Efforts should focus on women of all ages since younger women often turn to older female relatives for advice.

Evaluating the linguistic appropriateness and cultural sensitivity of a self-report system for spanish-speaking patients with cancer

Spanish speakers in the United States encounter numerous communication barriers during cancer treatment. Communication-focused interventions may help Spanish speakers communicate better with healthcare providers and manage symptoms and quality of life issues (SQOL). For this study, we developed a Spanish version of the electronic self-report assessment for cancer (ESRA-C), a web-based program that helps people with cancer report, track, and manage cancer-related SQOL. Four methods were used to evaluate the Spanish version. Focus groups and cognitive interviews were conducted with 51 Spanish-speaking individuals to elicit feedback. Readability was assessed using the Fry readability formula. The cultural sensitivity assessment tool was applied by three bilingual, bicultural reviewers. Revisions were made to personalize the introduction using a patient story and photos and to simplify language. Focus group participants endorsed changes to the program in a second round of focus groups. Cultural sensitivity of the program was scored unacceptable ([Formula: see text]) for audiovisual material and acceptable ([Formula: see text]) for written material. Fry reading levels ranged from 4th to 10th grade. Findings from this study provide several next steps to refine ESRA-C for Spanish speakers with cancer.

Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study

Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities. As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics. Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas' median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women's diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011). Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas' successful entry into, and progression through, the cancer care system.

Question context and priming meaning of health: effect on differences in self-rated health between Hispanics and non-Hispanic Whites

OBJECTIVES

We examined the implications of the current recommended data collection practice of placing self-rated health (SRH) before specific health-related questions (hence, without a health context) to remove potential context effects, between Hispanics and non-Hispanics.

METHODS

We used 2 methodologically comparable surveys conducted in English and Spanish that asked SRH in different contexts: before and after specific health questions. Focusing on the elderly, we compared the influence of question contexts on SRH between Hispanics and non-Hispanics and between Spanish and English speakers.

RESULTS

The question context influenced SRH reports of Spanish speakers (and Hispanics) significantly but not of English speakers (and non-Hispanics). Specifically, on SRH within a health context, Hispanics reported more positive health, decreasing the gap with non-Hispanic Whites by two thirds, and the measurement utility of SRH was improved through more consistent mortality prediction across ethnic and linguistic groups.

CONCLUSIONS

Contrary to the current recommendation, asking SRH within a health context enhanced measurement utility. Studies using SRH may result in erroneous conclusions when one does not consider its question context.

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women

OBJECTIVE

This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.

METHODS

The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40-86 years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n = 67), bilingual (n = 173), and Spanish-dominant (n = 148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression.

RESULTS

In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR = 0.84; 95% CI: 0.45-1.59) and bilingual (OR = 0.86; 95% CI: 0.55-1.35) MAs and significantly lower among Spanish-dominant MAs (OR = 0.53; 95% CI: 0.34-0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90 days (17%).

CONCLUSIONS

These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.

Challenges in recruiting Mexican women for cancer genetics research

Hispanic women often have low participation rates in cancer genetics research. Additionally, Hispanic sub-ethnicities may have varying accrual rates based on unique cultural factors. Hispanic women were recruited through flyers placed in the Tampa Bay Community to participate in an interview about knowledge of hereditary breast and ovarian cancer. The study goal was to recruit 20 women from each Hispanic sub-ethnicity: Puerto Rican, Mexican, and Cuban. This article reports on the difficulty in recruiting Mexican women. One hundred forty-three women called the study hotline to inquire about participation. Seventy-six callers were ineligible for the study. Thirty-four percent (n = 26) of ineligibles were Mexican women; within this group, 62% (n = 16) were unable to participate because they did not know the cancer site of their first degree relative. Inclusion criteria requiring knowledge of family history of cancer for behavioral research may be too stringent. The socio-cultural norms of Mexican families may not include discussions of cancer specifics. This study demonstrates Mexican women may have limited knowledge about their family history of cancer. Considerations of these knowledge limitations should be built into cancer genetics-related research. Referral criteria to assess the risk of hereditary breast and ovarian cancer by cancer genetics professionals are predicated on the patient providing details about cancer within multiple generations of family members, thus, posing a barrier for Mexican women who may have limited knowledge of their family history of cancer.

A cultural research approach to instrument development: the case of breast and cervical cancer screening among Latino and Anglo women

To illustrate the implementation of a bottom-up approach to the study of culture in health disparities, this article describes the development of a cultural cancer screening scale (CCSS) using mixed methodologies. The aim was to identify cultural factors relevant to breast and cervical cancer screening, develop an instrument to assess them and examine its preliminary psychometric properties among Latin American (Latino) and non-Latino White (Anglo) women in Southern California. Seventy-eight Latino and Anglo women participated in semi-structured interviews, which were content coded based on Triandis' methods for the analysis of subjective culture. Based on the emerging cultural elements, items relevant to cancer screening were developed and pilot tested with 161 participants. After the instrument was refined, 314 Latino and Anglo women from various socioeconomic backgrounds completed the CCSS and data were factor analyzed resulting in five cultural factors: cancer screening fatalism, negative beliefs about health professionals, catastrophic disease expectations, symptomatic deterrents and sociocultural deterrents. The instrument demonstrated measurement equivalence, adequate reliability and predictive validity. The research and the CCSS are discussed in terms of implications for the study of culture in relation to health disparities and the development of evidence-based interventions with culturally diverse populations and their health professionals.

Immigration, health care access, and recent cancer tests among Mexican-Americans in California

Immigrants' lower rates of cancer testing may be due to lack of fluency in English and other skills and knowledge about navigating US health care markets, lack of access to health services, or both. We analyzed 9,079 Mexican-American respondents to the 2001 California Health Interview Survey (CHIS) grouped as born in the US, living in the US 10 or more years, or living in the US less than 10 years. The CHIS provides the largest Mexican-American sample in a US survey. Access to care meant having health insurance coverage and a usual source of care. English proficiency meant the respondent took the interview in English. Multivariate logistic regression was used to predict outcomes. Respondents reporting more time in the US were more likely to report access to medical care and to report getting a cancer screening exam. Regardless of time in the US, respondents reporting access had similar test rates. Regression results indicate that time in the US and primary language were not significant relative to use of cancer screening tests, but access to care was. Cancer screening tests that are covered by Every Woman Counts, California's breast and cervical cancer early detection program, had smaller gaps among groups than colorectal cancer screening which is not covered by a program. California is the only state with a survey able to monitor changes in small population groups. Understanding barriers specific to subgroups is key to developing appropriate policy and interventions to increase use of cancer screening exams.

Promoting Knowledge of Cancer Prevention and Screening in an Underserved Hispanic Women Population

This article aims to measure the baseline knowledge of cancer prevention, screening, and early detection practices, to understand the barriers to cancer screening and sources of health information; and to evaluate the effectiveness of a culturally sensitive education program in an underserved Hispanic women population. A total of 180 women participated. Pre- and postsurveys were administered. Multivariate analysis was used to analyze the impact of program on knowledge and to determine factors affecting learning. Results showed Significant overall improvement in knowledge of cancer symptoms (1.85 baseline vs. 3.67 postintervention, p < .001), knowledge of risk-reducing behaviors (2.71 vs. 4.81, p < .001); and effect on planned behavior (89% planned to follow screening guidelines). Higher incomes and younger age are associated with better learning. Major barriers to cancer screening were financial limitations and lack of knowledge. The intervention was effective in promoting awareness and knowledge of cancer screening and prevention. Programs aimed at reducing cancer incidence and mortality should recognize the importance of cultural sensitivity and facilitating access to screening tests.

Breast cancer in Latinas: gene expression, differential response to treatments, and differential toxicities in Latinas compared with other population groups

Disparities in clinical outcomes of breast cancer have been described among different racial and ethnic groups in the U.S. Convincing data exist showing that Latina women have a lower incidence of breast cancer but a higher breast cancer-related mortality rate compared with white women. Noticeable differences in breast cancer incidence are present even within different Latina subsets with a higher incidence in second- and third-generation women compared with foreign born. An increasing amount of data exists pointing to significant differences in the genetics and biology of breast cancer in Latinas as a significant contributor to the higher mortality, including a higher incidence of triple-negative breast cancers (which do not overexpress HER-2 protein and are negative for estrogen receptors and progesterone receptors). Other social and environmental factors are likely to play a significant role as well, including a lower rate of screening mammography, variable access to medical care, among others. Recent data are inconclusive regarding differences among racial/ethnic groups in the response to chemotherapy. Data on racial/ethnic variations in the pharmacogenomics of chemotherapy, endocrine treatments, and toxicity are more limited, with some data suggesting differences in frequencies of polymorphisms of genes involved in the metabolism of some of these agents. Further studies are needed on this subject.

Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women

OBJECTIVES

We tested the effectiveness of a lay health worker intervention to increase breast and cervical cancer screening among low-income Hispanic women.

METHODS

Participants were women 50 years and older who were nonadherent to mammography (n = 464) or Papanicolaou (Pap) test (n = 243) screening guidelines. After the collection of baseline data, lay health workers implemented the Cultivando la Salud (CLS; Cultivating Health) intervention. Data collectors then interviewed the participants 6 months later.

RESULTS

At follow-up, screening completion was higher among women in the intervention group than in the control group for both mammography (40.8% vs 29.9%; P < .05) and Pap test (39.5% vs 23.6%; P < .05) screening. In an intent-to-treat analysis, these differences remained but were not significant. The intervention increased mammography self-efficacy, perceived susceptibility, perceived survivability, perceived benefits of mammography, subjective norms, and processes of change. The intervention also significantly increased Pap test self-efficacy, perceived benefits of having a Pap test, subjective norms, and perceived survivability of cancer. It did not change Pap test knowledge, perceived susceptibility, or perceptions about negative aspects of Pap test screening.

CONCLUSIONS

Our results add to the evidence concerning the effectiveness of lay health worker interventions for increasing Pap test screening and mammography. Future research should explore the effectiveness of CLS in other Hispanic groups, the mechanisms through which interpersonal communication influences decisions about screening, and how effective interventions such as CLS can best be adopted and implemented in community-based organizations or other settings.

Dissemination of a breast and cervical cancer early detection program through a network of community-based organizations

ENCORE (plus) , a breast and cervical cancer outreach, education, and screening referral program, was implemented by the YWCA of the United States and funded by Avon's Breast Cancer Awareness Crusade. ENCORE (plus) was designed to address the educational and access needs of low socioeconomic status and minority women who experience substantial barriers to breast and cervical cancer screening. This article describes the dissemination of ENCORE (plus) to 78 YWCAs in 30 states. It illustrates the application of social cognitive theory and diffusion theory to increase program adoption, implementation, and maintenance among community organizations that have not traditionally provided public health related services. The article highlights elements of the program that enhanced its adoption and implementation and describes procedures for accelerating the diffusion of the program across the country.

Health disparities in receipt of screening mammography in Latinas: a critical review of recent literature

BACKGROUND

Increased use of screening mammography is associated with lower death rates from breast cancer in the United States. Despite recommendations that women over 40 years of age should obtain regular screening mammography at least every 2 years, many women do not adhere to these guidelines. Historically, women from underserved and minority populations have been less likely to receive screening mammography.

METHODS

A critical review of recent research literature was conducted to evaluate whether Latinas are less likely to receive screening mammography, determine whether disparities in screening mammography persist when controlling for other variables, and examine what other variables are associated with screening mammography. The articles were obtained from a search of the PubMed database.

RESULTS

Fifteen published articles met the inclusion criteria and were critically reviewed. The unadjusted odds ratios (ORs) of the association between Hispanic ethnicity and screening mammography ranged from 0.40 to 0.93. For the most part, the ORs adjusted for other variables in multiple logistic regression analyses increased (range: 0.3 to 1.67). Age, education, income, health insurance, having a usual source of care, and having a recent visit to a physician were consistently related to screening mammography in multiple logistic regression analysis.

CONCLUSIONS

Hispanic ethnicity is a risk factor for lack of adherence to screening mammography. However, other demographic, socioeconomic, and health system variables account for some of the disparity related to Hispanic ethnicity.

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study

OBJECTIVE

To understand factors that women feel facilitate or hinder their receipt of diagnostic services following an abnormal screening mammogram.

METHODS

This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse women aged 40 or over who had a recent abnormal mammogram. Working with a community health center, breast evaluation center, and mobile mammography van, 64 women were interviewed to identify salient themes that differentiated women who received timely follow-up from those who did not.

RESULTS

Prominent themes among women who delayed follow-up included dissatisfaction with communication of results; perceived disrespect on the part of providers and clinic staff; logistical barriers to access of diagnostic services; anxiety and fear about a possible cancer diagnosis; and a lack of information about breast cancer screening and symptoms. Women who received timely care more often reported an appreciation of efforts by providers and clinic staff to support their prompt follow-up; availability of social support that facilitated appointment-keeping; confidence in their ability to advocate for their health; and a high priority placed on self-care.

CONCLUSION

A comprehensive approach to improving timely diagnostic follow-up among underserved groups must address patient beliefs and attitudes, provider practices and communication, and practices at the health care systems level.

PRACTICE IMPLICATIONS

Implications and strategies for improving patient education, patient-provider communication, and organizational practices are discussed.

Mexican immigrant male knowledge and support toward breast and cervical cancer screening

BACKGROUND

We conducted a focus group study to assess the influence of partner communication on breast and cervical cancer screening and the perceived existing and potential support from male partners in participating in cancer screening. Secondarily, Mexican male and female views on health care and cancer were explored.

METHODS

Seven focus groups (two female-only, three male-only, and two couples) were conducted in Spanish.

RESULTS

Findings suggest that knowledge about cervical cancer was significantly less than knowledge about breast cancer among both men and women. Barriers to cancer screening included language barriers, lack of health insurance, and lack of awareness of the need for screening. Male partners expressed willingness to support their female partners in cancer screening activities.

CONCLUSION

Cervical cancer education is desperately needed, including education on the availability of free and low cost screening services. Education efforts should include the male community members, especially as the males perceive themselves as responsible for the financial burden of care.

Testing three different cancer genetics registry recruitment methods with Hispanic cancer patients and their family members previously registered in local cancer registries in Texas

OBJECTIVE

To increase accrual among Hispanics to the Cancer Genetics Network national cancer genetics registry.

METHODS

Drawing from South Texas cancer registries, 444 Hispanic men and women were randomly assigned to one of three experimental conditions: standard direct-mailed procedures (X1), X1 plus culturally tailored materials (X2), and X2 plus interpersonal phone contact (X3). Participants were also surveyed about the effectiveness of the education materials and the phone contact. A refusal survey was provided for those who declined to join the study.

RESULTS

A total of 154 individuals joined the Cancer Genetics Network. The X3 condition yielded the greatest accrual (43.2%) compared to X1 (30.9%) and X2 (29.9%; p < 0.05). Tailored materials appeared to have no effect but were highly regarded. The main reasons for not participating were a lack of interest and time requirements.

CONCLUSION

Interpersonal communication can have a powerful effect on recruitment. However, more research is needed to determine the cost-efficacy of more labor-intensive approaches to registry accrual.

Redes En Acción. Increasing Hispanic participation in cancer research, training, and awareness

Hispanics are affected by many health care disparities. The National Cancer Institute (NCI), through its Special Populations Branch, is supporting networking and capacity-building activities designed to increase Hispanic participation and leadership in cancer research. Redes En Acción established a national network of cancer research centers, community-based organizations, and federal partners to facilitate opportunities for junior Hispanic scientists to participate in training and research projects on cancer control. Since 2000, Redes En Acción has established a network of more than 1800 Hispanic leaders involved in cancer research and education. The project has sustained 131 training positions and submitted 29 pilot projects to NCI for review, with 16 awards for a total of $800,000, plus an additional $8.8 million in competing grant funding based on pilot study results to date. Independent research has leveraged an additional $32 million in non-Redes funding, and together the national and regional network sites have participated in more than 1400 community and professional awareness events. In addition, the program conducted extensive national survey research that provided the basis for the Redes En Acción Latino Cancer Report, a national agenda on Hispanic cancer issues. Redes En Acción has increased participation in cancer control research, training, and awareness among Hispanic scientists and within Hispanic communities. Cancer 2006. (c) 2006 American Cancer Society.

Oral and pharyngeal cancer incidence and mortality among Hispanics, 1996-2002: the need for ethnoregional studies in cancer research

OBJECTIVES

We investigated whether oral cavity and pharyngeal cancer (OPC) incidence and mortality statistics among Hispanics in New York State differed from those among Hispanics in the United States as a whole.

METHODS

OPC incidence and mortality statistics for 1996-2002 were obtained from the New York State Cancer Registry and compared with national statistics released by the Surveillance, Epidemiology, and End Results (SEER) program for the same period.

RESULTS

Among Hispanic men, OPC incidence rates were approximately 75% and 89% higher in New York State and New York City, respectively, than national rates reported by the SEER program. No notable differences were identified among Hispanic women. Incidence rates among New York State Hispanic men were 16% higher than those of their non-Hispanic White counterparts. The difference was twice as high (32%) among Hispanic men in New York City. Mortality rates among both men and women exhibited patterns similar to the incidence patterns.

CONCLUSIONS

Ethnoregional differences exist in the incidence and mortality rates of OPC in the United States. New York State Hispanic men exhibit much higher incidence and mortality rates than US Hispanics as reported by the SEER program.

Celebremos la salud! a community randomized trial of cancer prevention (United States)

BACKGROUND

Compared to non-Hispanic whites, Hispanics in the United States are at higher risk for certain types of cancer.

METHODS

In a randomized controlled trial of 20 communities, we examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices.

RESULTS

We found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. We found no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities.

CONCLUSIONS

Our null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed.

Acculturation and mammography screening among Hispanic women living in farmworker communities

The relationship between acculturation and mammography screening practices among Hispanic women is unclear due to inconsistent study findings. The purpose of this research was to further investigate the effect of acculturation on mammography screening practices among Hispanic women and to explore the effect of biculturalism on mammography screening. Hispanic female farmworkers (N = 716) who were 50 years of age and older living in communities in Texas, New Mexico, and California were interviewed at their homes. Data collection was conducted from November 2001 to February 2002. Logistic regression models showed no significant effect for acculturation for the entire sample. Post hoc stratified analysis found that bicultural study participants in California were 3 times more likely to be adherent to screening compared to those with low acculturation. Study findings suggest that distinct differences might exist for Hispanic women living in farmworker communities in California, and perhaps other communities not on the United States-Mexico border. Women in such communities with low levels of acculturation can be targeted for interventions to increase mammography adherence.

Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations

BACKGROUND

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate annually to provide U.S. cancer information, this year featuring the first comprehensive compilation of cancer information for U.S. Latinos.

METHODS

Cancer incidence was obtained from 90% of the Hispanic/Latino and 82% of the U.S. populations. Cancer deaths were obtained for the entire U.S. population. Cancer screening, risk factor, incidence, and mortality data were compiled for Latino and non-Latino adults and children (incidence only). Long-term (1975-2003) and fixed-interval (1995-2003) trends and comparative analyses by disease stage, urbanicity, and area poverty were evaluated.

RESULTS

The long-term trend in overall cancer death rates, declining since the early 1990s, continued through 2003 for all races and both sexes combined. However, female lung cancer incidence rates increased from 1975 to 2003, decelerating since 1991 and breast cancer incidence rates stabilized from 2001 to 2003. Latinos had lower incidence rates in 1999-2003 for most cancers, but higher rates for stomach, liver, cervix, and myeloma (females) than did non-Latino white populations. Latino children have higher incidence of leukemia, retinoblastoma, osteosarcoma, and germ-cell tumors than do non-Latino white children. For several common cancers, Latinos were less likely than non-Latinos to be diagnosed at localized stages.

CONCLUSIONS

The lower cancer rates observed in Latino immigrants could be sustained by maintenance of healthy behaviors. Some infection-related cancers in Latinos could be controlled by evidence-based interventions. Affordable, culturally sensitive, linguistically appropriate, and timely access to cancer information, prevention, screening, and treatment are important in Latino outreach and community networks.

Assessing breast cancer knowledge, beliefs, and misconceptions among Latinas in Houston, Texas

BACKGROUND

Limited breast cancer knowledge and beliefs, risk factors, screening procedures, and cultural barriers may keep Latinas from seeking health care.

METHOD

We examined the breast cancer knowledge, beliefs, and misconceptions of 63 Latinas residing in Houston, Texas.

RESULTS

More than a third of participants held a negative or fatalistic view of breast cancer, 29% believed pain was a warning sign for the disease, and 11.1% had never heard of breast cancer.

CONCLUSIONS

Our findings indicate this population holds many misconceptions about breast cancer, which may have a negative impact on preventive behaviors on this minority population.

Correlates of colorectal cancer screening compliance among urban Hispanics

Colorectal cancer (CRC) is the second most common cancer among Latinos; screening can reduce mortality from CRC. The aims of this study are; to assess the current compliance with free colorectal cancer screening among Hispanic women who are participating in a national breast and cervical cancer screening program (NBCCEDP), and to examine the effects of a set of key constructs from the HBM and the TPB on compliance with the Fecal Occult Blood Test (FOBT). We consecutively recruited 950 women from among those attending an initial appointment at an NBCCEDP site in northern Manhattan, and administered a questionnaire. Patients were offered a free Hemoccult kit, alongside instructions and print materials. The rate of FOBT compliance (in kit return) was 77.3%. Fatalism remained a statistically significant influence on FOBT compliance in the multivariate models, and there was a trend for higher FOBT return among West Indies women (primarily from the Dominican Republic). The findings of this study demonstrate the feasibility and acceptability of distributing FOBT kits through an existing national program for cancer screening of women. The results justify replication in a more heterogeneous group of Hispanics, with longer-term followup.

Disparities across the breast cancer continuum

OBJECTIVE

We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.

METHODS

We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.

RESULTS

Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.

CONCLUSION

A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas

PURPOSE

Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California.

METHODS

Data from the1998 California Women's Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures.

RESULTS

Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90) and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.)

CONCLUSIONS

Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization.

Brief report: if you build it, they will come: methods for recruiting Latinos into cancer research

BACKGROUND

Latinos have low representation in cancer prevention trials and intervention studies. Culturally appropriate recruitment strategies are needed to address this issue.

OBJECTIVE

To describe and summarize the effectiveness of recruitment strategies used by the Latin American Cancer Research Coalition (LACRC).

DESIGN

Descriptive report of recruitment methods.

PARTICIPANTS

Uninsured Latino immigrants (N=1,170; 77% female, 23% male) from Central and South America recruited to 7 cancer control studies.

APPROACH

The LACRC recruitment model involved inclusion of Latino researchers and providers, and use of culturally acceptable materials released through culturally appropriate outlets such as Latino radio stations.

RESULTS

The overall participation rate was high-96% of patients identified as eligible agreed to participate. Women were excellent referrals for recruiting men to research studies. Additionally, a local Latino radio program was used to efficiently recruit eligible study participants.

CONCLUSIONS

Latinos are interested and willing to participate in cancer control studies when culturally relevant approaches are used. Research teams that partner with Latino researchers and with Latino service providers are important in educating Latinos about cancer control and encouraging participation in research.

Cancer screening among Latino subgroups in the United States

BACKGROUND

Relying upon the Health Belief Model and a behavioral model of health care utilization, the purpose of this study was to examine current adherence to cancer screening among Latino subgroups.

METHODS

Using data from the 2000 National Health Interview Survey, 5377 Latinos were surveyed for their use of Pap smear, mammogram, breast self-examination and the clinical breast exam among women, prostate specific antigen test among men, and the fecal occult blood test, sigmoidoscopy, colonoscopy, and proctoscopy among both men and women. Using sampling weights, multivariate logistic regression models were used to assess screening use.

RESULTS

Dominican women had 2.4 times greater likelihood of having had mammography than other Latinos. In addition, Latinas aged 50-69, who had more years of education, a personal history of cancer, who were not current smokers, had health insurance, had visited a primary care provider over the past 12 months, and had at least one other screening test had greater use of mammography. Younger age, marriage, greater acculturation, visits to a primary care provider, health insurance, and the use of other cancer screening tests predicted the uptake of the Pap smear. Latinas were more likely to use a CBE if they were younger, had a Bachelor's degree, a personal history of cancer, were more acculturated, had visits to a primary care provider over the past 12 months, and used other cancer screening tests. Puerto Ricans, Central or South Americans had half the likelihood of having colorectal cancer screening than other groups. Ages between 50 and 69, male sex, marriage, history of visiting a health care provider, and use of other screening tests predicted use of the FOBT. Older age, greater education, male sex, history of visiting a health care provider in the previous year, use of other screening tests, and better health status influenced the uptake of endoscopy for colorectal cancer screening. Cuban males had fivefold greater utilization of PSA testing. Additionally, PSA use among Latinos was predicted by older age, history of visiting a primary care provider in the past 12 months, and use of other screening tests.

CONCLUSIONS

Cancer screening programs must take into account differences among Latinos in age, gender, educational levels, marital status, cancer history, risk behaviors, insurance, health status and health services utilization.

A national agenda for Latino cancer prevention and control

Although cancer is a leading cause of morbidity and premature death among Latinos, there is limited knowledge of cancer-related issues and priorities of greatest significance to the Latino population, the largest minority group in the nation. This information is vital in helping to guide Latino cancer research, training, and awareness efforts at national, regional, and local levels. To help identify cancer issues of greatest relevance to Latinos, Redes En Accion, The National Hispanic/Latino Cancer Network, a major network among the National Cancer Institute's Special Populations Networks, conducted a survey of 624 key opinion leaders from around the country. Respondents were asked to rank the three cancer sites most important to Latinos in their region and the five issues of greatest significance for this population's cancer prevention and control. Recommendations were prioritized for three specific areas: 1) research, 2) training and/or professional education, and 3) awareness and/or public education. Among cancers, breast carcinoma was ranked number one, followed in order by cervical and lung carcinomas. The issues of greatest significance to Latinos were 1) access to cancer screening and care, 2) tobacco use, 3) patient-doctor communication, 4) nutrition, and 5) risk communication. This survey solicited information from scientists, health care professionals, leaders of government agencies, professional and community-based organizations, and other stakeholders in Latino health. The results laid the foundation for a national Redes En Accion Latino cancer agenda, thus providing a useful tool for individuals and organizations engaged in cancer prevention and control efforts among the Hispanic-Latino population.

Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey

BACKGROUND

Cancer screening rates vary substantially by race and ethnicity. We applied the Peters-Belson approach, often used in wage discrimination studies, to analyze disparities in cancer screening rates between different groups using the 1998 National Health Interview Survey.

METHODS

A regression model predicting the probability of getting screened is fit to the majority group and then used to estimate the expected values for minority group members had they been members of the majority group. The average difference between the observed and expected values for a minority group is the part of the disparity that is not explained by the covariates.

RESULTS

The observed disparities in colorectal cancer screening (5.88%) and digital rectal screening (8.54%) between white and black men were explained fully by the difference in their covariate distributions. Only half of the disparity in the observed screening rates (13.54% for colorectal and 17.47% for digital rectal) between white and Hispanic men was explained by the difference in covariates between the groups. The entire disparity observed in mammography screening rates for black and Hispanic women (2.71% and 6.53%, respectively) compared with white women was explained by the difference in covariate distributions.

CONCLUSIONS

We found that the covariates that explain the disparity in screening rates between the white and the black population do not explain the disparity between the white and the Hispanic population. Knowing how much of a health disparity is explained by measured covariates can be used to develop more effective interventions and policies to eliminate disparity.

Disparities in screening mammography. Current status, interventions and implications

OBJECTIVE

This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization.

DESIGN

We reviewed medline and other databases as well as relevant bibliographies.

MAIN RESULTS

The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities.

CONCLUSIONS

The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.

Recent trends and racial/ethnic differences in the incidence and treatment of ductal carcinoma in situ of the breast in California women

BACKGROUND

The rapid increase in the incidence of ductal carcinoma in situ (DCIS) of the breast in the U.S. has been associated with the widespread adoption of screening mammography. Little is known regarding the incidence and treatment of DCIS in women of racial/ethnic groups other than white and black. The current investigation examined recent trends and racial/ethnic differences in the incidence and treatment of DCIS in California.

METHODS

All cases of DCIS diagnosed in women age > or = 40 years in California between 1988-1999 were included. Age-adjusted incidence rates for white, black, Hispanic, and Asian-Pacific Islander women were calculated using the 2000 U.S. female population as the standard. The estimated annual percent change (EAPC) in the rates was calculated using least squares regression.

RESULTS

The average annual age-adjusted incidence of DCIS (1988-1999) was 45.3 per 100,000 in white women, 35.0 in black women, 30.9 in Asian-Pacific Islander women, and 21.8 in Hispanic women. Although a steady increase in the incidence of DCIS was noted in all racial/ethnic groups over the study period, Asian-Pacific Islander women were found to have experienced the steepest increase (EAPC = 9.1%), particularly in the age group 50-64 years (EAPC = 12.0%). The DCIS incidence was reported to increase with age in white, black, and Hispanic women, but remained fairly constant after the age of 50 years in Asian-Pacific Islanders. The proportion of women with DCIS treated with mastectomy decreased from 53% in 1988 to 32% in 1999. Younger women and Asian-Pacific Islander women reportedly were more likely to undergo mastectomy.

CONCLUSIONS

Considerable differences by race/ethnicity and age were observed in DCIS incidence and the change in the incidence in California between 1988 and 1999. Further information is needed to determine whether these differences are because of differential utilization of screening mammography or biologic characteristics of DCIS lesions.

Predictors of digital rectal examination in U.S. Latinos

BACKGROUND

Little is known about prostate and colorectal cancer knowledge, attitudes, and screening practices among U.S. Latino men. Even less is known about the population's subgroup variations. This study assessed predictors of having obtained digital rectal examinations (DREs) among four Latino subgroups.

METHODS

Findings in this report are based on a cross-sectional telephone survey conducted between October 1993 and June 1994 as part of a multisite demonstration project for cancer prevention and control. The survey was conducted in eight U.S. cities identified via census data as having relatively high concentrations of targeted Latino subgroups. The analysis included 1499 Latino men aged > or = 40 who self-identified as Central American, Cuban American, Mexican American, or Puerto Rican.

RESULTS

Overall, 53% of the sample reported ever having had a DRE and 68% reported ever having heard of the procedure. For all subgroups, the only significant predictor for obtaining a DRE was "ever heard of DRE." "Having your doctor discuss DRE" was a significant factor for Mexican Americans and Puerto Ricans.

CONCLUSIONS

The lack of a universal DRE cancer-screening model among Latino groups highlights the need to address barriers in the context of the population's diversity. Ecologic approaches and clinician communication with Latinos need to be tailored to accommodate subgroup differences in knowledge, attitude, and practices related to DRE.