Effectiveness in Prevention Increasing Breast Cancer Screening Among the Medically Underserved -- Dade County, Florida, September 1987-March 1991

Efforts to detect breast cancer at early stages are critical in reducing breast cancer-associated mortality. However, in the United States, different barriers (e.g., lack of insurance, limited access to medical care, and limited awareness of the importance of early diagnosis and treatment) prevent certain groups from using early detection services. To promote early detection of breast cancer among an estimated 67,000 medically underserved women aged greater than or equal to 40 years, the Early Detection Program (EDP) was begun in Dade County, Florida, in the fall of 1987 (1). This report summarizes the progress of the program for September 1987 through March 1991.

Dade is a multiethnic urban county with a population consisting of Hispanics, non-Hispanic blacks, and non-Hispanic whites; 17% of Hispanics, 30% of non-Hispanic blacks, and 10% of all other groups are classified as living in poverty (2). The EDP was initiated by the Cancer Control Division of the Sylvester Comprehensive Cancer Center at the University of Miami School of Medicine (UMSM), which assembled a coalition* of southern Florida health-care agencies to plan cancer screening strategies for low-income older women. The coalition selected seven primary health-care centers and the Dade County Health Department as initial program sites because of their accessibility to the target population. In addition, the staff of each center reflects the community's racial and ethnic background, providing a culturally sensitive environment for delivery of this new health-care service.

Use of the primary health-care centers as a base for the EDP has helped to facilitate cancer screening services for the target population by enabling the referral of women to secondary services and providing continuity of care. Because the individual primary health-care centers were not equipped to perform mammograms on site, a mobile mammography van was purchased with funds from a UMSM private endowment. The van, staffed by two licensed radiology technologists, circulates on a fixed schedule among the primary health-care centers and provides low- or no-cost mammograms (the maximum charge is $25).

At each health-care center, the professional staff provides clinical breast examinations and instructs patients in breast self-examination. Radiologists at the UMSM read the mammograms and report the findings to the primary health-care centers. The centers, in turn, notify patients of results, make referrals, provide follow-up care, and maintain patient records. For biopsies, women are referred through an expedited system to the Breast Tumor Surgery Clinic at Jackson Memorial Medical Center.

During its first 2 years, the EDP provided an average of 15 mammograms each day the van was operating. During 1990, the American Cancer Society provided additional funding that enabled the program to expand services. Consequently, in 1991, the number of women screened has increased to an average of 22 per day.

Of the more than 9400 women screened through December 1990, 52.8% were His panic, 40.8% were non-Hispanic black, and 6.1% were non-Hispanic white (Table 1). Most (50.1%) were aged 50-69 years. Almost three fourths (74.0%) of the women screened reported they had never had a mammogram. Although 68.0% initially had negative mammograms, 27.7% received appointments for a second mammogram or further evaluation, and 4.3% were referred to physicians to determine whether biopsies were necessary. Of the 274 biopsies that have been performed, 57 (20.8%) were positive for cancer. Reported by: CB McCoy, PhD, BB Nielsen, EdD, EJ Trapido, ScD, JJ Zavertnik, MD, EL Khoury, MA, Sylvester Comprehensive Cancer Center, Univ of Miami School of Medicine; HV McCoy, Dept of Health Svcs Administration, Florida International Univ; Dade County Public Health Unit, Florida Dept of Health and Rehabilitative Svcs, Miami, Florida. American Cancer Society, Atlanta, Georgia. Cancer Prevention and Control Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Late-stage diagnosis of cancer contributes to the 10%-15% lower survival rate among women of low socioeconomic status (3). Because of their limited access to medical care and awareness of, or belief in, the importance of early cancer detection, these women may be considered "underserved" (4). In a recent assessment of breast cancer patients who were initially diagnosed from 1983 through 1988 at Jackson Memorial Medical Center, 5-year death rates were 52% and 30% for indigent patients and private patients, respectively (N. Love, Jackson Memorial Med ical Center, unpublished data, 1990). This higher death rate among indigent patients was attributed, in large part, to diagnosis at more advanced stages of disease. For patients who were diagnosed at similar stages, the death rates were virtually identical.

Although the overall mammography rate for low-income women in the county cannot be estimated, the EDP has benefitted medically underserved women in Dade County and has established that low- or no-cost screening can be provided to underserved women. For the national health objectives for the year 2000, the estimated biennial baseline rates for mammography use among special target populations (such as those in Dade County) range from 15% to 19% (5). However, because 26% of the EDP's participants reported having had a previous mammogram, it is likely that the overall mammography rate among the target groups in Dade County is higher than the estimated baseline rate for women either recently screened or ever screened. Results of the EDP suggest that, if inability to pay and lack of insurance are eliminated as barriers, the long-term objective for breast cancer screening might be more readily achieved. Moreover, because participants are contacted for follow-up mammograms at recommended intervals, the benefits of the EDP should be sustained. However, the low level of participation among women aged greater than or equal to 70 years indicates a need for increased education and recruitment efforts targeted for this specific group.

An extensive communitywide education campaign stressing cancer prevention and early detection has helped to increase enrollment in the EDP. The educational campaign focuses on four topics: the warning signs of cancer, the value of early detection, prevention and risk reduction, and availability of medical care. Printed materials on early detection are also distributed at the community health-care centers, from the mammography van, and during educational programs at religious and community centers. Additional information regarding the program is available from Clyde B. McCoy, Ph.D., The Fox Building, Room 309, 1550 NW 10th Avenue (D4-11), Miami, FL 33136; telephone (305) 547-6005.

References

1. Nielsen BB. The nurse's role in mammography screening. Cancer Nurs 1989;12:271-5.

2. Office of Black Affairs. Profile of the black population. Miami: Metro-Dade County Planning Department, Research Division, 1984.

3. American Cancer Society Subcommittee on Cancer in the Economically Disadvantaged. Cancer in the economically disadvantaged: a special report. New York: American Cancer Society, 1986.

4. Farley TA, Flanagan JT. Late stage diagnosis of breast cancer in women of lower socio economic status: public health implications. Am J Public Health 1989;79:1508-12.

5. US Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, 1991; DHHS publication no. (PHS)91-50213.

• The coalition included representatives from the UMSM; Jackson Memorial Medical Center; Dade County Public Health Unit, Florida Department of Health and Rehabilitative Services; Cancer Information Service; and American Cancer Society.

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