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thesis entitled

THE DIFFERENCES IN REPORTED SYMPTOMS AND/OR RISK
FACIURS AND CLINICAL BREAST EXAM FINDINGS IN
LOW INCOME WHITE AND BLACK WOMEN

presented by

Afriyie Johnson

has been accepted towards fulfillment
of the requirements for

degree in

 

 

MASTER OF SCIENCE IN NURSING

 

Major pr essor

Date /j’3/’yy

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Michigan State

University

 

 

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FEB 1 3 2003

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1/98 Woes-p.14

THE DIFFERENCES IN REPORTED SYMPTOMS AND/OR RISK
FACTORS AND CLINICAL BREAST EXAM FINDINGS 1N
Low INCOME WHITE AND BLACK WOMEN
By

Afriyie Johnson

A THESIS
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing

1998

ABSTRACT
THE DIFFERENCES IN REPORTED SYMPTOMS AND/OR RISK
FACTORS AND CLINICAL BREAST EXAM FINDINGS IN LOW
INCOME WHITE AND BLACK WOMEN
By

Afriyie Johnson

This is a descriptive study of 33,873 first-time White and Black participants in a
state-subsidized breast screening program for low-income women. This study examined
whether there were differences in reported symptoms and/or risk factors and clinical
breast exam findings. The data were taken from the Breast and Cervical Cancer Control
Program of the Michigan Department of Community Health and were analyzed using
frequency and percent with chi-square analysis, t—test analysis and cross tabulation using
chi-square analysis.

Four symptoms were examined: lump, Skin change, nipple discharge and pain.
Five risk factors were also observed: personal history of breast cancer, family history of
breast cancer, personal history Of breast disease, personal history of breast surgery and
hormone use. Results indicate that the vast majority of women of both racial groups had
neither symptoms nor risk factors and had normal clincal breast exam findings. If there
were abnormal clinical breast exam findings the majority of women from both racial
groups reported neither risk factors nor symptoms. If symptoms or risks were reported,
White women most often reported risks and Black women most Ofien reported symptoms.
The primary risk reported by White women was use of hormones and the primary

symptom reported by Black women was breast pain.

Copyright by
AFRIYIE JOHNSON
1 998

DEDICATION

To my loving parents, Johnny D. and Ida A. Johnson.

iv

ACKNOWLEDGEMENTS

First, I wish to express my deep appreciation to my Lord Jesus Christ, who gave
me the knowledge and ability which has made it possible to complete this study. I also
wish to express my appreciation to the members of my committee, whose assistance was
invaluable in completing this thesis. Thanks to Gwen Wyatt, Ph.D., for her willingness to
accept the responsibilities of committee chairperson, which involved guidance and
extraordinary scholarly efforts to help me complete this project. Additional thanks to
committee members Rachael Schiffman, Ph.D., and Brigid Warren, M.S.N., for their
direction, encouragement and support. My thanks to the Michigan Department of
Community Health for allowing me to use their data set. I thank Paulette Valliere, Ph.D.,
and Carol Garlinghouse, M.S.N. for their support of my use of this data as well as sincere
thanks to Zhiwei Zhu, Ph.D. for running the analysis for this thesis. Finally, I wish to

thank my parents and prayer partners for their prayers and support during this effort.

TABLE OF CONTENTS

LIST OF TABLES ..................................................... viii
LIST OF FIGURES ..................................................... ix
INTRODUCTION ....................................................... 1
Statement of Purpose ............................................... 1
Statement Of the Problem ............................................ 2

Breast Self Exam (BSE) ............................................. 3

Risk Factors for Breast Cancer ....................................... 3
Clinical Breast Exam ............................................... 4
Summary of Study Concepts ......................................... 5
Research Questions ................................................ 6
CONCEPTUAL FRAMEWORK ........................................... 7
The Health Belief Model ............................................ 7
Conceptual Definitions ............................................ 11
Individual Perceptions ....................................... 11

Perceived susceptibility ................................ 11

Risk factors ................................... 1 1

Symptoms .................................... 12

Perceived severity .................................... 12

CBE findings .................................. 12

Modifying Factors .......................................... 12

Demographic Variables ................................ 12

White. ........................................ 13

Black ........................................ 13

LITERATURE REVIEW ................................................. 13
Race and Socioeconomics .......................................... 14

Risk Factors ..................................................... 1?
Symptoms ...................................................... 18
Summary of Literature ............................................. 20
METHODS ........................................................... 21
Sample ......................................................... 22
Instruments ...................................................... 23
Operational Definitions ............................................ 24

Data Collection and Analysis ........................................ 26

vi

Confidentiality of Human Subjects ................................... 28

 

Assumptions and Limitations ....................................... 28
RESULTS ............................................................ 29
Research questions ................................................ 30
Additional Findings ............................................... 39
DISCUSSION ......................................................... 39
Demographics ................................................... 39
Susceptibility Categories ........................................... 40

Risk Factors ............................................... 4O

Symptoms ................................................ 42

Severity Category ................................................. 44

CBE ..................................................... 44
Interrelationship of Concepts ........................................ 44
Susceptibility by race and severity .............................. 44

Implications for APNs ............................................. 46
Practice ................................................... 47

Education ................................................. 49

Research .................................................. 51
CONCLUSION ........................................................ 53
APPENDD( A ......................................................... 55
APPENDD( B ......................................................... 58
APPENDIX C ......................................................... 59
LIST OF REFERENCES ................................................. 60

vii

Table

Table

Table

Table

Table

Table

Table

Table

Table

LIST OF TABLES

Demographics of Sample
Percent and Frequency Of Reported Risk Factors by Race

Percent and Frequency Of Total Number of Reported
Breast Cancer Risk Factors

T-test for Independent Samples of Risks
Percentage and Number of Reported Symptoms by Race

Percent and Frequency Table of Total Number of
Reported Breast Symptoms

T-test for Independent Samples of Symptoms

Cross Tabulation of Clinicla Breast Exam Findings
by Race

Cross Tabulation Of Race and Clinical Breast Exam Findings

(CBE) by Susceptibility Category (Symptoms and/or
Risk Factors

viii

31

32

33

34

34

36

36

37

38

Figure 1

Figure 2

LIST OF FIGURES

The Health Belief Model

Adapted Health Belief Model

ix

10

INTRODUCTION

Cancer is the second leading cause of death in the United States, surpassed only
by heart disease. One in every four deaths is directly or indirectly attributable to cancer.
Cancer is a group of diseases characterized by a disturbance in the normal mechanism
that controls the growth and proliferation of cells. If the uncontrolled spread of these
cells go unchecked the result is the death of the patient (American Cancer Society, 1997).

As age increases so does the risk for the development of cancer. Most cases of
cancer occur in adults during mid-life and later years. Lung cancer is the leading cause of
death by cancer in both males and females; however, the leading site of new cancer cases
for males is the prostate and for females is cancer of the breast (American Cancer Society,
1997)

It has been estimated that in 1997 180,200 women will be newly diagnosed with
invasive breast cancer and 43,900 will die from breast cancer in this country. The most
recent data on mortality trends in breast cancer Show both progress and failure. Mortality
from breast cancer is decreasing among White women, while increasing in Black women.
Between 1989 and 1992, mortality rates among White women declined by approximately
5.5%, while rates among Black women increased 2.6%. Researchers have speculated that
this trend has more to do with early detection and better treatment than prevention
(American CancerSociety, 1997).
§t_atement of Purpose

This research study focused on the early detection of potential breast cancer in

women Of low socioeconomic groups from two races. The purpose of this study was to

2

assess if a relationship existed between reported risk factors and/or symptoms of breast
cancer and positive Clinical Breast Exam (CBE) findings when comparing White women
and Black women when both are of lower socioeconomic groups.
Statement Of the Problem

White women in the United States continue to be the group in which cancer of the
breast is most often found (American Cancer Society, 1997). However, information from
the Surveillance, Epidemiology, and End Results (SEER) Program and other sources
indicate that Black women and other minorities from low socioeconomic backgrounds are
being diagnosed at more advanced stages of the disease than their White counterparts
(National Cancer Institute, 1989, Vernon, Tilly, Neale and Steinfeld, 1985; Richardson et
al., 1987; Vernon et al., 1992). These data are of interest to the health care, social and
political arenas because they may give some indication of how to intervene to promote
earlier diagnoses. There is no identified prevention for breast cancer, other than the role
that the drug Tamoxifen plays as an adjunctive therapy in the long-term prevention of
cancer recurrence in the contralateral breast in women already diagnosed with breast
cancer (Jordan V., 1995 & Crabbe W., 1996; Noguchi, M., Rose, D., & Miyazaki I.,
1996). The most significant factors in the control of primary breast cancer are early
detection and intervention, namely, early screening with follow up.

Early detection has four dimensions: 1) recognition of symptoms of breast cancer
through Breast Self Exam (BSE), 2) identification of risk factors that may predispose a
person to breast cancer, 3) identification of signs (anomalies) of breast cancer through

CBE and 4) mammography. Although mammography is an important portion of the

3

screening process for breast cancer, this aspect of the screening was not considered in the
present research.
Breast Self Exam (BSE)

The most common initial symptom of breast cancer is a painless mass identified
by the woman herself through BSE. Other symptoms that may alert an individual to some
change in the mammary gland include nipple discharge, nipple or skin changes such as a
unexpected inversion of a nipple, dimpling of the skin on the breast, asymmetrical
thickening of the skin and/or pain.

Rislfimtors for Breast Cancer

An important part of the early detection process is the woman's medical history of
breast cancer risk factors. There are two categories of risk factors that contribute to the
incidence of cancer. Lifetime risks are those that refer to the likelihood that any
individual, during her lifetime, will develop or die from breast cancer. In the United
States, women have a 1 in 8 lifetime risk for developing breast cancer (American Cancer
Society, 1996b). Relative risk on the other hand, is the strength of the relationship
between risk factors and a particular cancer. When looking at breast cancer, relative risk
includes the development of breast cancer in women with certain environmental,
hereditary and/or personal risks when compared to women without these risks.

In practical terms, it is Often difficult for adult women to alter their relative risk
factors for breast cancer. Some of the factors that have been hypothesized as contributing
to the development of breast cancer include: 1) Genetics--women who have a strong

family history for breast cancer, such as those whose mothers and/or sisters had breast

4

cancer; 2) Age-women 40 or older; 3) Personal history of breast disease--included
women who have fibrocystic disease, have had prior breast cancer and/or breast surgery;
4) Hormonal factorS--included being 30 years Old or older at first full-term pregnancy,
and/or hormone replacement therapy (National Cancer Institute, 1994). These
contributing risk factors are most ofien outside the woman's control, thereby making
them, with a few exceptions, impossible to prevent. Risk factors aside, it should be
recognized that approximately 75% of women with newly diagnosed breast cancer had no
identifiable risk factors (Centers for Disease Control and Prevention, 1994).
Clinical Breast Exam

Signs or symptoms are those data which are either detectable by an observer,
experienced by an individual, or can be tested by using an accepted standard (American
Cancer Society, 1997). The CBE and the screening mammogram are the practitioner's two
most frequently utilized methods of initial screening for objective data or signs Of breast
disease (Centers for Disease Control and Prevention, 1994). Screening is the attempt to
detect unsuspected disease in asymptomatic patients. It is therefore important that the
practitioner be skilled in identifying breast signs. For the purpose of this study the CBE
means the performance of a sitting and supine breast examination which includes
inspection and palpation of the breast as well as the axillary and supraclavicular nodes by
a skilled clinician.

The mammogram is an important and valuable tool for breast cancer screening.
However, the subject of mammography in breast screening will not be addressed in this

research.

Summm of Study Concepts

There are a number of limitations found in the literature. A major limitation of
current and past research is that breast cancer screening in White and Black women was
examined in women from vastly disparate economic backgrounds. It has been proposed
that one may find fewer differences between the two racial groups if their social and
economic demographics are similar (Vernon et al., 1992). In the literature low income
was found to be related to more advanced stages of breast cancer at detection in minority
women. Socioeconomic status therefore, may imply a woman's ability to access early
screening (Dayal, Power & Chiu, 1982; Bassett & Krieger, 1986).

Research using the Health Belief Model has shown that when the benefits of
medical intervention equal or exceed the baniers, the predictability or likelihood of action
will be more favorable (Champion, 1991). Irrespective of race, if two groups Of women
have Similar barriers to breast screening--e.g., low socioeconomic status--they may also
have similar motivating factors which lead them to seek out breast cancer screening.

As an advance practice nurse (APN) practicing in primary care, it is important to
be aware that a number Of factors may be involved in whether a client seeks out breast
screening or not. When the APN is cognizant of factors that may hinder his/her clientele
from accessing screening services (e.g., a lack of knowledge or money, fear of the
unknown, lack of awareness of risk and/or symptoms), the APN is better able to assist the
client through education and facilitating contact with screening services.

This study will look at the differences in risk factors, symptoms and CBE findings

between White and Black women of similar low socioeconomic status who attended the

6

Breast and Cervical Cancer Control Program (BCCCP) in participating Michigan
counties.

Research Questions

 

This study addressed whether White women and Black women who came from
comparable low socioeconomic backgrounds and attended the BCCCP, had differences in
reported risk, symptoms and CBE findings. Past research relied mainly on middle-class
White women. This research fills a need by examining differences that race may or may
not play among women from lower socioeconomic backgrounds. To better understand
the role that reported risk factors and/or reported breast symptoms play in whether or not
there are positive CBE findings, this research addressed the following questions:

1) What percentage of White and Black women report each risk factor for breast
cancer?

2) Is there a statistically significant difference in the number Of risk factors for
breast cancer reported by White and Black women?

3) What percentage of White and Black women report each symptom related to
breast cancer?

4) Is there a statistically significant difference in the number of symptoms
reported by White and Black women?

5) Is there a proportional association between positive and negative CBE findings
in White and Black women?

6) IS there a proportional association between reported risk factors and/or

symptoms and CBE findings in the White and Black women?

7

CONCEPTUAL FRAMEWORK
The Health Belief Model

This research was guided by specific concepts of the Health Belief Model (HBM).
The HBM is a predictive model; however, this study examined selected relationships
within the model rather than the predictive or outcome nature of the model as a whole.
According to the original HBM, health actions are not likely to be taken unless or until
the individual has certain beliefs about the recommended health actions.

Rosenstock, Hochman and Kegels developed the HBM in the early 19505,
influenced heavily by Kurt Levvin (Becker & Marshall, 1974). This study utilized the
HBM due to the fact that the BCCCP was designed around certain concepts of the HBM
(Figure 1).

According to the HBM, there are three concept categories: 1) "Individual
Perceptions," under which one may identify factors that lead an individual to the feeling
Of perceived susceptibility to a given disease and perceived seriousness or severity of a
given disease. 2) "Modifying Factors" include factors that may alone or in combination
with individual perceptions lead to a perceived threat of a disease (e.g., demographic
variables and cues to action), which are external reminders from individuals, media etc.
may also prompt an individual to action. 3) The final category is "Likelihood of Action."
When the individual perceptions of susceptibility and severity, in combination with
modifying factors, are sufficiently significant, some decision about actions that need to be

taken will be made. If the perceived benefits Of the action outweighs the perceived

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barriers to the actions then there is an increased likelihood of taking recommended
preventative health action.

This research was a retrospective study in which the instruments used for
collecting data made no explicit inquiry about individual perceptions. The questionnaire
used in this study asked about risk factors and symptoms. It did not identify the risks and
symptoms as perceived susceptibility and/or severity factors. This study concentrated on
implied individual perceptions and modifying factors, specifically perceived
susceptibility, perceived severity and demographic variables (see Figure 2).

The HBM was adapted and certain of its concepts were used to categorize and
explore how reported risk factors, symptoms and CBE findings of White and Black
women from low socioeconomic groups interacted. In the modified model the concept of
individual perceptions had two subdivisions: 1) perceived susceptibility which included
reported risk factors and symptoms and 2) perceived severity that included CBE findings.
In this study these perceptions were assumed to be influenced by one modifying factor,
the demographic variable race, i.e., being White or Black. The study inquired whether
there were differences in the reported risk factors or symptoms for White women versus
Black women when both groups were of low socioeconomic status.

In the modified HBM (Figure 2) the concepts of susceptibility and severity
represented different perceptions. Susceptibility is the individual’s perception, personal
belief and/or knowledge, about her risks and/or symptoms. Severity is a validated
perception (meaning that there is expert corroboration with personal belief or

knowledge). The CBE finding provides Objective external information from the APN. If

10

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11

the CBE finding is revealed to the individual as positive (abnormal), this knowledge may
then lead the individual to move from a perceived susceptibility (an awareness of
symptoms and/or risks) to a validated perception, which includes the severity factors.
Conceptual Definitions

For the purposes of this study the following concepts and variables were used and

are defined as follows:
Individual Perceptions

Individual perceptions are subjective beliefs that an individual has concerning
breast cancer. Under the category of individual perceptions there were two areas or
concepts to be observed, perceived susceptibility and perceived severity.
Perceived susceptibility. Perceived susceptibility to breast cancer is what an individual
experiences, which results in the feeling that she may have a predisposition to breast
cancer. However, in the instrument used for this study there was no direct inquiry as to
whether the individual perceived that the questions asked were reflective of whether or
not the individual recognized and understood that the areas inquired about were indeed
identified by that individual as risks or symptoms. This is an assumption of this research.
In this study the perceived susceptibility factors included five risk factors and four
symptoms.

Risk factors. Risk factors are those factors that may lead an individual to feel that
she may have a predisposition to breast cancer. They include: 1) personal cancer history,
2) personal history for breast surgery (biopsy, cancer surgery, breast reduction surgery,

breast implants or other breast surgery), 4) personal history of benign breast disease

12

(diagnosed by a primary care provider), 5) family cancer history, such as a first-
generation relative with breast cancer (mother and/or sister) and/or 5) the use of hormone
replacement therapy.

Smptoms. Symptoms are self-reported changes in the breast, which are
perceived by the individual as possible cancer including: 1) a lump (a solid or cystic mass
in the breast tissue, axilla or chest wall located by touch), 2) nipple discharge (liquid
expressed from or discharging spontaneously from the nipple), 3) skin change (dimpling
in the skin of the breast, skin and/or nipple retraction or scaling) and/or 4) pain.
Perceived severity. Perceived severity is those findings that may lead an individual to feel
at particular peril Of having a potentially terminal and financially devastating illness.

CBE findings. CBE findings are the severity factors that are identified or verified
by the APN through objective assessment and reported to the individual being examined,
who then determines for herself whether or not she deems the finding as severe.
Abnormal CBE findings include any one or more of the following: I) an asymmetrical
thickening of the breast tissue; 2) any smooth, mobile round or oval mass; 3) an irregular,
firm, mobile mass--indeterrninate (requiring further evaluation); and/or 4) an irregular,
hard, fixed mass.

ModifyinLFactors
Demographic Variables

Demographic variables are those variables that describe the participants within

this study. They include women 40 years old or older who fall at or below 250% of the

poverty level and who are either White or Black.

13

flit; White means being of the majority racial group, having European ancestry
and most often identifiable by having Caucasian features. Being White comes with
certain cultural values, beliefs and attitudes, which are derived from their cumulative
heritage and which differ from those of Black women.

M Black means being of a minority racial group, having Afi'ican ancestry and
most often identifiable by having Negroid features. Being Black comes with certain
cultural values, beliefs and attitudes, which are derived from their cumulative heritage
and which differ from those of White women.

In summary, several key elements of the HBM were investigated in this study.
Individual perceptions were those elements that lead an individual to perceive that she
may be in danger of a given disease, in this case, breast cancer. These perceptions include
the category of perceived susceptibility to breast cancer, i.e., the specific risk factors and
symptoms under study. The category of perceived severity includes CBE findings, namely
the abnormal findings. Modifying factors are those that affect an individual’s
predisposition to take certain health actions based on her belief about the actions
recommended. In this study race was the only demographic variable under study. The
demographic variables in combination with perceived susceptibility and perceived
severity may give insight into the differences between White and Black women of lower
socioeconomic status to terms Of breast cancer screening.

LITERATURE REVIEW
Current literature has not directly addressed the relationship between risks,

symptoms and CBE findings. However, a number of studies looked at race, income, and

14

the stage of cancer at diagnosis; race and screening practices (attendance at screening);
income and screening practices; and symptoms, screening practices, and risk factors
(American Cancer Society, 1996b; American Cancer Society, 1995; Bassett & Krieger,
1986; Dayal, Power & Chiu, 1982; Burack & Liang, 1989; Farley & Flannery, 1989;
French et al., 1982; Maclean, Sinfield, Klein & Harnden, 1984; Roberts, Alexander,
Elton, & Rodgers, 1990; Well & Horm, 1992; Johnson & Murata, 1988; Lane & Fine,
1983; National Cancer Institute (NCI), 1989; Rutledge, Hartmann, Kinman, & Winfield,
1988; Swanson et al., 1993; Vernon et al., 1992) .

The literature in this review came from three related disciplines. The majority of
the literature came from nursing, along with medicine and public health.
Raggand Socioeconomics

A number of studies have addressed breast cancer screening practices (receiving
CBES and mammograms) of different racial groups. There are a number of factors that
may or may not influence whether an individual chooses to engage in these activities. A
recurrent theme in the literature is that minority women, i.e., Black and Hispanic, in the
United States are consistently found to be diagnosed during later stages of the disease and
subsequently have higher mortality rates than their White counterparts, who have higher
incidence rates (American Cancer Society, 1996b; American Cancer Society, 1995;
Farley & Flannery, 1989; National Cancer Institute (NCI), 1989; Swanson et al., 1993;
Vernon et al., 1992). The rationale given for these mortality and morbidity rates was

attributed to a number Of factors, one of which was income or socioeconomics.

15

An important factor associated with mortality from breast cancer, irrespective of
race, was income (Vernon et al., 1992). Studies have shown that the most significant link
between Black women and mortality from breast cancer is low socioeconomic resources
(Bassett & Krieger, 1986; Dayal, Power & Chiu, 1982). There are a number of studies
that either directly or indirectly cite the prohibitive cost of breast cancer screening
(primarily mammography) as a barrier to screening, irrespective of race (Burack & Liang,
1989; Johnson & Murata, 1988; Rutledge, Hartmann, Kinman, & Winfield, 1988; Lane &
Fine, 1983; Vernon et al., 1992). Because more Black women are of lower income, it was
found that low income was Often the rationale given for not seeking screening or
following through with recommended screening (CBE and mammograms) (Ansell,
Whitman, Lipton & Cooper,_,1994; Mettlin, 1992).

A positive relationship was found between higher education, income levels, and
cancer screening, as well as the use of other preventative services (Vernon et al., 1992).
A significant limitation found in the majority of cancer screening studies was the over
representation of women with higher education and subsequent higher family incomes
from all racial groups (Vernon et al., 1992). In addition, a disproportionate amount of the
research that looked at breast cancer screening and the HBM was performed among
middle-class White women (Brown & Williams, 1994; Champion, 1988; Champion,
1991; Champion, 1993, 1994). On the other hand, a number of studies show that even
when screening services were Offered to the economically disadvantaged to reduce

financial barriers, regardless of race, women still did not avail themselves of services

16

when they were asymptomatic (French et al., 1982; Maclean, Sinfield, Klein & Harnden,
1984; Roberts, Alexander, Elton & Rodgers, 1990; Well & Horm, 1992).

Only one recent study looked at both race and socioeconomic factors (Wells &
Horrn, 1992). In this study it was found that when White-Black differences in
socioeconomic status were small, there were only small differences in whether or not the
person had a more advanced stage of breast cancer when first diagnosed (screened)
(Wells & Horm, 1992). The study utilized the Surveillance, Epidemiology, and End
Results (SEER) Program data from the San Francisco-Oakland, Detroit and Atlanta
metropolitan areas. These locations were chosen because they were census traced and
therefore could be matched with census-tract indicators of socioeconomic status and
because they have sufficiently large numbers of Blacks for analysis.

The SEER sample consisted of 18,113 White and 2,861 Black women with
invasive breast cancer. After eliminating those cases identified incidentally at autopsy,
there were 17,949 invasive and 917 in Situ cases among White women and 2,838 invasive
and 126 in Situ cases among Black women. The mean family income criteria was based
on 200% of the poverty level for a family of four in 1979, which was $15,000.

The results of this study were that Black women with both lower educational
levels and income had a higher stage of breast cancer than White women with
comparable education and income. There were 45.7% of Black women diagnosed at a
curable localized and in situ stage, while 52.1% of White women were at the same stages.
Greater than 11% of Black women and less than 7% of White women had metastatic

cancer beyond localized or regional into distant stages.

17

In both groups of women there was a trend toward a less advanced stage of cancer
when there was higher education and income. An interesting trend emerged when the
researchers looked at women who were from higher educational and income strata.
Among the higher educated and income strata, Black women were found to be diagnosed
at a slightly lower stage of disease than were White women. In summary, failure to avail
oneself to screening probably has more to do with education and economics than race
(Well & Horm, 1994).

Risk Factors

Few studies on the topic of risk factors for breast cancer were found. However,
Mettlin (1992) cited a number of older articles that referred to individual risk factors.
Mettlin (1992) assessed 11 risk factors for breast cancer. In his review of the literature he
found that the most important risk factors for breast cancer were age (Older than 50) and
gender (female).

AS age increases so does the risk for breast cancer. Risk areas associated with age
included early menarche and late menopause. A 30% reduction of risk of breast cancer
occurred for women who experienced menopause at 45 or younger than women who
experienced it at 50 and Older. Late age at first full-term pregnancy (>30 years) showed an
increased breast cancer risk association. There was an estimated 3.5% increase in risk
with each year of childbearing delay (Mettlin, 1992).

Second to being 50 years of age or older and female, the most significant risk
factors were found in women who already have a history of breast cancer or other

cancers, and those with first-degree relatives with breast cancer (Mettlin, 1992).

18

Although race was another risk factor associated with breast cancer, according to Mettlin
(1992), it was included as a minor risk along with such risks as exogenous hormones,
lactation, parenchymal patterns, benign breast disease and socioeconomic status.
Symptoms

Symptoms of breast cancer and care-seeking behavior were the subjects that a
number of investigators have studied in recent years (Coates, et al., 1992; Lauver, 1994;
and Vernon, Tilley, Neal & Steinfeldt, 1985).Twenty to 26% Of women wait 2 to 3
months before seeking medical care after discovering breast cancer symptoms.

Lauver (1994) cites two recent studies (Lauver & HO, 1993; Richardson et al.,
1992) which indicated that even when controlling for socioeconomics Black and Hispanic
women with breast cancer symptoms sought out care later than did White women. Both
of these studies had a greater number of White participants than minority women.
Another study, which used a larger national sample, found that when looking at only
Black women and White women with similar economic background, both groups sought
Similar care (Coates et al., 1992). In this study the differences in seeking health care was
only two days (White women being more prompt). These differences were neither
statistically nor clinically significant. In other related studies, when Black and White
women were compared, Black women underestimated the prevalence Of cancer, survival
rates, effectiveness of treatment and preferred not to know that they had cancer (Lauver,
1992).

Lauver (1994) addressed the care-seeking behavior of White and Black women

with breast cancer symptoms. A breast-surgery clinic in a large teaching hospital which

19

provides care to an indigent clientele was the setting. The research sample consisted of
135 individuals 19 to 76 years old with an average age of 37 years. Caucasians made up
47% and African Americans made up 53% of the sample. The median family income was
$12,000.

The results Of this research revealed that 39% of those who participated had
contacted health-care systems in less than seven days afier finding a symptom. The
cumulative frequencies revealed that 49% of the participants connected with health care
within 14 days; 61% within one month; 76% by three months, 85% by six months and
96% by twelve months. In this study there were no demographic or clinical factors that
correlated with care seeking, including race, family history Of breast cancer and
socioeconomic measures.

Variables that showed statistically significant less delay in care seeking included
habit (how one usually acts with a symptom), greater optimism (general beliefs about
positive outcomes) and having a friend with breast symptoms. Two combinations Of
variables explained delay: 1) If a client had anxiety (fear that something was wrong), had
a primary care provider, had the habit Of not seeking care when she had a symptom and
had a barrier (things that precluded her from seeking out care), she would delay seeking
health care when she had a symptom; 2) If a client had anxiety, believed that there was
little value to care seeking, had a primary care provider, was basically an Optimist and had

a friend with breast cancer symptom, the woman was likely to delay seeking health care.

20

SummarLOf Literature

Much of the research available was over representative of White women and
women with higher educational levels and household incomes (Vernon et al., 1992).
Higher education and income levels were positively associated with the use Of screening
services irrespective of race (Vernon et al., 1992). Although a number of studies
examined the various aspects of screening, there were no studies that looked at specific
symptoms or risk factors. Further, there were no studies that looked at CBE results.

Some of the consistencies found in the literature were that economics and
education were associated with health screening behavior. Also it was found that lower
incomes and education were associated with delayed screening activities, as well as more
advanced stages of breast cancer at diagnosis. Although race was implicated in delayed
health care-seeking behavior, there were inconsistencies between the studies. The most
consistent differences found were those associated with income rather than with race,
when considering screening and health care-seeking behaviors.

NO literature was found that looked at whether Blacks and Whites reported
different or more symptoms and/or risk factors. In addition no literature was found that
addressed a relationship between risk and/or symptoms and CBE findings.

This research study looked at race as it related to susceptibility factors, such as
risks and symptoms and whether these factors were associated with perceived severity,
i.e., positive CBE findings, in a sample where income was controlled. This will add some

insights into how race relates to risks, symptoms and CBE findings.

21

METHODS

This investigation was a descriptive study of participants in a Michigan Breast and
Cervical Cancer Control Program (BCCCP) between October 1, 1993 and April 5, 1996.
This study used data collected through the district health departments and reported to the
Michigan Department of Community Health (MDCH). A secondary analysis of the
statistical information was performed. In order to answer the research questions, a
retrospective secondary analysis utilizing first-time visits to the BCCCP by clients from
October 1993 to April 1996 was Obtained from the MDCH.

The BCCCP was commissioned by the MDCH in 1990 and began during the
winter/spring of 1990/1991. The primary goal of this program was propelled by the idea
that if barriers to breast and cervical cancer screening were outweighed by the benefits,
there would be an increase in the likelihood of screening actions. It was the aim of the
program to provide screening and follow-up services for breast cancer control to female
Michigan residents age 40 and over with low or fixed incomes at no cost to the patient.
The endeavor was to provide services by using a model of holistic care. The aim of the
program was to serve as the primary contact system for women and to follow them
through their entire cycle of care (from breast cancer screening through treatment).

To participate in the BCCCP, the following eligibility criteria were required: one
needed to be a female Michigan resident, age 40 or older with proof of income at or
below 250% of poverty. Once an individual was found to be eligible to participate, four
required forms were completed prior to screening: 1) the Health History Form: 2) the

Client Enrollment Form (including client information, demographic information and

22

medical history information) (appendix A); 3) the Record of Informed Consent/Release of
Information Form (signed in the presence of staff and staff to Sign as witness) (appendix
C); and 4) Mammogram Availability Form (to help when scheduling mammograms).
SAMPLE

The population, from which the research sample was extracted, was the total
Michigan case load of first-time, Black and White participants of the BCCCP between
October 1, 1993 and April 5, 1996. The total population was 67,667 participants who had
been screened at least once in this program between 1990 and March 1997. The sample
population size was 33,873 individuals. Though women of any race may participate in the
BCCCP, the sample population included only self-reported Black and White women, 40
years or Older and whose income fell at or below 250% of the poverty level.

A criteria that limited the sample to include only certain individuals in this
program, was that only first-time participants in the program were included. This was due
to the fact that not all the participating health departments updated their Client
Enrollment form information and forwarded them to the MDCH each year. To decrease
the inaccuracies that may arise if, for example, one year the client may have a symptom or
risk factor that they did not have or were not aware of the previous year, the Screening
Form data and the Client Enrollment form data were not from the same year. To eliminate
this type of discrepancy, only first-time attendees to the program were used, thereby better

assuring that Client Enrollment forms and Screening Forms were current.

23

The current Client Enrollment Form and Screening Form were fully operational
by October 1, 1993. The beginning date was chosen in October 1993 for this reason. The
ending date was the date this researcher began this research project.

Instruments

The data utilized in this study were already collected and were found on two
forms; the Client Enrollment Form (appendix A) and the Screening Form (Clinical Breast
Exam) (appendix B). Both of these forms were developed by nurses and statisticians at
the MDCH using Centers for Disease Control (CDC) guidelines. These data collection
forms were taken to a committee composed of an epidemiologist, medical doctors and
researchers with an expertise in breast cancer to assure that they contained at least the
minimal elements needed to assess, screen and follow each case.

The Client Enrollment form was mailed to the client and completed prior to her
scheduled screening appointment. At the time of the screening, this form was reviewed
and clarified with the client by a screening staff member prior to the physical
examination. If the client had not completed the forms, the staff member assisted the
client in completing the form prior to the examination. The Screening Form (Clinical
Breast Exam) was completed by the Advanced Practice Nurse (APN) during the physical
examination.

The current data collection forms were operationally tested but not validated. In
1993 the data collection forms were updated for simplicity and designed so that the data
collected could be computer analyzed by both the MDCH and CDC. The current Client

Enrollment Form and Screening Form were fully operational by October 1, 1993. Only

24

certain items were analyzed from the Client Enrollment Form and Screening form. These
items were extracted and are displayed in Appendix (A).

Consistency was maintained through quality assurance audits for analysis and
tracking. This information was transmitted on the 15th of every month and a data error
report generated for each health department in Michigan that participated in this program.
Confidentiality was maintained at the MDCH by making the data accessable to only two
persons; the data manager and the statistician. All information gleaned fi'om this data was
identified by case number exclusively. This data was also available to the CDC cancer
registry, but only by case number.

Operational Definitions

The following definitions were specific to the research variables.

MAS defined as the self-report of any individual reporting that they are of a
particular ancestry. In this study only two races were included--Afi'ican American or
Black and Caucasian or White. On the Client Enrollment Form each individual identified
herself by checking her race as either Black or White. White was coded as l and Black
was coded as 2.

Risk Factors--There are five risk factors identified in this study. Each risk factor
was identified by the woman being screened who placed a check mark by the risk that
was applicable to her as found on the Client Enrollment Form - Medical History. For the
purposes Of this study a risk factor was a self-report that included any one or more of the
following: personal cancer history; family history of first-degree relative with breast

cancer (could be mother and/or sister); personal history of breast surgery (could be

25

biopsy, cancer surgery, breast reduction, breast implants and/or any other breast surgery);
personal history of benign breast disease (diagnosed by a primary care provider) and/or
hormone replace therapy. Each risk factor was coded as 1 for (yes), meaning that the
client identified at least one of the risk factors as applicable to her, or 2 (m), meaning no
risk factors were identified as applicable to her.

Smptomuln this study four symptoms were identified. For the purposes of this
study a symptom was one or more self-reported change in the breast that could be
perceived as possible cancer as found by the client upon BSE. Symptoms were identified
by self-report on the Client Enrollment Form - Medical History by placing a check mark
by any symptom applicable to the individual. The four symptoms under study included a
lump (a solid mass in the breast tissue, axilla or chest wall identified and located by
touch); nipple discharge (liquid expressed from or discharging spontaneously from the
nipple); skin changes (dimpling in the skin of the breast, chest wall and/or nipple
retraction) and/or pain. Each symptom was coded as 1 (yes), meaning that the client
identified at least one of the symptoms as applicable to her, or 2 (no), meaning no
symptoms were identified as applicable to her.

Positive CBE Findings—-These findings were defined as a sign found on CBE by
the APN that was suspicious for breast cancer. Any one or more of the following
abnormal breast findings in either breast were sufficient to represent a positive versus a
negative finding. There were four positive CBE findings identified for the purposes of
this study. A positive CBE finding was at least one Of the following: 1) an asymmetrical

thickening of the breast tissue; 2) smooth, mobile round or oval mass; 3) an irregular,

26

firm, mobile mass-indeterminate (meaning that the significance of the mass is unknown,
thereby requiring further evaluation); and/or 4) an irregular, hard, fixed mass. Each
abnormal finding was identified by the APN during the exam by placing a check mark by
any abnormal finding that applied to the individual being screened as found on the
Screening Form. An abnormal finding or a positive CBE was coded as 1 (yes), meaning
that at least one abnormality was found, or 2 (pp), meaning no abnormality was identified
and that this was a negative CBE.

Mollectionand Analysis

The preliminary data were collected by the BCCCP and compiled and analyzed by
the MDCH and CDC. A letter was sent to the MDCH requesting the use of the BCCCP
data. Specific data requested included risk factors, symptoms and CBE findings. Specific
population parameters included women who self-reported being either Black or White.
Certain additional demographic data about the sample population requested included age,
education and employment.

Each of the research questions was analyzed as follows:

Question 1: What percentage of White and Black women report each risk factor
for breast cancer? Frequency and percentages were calculated for each risk factor by race
with chi-square analysis.

Question 2: Is there a statistically significant difference in the number of risk
factors for breast cancer reported by White and Black women? A t-test was performed to
determine if there was a statistically significant difference in the number of risk factors

between the two races.

27

Question 3: What percentage of White and Black women report each symptom
related to breast cancer? Frequency and percent was calculated for each symptom and by
race with chi-square analysis.

Question 4: Is there a statistically significant difference in the number of
symptoms reported by White and Black women? A t-test was performed to determine if
there was a statistically significant difference in the number of symptoms between the
two races.

Question 5: Is there a proportional association between positive and negative CBE
findings in White and Black women? A 2x2 cross tabulation with chi-square analysis was
performed between CBE findings (positive or negative) and race (White or Black) to
determine if statistically significant pr0portional differences exist.

Question 6: Is there a proportional association between reported risk factors
and/or symptoms and CBE findings in Black and White women? A 4x4 cross tabulation
with chi-square analysis was done by creating two categories: A) a "susceptibility
category" consisting of four susceptibility groups: 1) neither symptoms nor risk factors, 2)
only symptoms, 3) only risk factors and 4) both symptoms and risk factors. B) a "Race by
positive CBE category" consisting of four race by positive CBE groups as follows: 1)
Black women with positive CBE findings, 2) Black women with negative CBE findings,
3) White women with positive CBE findings and 4) White women with negative CBE

findings.

28

The cross tabulation looked at the susceptibility groups by race, by CBE findings
groups and (4 X 4 table) with chi-square analysis was performed to determine if there is a
statistically significant proportional differences found between each race.
Confidentiality of Hum Subjects

Because these data were collected and analyzed by the MDCH, the researcher had
no direct contact with the subjects or the raw data. This study did not request identifying
information, therefore, there was no breach in confidentiality. In accordance with thesis
protocol an Application for Approval of a Project Involving Human Subjects was
submitted for review and approval to the University Committee on Research Involving
Human Subjects (UCRIHS)(appendix C).

Due to the fact these data are confidential, direct access to these data was not
possible; however, specifically requested analysis of the data was acquired through the
demographics and statistical liaison for the BCCCP at the MDCH.

Assumptions and Limitations

There are a number of assumptions and limitations in this study. It was assumed
that the women understood the questions on the Client Enrollment form and answered
them truthfully to the best of their knowledge. It was assumed that data were collected
and entered into the data base accurately both at the local and state levels. It was also
assumed that the requested information and analysis of the MDCH statistician was done
accurately and as requested. It was assumed that the CBE was performed following the
CDC and National Cancer Society guidelines by all the participating APNS and that

documentation was accurate.

29

This researcher assumed that the women who answered that they had symptoms
and/or risks were aware that a symptom or risk could indicate that something could be
potentially wrong with them or placed them at increased potential for breast cancer. It was
also assumed that either of these two variables (symptoms or risks) could increase the
participants perceived cancer susceptibility. It was assumed that when clients were made
aware of positive CBE findings, they perceived that the findings implied severity.
Limitations

The assrunptions regarding perceived susceptibility and severity were also
limitations to this study. Symptoms, risks and CBE findings were inquired about on the
questionnaires; however, they were neither explicitly nor implicitly identified as
perceived susceptibility or severity factors. However, for the purposes of this study the
researcher assumed that these women knew or perceived that the items identified as
affirmative on the Client Enrollment form and/or Screening form were or could have been
perceived as susceptibility or severity factors. This, however, limited the accuracy of the
perception factors in this study.

RESULTS

The case load data were obtained from the BCCCP of first-time users between
October 1993 and April 1996 and the statistical analysis was executed by the statistician
from the MDCH. The ages of the participants in this sample ranged from 40 to 95 years
old. White women in the sample had a mean age of 55.6 and Black women had a mean

age of 53.8 years. The characteristics of the sample are displayed in Table 1. In looking at

30

the overall sample, the majority of the participants were approximately 55 years old,
unemployed White women with some high school education.

Research questions

(1) What percentage of White and Black women reported the

presence of each risk factor for breast cancer?

The percentage of White women with a particular breast cancer risk factor ranged
from 1.8% (personal history Of breast cancer) to 18.7% (use of hormone treatment). The
percentage for Black women with breast cancer risk factors ranged from 2.2% (personal
history of breast cancer) to 17.5% (personal history of breast surgery). Table 2 displays
each risk factor and reveals the number and percentage of women who reported each risk
factor.

The two most frequently reported risk factors by White women were use of
hormone treatment and personal history of breast surgery (18.7% and 18.6%
respectively). The difference between these two risks were negligible, however, the next
most frequently reported risk for White women was family history of breast cancer
(13.4%). For Black women, the two most frequently reported risks were personal history
of breast surgery and hormone treatment (17.5% and 11.3% respectively).

There was a significantly higher proportion of White women who reported four of
the five risk factors. Personal history of breast cancer had a low and non-significant
percent in both racial groups.

(2) Is there a statistically significant difference in the number of risk factors for breast

cancer reported by White and Black women?

31

Table 1

Demographics of Sample

 

Group %

1:3

 

Race (N = 33,873)

White 82.0 27,881
Black 1 8.0 5,992
Education (Q = 31,878)
Grade School 1.2 399
Some High School 71.2 24,101
Some College 22.7 7,378
Employment (p = 29,953)
Part Time 23.0 7,786
Full Time 17.3 5,860
Not Employed 58.3 16,307

 

 

Age in Years M S_D_ Range
White 55.6 11.37 40 - 95
Black 53.8 9.94 40 - 92
Total 55.2 11.15 40 - 95

 

Table 2

32

Percent and Frequency of Reported Risk Factors by Race (N = 20.408).

 

 

 

White Women Black Women
Risk Factors % p % p X2 p
Personal history
of breast cancer 1.8 513 2.2 129 2.60 .11
Family history
of breast cancer 13.4 3,745 10.9 655 27.29 .00“
Personal history
breast surgery 18.6 5,186 17.5 1,048 4.05 .04“
Personal history
breast disease 10.5 2,925 5.2 310 161.44 .00“
Use of hormone
treatment 18.7 5,221 1 1.3 676 190.09 .00"
*p 5 .04

In this sample there was a potential that anywhere from zero to five risks could

have been reported by any individual in this study; however, no more than three risk

factors were reported by any one individual irrespective of race (table 3).

The highest percent for both racial groups was the category Of "no risks." The

difference in the number of risk factors for breast cancer reported by White and Black

women was statistically significant using the unequal variance formula t-test summarized

in Table 4. White women had an average of .31 risk factors, while Black women reported

.19 risk factors.

33

(3) What percentage of White and Black women report each symptom related to breast
cancer?

Table 5 shows the frequency and percents calculated for each symptom and their
rank order by race from the least frequently reported to the most frequently reported. The
ranking from least to most frequently reported symptom were the same for both White
and Black women. The percentages differed between the two groups: White women
ranged from 2.7% (skin changes) to 17.3% (pain); while Black women ranged from 3.1%
(skin changes) to 22.4% (pain). Black women had higher percents in each symptom

category.

Table 3

Percent and Frequency of Total Number of Reported Brea_st Cancer Riskjactors

 

 

 

(N = 33.873).
Number of Risks White Black

% p % p
No Risks 72.3 20,150 83.1 4,978
One Risk 24.5 6,821 15.3 918
Two Risks 3.2 892 1.5 91

Three Risks .3 18 .1 5

 

34

Table 4

T-test for Independent Samples of Risks (N = 33.873).

 

 

Race a M _S_D_ Range
White 27,881 .31* .53 O - 3
Black 5,992 .19* .43 0 - 3

 

* .t. (10274.76) = 19.37, p < .00.

Table 5

Percergage and Number of Reported Smtoms by Race (N = 11.569).

 

 

 

White Black
Symptoms % p % p X’ p
Skin
Changes 2.7 749 3.1 184 2.72 .09
Nipple
Discharge 3.1 871 4.0 240 12.08 .00“
Lump 9.6 2,688 1 1.2 669 12.83 .00“
Pain 17.3 4,824 22.4 1,344 87.07 .00*
"' p < .00

(4) Is there a statistically Significant difference in the number of symptoms reported by

White and Black women?

35

In this sample a potential existed that anywhere from zero to four symptoms could
have been reported by any individual in this study. The vast majority of the individuals in
this study reported no symptoms. A small percent in each group reported all symptoms.
The distribution of White and Black women by the total number of symptoms reported is
reported in Table 6. The difference in the number of symptoms for breast cancer reported
by White and Black women was statistically significant using the unequal variance t-test
summarized in Table 7. White women averaged .33 symptoms, while Black women
reported .41 symptoms.

(5) Is there a proportional association between positive and negative CBE findings in
White and Black women?

Table 8 shows a cross tabulation that was performed between CBE findings and
race to determine if statistically significant proportional differences existed.

Only about 13% of the White women and about 20% Of Black women were found
to have positive CBE findings. There was a statistically significant difference between
race and CBE findings. The Black women in this study exhibited a statistically significant
greater percentage of abnormal or positive CBE finding than did their White counterparts.

Though not explicitly shown in the table, of the total number of women who
attended the BCCCP, 1.7% (p=555) did not receive a CBE. Of those who did receive a
CBE, 82.2% n=27,189) were White and 17.8% (p=5,875) were Black. Together the two

groups made up 98.3% Of the total case load.

36

Table 6

Percent and Frequency Table of Totalfl umber of Reported Bregt Symptoms

 

 

 

(E=33,873 ).
Symptom Reported ' '1 White Black

% a % B
No Symptoms 75.8 21,120 70.3 4,210
One Symptom 17.2 4,785 20.7 1,238
Two Symptoms 5.8 1,620 7.5 451
Three Symptoms 1.1 317 1.3 75
F our Symptoms .1 39 .3 18
Table 7

T-test for Independent Samples of Symptoms (N = 33,873).

 

 

Race p M SD Range
White 27,881 .33* .65 O - 4
Black 5,992 .41* .71 0 - 4

 

* 1 (8285.02) = -7.95, p < .00.

37

Table 8

Cross Tabulation of Clinigrl Breast Exam (CBE) Findings by Race (E=33,619).

 

 

 

CBE Results White Black

% p % p
Normal 85.6 23,704 78.9 4,684
Abnormal 12.6* 3,485 20.1 * 1,191
Not performed 1.8 492 1 .1 63

 

* X2(2, M = 33,619) = 237.60, p < .00

(6) Is there a prOportional association between reported risk factors and/or symptoms and
CBE findings in the White and Black women?

A cross tabulation was done by creating two categories: A) the "susceptibility
category" consisted of four susceptibility groups on the horizontal axis: 1) neither
symptoms nor risk factors, 2) only symptoms, 3) only risk factors and 4) both symptoms
and risk factors; B) the "severity category" consisting of four race by CBE groups on the
vertical axis: 1) White women with positive CBE findings, 2) White women with
negative CBE findings, 3) Black women with positive CBE findings and 4) Black
women with negative CBE findings.

Table 9 presents the cross tabulation of susceptibility groups, with CBE findings
by race. The vast majority of both White and Black women had normal CBES (23,212

and 4,621 respectively). There was an overall statistically significant difference (p<.00)

38

between severity by susceptibility. Due to the large number of cells in the cross
tabulation, it was not possible to determine exactly where the Significance occurred.
However, certain patterns were observed in this sample which may explain the statistical

significance.

Table 9

Cross Tabulation of SeveritLCate ories Race and Clinical Breast Exam findinga (CBEn by

 

 

Susceptibility Categogy (Smptom and/or/nor Risk Factors) (N = 33.064).

 

Susceptibilig Categories

Severig Categories Neither Symptoms Risks Both Total
only only
% a % a % a % fl 0

 

White/normal CBE 72.6 10,048 59.3 2,664 75.5 7,459 62.5 3,041 23,212
White/abnormal CBE 8.2 1,139 16.8 756 10.9 1,078 20.6 1,004 3,977
Black/normal CBE 16.4 2,265 15.9 713 l 1.2 1,108 11.0 535 4,621
Black/abnormal CBE 2.8 383 7.9 356 2.3 228 5.9 287 1,254

Total 100.0 13,835100.0 4,489 100.0 9,873100.0 4,867 33,064

 

X2 (9, E = 33,064) = 1299.49, p < .00

First, when looking vertically, down the rows, it was observed that the majority of
both White and Black women were found to have neither symptoms nor risks. The second
most Often reported susceptibility category, by both White and Black women was risks
only. Two of the susceptibility categories (neither risks nor symptoms, and risks only)

accounted for the vast majority of the women in the sample, with both normal and

39

abnormal CBES. The third most commonly reported susceptibility category for both
White and Black women was the category of both risk, and symptoms (n=4,867). Finally,
the least Often reported category was symptoms only, in which there was a total of 4,489.

Once the neither risks nor symptoms category were accounted for, White women
who had abnormal CBE findings most frequently reported risks only, followed by both
symptoms and risks (1 ,078 and 1,004 respectively). Conversely, when Black women had
abnormal CBE findings they most often reported symptoms followed by both risks and
symptoms (3 56 and 287 respectively).
Additional Findings

Four of the five risk factors reported showed significant differences between the
two racial groups (see Table 2). The statistically significant risks in this study included
family history of breast cancer, personal history of breast surgery, personal history of
breast disease and use of hormone treatment. The only risk factor that showed no
statistical significance was the risk of personal history of breast cancer.

Significant differences between groups were found for the following symptoms:
1) nipple discharge, 2) breast lump, and 3) pain (see Table 4). All differences were at the
p < .00 level. The symptom skin change was not found to be statistically Significant.

DISCUSSION

Demogrzgrhics

Certain of the demographic characteristics of this sample were consistent with
those reported in the literature (Vernon et al.,1992, American Cancer Society, 1996b;

American Cancer Society, 1995; Swanson et al., 1993) in that it is often the case that a

40

disproportionate number of white participants attend screening programs. The BCCCP is
no exception to this. Of the total sample, White women made up 82%. Since this sample
was large, the findings are more generalizable. The sample was also unique in that it
consisted of women of both races who were financially disadvantaged (based on the
eligibility criteria).

An interesting result for the overall sample was that the mean age of the women
was 55.2 years old, which is relatively young. Generally, breast screening targets women
in midlife and older, since cancer diagnosis increases with age (American Cancer Society.
1997; Shapiro & Clark, 1995). This sample was younger than expected, based on national
incidence rates. National incidence rates indicate that the largest number of new cases of
breast cancer are found in women between 70-79 years old (American Cancer Society,
1997).

SMsceptibiliw Categories

Risk Factors. When looking at risk factors a number of interesting findings
emerged within this study. There was a lack of literature that examined risk factors;
therefore, in some cases, one could only surmise why the results were as they were. The
primary risk factors reported by White women were the use of hormone treatment,
followed closely by personal history of breast surgery. For Black women, breast surgery
was the most commonly reported risk, while use of hormones followed at a comparatively
distant second.

There may be a number Of reasons for the differences in the reported risk factors

between the two races. One reason may be that a disproportionate number of White

41

women in this sample used hormone treatment (18.7%) as compared to Black women
(11.3%). This could be due to the fact that White women have greater access to care and
perhaps seek out health maintenance more readily than Black women. Other factors that
may have contributed to this disparity between the races could be that hormone
replacement therapy (HRT) was financially prohibitive, was not offered by primary care
providers, may not be valued culturally and may be considered untrustworthy by Black
women.
The primary risk factor reported by Black women was a history of breast surgery.
The significance of these risk factors may be a reflection of the fact that Black women of
low socioeconomic status are sometimes driven to seek out health care after there has
been a perceived problem rather than for screening exclusively (Dayal, Power & Chiu,
1982; Vernon et al., 1992; Mettlin, 1992; Ansell, Whitman, Lipton & Cooper, 1994).
The one reported risk factor with similar percentages between the White and black

women was the risk factor of personal history of breast surgery (18.6% and 17.5%
respectively). The overall samples were relatively young (55 years). The literature
consistently indicated that as age increases so does the risk for breast cancer (Mettlin,
1992; American Cancer Society, 1997). This sample’s relative lack of risks might be a
reflection of its youth. The three least frequently reported risk factors for both racial
groups were the same (personal history of breast cancer, personal history of breast disease
and family history of breast cancer).

When looking at the number of risk factors reported by each racial group the large

majority of women reported no risks (Table 3). The average White woman reported less

42

than one risk (.31), while the average Black woman reported even less (.19) than did
White women. More Black women reported no risks (83.1%) than White women (72.3%)
(Table 3). A number of factors may contribute to this finding. One reason could be that a
number of women may not be aware of what constitutes a risk factor. Black women may
not be aware of their family history of breast cancer because culturally, cancer is often not
discussed openly even in families. AS a result, consistent with the literature, Black
women have historically, underestimated the prevalence of cancer, survival rates and
effectiveness of treatment and preferred not to know that they had cancer (Lauver, 1992).
This may have placed these minority women at a disadvantage because their family and
personal histories may be sketchy, due to the fact that they have avoided screenings, have
limited reportable history, and limited knowledge of susceptibility factors.

Screening is designed to target the asymptomatic individual; however, Black
women with risks in this sample most likely had symptoms that resulted in surgery. This
indicates that they were already in the health care system at some point. This could mean
that they had a sign or symptom at an earlier date or a perceived susceptibility that was
confirmed and progressed to a perceived severity factor, thereby increasing their overall
individual perceptions of a breast cancer threat. No distinction was made as to what type
of surgical intervention was performed on the breast. It is probable, based on the fact that
the women screened were low-income, that most of these surgeries were not cosmetic,
but rather for treatment of disease.

Smptoms. The four symptoms under study (skin change, lump, nipple discharge,

and pain) were found to be identically rank ordered by both races. Although all the

43

symptoms except skin change, were found to be significantly different between the races,
the percentages of each symptom were relatively close (Table 5). The greatest percentage
disparity was for the symptom of pain. Pain was reported by 5% more Black women than
White women. This is consistent with the literature, which reveals that the most common
and often most nonspecific symptom reported by women is pain (Cady etal., 1994).
Although pain may be a symptom of breast cancer, the APN in clinical practice should
make her clientele aware, through education, of the reality that the most frequent
etiologies for breast pain are hormonal changes during the menstrual cycle and
"fibrocystic" changes (Cady et al., 1994). Encounters also afford the APN an opportunity
to educate on ways to decrease or even eliminate this symptom.

The breast lump was the second most common reported symptom, followed by
nipple discharge and skin changes. All four symptoms were reported by a higher
percentage of Black women than White women. The literature revealed that minority
women tended to seek out care later than White women when they discovered a symptom
(Lauver, 1994; Lauver & HO, 1993; Richardson et al., 1992).

When looking at the number of symptoms reported by each race overall, Blacks
reported more symptoms. This is consistent with the literature in that one could
extrapolate from these results that perhaps minority women who presented for screenings
were more likely to perceive that they had a problem. In light of this, the APN needs to be
concerned with recruitment in the Black community. The APN with Black clientele may
need to use a different approach in recruiting within this population. When the client

presents with any of these symptoms, the APN has an optimal opportunity to educate and

44

facilitate follow up while positively reinforcing the importance and benefits of annual
breast screening.
Severity Category

9&1; A majority of both White and Black women had normal CBEs; however,
when looking at positive CBES a Significantly higher percent Of Black women had
abnormal findings than White women (Table 8). Much of the literature agreed that
minority women are consistently found to have more advanced stages of breast cancer
when first diagnosed (American Cancer Society, 1996b; American Cancer Society, 1995;
Farley & Flannery, 1989; National Cancer Institute (NCI), 1989; Swanson et al., 1993;
Vernon et al., 1992; Wells & Horm, 1992). This study did not investigate at what stage or
even if a cancer may have been found; however, it would be consistent with the trend of
later stage diagnosis that a positive CBE was found more often in Black women.
Interrelationship of Concepts

Misceptibility by race and severity. Looking at the interrelationship between
susceptibility with race and CBE, a number of interesting differences were found between
the races. Most of the women screened had neither risks nor symptoms. This was
encouraging in that this was the target population for screening. The literature clearly
indicated that 70-75% of women diagnosed with breast cancer had no identifiable risk
(American Cancer Society 1997).

Even though the majority of women who had the primary susceptibility category
(neither risks nor symptoms) had normal CBES, the greatest number of women who had

abnormal CBES also fell in the same susceptibility category of neither risks nor

45

symptoms. This would indicate that with or without a severity factor women in this
sample most likely had neither risks nor symptoms.

The second largest group who were screened were those with normal CBES and
risks only. This group was quite a bit smaller than the majority group. This finding was
due probably, in part, to the large number of White women in the sample.

When looking at the data once the neither risks nor symptoms category was
removed, White women were most likely to report risk if they had an abnormal CBE.
The two smaller groupings included those with both risks and symptoms and lastly
symptoms. This finding was probably also due to the large number of White women in
this sample. As severity is a reflection of abnormal CBE findings in this study, the
differences found between the races and the susceptibility categories were of particular
interest. White women with the susceptibility category of risks had the highest number of
abnormal CBE findings (1,078), followed by those with both risks and symptoms (1 ,004).

Among White women, the individual perception of risk may, in itself, have been a
sufficient threat of disease (breast cancer) to cue attendance for breast cancer screening.
The fact that over a quarter of the White women screened, reported risk could be
indicative of the fact that White women are more aware of their risks Or deem risks an
important enough threat of potential breast cancer to warrant screening. The fact that both
risk and symptoms are the next susceptibility category for White women, is largely due to
the high number of risks reported, rather than symptoms.

When the category of neither risks nor symptoms was removed, it was found that

among the Black women, the susceptibility category of symptoms, had the highest

46

number of abnormal CBES (3 56), followed by those with both risks and symptoms (287).
As mentioned earlier, Black women tend to underestimate prevalence, survival and
effectiveness of treatment (Lauver, 1992) therefore, they may be less likely to discuss
breast cancer with family members, resulting in a lack of knowledge about risks. Once a
woman had a symptom, this was perceived as a threat and screening was sought. Another
factor which might contribute to the fact that Black women are more likely to have a
symptom before seeking screening may be the way in which screenings are presented by
the media. It could be that advertisement for screenings based on neither risk nor
symptom, or risks alone are either not reaching the Black community or are not presented
in a way that is meaningful, valuable or relevant to this segment of the population. It is
therefore, important that the APN approach this population in a culturally appropriate,
relevant and sensitive manner, e.g., utilizing community leaders to present the importance
of breast cancer screening. The category of both risks and symptoms was reported next
and was due to the large number of individuals with symptoms rather than risks.
Implications for APNS

This study has a number of implications for the advanced practice nurse (APN)
caring for not only White and Black women, but all women and particularly those who
are underserved. This study looked at the HBM concepts of susceptibility and severity as
a framework to guide this study. However, the result of looking at these areas revealed
that the APN may need to take a different strategy for recruiting and educating his/her

clientele.

47

Risks and symptoms may bring certain women for screening; however, the
women in this research to a great extent presented with neither. It is therefore, important
that the APN be more aggressive in targeting both women with and without susceptibility
factors for screening. The concept of susceptibility found in the HBM may be utilized as a
guide to assist the APN in his/her role of educating women and increasing their individual
perceptions of susceptibility. Other concepts of the HBM may be even more appropriate
areas to target for more effective screening recruitment. A more applicable concept found
within the HBM for community awareness and recruitment most likely falls under the
category of cues to action. The APN may contribute to community awareness and public
education by becoming involved in offering public service talks regarding breast cancer
screenings at community churches, senior citizen communities, women’s clubs, business
gatherings that target women (women fashion, cosmetologists and health club owners,
etc.). In these venues women who may not be reached can be reached and educated by
word of mouth from their peers at locations and under circumstances where they feel
comfortable and from people they trust and value.

M The APN in clinical practice can influence the individual client's
perceptions of what constitutes standard quality care. This can be achieved in a number of
ways. First, the APNS can accomplish this by implementing through annual histories
and/or history updates, performing CBES, instruction in BSE (breast self exam) and
referring women 40 year and older for annual mammographies as a routine portion of
their health maintenance regiment. In so doing the APN normalizes these screening

practices and assists the client in expecting and seeking out this care as standard.

48

The APN as a coordinator of care and advocacy can facilitate his/her clients in
accessing cost effective screening. This data shows that the report of a symptom could be
of vital importance with regards to its association to the increased likelihood of an
abnormal CBE. When a client contacts the health care system via telephone to voice a
concern or breast cancer symptom, the APN should immediately Obtain a risk profile and
arrange an appointment for evaluation of the symptoms as expeditiously as possible.
Once they come in for evaluation is also important that the APN spend sufficient time
with the clients in order to assess whether or not they can afford what he/she is
recommending and refer them to subsidized programs (such as the BCCCP) when
appropriate.

In the area of recruitment the APN should encourage her clientele to influence
their friends and relatives, based on awareness of susceptibility factors, to seek out
screening appropriately. It is important that the APN'S clientele be aware of the fact that
70-75% of women diagnosed with breast cancer had no risk factors. Also the clientele
should be encouraged to seek early diagnosis for the best prognosis.

In this research sample in the area of risk, it was found that White women who
reported risks most often reported hormone use, followed closely by breast surgery. With
this information the APN can find areas for intervention. Based on this risk data, an area
that has clinical importance among White women, with regard to recruitment for breast
cancer screening (CBE and mammography), includes education about susceptibility
associated with the value versus the risk of hormone replacement therapy. Another area

that should be stressed, based on the data, is the need for annual CBES especially when

49

there appears to be no risks or symptoms. Generally, one could surmise that women with
risks or symptoms would be more likely to seek screening. However, this research data
did not bear this out. Most of the women in this study had less than one risk. As an APN
there is a need to especially target those without any risks. However, this data leaves one
to wonder whether there is a whole segment of the population with risks and symptoms
who are not attending screening. The APN must also target this non-attending population
of women who may be at risk.

Black women in this sample most frequently reported personal history of breast
surgery, followed by use of hormones. This is of particular relevance to the APN in
clinical practice because the Black women being screened who have risks have at times
already had some breast surgery. In clinical application this is key. Black women with
risks who present for screening often already have experienced some breast disorder that
required surgery. This assumes that they have previously been in the health care system.
It is therefore, important that education begin the very first time a Black client enters the
health care system.

Education

AS a change agent and educator, the APN can utilize his/her primary care
encounters to educate clients about risk factors and symptoms of breast cancer, thereby
giving a realistic concept of susceptibility and severity. These encounters can hopefully
change many of the false perceptions that sometimes accompany breast screening. Some

of the misconceptions that the APN may be able to change include ideas that a lack of

50

susceptibility factors means that women are not at risk for breast cancer, that the value of
screening is limited, or that CBES or mammograms are exclusively reliable.

The APN has an excellent opportunity to teach BSE and breast care during the
annual exam. The APN in his/her practice and intervention also has an opportunity to
give his/her client information about what a risk factor is and what it may or may not
mean. The APN should inform the client of what constitutes a symptom, how it should be
addressed and how to make a determination as to how to proceed should a symptom
occur. The APN can also teach about factors that may reduce the risk of developing
cancer in general (low-fat diet, avoiding carcinogens, exercising regularly and eating
well-balanced meals) (American Cancer Society, 1997) and early diagnosis for better
prognosis (getting annual screenings), while educating the client that there is no proven
prevention for breast cancer. The APN can also facilitate the client in being informed
about her overall health maintenance.

An area of needed education among health care professionals is in the area of
educating providers about the BCCCP and its potential value to their under and uninsured
clientele. Health-care providers also need education in the area of sensitivity with regard
to dispensing subsidized and free services. Providers need to be sensitive to the fact that
the underserved often suspect that they are receiving substandard treatment based on their
socioeconomic status. In order to foster confidence in the services being rendered,
providers must be sensitive to, and aware of, the stigma and apprehension of minority and

underserved individuals who receive state subsidized programs. Providers should reassure

51

clients that they are receiving good quality care by treating everyone with thoroughness,
respect and decency.

It is also imperative that the APN constantly update his/her own knowledge base
as new information and recommendations become available. The APN must not only
keep him/herself apprised of new innovations and research but should also inform his/her
clientele. APNS must become experts in the art and science of CBE. As one of the top
cancer killers of women in the United States, it is essential that APNS be involved in
continuing community education on the importance of breast cancer screening even when
there are no apparent susceptibility factors. The APN may also contribute greatly to the
body of screening knowledge and community awareness by being involved in research of
screening practice.

Research

There is always a need for continuing research in the area of early cancer
detection. As the morbidity from breast cancer among minorities (namely Black women)
and the underserved (low income and women with limited education) is higher when
compared with the majority (namely well educated, middle income or greater, White
women). In the vast body of research on breast cancer screening, this author found that in
the area of CBE there is little research. One would think that the use, value and/or lack of
the use or value of the CBE would be addressed to a greater extent in nursing literature.
The value of SBE is documented in the literature, however CBE value seems to be less

emphasized.

52

Breast cancer is a disease which has, as yet, no scientifically identifiable
prevention. There are two areas (risk factors and symptoms) that might lead a primary
care provider to more aggressively screen and intervene in the health of the client.
However, as implied in the findings of this research, the APN must aggressively and
innovatively target those women with no susceptibility factors as well. Several questions
have arisen out of this study, which may be beneficial to add to the growing body of
screening knowledge. One area of interest is target population recruitment. Could the lack
of Black participation in screening be the result of a lack of appropriate recruitment
tactics and strategies? A look at barriers to participation in screening activities among low
income populations may be of value to this growing body of knowledge. Research into
what role risk factors might play in whether or not an individual seeks out screening. It
might also be interesting to know what clients would identify as risk factors and/or
symptoms. Another area that might be interesting to research would be, what symptoms
mean to clients and the role they play in whether the client seeks screening.

Although there is a growing body of research among the underserved and
minorities, it needs to be strengthened. This research takes a unique look at breast
screening, in that it examines relationships between what the client knows and what the
clinician assesses. As collaborators in care, the APN can utilize client data and clinician
expertise to individualize care while meeting the client’s individual needs more
comprehensively.

Further research needs to be done in the area Of screening the underserved

regardless of race (socioeconomically and educationally). More research in the areas Of

53

access to health promotion activities is also crucial. With further study, all women will
benefit by research based teaching, healthcare, and healthcare policy formulation for early
detection of breast cancer.

CONCLUSION

In conclusion this research was consistent with the literature in that, overall, most
women who are screened and found to have abnormal breast findings have no apparent
risks or symptoms for breast cancer.

This research attempted to determine if there was a relationship between
perceived susceptibility (risks and/or symptoms) and perceived severity (abnormal CBE
findings) factors for White and Black women. Statistically, there was a relationship
between the two factors. However, due to the large sample, it was difficult to tell exactly
where this significant relationship occurred.

There are several areas that are clear from this study. First, a large majority of
both Black and White women who presented for screening were without either risk or
symptom and had normal CBES. Secondly, if an individual had an abnormal CBE she
was also most likely to have neither symptoms nor risks. Third, when the category of
neither symptoms nor risks were removed from the equation, if an individual had an
abnormal CBE she was most likely to have risks if she was White, or symptoms if she
was Black. Fourth, when looking at the number of susceptibility factors reported, though
statistically significant, clinically it appeared insignificant with less than one risk or

symptom reported by the average screening participant.

54

As an APN, knowing this information is important. Those involved in screening
are trained to target asymptomatic individuals. In practice, education and research, the
APN should attempt to get this message out, "BEING A WOMAN IS REASON

ENOUGH TO BE SCREENED FOR BREAST CANCER."

 

APPENDIX A

55

APPENDIX A
CLIENT ENROLLMENT FORM
1. WHAT IS YOUR RACE? (check one)
1. WHITE
2. BLACK/AFRICAN AMERICAN
2. WHAT IS THE HIGHEST GRADE IN SCHOOL YOU

COMPLETED?

 

3. ARE YOU EMPLOYED? (check one)

1. YES, PART TIME

2. YES, FULL TIME

3. NO NOT EMPLOYED
4. HAVE YOU EVER HAD BREAST CANCER? (check one)

1. YES

2. NO
5. HAS YOUR MOTHER AND/OR ANY OF YOUR SISTERS EVER HAD BREAST
CANCER?(check one)

1. YES

2. NO
6. HAVE YOU EVER HAD BREAST SURGERY OTHER THAN FOR BREAST
CANCER?(check one)

1. YES

2. NO

56
7. HAVE YOU NOTED ANY OF THE FOLLOWING BREAST SYMPTOMS

RECENTLY?
A. LUMP (check one)
1. YES
2. NO
B. NIPPLE DISCHARGE (check one)
1. YES
2. NO
C. SKIN CHANGES (dimpling, skin and/or nipple retraction, scaling, etc.)
(check one)
1. YES
2. NO
D. PAIN (check one)
1. YES
2. NO
8. ARE YOU USING HORMONE PILLS, SUCH AS ESTROGEN OR BIRTH
CONTROL PILLS? (check one)
1. YES

2. NO

57

9. HAVE YOU EVER BEEN TOLD BY A HEALTH CARE PROVIDER THAT YOU
HAVE BREAST DISEASE? (check one)
1. YES

2. NO

APPENDIX B

 

RIGHT

58

APPENDIX B
SCREENING FORM
CLINICAL BREAST EXAM
RESULTS

(check where applicable)

NORMAL FINDINGS
NO MASS PRESENT
BREAST REMOVED
SYMMETRICAL THICKENING
ABNORMAL FINDINGS
ASYMMETRICAL THICKENING

SMOOTH, MOBILE, ROUND/OVAL MASS

IRREGULAR, FIRM, MOBILE MASS-INDETER.

IRREGULAR, HARD, FIXED MASS

LEFT

APPENDIX C

59

MICHIGAN STATE

UNIVERSITY

May 27, 1997

TO: Gwen Wyatt .
A230 Life Scienees
College Of NurSing

RE: IRB#: 97-337 '
TITLE: THE DIFFERENCES IN REPROTED SYMPTOMS AND/OR RISK

FACTORS AND CLINICAL BREAST EXAM FINDINGS IN LOW
INCOME BLACK AND WHITE WOMEN

REVISION REQUESTED: N/A

CATEGORY: l-E

APPROVAL DATE: 05/22/97

The University Committee on Research Involving Human Subjects'iUCRIHS)
review of this project is complete. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this project and any reVisions listed

above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a progeet be ond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u date certification. There is a
maximum of four such expedite renewals possible. Investigators
wishin to continue a project beyond that time need to submit it
again or complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjeets, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
reVise an approved protocol at any other time during the year,
send your written request to the_ CRIHS Chair, requesting revised
approval and referencing the project's IRE # and title. Include
in your request a description of the.change and any revised
instruments, consent forms or advertisements that are applicable.

PROBLEMS/
CHANGES: Should either of the following arise during the course of the
work, investigators must noti y UCRIHS promptly: (1) roblems

 

cents? (unexpected Slde effects. comp aints, etc.) involving uman
subjects or I2).changes in the research environment or new
RESEARCH information indicating greater risk to the human sub ects than
AND eXisted when the protocol was preViously reviewed an approved.
GRADUATE

If we can be of an future hel , lease do not hesitate to conta t
STUDIES at (517)355-2180 oi! FAX (517)452- 171. c “5

ersity Committee on
Research Involving S ince rely,
Human Subjects
(UCRIHS)

11cmgan State University . ' .
Administration Building mud E- Wright, Ph

EnumwnMOWm UCRIHS Chair
48824-1046 DEW : bed

517/355-2180 ,/
FAX; 517/432-1171 ,."
\fc: Afriyie Johnson

 
  

 
  
 

LIST OF REFERENCES

 

60
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