E-messaging for Abnormal Mammogram Follow-up in Latinas

Institution: Cancer Prevention Institute of California
Investigator(s): Ingrid Oakley-Girvan, Ph.D. - Carlos Londono,  -
Award Cycle: 2012 (Cycle 18) Grant #: 18AB-1500 Award: $203,730
Award Type: CRC Pilot Award
Research Priorities
Community Impact of Breast Cancer>Sociocultural, Behavioral, and Psychological Issues: the human side

Initial Award Abstract (2012)

Introduction: Latina women are more likely to be diagnosed with an advanced stage of breast cancer and are 20% more likely to die of breast cancer than non-Hispanic white women. Early diagnosis and treatment has been shown to improve survival, and following up on abnormal breast exams is critical to reduce death from breast cancer. Reminder systems can encourage women to have mammography exams. Fortunately, U.S. Census data show that 95% of families below the poverty level have telephones, and telephone reminders are more effective than mailed ones.

Question(s) or hypotheses: We believe that encouraging women to go to follow-up appointments soon after they have an abnormal breast exam will reduce the number of late stage breast cancers in Latina women, and improve overall survival from this disease. We propose an 18 month research pilot project to develop a culturally sensitive automated Breast follow-up Communication (ABC) message approach to improve attendance at follow-up appointments for abnormal mammogram results. We will talk to breast cancer survivors and health care professionals to find out what types of messages would be acceptable and culturally appropriate. We will also test the ABC messages with women from Tiburcio Vasquez Health Center (TVHC) who have received an abnormal mammogram. TVHC is a federally qualified health center that has four clinics in southern Alameda County, serving primarily Latinos

General methodology: Aim I. We will hold 3 one hour focus groups with Latina breast cancer patients enrolled through groups connected to our community advisory board (CAB). Based on this information, the team will develop culturally acceptable patient ABC messages to motivate patients to complete follow-up care for their abnormal mammogram. Aim 2: We will interview 10 primary care providers at TVHC and referral health centers. Provider ABC messages will be developed from this input. Aim 3: Thirty women who have had an abnormal mammogram result will be assigned by chance to receive either current standard of care plus the messages right away (the intervention arm,15 women) or to get current standard of care but wait to get the messages (wait-list control arm, 15 women). Women in the intervention arm will receive four reminder ABC messages spaced over a two week period from the date of their abnormal mammogram receipt at TVHC. Women in the control arm will not receive these messages for four weeks but will then receive the same intervention. Data Analysis: Age and other characteristics will be collected to make sure they are no important differences in the two groups. We will compare how long it takes for women to come to their follow-up appointment. This will allow us to determine the impact of the ABC messages and whether specific characteristics are more likely to be present in women that quickly attend their follow-up visits.

Innovative elements: There are currently no other studies looking at electronic messaging reminder systems to ensure high-quality and timely follow-up of abnormal mammogram results. These systems must be built in conjunction with the needs of overburdened, understaffed and underfunded health clinics such as TVHC, and understanding the cultural requirements of the patient population. The long-term potential of this research is to increase breast cancer survival and reduce disparities.

Community involvement: TVHC has been instrumental in developing this proposal and initially discussed a collaboration with the Cancer Prevention Institute of California staff. Additionally, breast cancer advocates have been involved in developing this proposal, and will continue to be involved throughout the research project. Our CAB includes participation from major breast cancer advocacy organizations in the Bay area. Through our collaboration with TVHC and the CAB, we have integrated aspects into the project to ensure the sensitivity to the human issues and breast cancer advocacy concerns.

Future Plans: We anticipate that the results of this pilot project will be used as preliminary data for a larger application to evaluate the ABC message intervention in a large randomized trial. This application will be directed to CBCRP, Department of Defense or the National Institutes of Health.

Final Report (2015)

When breast cancer is discovered in Latinas, they are more likely to be diagnosed with an advanced stage partly because of delays in diagnosis. Making sure that women receive high-quality follow-up care after an abnormal breast exam or mammogram is particularly challenging for federally qualified primary care clinics, where many diverse lower income women receive their care. Our hypothesis was that we could increase the proportion of women who receive timely follow-up for an abnormal mammogram using text messages to inform the women about the need for follow-up care.

We completed two focus groups to assess the acceptability, content and methods of implementing a culturally sensitive Automated Breast follow-up Communication (ABC) message approach to improve attendance at follow-up appointments for abnormal mammogram results. One focus group consisted of Spanish-speaking breast cancer survivors, and one consisted of Spanish-speaking women who had an abnormal mammogram but were not diagnosed cancer. The average age of participants was 47.5. Cell phones were used by all participants, and most were familiar with text messaging. Six focus group participants agreed to participate as "Rapid Testers" following the focus group, and received five different text messages with instructions to provide feedback. The Community Advisory Board selected one of the two messages liked the most by the Rapid Testers.

We conducted semi structured interviews with five health care professionals at Tiburcio Vasquez Health Center (TVHC) who work with Latinas referred for mammography. All of the health care professionals agreed that patients do have cell phones and are familiar with how to use them. However, patients do change telephone numbers. The health professionals provided suggestions on what should be included in the text message to the women.

We enrolled 31 Spanish-speaking Latina women with abnormal mammograms into the study; 15 were randomized to receive text messages within 24 hours of when TVHC obtained the abnormal mammogram report (intervention group), and 16 were randomized to receive text messages four weeks later (cross-over intervention group). On average, women in the intervention group returned for their follow-up appointment 23 days sooner than women in the control group. The median number of days between the receipt of the abnormal mammogram report and the return for follow-up was 23 days for the intervention group and 59 days for the control group. These results were significant at a level of p = 0.0569.

Our study successfully developed a text message that significantly decreased the amount of time from when the women received an abnormal mammogram report to when she attended a follow-up visit with her physician. This simple low cost approach could result in earlier detection of breast cancers, and thus lower morbidity and mortality.