Study of Inadequate Follow-up of Mammographic Abnormalities

Institution: Bay View-Hunter's Point Health Care Task Force
Investigator(s): Arthur  Coleman , M.D. - Marion  Lee , Ph.D. -
Award Cycle: 1998 (Cycle IV) Grant #: 4AB-2500 Award: $0
Award Type: CRC Pilot Award
Research Priorities
Community Impact of Breast Cancer>Health Policy and Health Services: better serving women's needs



Initial Award Abstract (1998)
The Bayview Hunters Point Health Care Task Force, a community-based grass roots initiative, was established in October, 1995 to provide guidance, information, and follow-up on the early detection of breast cancer among African American women in the Bay View Hunters Point Community of San Francisco. As we marked our second anniversary in the Fall of 1997, the BVHP Health Care Task Force focused on the low breast cancer survival rate among African American women. The Task Force discussed the issue of breast cancer survival with Dr. Daramola Cabral Evins, Cancer Epidemiologist with the San Francisco Department of Public Health, and established a collaborative effort with her to research the matter. Our long range goal is to increase the proportion of women who receive the recommended follow-up for mammographic abnormalities, thereby improving the survival of women with breast cancer. Our general hypothesis is that factors in the personal and social environment of the women, as well as in the health care delivery system, may be associated with inadequate follow-up of mammographic abnormalities. This pilot study aims to identify and describe, from the patient's perspective, factors that create barriers to timely, adequate follow-up of abnormal mammograms. This information will guide the development of culturally sensitive and appropriate questionnaire items specific to African American women to identify factors in the personal and social environment of the women, as well as in the health care delivery system that may he associated with inadequate follow-up of mammographic abnormalities.

In pursuing this area of research, we seek to analyze a perplexing question, an area of concern voiced by the African American community, that is, why is the breast cancer mortality rate higher in African American women compared to whites, and what role does inadequate follow-up play in explaining these racial/ethnic disparities? We also address the CIRC priority area, innovative models of care, by exploring the sociocultural, behavioral, and psychological issues that impact the health seeking behaviors of African American women after being informed of an abnormal mammogram result.

We will conduct an extensive review of the literature including literature from other disciplines such as psychology. We will then conduct in-depth interviews with breast cancer experts and conduct six focus groups with African American women to identify key concepts and factors to help assess barriers that may he associated with inadequate follow-up of abnormal mammograms among African-American women. Based on this work, we will develop a culturally-specific survey questionnaire. We will pilot tests the questionnaire in a random sample of 100 women with abnormal mammograms, 50 that received adequate follow-up and 50 that did not receive adequate follow-up of abnormal mammograms within 8 weeks of the due date. Based on the outcomes of this work, we will refine our study hypotheses and prepare the full CIRC application.

The earlier a breast cancer is diagnosed and treated, the greater the likelihood of long-term survival. Untimely follow-up may negate the benefits of early detection through mammography screening, and inadequate follow-up of abnormal mammogram results might explain some of the racial/ethnic differences in breast cancer survival. We expect that improving timeliness of follow-up after abnormal mammograms will result in improvements in breast cancer survival among African American women.


Final Report (1999)
The ultimate goal of this research is to decrease breast cancer morbidity and mortality among African American women in San Francisco. In this one-year Community Collaborative Research Pilot Study, we aimed to identify and describe, from the patient's perspective, factors in their personal and social environment, as well as in the health care delivery system that create barriers to timely adequate follow-up of abnormal mammograms.

Factors in the personal and social environment of women, as well as in the health care delivery system, are associated with inadequate follow-up of mammographic abnormalities.

In pursuing this area of research, we seek to answer a perplexing question, and address an area of concern voiced by the African American Community, that is, why is the breast cancer mortality rate higher in African American women compared to whites, and what role does inadequate follow-up play in explaining these racial/ethnic disparities?

Qualitative. First, we conducted in-depth interviews with eight breast cancer experts to identify and explore the reasons why women do not receive timely follow-up of abnormal mammography. Secondly, we conducted four 2-hour focus groups to explore three domains, issues of social support, perceptions of disease and of the health care system; and logistical barriers including social and economic influences.

Quantitative. Key informant and focus group data contributed towards the development of a culturally specific questionnaire piloted tested among 51 African American women with abnormal mammograms.

Key informants indicated that access to care, previous experience with the health care system, family factors, e.g., competing priorities, and physician communication were important predictors of timely follow-up. Several themes appeared within the four focus groups. Fear, satisfaction as well as dissatisfaction with the health care system, time, belief in God, the need for information, and the need for social support were the most common. Fear was expressed most often and was linked to the experience o f getting a mammogram, both in the expectation of a painful mammographic procedure and the contemplation of the possibility that the results might reveal a malignancy. Fear was also linked to the loss of a breast or breasts. Fear was considered a barrier and a promoter to follow-up of abnormal mammograms and was often considered the cause of denial.

The earlier a breast cancer is diagnosed and treated, the greater the likelihood of long-term survival. Untimely follow-up may negate the benefits of early detection through mammography screening, and inadequate follow-up of abnormal mammograms might explain some of the ethnic differences in breast cancer survival. A full-scale study to further elucidate predictors of inadequate follow-up is planned.