Mammography Screening for Latinas with Diabetes

Institution: Golden Valley Health Centers
Investigator(s): Christine Noguera, M.S. - Stergios Roussos, PhD, MPH -
Award Cycle: 2006 (Cycle 12) Grant #: 12AB-1900 Award: $110,332
Award Type: CRC Pilot Award
Research Priorities
Community Impact of Breast Cancer>Disparities: eliminating the unequal burden of breast cancer

This is a collaboration with: 12AB-1901 -

Initial Award Abstract (2006)
Background: Latinas experience health disparities in both breast cancer and diabetes. Latinas have a lower survival rate than non-Latina white women, due predominantly to later diagnosis. Latino mortality rates of Type 2 diabetes are 1.5 times higher than non-Latino groups. Breast cancer and diabetes are linked in two ways that may be used to reduce disparities for both illnesses for Latinas. First, obesity/overweight and inactivity – both preventable – are leading risk factors for both breast cancer and diabetes for Latinas. Second, women with diabetes are less likely to receive age-appropriate mammography despite more health visits (where the complexity of caring for chronic illness is predicted to interfere with mammography).

Hypothesis/Questions addressed: This Collaborative Pilot Award project will assist an existing community health center and researcher partnership to improve cultural and linguistically appropriate services (CLAS) in the Central Valley, home to one of the highest concentrations of Latinos in the USA. The Pilot Award will build on the team’s experience in CLAS to establish the infrastructure for outcomes research for known health disparities. The Pilot Award project will develop and test an intervention that adds breast cancer prevention to an evidence-based, culturally-tailored Diabetes Program serving Latinas in order to improve mammography.

The Specific Aims of this Pilot Award are:
1. Develop an intervention that incorporates breast cancer prevention into the evidence-based GVHC Diabetes Program in a manner that is consistent with the Diabetes Program’s tailoring to cultural of Latinos with attention to patients with limited English proficiency.
2. Assess differential change in mammography compliance for Latinas age 40 and over participating in the Diabetes Program alone with those participating in the pilot Diabetes + Breast Cancer Detection Program.
3. Identify and prepare the programmatic/intervention components, research components, and infrastructure of the community-research partnership necessary to apply and successfully implement a Full Award.

Methods: A Collaborative Team will consist of GVHC and SDSU staff and a Community Research Action Group (CRAG) representing community members with a stake in breast cancer, diabetes, and health disparities. The Team will review and refine elements of the healthcare “team” driven Diabetes Program: modify the diabetes registry to track and prompt for age-appropriate mammography, modify monthly mailers so that culturally tailored education and reminders include breast cancer prevention (while avoiding stigma and fear related to mammography) and train the Diabetes Program team to comply and support breast cancer screening guidelines. Once developed, the intervention will be tested by comparing changes in mammography among women age 40 and over with the Diabetes Program alone (site 1) compared to women in the Diabetes + Breast Cancer Detection Program. Diabetes Program participation rates and self-management variables (e.g., meeting self-care goals, Hb levels) will be tracked to assess potential positive or negative influences related to the addition of the breast cancer component. The Pilot project will provide information on intervention appropriateness and feasibility, ideal recruitment and retention strategies, estimated effect size, and protocols that would support planning and implementation of a Full Award to assess the efficacy of the intervention.

Impact on breast cancer: Health disparities for mammography for Latinas are correlated with cultural and linguistic factors, such as fear due to equating a mammogram with death, and lack of trust and poor communication with healthcare staff. Given that over 25% of Latinas have diabetes, adaptation of diabetes care to take advantage of the more frequent visits and opportunities to strengthen patient-provider relationship may allow for a quick and non-threatening way to improve mammography for Latinas. This may result in earlier detection of cancer, which is currently not occurring for Latinas as with non-Latina white women, and which contributes to lower survival rates.

Community involvement: Women of Courage, a nonprofit, grassroots group led by breast cancer survivors including GVHC staff, serves Merced County women who may be too young to receive insurance-subsidized mammography and/or have other barriers to screening and treatment. Women of Courage participated in the design of this Pilot Award proposal and will lead a Community Research Action Group during the Pilot Award. The CRAG will involve women with a stake in breast cancer, diabetes and health disparities in our community in active and meaningful partnership with the research and community healthcare agency in all facets of the Pilot Award.


Final Report (2008)

Latinas experience health disparities in both breast cancer and diabetes. Latinas have a lower breast cancer survival rate than non-Latina white women, due predominantly to later diagnosis. Latino mortality rates of Type 2 diabetes are 1.5 times higher than non-Latino groups. Breast cancer and diabetes are linked in two ways that may be used to reduce disparities for both illnesses for Latinas. First, obesity/overweight and inactivity – both preventable – are leading risk factors for both breast cancer and diabetes for Latinas. Second, women with diabetes are less likely to receive age-appropriate mammography despite more health visits (where the complexity of caring for chronic illness is predicted to interfere with mammography).

A collaboration between a community health center, a grass roots breast cancer community group, and a university-based academic team proposed a pilot study to examine the feasibility and potential effects of a systems-level intervention to improve mammography screening for diabetic Latina patients in a primarily farm-working Mexican community. The collaboration also sought to improve the infrastructure and capacity for community-based participatory research (CBPR). The intervention built on an existing diabetes program to encourage diabetes self-management. Intervention components were designed to be easily implemented and sustainable by clinic and community members: a diabetes progress chart note designed to prompt for annual gynecological exam screening (a precursor to mammography), a 1-page guide to prompt provider-patient discussion on behavioral risk factors related to diabetes and breast cancer, a one-time brief educational presentation on the project to providers, a waiting room life-size “cut-out” poster of a physician with motion-activated message (English and Spanish) to promote mammography, a bilingual fotonovela on mammography, and ongoing monitoring and tailoring of the intervention with community advisory board consisting of diabetes and breast cancer stakeholders.

A pre-post test design was used with one comparison and one intervention clinic (N=48 and 81, respectively) to assess the effect of the pilot study and plan for a more rigorous trial. Following a 6-month intervention period, chart review found that within-group intervention group referral to mammogram had an increase of 41% (vs 30% in the control group; P=.06 for group-difference) and within-group mammogram completion rate had an increase of 18% in the intervention group (vs 12% in the control group, P<.05 for group difference). HbA1c levels (assessed by chart review to capture any fluctuations in diabetes care or status) remained stable in both groups across the intervention period (Mean=8.0). Results from a telephone survey showed that patient barriers to mammography included fear of showing their breasts to a doctor (28%), fear of pain (58%), and fear that they might find they have cancer (72%). These potential barriers reflect common cultural reasons against cancer screening. The survey found that 26% of women thought they were at risk for developing breast cancer and 34% knew of a woman who had died from breast cancer. Forty-nine percent had asked their doctor for a mammogram and 76% would like more information from their clinic about how to reduce the risk of breast cancer.

CBPR capacity grew for the community-academic team. Clinic staff and community advisory group (CAG) members were able to understand and critically inform development and implementation of measurement and intervention activities. The CAG recruited and maintained more members reflective of the target patient population. The academic and clinical investigators were able to indentify and address methodological challenges to strengthen intervention components and measurement accuracy. The positive results on the primary outcomes for mammography referral and mammogram completion and on variables indicating patient need and support for further intervention on breast cancer were used to plan a 3-year project with a more rigorous experimental study of intervention effects. This proposal was successfully awarded a CBCRP Community Research Collaboration Full Award to begin in October 2008.