Running head: BREAST CANCER EDUCATION 1

Breast Cancer Education for Women Aged 29-39 in Madison County

Rachael Petersen

NURS 433C

Joann Dalling

Brigham Young University-Idaho

March 2, 2018

BREAST CANCER EDUCATION 2

Breast Cancer Education for Women Aged 29-39 in Madison County

Part 1: Defining the Population

Breast Cancer as a Health Issue

Breast cancer is a type of cancer that originates in the breast tissue of both men and

women, although more commonly in women. Cancer results from various genetic mutations

within cells that cause rapid proliferation and loss of differentiation ability. This means that the

cells not only forget what their purpose is, but will also multiply quickly, taking over space

meant for healthy cells. If untreated, the affected cells can relocate, or metastasize, to other

organs and tissues, interfering with normal cell function in both the originating tissues and

metastasis sites. Eventually, normal body processes are compromised, causing health decline

and subsequent death.

Breast cancer is no exception to this process, but it does have higher survival rates than

other cancers, if caught early enough. Five-year survival rates are as high as 98.9% for females

when breast cancer is diagnosed while in the localized stage, or when the cancer cells are still

localized to the breast tissue (National Cancer Institute, 2018b). This is because breast tissue is

not essential to life so more aggressive treatments can be used on the originating tissues. The

aggressive treatments decrease the probability of metastasis if it has not already occurred.

The prevalence of breast cancer is staggering. It is the most common cancer for women

and it is estimated that 266,120 women in the United States will be diagnosed in 2018,

representing 30% of all cancer diagnoses in women (American Cancer Society, 2018c).

Additionally, the National Cancer Institute states 12.4% of women, or one in eight, will be

diagnosed with breast cancer in their lifetime (2018b), illustrating the significance of this public

health concern.

BREAST CANCER EDUCATION 3

Death rates are significantly higher for women if diagnosed at later stages when cancer

cells have successfully relocated to more distant tissues beginning in surrounding and then

regional lymph nodes. At this point the cells can continue to metastasize even farther and can

reach tissues including, but not limited to, the brain, bones, or liver. The five-year survival rate

for women diagnosed in distant metastasis stages is only 26.9% (National Cancer Institute,

2018b). Early detection has the biggest influence on survival rates, making it clear why

education about the disease is imperative for optimal women’s health. Furthermore, breast

cancer is the second leading cause of cancer deaths in women when compared to all types of

cancer, regardless of gender specificity (National Cancer Institute, 2018b). This is substantial,

considering that breast cancer affects women significantly more often than it does men, which

illustrates the severity of this population health concern.

Healthy People 2020

Cancer, in general, is a population health concern, and the United States government has

addressed it in the Healthy People 2020 goals and initiatives. The cancer goal presented in this

initiative states, “Reduce the number of new cancer cases, as well as illness, disability, and death

caused by cancer” (Healthy People 2020, 2018). Objectives listed under this goal specific to

breast cancer include objective C-3 and C-11 which read, “reduce the female breast cancer death

rate” and “reduce late-stage female breast cancer,” respectively (Healthy People 2020, 2018). In

2007, there were 23.0 women who died from breast cancer per 100,000 females in the United

States (Healthy People 2020, 2018). The national Healthy People 2020 target for breast cancer

death rates is 20.7 deaths per 100,000 females, representing a 10% improvement rate (Healthy

People 2020, 2018). Additionally, in the United States there were 44.5 new late-stage breast

cancer diagnoses per 100,000 females reported in 2007 (Healthy People 2020, 2018). The

BREAST CANCER EDUCATION 4

Healthy People 2020 target for this objective is 42.2 new cases per 100,000 females (Healthy

People 2020, 2018). As illustrated in Figure 1, in 2015 there were 21.7 per 100,000 females who

died from breast cancer in Idaho. Figure 2 shows that there were 42.4 per 100,000 new late-

stage diagnoses in Idaho in 2013. Both figures demonstrate that Idaho has yet to reach the

Healthy People 2020 national target goals for either of these categories.

Figure 1. Female breast cancer deaths by state (Healthy People 2020, 2018)

BREAST CANCER EDUCATION 5

Figure 2. New Cases of late-stage female breast cancer by state (Healthy People 2020, 2018).

Specific Population

Gender and Age

Women aged 29-39 years will be assessed for access to information regarding breast

cancer. Figure 3 shows breast cancer prevalence by ages within the United States. As noted in

the figure, there is a spike in the breast cancer diagnosis rates between this target age range of

29-39 years old with the peak of the spike hitting between the ages of 30-34 years. This is

problematic since the current mammography recommendations for females living within the

United States begin at age 45; although it is optional to begin at age 40 (American Cancer

Society, 2018a). Without proper education for women aged 29-39 in the United States,

diagnosis could be prolonged, adversely affecting survival rates.

BREAST CANCER EDUCATION 6

Figure 3 - Age-Specific Rates of Breast Cancer in the US (Susan G. Komen Foundation, 2018).

Females comprise 49.5% of the population in Madison County (County Health Rankings

and Roadmaps, 2018). The target age range for this assessment encompasses a large portion of

the population. Figure 4 shows age distribution for all genders within the county. It is important

to recognize that nearly 23% of the population in Madison County is between the ages of 25-44

years, correlating to the target age range for this assessment which is women aged 29-39 years.

Figure 4 - Age Groups in Madison County (Community Commons, 2018b).

BREAST CANCER EDUCATION 7

Ethnicity, Race, and Language

All ethnicities and races within Madison County will be included in the assessment.

Particular attention will be given to the ethnicity populations of African-American and Caucasian

women due to the fact that Caucasian women are at highest risk for breast cancer overall and

African-American women are at greatest risk for breast cancer at younger ages (American

Cancer Society, 2018b). Current racial demographics in Madison County are included in Figure

5, which shows that 99.32% of the population is considered White with the next highest single

race being Asian at 1.10%. Additionally, 1.66% of the population is comprised of multiple races

and only 0.69% are Black. All other races are negligible in comparison. Because most of the

population is white (Community Commons, 2018b), it can be assumed that although there will

be no races excluded from the assessment, most of the women involved will be Caucasian.

Figure 5- Madison County Race Distribution (Community Commons, 2018b)

Ethnic demographics for Madison County are represented in Figure 6. The majority of

the population is non-Hispanic. Although there are not any ethnic requirements for the

assessment, assessments done within this community will reflect the more prevalent non-

BREAST CANCER EDUCATION 8

Hispanic population. This is important to note as other communities try to relate the assessment

findings to their own demographics.

Figure 6 - Ethnic Demographics in Madison County (Community Commons, 2018b)

Language preferences will not be a consideration for this assessment. All females within

the 29-39 age range will be considered, regardless of spoken language. It is important to note

that 9.9% of the population speak a language other than English in their home (United States

Census Bureau, 2018). Eventually, community assessments may need to focus on breast cancer

information available to women for whom English is not a primary language.

Mammography Screenings and Breast Cancer Incidence

Mammography screening rates within Madison County are lower than state and national

rates. Figure 7 shows the disparities between the rates. Except in 2013, Madison County has

consistently scored low and has not followed state and local trends for mammography screening

in the past (Community Commons, 2018d).

Figure 7- Mammography Rates in Madison County (Community Commons, 2018d).

BREAST CANCER EDUCATION 9

Despite the lower rate of mammography, Madison County does have a lower breast

cancer incidence rate. As noted in Figure 8, incidence rates are well below the state and national

rates (Community Commons, 2018b). Even with these good statistics, it is still important to

provide easily accessible information about breast cancer to women to ensure better health

outcomes in the event of a cancer diagnosis.

Figure 8 - Breast Cancer Incident Rates (Community Commons, 2018b).

Community

People

Madison County income rates are poor. As shown in Figure 9, median family income is

nearly half of the national average and only 60% of the median income for all of Idaho. With a

median income of only $34,783, it must be questioned whether residents take advantage of

regular check-ups with primary care physicians. Similarly, 35.65% of the population currently

lives in poverty, representing 2.3 times the state and national levels (Community Commons,

2018e). Economically disadvantaged communities may not be as proactive in their health care

needs. There are also excessive income inequalities when compared with state and national

levels (Community Commons, 2018e). This means that income is not spread evenly throughout

BREAST CANCER EDUCATION 10

the community or that fewer homes are responsible for earning a majority of the local income.

This creates larger differences in classifications of socioeconomic status. Both the lower median

income and the larger income inequalities may be reflective of the large student population that

attend the local University in Madison County. The students would not be earning the same

amount as local community members and could potentially skew these results.

Figure 9- Income levels (Community Commons, 2018e).

The population of people residing in Madison County does have high rates of health

insurance. Only 10.3% of the population is uninsured, well under the state and national levels of

14.71% and 12.98% respectively (Community Commons, 2018e). Additionally, 17.33% of the

population receives Medicare, which is comparable to state and national percentages. This may

mean that despite the lower incomes, health management is still possible. However, there is no

information available with regard to co-pay amounts or the quality of the health insurance (high

deductibles and lower pay-outs vs. low deductibles and higher pay-outs) which are also

determining factors to health care accessibility.

People within Madison County are generally health conscious. According to the

Community Health Needs Assessment reports provided by Community Commons, residents of

Madison County scored far below the state and national averages in adverse health behaviors,

including alcohol consumption and expenditures, soda expenditures, physical inactivity, tobacco

expenditure, and current tobacco users (2018c). Residents of Madison County also scored well

above the state and national averages in walking or biking to work, but scored above the national

BREAST CANCER EDUCATION 11

average for inadequate fruit and vegetable consumption (Community Commons, 2018c). The

Madison County Population scored similarly in rates of obesity as state and national averages

(Community Commons, 2018d). These statistics are promising for the population of Madison

County, considering the fact that alcohol consumption, obesity or being overweight, and

sedentary lifestyles are some of the many risk factors for breast cancer (American Cancer

Society, 2018d).

Place

Madison County is located in East Idaho, outlined in red in Figure 10. It is located within

about 90 miles of the West entrance of Yellowstone National Park and Jackson Hole, Wyoming,

and is close to the St. Anthony sand dunes, making it centrally located to diverse ecological

settings. Much of Madison County is a shield volcano (Madison County, 2018) and there is

evidence of volcanic rock in many of the surrounding areas. The total land area is 473.36 square

miles with only 0.39% comprising water (Madison County, 2018).

Figure 10 - Madison County Idaho (United States Census Bureau, 2018).

BREAST CANCER EDUCATION 12

Function

There is not only a shortage of primary care physicians, but also mental health providers

within Madison County. Figures 11 and 12 show how Madison County measures up with state

and national provider ratios. Additionally, 100% of the population in Madison County lives

within a health professional shortage area (Community Commons, 2018a). This could be

indicative of poor access to health care. However, Madison County also scores low in

preventable hospital events (Community Commons, 2018a), or events that are preventable if

primary health care providers are seen before hospital admittance become necessary. Thus, it

may be that the population is healthier as a whole and may not need as many health professionals

as other areas.

Figure 11 - PCP Ratios (CHNA, 2018).

Figure 12- Mental HCP Ratios (CHNA, 2018).

Madison County is home to Madison Memorial Hospital in Rexburg, ID (as pictured in

Figure 13). The hospital has greatly expanded since its opening in 1951. It began as just a 29-

bed facility but now offers many additional services including an emergency department,

surgical center, physical therapy center, maternity center, radiology, laboratory, cancer care

BREAST CANCER EDUCATION 13

center, infusion center and more (Madison Memorial Hospital, 2018b). It is a great resource for

the community and surrounding areas.

Figure 13 - Madison Memorial Hospital (Madison Memorial Hospital, 2018b).

Madison County is home to a variety of educational resources. Within the first year of

settlement back in March 1883, an academy was established for the purpose of education. Since

that time, the academy has made several transitions to compile what is currently Brigham Young

University – Idaho (City of Rexburg, 2018). Madison County has several museums, including

the Legacy Flight Museum and the Rexburg Museum. The Madison County library, located in

Rexburg, provides over 90,000 items as resources for patrons (Madison Library District, 2018).

These establishments provide valuable informational and educational resources for community

members.

Figure 14 – Brigham Young University – Idaho in 2013 Figure 15- Madison County Library (Madison Library District, 2018). (Brigham Young University – Idaho, 2018).

BREAST CANCER EDUCATION 14

Plan

A nurse who works in a primary health care provider’s office within Madison County

Idaho will be interviewed as a key informant. She will be questioned regarding breast cancer

information available to women aged 29-39 who come into the office she works at. Information

can include, but is not limited to, routine education, pamphlets, and or flyers. The key informant

will be assessed if this information is provided to all women within that age group or only if

specific risk factors are present. For example, is any special attention given to women that are

African American, those who drink alcohol, are obese or overweight, or live sedentary lifestyles.

The rate of female patients between the ages of 29-39 years who are either uninsured or have

incomes below the national poverty line that visit the office will also be assessed. Assessment of

additional resources for the uninsured and low-income females aged 29-39 years will also be

included.

A woman who was diagnosed with breast cancer between the ages of 29-39 years who

resided in Madison County at the time of diagnosis will also be interviewed. She will be

assessed for information regarding her personal breast cancer knowledge base prior to her breast

cancer diagnosis. She will also be asked about opportunities provided to her by her health care

provider prior to her diagnosis that contributed to her knowledge base or health status. These

opportunities include assessment of risk factors, clinical breast exams, and evaluation of

understanding of breast cancer signs and symptoms. Lastly, she will be given the opportunity to

provide any information she wished all women aged 29-39 years knew.

A windshield survey will include driving around Madison County and looking for

billboards or any other signs located in the community that offer information about breast cancer.

Any mention of breast cancer will be included whether it refers to primary, secondary, or tertiary

BREAST CANCER EDUCATION 15

prevention measures. Observations will be made at the Rexburg Medical Center, District Health

Office, and Season’s Medical Center offices in Madison County. These facilities will be

assessed for pamphlets or flyers in waiting rooms that provide information about breast cancer.

Resources to support responses include Community Commons, Eastern Idaho Public Health

District, American Cancer Society, and the National Cancer Institute.

Part 2: Assessment

Primary Data

Primary data was gathered through interviews, a windshield survey, and other

observations. The first interview was with a key informant who currently works at Rexburg

Medical Center in Madison County as a nurse. She has been employed there for the last 8 years.

The second interview was with a woman who was diagnosed with breast cancer 4 years ago at

the age of 37 years. She has resided in Madison County for 40 years. The windshield survey

involved driving around Madison County to see if there were any billboards or other signs that

provided information about breast cancer. Other observations included assessing for pamphlets

and flyers in waiting rooms of medical care facilities in Madison County. These facilities

included Season’s Medical Center, the District 7 Health Office, and Rexburg Medical Center.

Key informant interview.

1. Q: What kind of breast cancer information is provided to women aged 29-39 that come

into your clinic?

A: I believe we don’t routinely give them anything. We should. I am sure as the doctor

visits with each patient that is coming in, especially for a women’s physical, he would

ask if she had noticed any breast changes. Then, if they were doing a pap he would ask

her if she would want to do a clinical breast exam. I would have to ask all of the doctors

BREAST CANCER EDUCATION 16

if they routinely do that on that age group. I know they would do that on an older

woman, but for that age group, I am just not sure.

2. Q: Is this information provided (or not provided) to all women in that age range or are

any risk factors taken into consideration? For example, for that age group, African

American women are at greater risk for breast cancer whereas Caucasian women have a

greater risk over the course of a lifetime. So, do you pay attention to those kinds of

things and are more proactive with those women at greater risk, or is the information

provided the same regardless of the risk factors?

A: Our clinic sees very few African Americans. So, we probably don’t see enough to

have that routinely kept in mind, would be my guess. Strangely enough, during the

month of October, we are more proactive on these things just because we become more

aware. We are very proactive with any woman over the age of 40 and make sure she has

her mammogram ordered and that she gets in to do that. But, that younger age group,

um… only if they have a family history or if the person herself is very adamant that she

wants a mammogram done because she wants a baseline done at an early age – especially

if the family member had it at a young age, then we are more proactive. So, I would say,

in that age group, it is left more up to the patient and her awareness before we take any

big steps. Like I said, the doctor would probably offer a breast exam while she was there

but if she refused or didn’t want it, he obviously wouldn’t encourage her to do that.

3. Q: Does your office have any pamphlets, flyers, or any other informational resources that

could be provided to women aged 29-39 years?

A: Yes, we do have some right at the triage area that we could hand out. We don’t

routinely hand them out to each well woman that comes in for a check-up. But, we do

BREAST CANCER EDUCATION 17

have them should anyone ask for more information. I wouldn’t say we had enough to

hand them out to every single person, but it is there if someone is interested.

4. Q: Do you feel like the information provided to this younger age group is adequate or

would you like to see changes?

A: I think we should probably be more proactive in teaching the self-breast exams. In

our triage process, we ask a lot of personal questions about mental health and

immunizations and history or family history. Maybe there should be a little box we could

check. I was thinking about that this morning and I think there should be a question there

where we can ask “Do you know how to do self-breast exams?” and “Would you like

more information?” or something like that. We ask people about their living wills and

blood transfusions and all kinds of stuff. So, on a woman, that is something that could

definitely be looked into, I think - for a wellness visit for a woman, or any woman over

the age of 20, really.

5. Q: Based on your observations, how frequent is a breast cancer diagnosis in the women

aged 29-39 in your clinic?

A: Hmm… for the younger age group…Probably from our patient client group. Maybe 1

every 18 months or something like that. So, not real often. And then in the older group

maybe 1 a year, or maybe 2 a year in the women 40 and older.

6. Q: What other concerns, if any, take priority over addressing breast cancer in the younger

age group?

A: Like I said, I think it would be wise if we asked those questions we talked about right

upfront just like all the others. So, I can see maybe there is a lack there. I mean we ask

someone if they ever feel depressed, so we should ask if they ever do self-breast exams or

BREAST CANCER EDUCATION 18

have any questions about how to do that. I am sure that the doctors address that more

behind closed doors when the nurses aren’t in there. So, it might be good for you to ask

one of the doctors, actually. But, that would be my perception, that we become more

forthcoming about what their feelings are about that or if they have any questions or want

to be taught more or want to learn more or something like that. We ask so many other

personal questions there is no reason why we couldn’t ask those kinds of questions. It is

not built into our program, but we’ve only had our program for 6 months, so I think that

would be a good thing to look into… I will ask someone!

7. Q: How often in this age group come into your office?

A: I think we get a lot of that age group. I don’t think they come in as much for wellness,

but our clinic delivers a lot of babies, so we see a lot of women in that age group for

pregnancies. Or, they may be in with their children, but they will ask questions about

themselves while they are there. I would say they are a big hunk of our clientele - more

so than their spouses of the same age.

8. Q: Do you see clients of this age who do not have insurance?

A: Oh, yeah! We get a lot of self-pays. In recent years because the Medicaid was

boosted, we had a lot of Medicaid patients – which was great. But I am afraid that is

going to cut back with recent changes. But, yeah, we do see a lot of women who are

uninsured. I know there is a program through the …um… I don’t think it is through

District 7 Health… but there is a women’s health clinic that is a free clinic if they meet

certain criteria for finance. I don’t think it has anything to do with age, just finance. But

we do have information that we can give women that they could go get a pap, a breast

exam, or a mammogram, especially if the woman came in that is a high risk (not

BREAST CANCER EDUCATION 19

necessarily for breast cancer) but more for other female problems like STDs. They can

get help and not have to pay for it if they qualify for it based on income. I know there is

some help out there. You have to fill out the paperwork to get it, but there is some help

and we definitely have women who fit into that category.

Follow-up Q: Do you find that the women take the time to fill out the paperwork and take

care of their health needs?

A: I think if they are really worried about something then they do. Then they’ll take the

time to do that. If it’s just more of a routine type thing, then probably not. But if it’s

something that they are afraid that they may have contracted something, then they would

be more willing to follow through with that.

Revision. A few days after the interview, the key informant provided additional

information after speaking to the doctors she works with. Both doctors that work in the clinic

said they do not do routine manual breast exams in women under age forty and that the newest

data suggests that clinical breast exams don’t catch hardly any breast cancer. Recommendations

are lengthening years between such exams to two or more. They also reported that the clinic

catches breast cancer in a younger patient only once in every three to five years whereas it is as

many as three per year in the older population.

Survivor interview.

1. Q: Prior to your diagnosis, had you been given the opportunity to assess your breast

cancer risk factors with a medical professional (nurse, doctor, etc.)? If not, would you

have taken the time to assess your risk if given the opportunity? Why or why not? If so,

what came out of the risk assessment?

BREAST CANCER EDUCATION 20

A: I had no thought of assessing the risks of breast cancer. When I felt my lump, I was

strongly impressed that I needed to get into someone as soon as possible. I was in shock

and alone at the time of diagnosis. My husband at the time was out of town and I had no

one around to think of this.

2. Q: Prior to your diagnosis, were you ever asked by a medical professional if you were

comfortable in recognizing changes in your breast tissue? Or if you wanted more

information about breast self-exams?

A: I always had a breast exam at each of my OB visits. However, I was never asked if

there were any changes in my breasts. I thought it was silly that we had to go through

that exam in the first place.

3. Q: What kind of exposure did you have to information about breast cancer prevention

and/or risk factors before your diagnosis? And, was this information enough that you felt

comfortable knowing what kind of breast changes required further evaluation by a

medical professional?

A: Prior to my breast cancer, I don’t ever remember thinking about breast cancer or

cancer in general. It doesn’t run in my family.

4. Q: Do you feel the knowledge you had prior to breast cancer was adequate enough to

help you get an early diagnosis?

A: I always knew that if you felt a lump that you should have it checked out. I now

know that finding a lump is not the only thing you should look for. The doctors and

others need to be more specific with this to everyone at every visit. I can’t believe what I

was absent to.

BREAST CANCER EDUCATION 21

5. Q: Did you or your primary care physician initially feel your breast cancer lump?

A: I was the one who found my lump. I was so scared, because I swear that I had done a

breast exam the week prior and nothing was there. I know nothing was there.

6. Q: As best as you can remember, had you ever had a clinical breast exam (one performed

by your primary care provider) prior to your diagnosis?

A: Breast exams were done every year except not so much after I had my hysterectomy

in years earlier. I think that was 2010?

One other thing – Dr. Dickson [a local oncologist] later told me that he likes to see his

patients prior to any surgery. The OB doctors need to know this and let their patients

know this.

7. Q: What information do you know now that you wish had been provided to you before

your diagnosis (i.e. What breast cancer information would you feel is important enough

to be given to all women aged 29-39 years)?

A: Even though breast cancer doesn’t run in a person’s family, there is still a chance of

them getting it. I am the only one in my family ever to have breast cancer or any type of

cancer. I feel deeply things should change when it comes to when one gets their first

exam and mammogram. I feel that breast exams, as well as mammograms, should be

mandatory prior to marriage and at each birth so that everyone involved knows the tissue

and can see changes.

Windshield survey. A windshield survey was conducted in Madison County. Billboards

and signs provided throughout the community were assessed for breast cancer information that

was readily available to community members. Although there were no billboards or signs that

were specific to breast cancer, there were several signs throughout the community on banks,

BREAST CANCER EDUCATION 22

restaurants, and other local establishments that were promoting “Hello” week. This campaign is

put on by an organization created by the local school district in Madison County called Madison

Cares. This specific campaign is an effort to encourage not only reaching out to others, but to

also notice signs of isolation in children. It is meant to promote social inclusion. Having

multiple establishments promoting this campaign is evidence of community caring and

involvement. The windshield survey was conducted in the month of February. Based on the

local involvement for “Hello” week, it may be more applicable to repeat the survey during the

month of October when breast cancer information is more likely to be promoted.

Other observations. Assessments were made at a few of the local medical

establishments with the specific intent to see what kind of pamphlets or flyers were readily

available to community members that addressed breast cancer information or resources. At the

Season’s Medical Center in Rexburg, three different clinics were assessed, including the Adult

and Family Care, Family Medicine, and The Women’s Center offices. Out of the three clinics

assessed, there were no breast cancer-related resources in the waiting rooms. There were other

pamphlets and flyers available, just not any that referenced breast cancer. In the Women’s

Center, there was one pamphlet about what to expect after a positive cervical cancer screening,

but that is as close to breast cancer as it got.

At the District 7 Health Office, there were several flyers that gave information about the

Women’s Health Check. This is an organization that will provide free pap smears,

mammograms, and STD testing for women who qualify based on income requirements. Not

only was there a flyer for the Women’s Health Check, there was also a small poster and a paper

that had the contact information for the primary nurse overseeing the program on tabs at the

bottom of the paper that could be torn off. Even though there were plenty of flyers for the

BREAST CANCER EDUCATION 23

Women’s Health Check, there were no other flyers or pamphlets that addressed breast cancer

besides those already mentioned.

The Rexburg Medical Clinic had no pamphlets or flyers of any kind in the waiting room.

However, at the nurse’s triage area there were several pamphlets available for clients. One of

these was a flyer for Teton Radiology that advertised mammograms. Other than that, there were

no other breast cancer-related resources readily available.

Secondary Data

Secondary data has been gathered from local, state, and national governmental agencies

that provide information on breast cancer. Both life-style-related and non-modifiable risk factors

are addressed. Additionally, local, state, and national information about the number of cases,

incidence rates, mortality rates, and available breast cancer information is provided.

Life-style-related risk factors. There is a lot of information about breast cancer and

specific risk factors that has yet to be discovered. Despite this knowledge deficit, there are a few

risk factors that have been shown to be correlated with breast cancer. Some are related to

personal behaviors while others are out of individual control. One of the life-style related risk

factors is alcohol consumption. According to the American Cancer Society, drinking one

alcoholic drink per day only increases the risk of breast cancer a very small amount (American

Cancer Society, 2018d). However, women who drink 2-3 alcoholic beverages a day increase

their chance of being diagnosed with breast cancer by 20% compared to those who don’t drink

alcohol (American Cancer Society, 2018d).

Other modifiable risk factors include being overweight or obese and having a sedentary

life-style. Interestingly, research suggests that weight distribution and age of obesity or

overweightness onset are contributing factors to breast cancer (American Cancer Society,

BREAST CANCER EDUCATION 24

2018d). Excess fat in the mid-section is a higher risk factor than having similar amounts of fat in

lower-body portions. The risk is higher for women who gained weight as an adult rather than

being overweight since childhood. There is evidence building that correlates decreased breast

cancer risk to being physically active. This is still a topic that is being studied to find out if there

is an optimal level of activity to achieve the best protection, but preliminary findings suggest that

although a few hours a week might provide some benefits, it would be best to do more

(American Cancer Society, 2018d). It is important to watch for further research in this area so

optimal benefits can be obtained.

There are multiple risk factors associated with reproductive life-styles. These risk factors

are especially applicable to women aged 29-39 years, since they are in their reproductive years

and may participate in these activities without fully understanding the risk it puts them in for

incurring breast cancer. Women who do not have children or who do not have a first child until

after age 30 years are at an increased risk for breast cancer (American Cancer Society, 2018d).

There have been a few studies that suggest breastfeeding lowers breast cancer risk, particularly if

done for 18 to 24 months (American Cancer Society, 2018d). However, this topic is hard to

study in the United States since most mothers do not typically breastfeed that long.

One last risk factor that involves reproductive life-style is birth control use. Oral

contraceptive use has been shown to slightly increase the risk of breast cancer but this increase

returns to normal after 10 years of stopping the medication (American Cancer Society, 2108d).

There is also an increased risk with the Depo-Provera injection, with normal risk being

reestablished after 5 years of stopping the injections (American Cancer Society, 2108d). Other

less common forms of birth control such as implants, patches, and rings have not been studied as

BREAST CANCER EDUCATION 25

intensely as the other forms. It is unclear what effect, if any, these types of birth control have on

a woman’s risk of getting breast cancer.

Non-modifiable risk factors. Non-modifiable risk factors are factors that cannot be

manipulated or changed. For example, women are 100 times more likely to get breast cancer

than men (American Cancer Society, 2018b). Age is also a big contributing factor. The rates of

new cases of breast cancer based on age in the United States were shown previously in Figure 3.

It is apparent from the graph that the older a woman gets, the more likely she is to be diagnosed

with breast cancer. Most breast cancers are found in women age 55 years and older (American

Cancer Society, 2018b).

There is also a strong genetic link to breast cancer. However, even though the link is

strong, less than 15% of women that are diagnosed with breast cancer have a family member

with the disease (American Cancer Society, 2018b). Research has shown that having a first-

degree relative with breast cancer doubles the risk and having two first-degree relatives with the

disease triples it (American Cancer Society, 2018b). Just keep in mind that there are other

unknown causes of breast cancer that play a role in a majority of the breast cancer cases.

Additionally, there have been certain gene defects that can be identified as increasing the risk for

cancer significantly. The genes BRCA1 and BRCA2 have the biggest impact compared to other

genes. If a woman has a mutation in the BRCA1 or BRCA2 genes, her chance of getting breast

cancer by age 80 is 7 in 10 (American Cancer Society, 2018b). These women are also more

likely to be diagnosed at a younger age, have cancer in both breasts, and have a higher risk of

developing ovarian cancer. Even with these significant risk factors, only 5-10% of breast cancer

cases are thought to be directly related to gene defects (American Cancer Society, 2018b).

Women with genetic mutations need to understand how significant these mutations are, while

BREAST CANCER EDUCATION 26

those without the mutations need to realize that the odds of getting breast cancer are still fairly

high.

National data. As mentioned previously, a woman’s risk for breast cancer is

approximately 12% in the United States. Based on data collected from 2010-2014 throughout

the United States, breast cancer incidence rates are 123.5 per 100,000 (Community Commons,

2018d). Whites are most likely to get breast cancer with Blacks following in a close second. The

national incidence rate for Whites is 124.5 per 100,000 and 122.8 per 100,000 for Blacks in the

United States (Community Commons, 2018d). Other races and ethnicities are still susceptible.

In the United States, Asian and Pacific Islanders have incidence rates of 90.2 per 100,000,

American Indian and Alaskan Natives of 72.7 per 100,000, and Hispanic or Latino of 92.3 per

100,000 (Community Commons, 2018d).

There are approximately 190,301 Whites that are diagnosed with breast cancer annually

in the United States (Community Commons, 2018d). National annual new cases for Blacks is

26,354 and for Hispanic/Latinos it is 17,547 (Community Commons, 2018d). Of the Asian and

Pacific Islander populations, 8,603 are diagnosed in the United States every year, while 1,254

American Indian and Alaskan Natives will be. Figure 16 shows national, state, and local cancer

mortality rates by race and ethnicity. Although mortality rates from all cancers are included in

the figure, it is apparent that Blacks and Whites are most at risk for cancer-related deaths.

BREAST CANCER EDUCATION 27

Figure 16 - National, State, and Local Cancer Mortality Rates (Community Commons, 2018d).

There are many resources available online through national government websites that

provide information about breast cancer. One of the websites is organized by the National

Cancer Institute. This website offers a public tool that assesses breast cancer risk. Figure 17

provides the assessment questions used in the tool. Each question highlights the biggest risk

factors. However, there are limitations to this tool. The tool is not advised for those with a

history of breast cancer or who have tested positive for the BRCA1 or BRCA2 genes. The tool

is also only designed for women who are at least 35 years old or older, restricting applicability to

those women who are younger (National Cancer Institute, 2018a).

BREAST CANCER EDUCATION 28

Figure 17 - Breast Cancer Risk Assessment Tool (National Cancer Institute, 2018a).

State data. Breast cancer incidence rates are only slightly lower in the state of Idaho

compared to national levels. Data collected in 2010-2014 suggests that the incidence rate in

Idaho is 120.5 per 100,000 population (Community Commons, 2018d). There are multiple

differences in state and national incidence rates based on race and ethnicity. In Idaho, Whites

have a 120.5 per 100,000 incidence rates, Asian or Pacific Islanders have 76, American Indian

and Alaskan Natives have 103.5, and Hispanic or Latinos 89.1 (Community Commons, 2018d).

All rates are based on population per 100,000 people. There is no data available on the state

level for incidence rates for Blacks. All other incidence rates are lower than the national statistics

BREAST CANCER EDUCATION 29

besides the American Indian and Alaskan Natives. This ethnicity has a significantly higher

incidence rate in Idaho compared to the national rates.

Across the state of Idaho, there are approximately 1,026 new cases of breast cancer in

Whites reported each year (Community Commons, 2018d). There is no state data for Blacks, but

average annual new cases for Asian or Pacific Islanders is 10, for American Indian or Alaskan

Native it is 11, and for Hispanic or Latino is 40 (Community Commons, 2018d). Mortality rates

for cancer in general within Idaho can be noted in the previously mentioned Figure 16. Mortality

rates are comparable between state and national statistics for Whites and Hispanic or Latino

populations. Mortality rates are decreased in Asian or Pacific Islander ethnicities in Idaho but

significantly increased in the American Indian and Alaskan Native populations, when compared

to national statistics. There is no mortality rate data available for Blacks in Idaho.

There are limited online resources specifically for breast cancer within the State of Idaho

beyond the national governmental websites. However, there is some beneficial information

provided by the Susan G. Komen Foundation of Idaho/Montana. Figure 18 shows an image

provided on this website that illustrates the breast changes that should be reported to a health-

care provider. This information can be useful to all women within the state of Idaho, regardless

of age. Therefore, women in the target age range of 29-39 years included in this assessment can

also benefit from this resource.

BREAST CANCER EDUCATION 30

Figure 18 - Reportable Breast Changes (Susan G. Komen Foundation of Idaho/Montana, 2018).

Local data. Breast cancer incidence rates are significantly lower in Madison County

compared to both state and national levels. The overall incidence rate is 74.5 per 100,000 people

based on data collected from 2010-2014 (Community Commons, 2018d). However, there is no

data available for any race or ethnicity incidence rates in Madison County besides for Whites. In

this case, the incidence rates for Whites is 71.8 per 100,000 (Community Commons, 2018d).

There is an average of 8 White people diagnosed with breast cancer annually in Madison County

BREAST CANCER EDUCATION 31

(Community Commons, 2018d). Again, there is no data available for other races or ethnicities

for comparison with state and national annual new case rates.

Mortality rates from cancer in general for Non-Hispanic Whites in Madison County are

significantly lower when compared to state and national rates. Again, Figure 16 provides cancer

mortality rates of local, state, and national statistics. Note there is no data on the local level for

those of different races or ethnicities other than Non-Hispanic White.

There is very little information online about breast cancer available to Madison County

residents on the local level. The Eastern Idaho Public Health website, which serves Madison

County and other surrounding Idaho counties, provides some information about cancer in

general, but focuses mainly on colorectal and skin cancer programs (Eastern Idaho Public

Health, 2018). There is a cancer support group offered by Madison Memorial Hospital located

in Rexburg. Contact information for the team-lead person and meeting times can be found on the

hospital website, but this is not specific to breast cancer and encompasses all ages and cancer

types (Madison Memorial Hospital, 2018a). The lack of online information available on the

local level is drastic in contrast to that offered at the national level.

Part 3: Data Interpretation

After assessing the data on breast cancer information availability, specifically for women

ages 29-39 years in Madison County, it is apparent that there are several community resources

available; although, it takes proactive effort to locate and utilize these resources. Breast cancer is

a national concern with risks that span a lifetime. Though the rates of breast cancer are lower in

Madison County compared to state and national rates, this may be due to the lower median age in

Madison County, since breast cancer incidence rates increase with age. Because breast cancer

can be life-threatening if not caught soon enough, it is imperative that women of all ages are

BREAST CANCER EDUCATION 32

aware of what breast changes need to be followed up with a primary care physician. Discerning

atypical breast changes is an area that needs to be better addressed for women aged 29-39 that

reside in Madison County.

Data Similarities

Lack of readily available information. The windshield study and other observational

assessments indicated that there are limited educational resources about breast cancer available

throughout Madison County. Even local websites were lacking information about breast cancer.

The breast cancer survivor that was interviewed as part of the assessment also indicated that her

knowledge about the signs and symptoms of breast cancer was severely limited to only knowing

that a lump in the breast tissue was not a good thing. She had been a Madison County resident

for nearly forty years at the time of her diagnosis, indicating the lack of readily available

information for women aged 29-39 in Madison County.

Decrease in risk factors equates to decrease incidence. There is a decreased incidence

of breast cancer incidence in Madison County. Not surprisingly, Madison County scored low for

alcohol use, obesity rates, and sedentary lifestyles. All of those factors are considered to increase

breast cancer risk. Thus, it is not surprising that breast cancer rates are decreased in Madison

County when those risk factors are also decreased.

Call for more proactive medical care. Both interviewees concurred that Madison

County needs to encourage more proactive care when it comes to breast cancer information and

screenings for women aged 29-39 who are Madison County residents. The key informant, or the

nurse working at Rexburg Medical Center, saw the need to include self-assessment questions as

part of the triage questionnaire. The breast cancer survivor thought it would be beneficial to

BREAST CANCER EDUCATION 33

increase mammography frequency so patterns could be more readily detected over a lifetime.

Either way, both informants called for a change in the community’s current standard of care.

Data Differences

Lower local occurrence. Differences exist between the rates of breast cancer incidence

in Madison County, the State of Idaho, and within the United States. Overall rates are increased

on the national level, with state levels being slightly lower than that. Breast cancer incidence

rates are significantly lower in Madison County. However, some of this may be due to the fact

that the median age is also significantly lower in Madison County compared to state and national

median ages, and breast cancer incidence increases with age.

Genetic emphasis. There is a strong emphasis on genetics being a major contributing

risk factor. A woman’s risk for breast cancer dramatically increases if she has a family history of

the disease or tests positive for the BRCA1 or BRCA2 genetic mutations. However, even though

those women are at an increased risk, genetic factors only account for less than 15% of all breast

cancer diagnoses (American Cancer Society, 2018b). The survivor that was interviewed had no

history of breast cancer, or of any cancer. The genetic risk factor is emphasized so strongly that

women can get the false impression that the risk is minimal without a genetic history. In fact, the

second question provided on the risk tool on the National Cancer Institute’s website as seen in

Figure 17, asks about testing positive for the BRCA1 or BRCA2 genetic mutations (National

Cancer Institute, 2018). Being listed as the second question indicates how strongly genetic

factors are underscored when it comes to risk factors. It comes second only to a previous

diagnosis of breast cancer. The survivor that was interviewed admitted to not ever thinking

about breast cancer because she had no family history of it. Information resources need to be

clearer on this differentiation.

BREAST CANCER EDUCATION 34

Decreased mammography and screening guidelines. In 2015, the American Cancer

Society loosened mammography guidelines from age 40 for the first mammogram to age 45, as

well as from every year to every other year starting at age 55 (CBS News, 2015). Additionally,

the nurse from the Rexburg Medical Center mentioned the doctors she works for said current

guidelines are no longer emphasizing clinical breast exams either. Contrarily, the survivor that

was interviewed strongly felt that mammograms should be done more frequently, not less. For

those who have experienced cancer, the reality of it shapes how firmly they want other women to

be protected from late diagnoses.

Population Strengths

Doctor visits. Women aged 29-39 in Madison County visit the doctor more regularly

than their male counterparts, at least according to the nurse that works at Rexburg Medical

Center. They are often seen by their physician for reproductive health. If a woman is pregnant,

she will be visiting her physician fairly regularly if she follows the current recommendations for

prenatal care. If she is not pregnant, there is a good chance she sees her physician for other

reproductive health concerns like birth control. Because of these factors, women aged 29-39 in

Madison County may have a greater opportunity to express concerns about breast changes or

other health issues that they may not have otherwise made an appointment for.

On-line resources. Although there are limited on-line resources available on a local

level, women aged 29-39 in Madison County have access to information from national databases

like the American Cancer Society and the National Cancer Institute, just to name a few. These

online resources are incredibly valuable in recognizing concerning breast changes and

understanding risk factors. Women in Madison County aged 29-39 years are generally

comfortable using computers and accessing online information. As long as they are willing to be

BREAST CANCER EDUCATION 35

forward thinking, they should be able to access the information they need to gain a good

knowledge base about breast cancer.

Supportive community. Madison County represents a strong and supportive

community. Several businesses were observed supporting “Hello” week, as mentioned

previously. That support shows the strong commitment which community members have to

community health and education. Women who live in Madison County and are 29-39 years old

are more apt to have exposure to these kinds of community programs. There is a good chance

that as the year progresses, there will be support for breast cancer awareness and other health

issues that are more relative to women aged 29-39 years within Madison County.

Population Weaknesses

Limited resources. Although there are sufficient on-line resources for women aged 29-

39 who reside in Madison County, a woman must be proactive in her health education efforts in

order to access the information. This means she has to look the information up on her own and

that it won’t be readily provided to her. Similarly, there is very little information available to

these same women within the community itself. There were few flyers, pamphlets, and no

billboards or signs that were placed for these women to see with minimal effort. Women who

are not proactive in their health status are at a severe disadvantage for gaining valuable

information about breast cancer and personal risk factors.

Reproductive health decisions. Women aged 29-39 are in the prime of their

reproductive years. There are many breast cancer risk factors tied to reproductive health

decisions. Pregnancy before age 30 is a protective factor, whereas most birth control measures

are considered contributing factors (American Cancer Society, 2018d). Many of the decisions

BREAST CANCER EDUCATION 36

which women aged 29-39 years make regarding their reproductive health impact their risks for

breast cancer. This is also true for the women aged 29-39 years in Madison County.

Low-income. As previously established, income rates in Madison County are poor.

Although those results may be skewed due to the college student population, women aged 29-39

years may still be working on establishing themselves financially. They may also have added

expenses as they are in the age range where they may be growing their families. Low income

rates or other financial setbacks may limit how often women aged 29-39 years in Madison

County access health care.

Significant Information Validating Health Issue

Increased susceptibility. Although most breast cancers are diagnosed in women over 55

years old within the United States, there is a spike in incidence between 29-39 years of age as

previously illustrated in Figure 3 (Susan G. Komen Foundation, 2018). Mammography

recommendations begin as optional at age 40 years, after the initial spike. Because of this,

women aged 29-39 years may go undiagnosed before significant signs and symptoms appear,

indicating diagnosis during later stages.

Limited local promotion. As evidenced in the key informant interview and other

observations, there is severely limited breast cancer informational resources readily available in

Madison County. Physicians in Madison County may not be as proactive in assessing the risk

factors for breast cancer in women aged 29-39 years either. If a woman aged 29-39 years in

Madison County is not actively curious or seeking information about breast cancer, she may not

have access to crucial, life-saving information.

Early detection needed for successful outcomes. Breast cancer is a highly prevalent

and serious disease, sometimes ending in death. With 12.4% of women in the United States

BREAST CANCER EDUCATION 37

being diagnosed at some point in their lifetime, it is important that all women are familiar with

the signs and symptoms of breast cancer (National Cancer Institute, 2018b). The sooner

suspicious breast changes are followed up with a health care provider, the better. Success rates

are dramatically increased with early breast cancer diagnoses.

Part 4: Population Health Plan

Population Plans

Greater confidence in identifying adverse breast changes. Women aged 29-39 years

who reside in Madison County may not be getting the breast health education they need to

properly recognize symptomatic signs of breast cancer. The breast cancer survivor that was

interviewed for this assessment admitted to knowing very little concerning other signs of breast

cancer besides a lump in the breast tissue. It is important that the women in Madison County

that are between the ages of 29 and 39 years become confident in recognizing all signs and

symptoms of breast cancer so that diagnosis is not prolonged.

In order to fulfill this need, it is recommended that the accessibility of concerning breast

changes improves. Creating and distributing pamphlets with information similar to that provided

in Figure 18 could be incredibly valuable for all women within Madison County, but especially

for those aged 29-39 years as the primary care doctors may not be as proactive with this age

range as compared with women over 40 years. These pamphlets should be made available to as

many women as possible that are 29-39 years old and live in Madison County, and should be

offered to clients at doctors’ offices, the District Health Office, and the WIC office. Each client

will be asked if they would like a pamphlet describing worrisome breast changes. Those who are

interested will be given the pamphlet.

BREAST CANCER EDUCATION 38

Evaluating the effectiveness of this intervention will include offering a Likert scale

survey encompassing how comfortable and confident each woman surveyed feels about

recognizing breast changes that need to be followed up with a health care provider before the

pamphlet is provided. A second survey, identical to the first, will be given at the next

appointment and a comparison will be made between the before and after surveys.

Increase proactive health care. One area of improvement in Madison County for

women aged 29-39 years is for primary care physicians to become more proactive in teaching or

asking about breast health. Both key informants, the nurse working at Rexburg Medical Center

and the breast cancer survivor, felt that physicians in Madison County were not forthcoming

enough in approaching their clients that are women aged 29-39 years in regards to breast health

and breast cancer information.

To remedy this problem, it is recommended that questions regarding breast cancer risk

factors as well as specifically addressing breast changes be incorporated into client triage and

health histories. Asking specific questions to women aged 29-39 years in Madison County will

make knowledge gaps more apparent as well as draw attention to important risk factors that may

not be addressed otherwise.

Data on cancer stage at diagnosis for women aged 29-39 years in Madison county will be

collected. This will need to be a long-term study since diagnoses in this demographic isn’t as

common as in women older than 40 years. Data from the previous 10 years will be compared to

the succeeding 10 years post-implementation.

Clarify genetic risk factors. Women aged 29-39 years in Madison County may not

fully understand the role genetics play as a breast cancer risk factor. The breast cancer survivor

that was interviewed mentioned that she had never really thought about breast cancer previous to

BREAST CANCER EDUCATION 39

her diagnosis since it did not run in her family. Although family history does heavily influence a

woman’s personal risk for breast cancer, genetics are only responsible for 15% of all breast

cancer diagnoses (American Cancer Society, 2018b). Women aged 29-39 years in Madison

County need to be aware that this means that 85% of women diagnosed with breast cancer have

no family history or other genetic link to breast cancer. This will help avoid a false sense of

security and bring more knowledge and awareness to one’s own personal risk for developing

breast cancer.

Awareness and education about breast cancer risk and genetic factors can be brought to

the community via a simple billboard. The billboard can present the above-mentioned statistics

in a location where a majority of the community will see it. Evaluating the effectiveness of the

billboard may be difficult; however, physician’s offices and other health care facilities in

Madison County can keep track of the number of women aged 29-39 years who ask more

questions regarding their personal risk factors both before and after the billboard

implementation. If there is an increase in the number of women aged 29-39 years in Madison

County who ask more questions, indicating an increase in proactive health education, then it may

be that the billboard was effective in its purpose.

Reflection

I really enjoyed completing this project. As a breast cancer survivor, I am passionate

about wanting every woman to be aware of her own body and what changes need to be followed

up with by a primary care physician. I will be forever grateful that I sought medical attention

quickly and that my doctor did not just brush it off since I was only 30 and had no family history

of breast cancer, or any cancer for that matter. Although I am passionate about this topic, I

recognize that my personal crusade may not be as important or as powerful as I think it should

BREAST CANCER EDUCATION 40

be. The statistics for being diagnosed at the younger age group is relatively low. However,

being a fighter and then a survivor has put me in unique opportunities to meet other younger

women who were diagnosed at later stages. It is heartbreaking to me to know these young

mothers and women who should have much life left in them become forever fighters – or those

who end up fighting for the rest of their (shortened) lives and never reach survivor status. Being

able to research the topic, helped me better realize what exactly could be done to help other

younger women out. It also helped me realize that although I feel like breast cancer information

should be available EVERYWHERE, there may be other community needs that take priority

over this demographic and problem. Researching the topic helped me truly assess the

community needs and come up with more realistic goals to improve breast cancer education for

younger women, without going overboard or just jumping in and implementing all these

unneeded and unnecessary strategies.

I can take these skills and be more successful in the workforce by remembering to assess

the specific needs and goals of a target population. This can be true for individuals as well. I

will not get very far with a patient if I do not take the time to figure out what he or she already

knows and what they are willing to try. I can’t just jump in and start implementing all these

interventions without a good foundational knowledge base of my client (whether an individual or

a community).

Most of my assessments focused on what was available in clinics or at the District Health

Office. I realize that there may be a portion of the target population that have never visited one

of these places or at least do not visit very frequently due to low incomes or other stressors. This

project helped me realize where health disparities exist, or at least where the weaknesses are and

that effort needs to be placed to reinforce those areas.

BREAST CANCER EDUCATION 41

This project helped change my thought processes by really focusing on what the

community needs the most. If my implementations save a few lives over the course of several

years, those implementations will be valuable. But if those resources were spent somewhere else

and could make a better life for more people, then I need to be okay with letting my crusade go

for the time being. It was personally beneficial for me to see how important it is to use evidence-

based practice to solidify goals and reinforce the needs of the community. Resources are

valuable and need to be used in a way to help the most community members.

BREAST CANCER EDUCATION 42

References

American Cancer Society. (2018a). American cancer society recommendations for the early

detection of breast cancer. Retrieved from https://www.cancer.org/cancer/breast-

cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-

for-the-early-detection-of-breast-cancer.html

American Cancer Society. (2018b). Breast cancer risk factors you cannot change. Retrieved from

https://www.cancer.org/cancer/breast-cancer/risk-and-prevention/breast-cancer-risk-

factors-you-cannot-change.html

American Cancer Society. (2018c). Cancer facts and figures 2018. Retrieved from

https://www.cancer.org/research.html

American Cancer Society. (2018d). Lifestyle-related breast cancer risk factors. Retrieved from

https://www.cancer.org/cancer/breast-cancer/risk-and-prevention/lifestyle-related-breast-

cancer-risk-factors.html

Brigham Young University – Idaho. (2018). Ariel photos of BYU-Idaho campus. Retrieved from

http://photo.byui.edu/mediaphotos/h718DCAFE#h718dcafe

CBS News. (2015). American Cancer Society changes mammogram guidelines. Retrieved from

https://www.cbsnews.com/news/american-cancer-society-changes-mammogram-

guidelines/

City of Rexburg. (2018). City history. Retrieved from http://rexburg.org/pages/city-history

Community Commons. (2018a). Community health needs assessment: Madison County, ID:

Clinical care. Retrieved from https://assessment.communitycommons.org

Community Commons. (2018b). Community health needs assessment: Madison County, ID:

Demographics. Retrieved from https://assessment.communitycommons.org

BREAST CANCER EDUCATION 43

Community Commons. (2018c). Community health needs assessment: Madison County, ID:

Health behaviors. Retrieved from https://assessment.communitycommons.org

Community Commons. (2018d). Community health needs assessment: Madison County, ID:

Health outcomes. Retrieved from https://assessment.communitycommons.org

Community Commons. (2018e). Community health needs assessment: Madison County, ID:

Social and economic factors. Retrieved from https://assessment.communitycommons.org

County Health Rankings and Roadmaps. (2018). Madison Idaho. Retrieved from

http://www.countyhealthrankings.org/app/idaho/2017/rankings/madison/county/outcomes

/overall/snapshot

Eastern Idaho Public Health. (2018). Cancer programs. Retrieved from

https://eiph.idaho.gov/Health%20Promotion/Cancer/cancermain.htm

Healthy People 2020. (2018). Cancer. Retrieved from

https://www.healthypeople.gov/2020/topics-objectives/topic/cancer

Madison County. (2018). Geography. Retrieved from https://www.co.madison.id.us/about-

us/geography

Madison Library District. (2018). About us. Retrieved from https://madisonlib.org/about-us/

Madison Memorial Hospital. (2018a). Cancer support group. Retrieved from

https://madisonmemorial.org/cancer-support-group/

Madison Memorial Hospital. (2018b). Our history: A legacy of caring. Retrieved from

https://madisonmemorial.org/about-us/our-history/

National Cancer Institute. (2018a). Breast cancer risk assessment tool. Retrieved from

https://www.cancer.gov/bcrisktool/

BREAST CANCER EDUCATION 44

National Cancer Institute. (2018b). Cancer stat facts: Female breast cancer. Retrieved from

www.cancer.gov

Susan G. Komen Foundation, Inc. (2018). Age-specific rates of breast cancer in the United

States. Retrieved from https://ww5.komen.org/BreastCancer/GettingOlder.html

Susan G. Komen Idaho Montana. (2018). What is breast cancer, warning signs. Retrieved from

https://komenidahomontana.org/about-breast-cancer/what-is-breast-cancer-warning-

signs/

United States Census Bureau. (2018). Quick facts Madison County, Idaho. Retrieved from

https://www.census.gov/quickfacts/table/PST120214/16065/accessible