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Concordia University Nebraska

Mazalo Looky

Dr. Davila

MPH 510, Fall 2012

December, 20, 2012

Week 8 Assignments - Capstone Screening Project

Dear Mazalo,

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Score: 85. Good job but some areas improvement, see comments below. Also, I wanted this in a

paper format with full continuous paragraphs like when you read articles/manuscripts, not in the

format you presented. I explained this in the discussion board, perhaps you did not see.

The Screening Capstone project is a paper that addresses the following:

1. Select a disease/condition (other than prostate cancer) that is commonly screened for and

that you have a personal and/or professional interest in.

I picked breast cancer because my cousin’s mother died for it in Africa last year. My cousin

said that when they find out that her mother had the breast cancer, the doctor told them the

option to do the surgery before it spread in her mother’s body, but her mother refused and said

that she will only need traditional medicine to cure her cancer. My cousin then called me here in

the U.S to see if there is something I can do to help them out. I then told her yes because her

mother can go through treatment and live longer than before. Her mother said no that she think

they can take good care of her while in Africa. After a year of her diagnostic, her daughter has

decided to send her to China for the treatment. She then started going through the formalities to

travel, but this did not take her mother longer to discover that her cancer has metastasized in her

body. I was still calling and supporting them and asking them if they still want to come in U.S or

go to China for treatment. In the length of two years, her mother died without going through a

proper treatment and this was very sad because if it was caught early, she could have get more

help and live longer.

Breast cancer is the second leading cause of cancer death in the United States, and leads to

about 40,000 deaths annually among all women (CDC, 2012). According to “Breast Cancer

Basic Facts”, breast cancer is defined as a group of diseases that cause cells in the body to

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change and grow out of control. Most cancer cells form a lump or mass called a tumor and are

named after the part of the body where the tumor originates. Breast cancer begins in breast

tissue. In fact, the breast tissue is made up of glands for milk production that is called lobules and

the ducts which connect the lobules to the nipple. The rest of the breast part is made up of fatty,

connective, and lymphatic tissue. In this, most breast cancer masses are benign, which means

that they are not cancerous, they do not grow uncontrollably or spread and are not life-

threatening (Alteri & Bandi, 2012).

According to “Breast Cancer Basic Facts”,

“Some breast cancers are called in situ because they are confined within the ducts

(ductal carcinoma in situ or DCIS) or lobules (lobular carcinoma in situ or LCIS)

where they originated. Many oncologists believe that LCIS (also known as lobular

neoplasia) is not a true cancer, but an indicator of increased risk for developing

invasive cancer in either breast” (Alteri & Bandi, 2012).

2. Identify a specific target population, setting, and location (city and/or state) for which this

screening is appropriate and indicated.

African American women in North Carolina age 24 to 40.

Breast cancer increases with age. There are 95% percent of new cases and 97% of breast

cancer deaths occurred in women 40 years of age and older. African American women are more

likely to get breast cancer between age 24 and 40. However, they are less likely than white

women to get breast cancer after age 40 (Angelou, 2011). At the same time, breast cancer did not

stop at that age, but can be also found among other generation. Risk factor including family

history of mother, sister, or daughter developing premenopausal breast cancer, age more than 50,

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menses begins before age 12, no children or first pregnancy occurs after age 30, menopause after

age 55 (Angelou, 2011). More risk factors is shown in the table below:

Factors That Increase the Risk for Breast Cancer in Women

Relative Risk Factor

>4.0 Age (65+ vs. <65 years, although risk increases across all ages until

age 80)

• Biopsy-confirmed atypical hyperplasia

• Certain inherited genetic mutations for breast

cancer (BRCA1 and/or BRCA2)

• Mammographically dense breasts

• Personal history of breast cancer (Alteri & Bandi, 2012).

2.1-4.0 High endogenous estrogen or testosterone levels

• High bone density (postmenopausal)

• High-dose radiation to chest

• Two first-degree relatives with breast cancer (Alteri & Bandi,

2012).

1.1-2.0 • Alcohol consumption

• Ashkenazi Jewish heritage

• Early menarche (<12 years)

• Height (tall)

• High socioeconomic status

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• Late age at first full-term pregnancy (>30 years)

• Late menopause (>55 years)

• Never breastfed a child

• No full-term pregnancies

• Obesity (postmenopausal)/adult weight gain

• One first-degree relative with breast cancer

• Personal history of endometrium, ovary,

or colon cancer

• Recent and long-term use of menopausal hormone therapy

containing estrogen and progestin

• Recent oral contraceptive use (Alteri & Bandi, 2012).

American Cancer Society Guidelines for the Early Detection of Breast Cancer in

Average-risk, Asymptomatic Women age 20-39: Clinical breast examination at least every 3

years, breast self-examination (optional). Age 40 and over: Annual mammogram, annual clinical

breast examination (preferably prior to mammogram) and breast self-examination is optional

(Alteri & Bandi, 2012).

3. Access screening epidemiological data and studies from the CDC and/or other sites for

the different tests.

Mammography screening, clinical breast examination and breast self-examination are

three methods that are used to detect breast cancer early. It is recommended that women after age

40 should get mammogram screening done each year to detect breast cancer. A mammogram is

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an X-ray picture of the breast. According to the Center of Disease Control and prevention

(CDC), Black women still have higher breast cancer death rate that is about 41% higher than

white women. This finding is based on 2005 to 2009 data, showing that even though African-

American women have a lower incidence of breast cancer, they are more likely to die of this

disease than women in any other racial or ethnic group. According to CDC, if one takes 100

people who have breast cancer, there will be nine more deaths among black women diagnosed of

breast cancer compared to white women. Based on self-report data, mammogram may be less use

among African American women. The study has showed that black women more commonly

have subtypes of tumors that are harder to treat, especially a kind called triple negative breast

cancer (CDC, 2012).

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Mammogram Images of Breast

http://www.bing.com/images/search?

q=Mammogram+Images+Of+Breast+Cancer&FORM=RESTAB#

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Angelou in North Carolina has provided some tips for breast cancer:

She said that if someone has age 40 or above, she should get regular mammograms and breast

exams that she should talk to her health care provider about how often. Spread the word to

women you know to do the same. She also said that breast cancer that is detected early is usually

more treatable. If one has been diagnosed with breast cancer, she should think about seeking

treatment from one of the three Comprehensive Cancer Centers in North Carolina or from

another large cancer center. If you know of other African American support groups in North

Carolina, or if you are forming one yourself, please let us know at 800.514.4860 or

http://www.bcresourcedirectory.org. She said if one needs help paying for mammograms or

treatment, to see Financial and Other Assistance and that one should be an advocate for her

health care. If you have been diagnosed with breast cancer, become informed about your

diagnosis, treatment, and long-term follow-up care. She wants African American woman to

participate in making decisions about their own care and too use the Resource Directory to help

them learn more about their options and to find additional resources for more information.

Women should communicate as much and as openly as possible with their healthcare providers

and if they are not comfortable talking openly with a provider, they should look for another in

whom they can trust. Angelou concluded that women should think about attending a support

group for African American women or joining an African American breast cancer advocacy

organization or consider starting their own support group (Angelou, 2011).

4. If possible, either locate or calculate sensitivity, specificity, PV+ and PV-, LR+ and LR-,

for the given tests and interpret the results including discussion on validity and bias.

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Sensitivity is defined as the percentage of women with a previous breast cancer

documented in the cancer registries or pathology databases who self-reported a prior breast

cancer while specificity is defined as the percentage of women without a previous documented

breast cancer and with a prior (assumed accurate) self-report of no breast cancer who, on a

subsequent questionnaire, self-reported no prior breast cancer.

According to “Accuracy of Self-reported Breast Cancer Among Women Undergoing

Mammography”, researchers took 24,631 women with and 463,804 women without a prior

diagnosis of breast cancer who completed a questionnaire that included their breast cancer

history at participating U.S. mammography facilities between 1996 and 2006. They determined

true cancer status using cancer registries and pathology databases. They also used multivariable

logistic regression models to examine associations with patient factors and pathologic findings

(Abraham & et al, 2009).

As a result, they discovered that sensitivity of self-reported breast cancer was higher for

women with invasive cancer (96.9%) than for those with ductal carcinoma in situ (DCIS)

(90.2%). Also, the specificity was high overall (99.7%), but much lower for women with a

history of lobular carcinoma in situ (LCIS) (65.0%). For multivariable models, women

reporting older ages, a nonwhite race or ethnicity, or less education had lower sensitivities and

specificities. Thus, sensitivity was reduced when there was evidence of prior DCIS, especially

when this diagnosis had been made more than 2 years before questionnaire completion. Finally,

women reporting a family history of breast cancer had higher sensitivity; therefore, evidence of

prior LCIS was associated with lower specificity (Abraham & et al, 2009).

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Positive predictive value (PPV) is the chance that a person with a positive test has cancer.

NPV is the chance that a person with a negative test does not have cancer. PPV and to a lesser

degree, Predictive negative value (NPV) are affected by the prevalence of disease in the screened

population. For a given sensitivity and specificity, the higher the prevalence, the higher the PPV.

Positive Likelihood Ratio (LR+): Rule-In Condition1.Extent to which a positive test

increases the likelihood that a patient has that disease.

LR Positive (LR+) = (0.97)/ (1-0.997) = 97. A positive Mammogram is highly suggestive of

Breast Cancer.

LR Negative (LR-) = (1-0.969)/ (0.997) = 0.31.A negative Mammogram is very

reassuring.

Based on fair evidence, screening mammography in women aged 40 to 70 years

decreases breast cancer mortality. The benefit is higher for older women, in part because their

breast cancer risk is higher.

Validity: Validity of randomized controlled trials (RCTs) varies from poor to good.

Internal validity of meta-analysis is good.

Bias: Lead-time bias: Survival time for a cancer found mammographically includes the

time between detection and when the cancer would have been detected because of clinical

symptoms, but this time is not included in the survival time of cancers found because of

symptoms. Length bias: Mammography detects a cancer while it is preclinical, and preclinical

durations vary. Cancers with longer preclinical durations are more likely to be detected by

screening; these cancers tend to be slow growing and to have good prognoses, irrespective of

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screening. Overdiagnosis bias: An extreme form of length bias; screening may find cancers that

are very slow growing and that would never have become manifest clinically. Healthy volunteer

bias: The screened population may be healthier or more health conscious than the general

population.

5. Discuss ethical considerations as a public health professional and specifically as an

epidemiologist.

Lack of health insurance, low socioeconomic status, and lack of social support (Mattox,

2011). Breast cancer is eventually a burdensome on African American women. Although the

incidence of breast cancer is highest in White women, on African American women have a

higher breast cancer mortality rate than any other racial or ethnic group at every age.

There are five-year survival rate for breast cancer among on African American women

that is 73% compared to 88% among White. Despite many programs that are aimed to increase

breast cancer screening rates among AAW and research studies aimed to identify variables that

relate to AAW compliance and acceptance of breast cancer screening activities.

Some ethics arose from the study of breast cancer screening on African American

women including: attitudes, beliefs and perceptions; barriers; decision making; factors

influencing breast cancer screening behaviors; design and evaluation of research instrumentation;

assessment of breast cancer educational and outreach interventions; and utilization of breast

cancer screening services. These perceptions are predominate concepts in breast cancer screening

behavior of AAW. There also existed some misperceptions, fear and fatalism among African

American women (Conway-Phillips & Millon-Underwood, 2009).

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6. Based on the research and findings, ethical considerations, as well as the discussion on

the controversies of screening, discuss: what screening test would you recommend for your

city/state and for what target population and in what setting. Why?

I will recommend to my state to encourage women to get mammogram done once they

turn 40 each year because CDC epidemiologist in CDC said that to detect early breast cancer,

one must undergo a mammogram screening, but from age 12 and over women should be able to

do self-breast examination.

How you would you go about increasing the participation levels in the screening?

By educating, talking to women, and referring them to the places where they can get help

financially as stated Maya Angelou.

What role should public health play in increasing screening participation e.g. but not

limited to education, funding, access, etc.?

In this situation, education alone is not usually effective in changing people’s behavior.

One must have a social connection or relationship formed between him or her or a nurse and

patient for results to be seen. If it happen to someone to be a nurse, he or she must have one

effective approach for dealing with non-adherent patients that could be the use of motivational

interviewing. In fact, motivational interviewing is a client-centered counseling style with the goal

of changing the behavior of your clients. Usually emotions are involved thus, clients cannot be

convinced or compelled to absorb new information. Instead, nurses should maintain calm, quiet

and clients tone and encourage them to speak. Nurses perhaps need to express empathy and

cultural sensitivity with their clients. This means an acknowledgement of the some of the

common misconceptions about breast cancer screening for African American clients (Mattox,

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2011). As a result, beside the education and financial support, public health should open more

rooms or space when women can get screen more for the breast cancer.

Conclusion:

With breast cancer, early detection of a lump in the breast is treatable that late detection.

One should do self-breast examination starting age 12 and do mammogram screening at age 40

each year. And if detected early make sure you seek for treatment.

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References:

Abraham, L. Geller, B. Yankaskas, B. Bowles, E. Leah S. Stephen, K. & Miglioretti, D. (2009).

Accuracy of Self-reported Breast Cancer Among Women Undergoing Mammography retrieved

from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784159/

Alteri, R., & Bandi, P. (2012). Breast cancer facts & figures 2011-2012. Retrieved from :

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/

document/acspc-030975.pdf.

Angelou, M. (2011). Breast cancer resource directory of North Carolina. Retrieved from:

http://bcresourcedirectory.org/directory/05-african_american.htm

Benard, V. B., Saraiya, M. S., Soman, A., Roland, K. B., Yabroff, K., & Miller, J. (2011).

Cancer Screening Practices among Physicians in the National Breast and Cervical Cancer

Early Detection Program. Journal Of Women's Health (15409996), 20(10), 1479-1484.

Breast Cancer Screening Modalities Retrieved from:

http://www.cancer.gov/cancertopics/pdq/screening/breast/HealthProfessional/page4.

Conway-Phillips, R., & Millon-Underwood, S. (2009). Breast cancer screening behaviors of

African American women: a comprehensive review, analysis, and critique of nursing

research. ABNF Journal, 20(4), 97-101.

Do it yourself. Breast self-examination. Retrieved from: http://www.bing.com/images/search?

q=image+of+breast+self+examination&id=4364DE66E675C92689B4BC787B030D59D

DE08D17&FORM=IQFRBA#

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Mammogram Images of Breast Retrieved from: Cancerhttp://www.bing.com/images/search?

q=Mammogram+Images+Of+Breast+Cancer&FORM=RESTAB#

Mattox, K. (2011). Lack of adherence to breast cancer screening guidelines in African American

women in the community health setting. JOCEPS: The Journal Of Chi Eta Phi Sorority,

55(1), 19-23.

Landau , E. (2012). Centers for disease control and preventionbreast cancer. Retrieved from

http://www.cdc.gov/cancer/breast/basic_info/screening.htm

Phillips, J., & Cohen, M. Z. (2011). The Meaning of Breast Cancer Risk for African American

Women. Journal of Nursing Scholarship, 43(3), 239-247.

Reiter, P. L., & Linnan, L. A. (2011). Cancer Screening Behaviors of African American Women

Enrolled in a Community-Based Cancer Prevention Trial. Journal Of Women's Health

(15409996), 20(3), 429-438.

Rosenzweig, M., Brufsky, A., Rastogi, P., Puhalla, S., Simon, J., & Underwood, S. (2011). The

attitudes, communication, treatment, and support intervention to reduce breast cancer

treatment disparity. Oncology Nursing Forum, 38(1), 85-89.