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Risk factors for breast cancer

OCT 2011 Gender, This is the strongest risk factor for breast cancer. Men can develop breast cancer, but its 100 times more common in women than men, mostly because womens breast tissue is far more exposed to hormones such as estrogen that promote abnormal cell growth. SOURCE:http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2011/Octo ber/risk-factors-for-breast-cancer

Epidemiology and risk factors for breast cancer

Authors Mary E Costanza, MD Wendy Y Chen, MD, MPH

In the US, breast cancer is the most common female cancer, the second most common cause of cancer death in women, and the main cause of death in women ages 40 to 59. About one-half of cases can be explained by known risk factors, such as age at menarche, first live birth, menopause, and proliferative breast disease. An additional 10 percent are associated with a positive family history. Understanding the risk factors for breast cancer permits us to identify women at increased risk and to intervene to modify risk, both individually and societally. Literature review current through: Apr 2012. | This topic last updated: Jan 29, 2012. SOURCE:http://www.uptodate.com/contents/epidemiology-and-risk-factors-for-breast-cancer

Breast Cancer Prevention with Older Women: A Gender-Focused Intervention Study DONNA E. HURDLE Breast cancer continues to be the most frequently diagnosed cancerin American women, with older women at highest risk (AmericanCancer Society [ACS], 2007). In this study, the researcher exploredwhether an educational intervention using feminist pedagogical methods would affect the use of breast cancer screening methods(mammography and breast self-exam) by older women. At 6-monthfollow-up, those women receiving the education intervention were found to have signicantly increased their use of screening methods in comparison with a control group of women of similar age fromthe same community. The results of this study indicate support for the use of gender-focused educational methods with an emphasis on empowerment to increase the cancer screening practices of older women. Cancer is the leading cause of death for American women between 40 and 79 years of age (Greenlee, Hill-Harmon, Murray, & Thun, 2001). Of the various cancers common in American women, breast cancer is the most frequently occurring cancer and is more than twice as prevalent as lung cancer and nearly four times as prevalent as colon cancer (Greenlee et al. 2001). The American Cancer Society (ACS) estimates that more than 178,480 new cases of breast cancer will develop in women during 2007, which is 26% of all cancers and almost twice as many as other sites (ACS, 2007). Breast cancer kills more than 40,000 women per year, and is the second most deadly cancer for women (ACS, 2007). While primary prevention is possible for some diseases using good diet, exercise, and appropriate vitamins, for most Received 12 June 2005; accepted 25 June 2007. Address correspondence to Donna E. Hurdle, Ph.D., Department of Social Work, University of North Carolina at Wilmington, 601 S. College Road, Wilmington, NC 28403, USA. E-mail: hurdled@uncw.edu 872Breast Cancer Prevention Study 873

cancers it is secondary prevention (early detection through the use of various screening methods) that is the best hope for saving lives. While extensive research has been undertaken to identify effective means of promoting breast cancer screening in high-risk groups, most approaches have not been particularly effective (Vernon, Laville, & Jackson, 1990). As more than half of all breast cancer deaths occur in older women, this is one group that desperately needs to increase its use of cancer detection procedures (American Geriatrics Society [AGS] Clinical Practice Committee, 2000). Various research studies have targeted this population, and some approaches have been effective in increasing the use of mammography and breast self-exam by older women; however, these efforts have required intensive health education outreach efforts that are not feasible in community-based clinic or human service settings. Research into effective methods of secondary prevention is needed to increase the use of breast cancer screening by women in their later years; this then could be routinely incorporated into community services for older women. This study examined whether an educational intervention using feminist pedagogical methods and delivered in community-based settings would improve the use of breast cancer screening practices in older women. This approach shows promise, as it was found to increase the use of mammography and breast self-examination on 6-month follow-up. BREAST CANCER AND SCREENING PRACTICES IN OLDER WOMEN The incidence of breast cancer has risen steadily in the last 30 years, with older women disproportionately affected (Greenlee et al., 2001; ACS, 2005). Nearly half of all breast cancers occur among women older than 65 years, as well as more than half of the breast cancer deaths (AGS Clinical Practice Committee, 2000). Incidence rates of breast cancer for women of all ages increased in the 1980s, with women over 50 years having the highest rates; since that time, rates have declined for women in their forties, while the rates for women 50 and older continue to increase (ACS, 2005). While mortality rates have fallen slightly in recent years due to greater screening efforts and more effective treatments, they vary signicantly by ethnic/racial and age groups. Survival rates are reduced signicantly for older women, women of color, poor women, and women without health insurance (AGS Clinical Practice Committee, 2000; Eley et al., 1994). Recent reports identify that while Black women had a 9% lower cancer rate than White women, they had an 18% higher death rate (Kaiser Family Foundation, 2007). Such disparities reinforce the importance of cancer prevention activities. Despite the advances in medical science, breast cancer cannot be prevented; however, the use of breast cancer screening methods, such as874 D. E. Hurdle mammography, clinical breast examination, and breast self-examination, can greatly increase survival by identifying and treating the cancer in its early stages. The ACS recommends that women aged 40 and older obtain a yearly mammogram and an annual clinical breast examination; monthly breast self-examination is optional but encouraged (ACS, 2005). Despite these recommendations, the use of breast cancer screening methods varies greatly by womens age, ethnicity, socioeconomic status, and insurance coverage. Womens use of mammography decreases as they age, as does their use of both clinical and breast self-examination (ACS, 2005; AGS Clinical Practice Committee, 2000). Studies have found that older women have less knowledge about and are less likely to perform breast self-examination (Dunbar, Begg, Yasko, & Bell, 1991; Millar & Millar, 1992). Less educated women and those without health insurance also have signicantly lower use of mammography and clinical exams (ACS, 2005; Makuc, Fried, & Parsons, 1994). Women of color use breast cancer screening methods less frequently than Caucasian women at all ages. Nationwide studies have found that the women most likely to be unaware of the need for a mammogram and never to have received one are women of color, low-income women, and women with a high school education or less (Centers for Disease Control, 1993; Wirthlin Group, 1992). As breast cancer has become a signicant public health problem,

a variety of research studies and community education programs have been developed to encourage the use of breast cancer screening methods, particularly for women at greatest risk. Risk groups are identied as older women, women of color, women of lower socioeconomic status (SES), and those with limited formal education. Paradoxically, while many educational efforts have targeted these groups of women, they actually have provided screening to women at low risk: those who were younger, White, educated, and middle-class (Mayer et al., 1992; Vernon et al., 1990). Typically, breast cancer screening programs are designed either for women living in a dened geographical area or those who use a particular health care provider, such as a public health clinic or a health maintenance organization (HMO). Screening programs located in a medical environment have been more successful than media-based efforts in serving high-risk populations. This may be due to the fact that targeting a clinic population ensures that subjects are receptive to health care and have access to a medical provider. Community-based programs have had mixed success in recruiting high-risk women for mammograms. Those bringing services to residential settings (mobile mammography) or using outreach techniques (home visits) have been successful, but they typically are part of demonstration or research projects that last for a short period of time (Champion, 1994; King, Rimer, Seay, Balshem, & Engstrom, 1994; Polednak, Lane, & Burg, 1993; Rimer et al., 1992; Skinner, Arfken, & Waterman, 2000). Worksite-based programs also have been useful (Allen, Stoddard, Mays, & Sorensen, 2001), but this typeBreast Cancer Prevention Study 875 of intervention is not appropriate when older women are the target, as they are more likely to be retired. Other types of breast cancer prevention outreach are necessary that are easily accessible, low cost, and can be readily incorporated into on-going social and health programs for high-risk women. THEORETICAL BASIS FOR THE STUDY In order to address the limitations of typical breast cancer prevention efforts, an educational intervention targeting older women was developed that could be implemented by health care workers in community-based settings. This educational intervention was based on theories related to womens development and specic learning needs, with a goal of applicability to diverse groups of women with different literacy abilities. As previous research into wellness education with seniors has found that programming in community senior centers is effective in changing the health practices of older people for years postintervention, this venue was chosen as the program location for the study (Lalonde & FallCreek, 1985; Lalonde, Hooyman, & Blumhagen, 1988). Two gender-based theories were used as the basis for the intervention tested in this research study. The self-in-relation theory developed by Miller (1976, 1991b; Miller & Stiver, 1997), Surrey (1991), and Gilligan (1982) draws attention to the importance of relationships for females at every stage of life development. While traditional developmental theorists trace the evolution of development stages toward a goal of independent functioning in identity formation and moral reasoning, the self-in-relation theorists take a more contextual view (Miller & Stiver, 1997). From this perspective, females concern themselves with growth-fostering relationships at all life stages, and all life decisions are made in the context of these relationships. In regard to health issues, the importance of relationship to others is indicated clearly in the inuence of social support on womens health (Hurdle, 2001). The self-in-relation theory inuenced both the content and the format of the intervention. Topically, there was an emphasis on the importance of connection with others in health promotion, such as the encouragement of participants to connect with a buddy to remind each other monthly to perform breast self-exams and to obtain their yearly mammogram. During the educational intervention, small groups were used in various exercises to encourage the development of new relationships, as many older women are quite isolated and frequently lack social support. The theory underpinning the methodology of the educational intervention in this study is feminist pedagogy.

As womens learning styles are different from mens styles, feminist pedagogies have been developed that maximize the involvement and learning of female students (Belenky, Clinchy, Goldberger, & Tarule, 1986; Goldberger, Tarule, Clinchy, & Belenky,876 D. E. Hurdle 1996). While much of this literature has focused on college education, there have been some efforts to apply this in community settings (Belenky, Bond, & Weinstock, 1997; DAbundo, 2007; Maher & Tetreault, 1994). DAbundo (2007) identies feminist pedagogy as a useful framework for aerobics and wellness instruction with women, and emphasizes creating an inclusive environment, distributing authority and power between the instructor and participants, and encouraging interaction. Nursing education clearly has identied feminist pedagogy as a useful framework for educating their students, and this approach also can be translated into community health education programs (Morse, 1995). Elements of the educational intervention used in this study that relate to feminist pedagogy were an emphasis on personal empowerment, connection of personal experience with new information, sharing life stories among participants, and developing connection and support. The educator/researcher deemphasized her role as an authority gure, and encouraged a collaborative atmosphere in the education sessions. Some theorists emphasize that empowerment is an important goal in working with older women (Brown, 1995). The concept of social support also was inuential in this study, both as an essential element of feminist pedagogy and as a research variable. Research indicates that social support is inuential in womens use of cancer screening, in obtaining mammograms, pap smears, and breast exams (Kang & Bloom, 1993; Kang, Bloom, & Romano, 1994; Suarez, Lloyd, Weiss, Rainbolt, & Pulley, 1994). Social support also has been found to inuence the health status of older persons, their use of a variety of preventive health behaviors, and their ability to cope with chronic disease (Ell, 1984; Gallo, 1982, 1984; McNicholas, 2002; Minkler, Schaufer, & Clements-Nolle, 2000; Seeman, 2000). Social support has been linked to mortality, as various studies have shown decreasing levels of social support are associated with increasing mortality for individuals of all ages (Seeman, 2000). The importance of social support is so signicant that it is now being integrated into studies designed to improve the health of older people (Hurdle, 2001; Minkler et al., 2000). Intergenerational and senior volunteer programs also have increased as other ways to increase the social support of older persons living in the community. In this study, social support was investigated as a variable inuencing the use of breast cancer screening and also guided the design of the intervention through the use of small groups and activities that required participants to become involved with others in various ways. RESULTS The sample used for data analysis completed both the pretest and posttests; these women were predominantly Caucasian, with some women of Asian/Pacic Islander, African American, or Native American ethnicity. Most participants were between the ages of 66 and 75 years, with a mean of 71.84 years, and were widowed or divorced. Regarding education completed, most subjects were either high school graduates or had completed one year of college. Most subjects fell in the low or middle range of SES. demographic characteristics; however, more experimental group subjects were Caucasian, divorced, and high school graduates compared with the control group, but this was not a signicant difference. This information is presented in Table 1. In comparing the use of breast cancer screening by women in this study with national studies, they were somewhat lower in their use of breast cancer screening methods. While all subjects had a mammogram at some time, only about half had a mammogram within the previous year. Recent national data collected by the Center for Disease Controls Behavioral Risk Surveillance System indicate that 75% of women aged 65 to 74 years had a mammogram within the last 2 years (Minkler et al., 2000). Yearly

mammography is recommended for all women over 50 years of age by the ACS; however, older women are less likely to be screened than younger lower-risk women (AGS Clinical Practice Committee, 2000). Regarding the use of breast self-examination, while most subjects reported that they Breast Cancer Prevention perform this practice, only about a third completed the exam each month as is recommended. Table 2 presents use of mammography and breast self-exam by medical guidelines for the control and experimental groups. These two groups are nearly identical in their usage patterns, with no statistically signicant differences. Overall, individuals in this sample were less compliant with mammography screening than the majority of older women. Looking at the participants use of screening methods by race and ethnicity, we see that more Caucasian women had a mammogram in the last year and performed breast self-examination monthly than did women of color. This nding is signicant in the entire study sample, but not in the sample completing both pre- and post-tests. These ndings parallel the research literature on usage of breast cancer screening methods by ethnicity, and conrm the study hypothesis (see Table 3). Another consistency with national data was found for SES. For the larger sample, a statistically signicant relationship was found between socioeconomic level and breast cancer screening as hypothesized (see Table 4); however, in the smaller sample this was not signicant. National studies have found that women of lower income levels use mammography less frequently than do women of higher incomes (Minkler et al., 2000). This also may be related to education level and access to health care resources. Neither age nor risk factors were found to be signicantly associated with the use of breast cancer screening in this sample. Research has found a relationship between social support networks and use of mammography and other preventive health behaviors (Minkler et al., 2000), but this was not conrmed in this study. In this study, women at different levels of social support were fairly evenly divided into recent use of mammography and breast self-exam; see Table 5. As prior research was based on large samples, the size of this sample may be a factor. Comparing the results of the control and experimental groups on their use of breast cancer screening methods after the 6-month study period, we found that women in the experimental group used both mammography and breast self-examination more frequently than did women in the control group. This was found to be statistically signicant at the P < .05 level, as shown in Table 6. The post-test survey asked subjects whether they had obtained a mammogram during the study period (6 months) and how frequently they had used breast self-exam. Positive responses were coded for obtaining a mammogram during this period and using breast self-exam monthly or bimonthly. While the experimental group was fairly small, this nding indicates that the educational intervention may have been instrumental in encouraging senior women to use breast cancer screening methods. As previously noted, demographic variables and social support do not appear to have inuenced the use of screening methods in these groups. DISCUSSION Health professionals of various disciplines (social work, nursing, health education) can play an important role in health promotion efforts with older women. This study has shown that participation in an educational intervention, based on principles of feminist pedagogy and provided in a community-based setting, was inuential in encouraging older women to use breast cancer screening methods. This is a signicant nding, as this health education approach can be readily used in community-based settings with older women on a variety of health topics. It is also a cost-effective method, as existing health and human service staff (or even volunteers) could be trained to provide the program, thus eliminating the need for grant-funded programs where research assistants perform such an intervention. The subjects in this study were found to have health care practices that are typical of their age and circumstances as compared with national studies. This lends credibility to the suggestion that the intervention used in this study could be

helpful to other groups of older women in various parts of the country. The ndings of this study strongly suggest that health education using feminist pedagogical methods is instrumental in encouraging older women to use breast cancer screening methods, which is critically important to maintaining health during the retirement years. The method developed in this study was not directly compared with traditional health education methods; however, their utility can be ascertained indirectly by the reviewed studies that show limited success in encouraging older women to use breast cancer screening. The innovative approach used in this study, which focused884 D. E. Hurdle on interpersonal support and empowerment, may be more inuential in developing prevention behaviors. Further study in comparison of educational methods could be useful in clarifying this question. Health education using feminist pedagogical methods may be applicable worldwide, and may be of particular benet in countries with a more communal, group-focused culture. Freires (1970) work with impoverished individuals in rural South American countries demonstrated that innovative methods of teaching can raise consciousness and improve literacy and health awareness in various cultural settings. Similarly, using feminist pedagogical methods with women in different countries may build on their inherent bonding and connection to teach them new health and prevention practices. The stronger the naturally occurring bonds between women, the more support they may give one another to engage in preventative health practices. Limitations of the Study As this study used a convenience sample, it cannot be construed as representative of all older women living in this northern city. The number of women participating in the experimental group was smaller than in the control group, and they were predominantly Caucasian; this may limit the interpretation of the ndings for women of color. The small number of women in the experimental group also may limit generalizability. Future studies should emphasize the recruitment of women of color, as this is a signicantly underserved group and may need specially targeted strategies. While this study included few women of color, it was reective of the population of older women in the city in which it was conducted. Overall, the sample was of modest size, which is another limiting factor. Last, the research design used in this study was not as rigorous as a true experimental design, which may somewhat affect the interpretation of the ndings. This approach is typical of community-based studies, however, when random sampling is not considered feasible due to the need to educate as many individuals as possible about an important health topic. CONCLUSION In this study, the researcher has demonstrated that an educational intervention based on feminist pedagogy can be effective in increasing the use of breast cancer screening methods by a sample of older women. Older women are a particularly high-risk group for breast cancer, as they are disproportionately affected by the disease and do not frequently use cancer screening methods. The integration of social support into the educational methodology used in this intervention provides an opportunity for older women to develop new relationships with women proactive about theirBreast Cancer Prevention Study 885 health. The educational method used in this study can be provided by a range of health professionals, and easily can be integrated into senior health programming in community settings. Provided in this manner, breast cancer prevention education can be cost effective for providers and consumers. With the high cost of health care, encouraging early intervention such as screening for breast cancer can make a signicant difference in the lives of older women.