1. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment Among Racial and Ethnic Minority Women Christopher Masi, MD, PhD Dionne Blackman, MD Monica Peek, MD, MPH University of Chicago American Cancer Society’s Bridging the Health Care Divide New Orleans, Louisiana April 19, 2007

2. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Racial/Ethnic Disparities in Breast Cancer Incidence & Mortality, 2000-2003 Ries et al. SEER Cancer Statistics Review, 2006 IncidenceMortality Per 100,000

3. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Racial/Ethnic Disparities in 5-Year Breast Cancer Survival and Risk of Death, 1992-2000 Jemal et al. Cancer 2004;101(1):3-27 Cause-Specific SurvivalAdjusted Relative Risk of Death

4. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Goal  To review the literature and determine which clinic-based initiatives most effectively enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women

5. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Method  MeSH terms from the following categories: –Breast neoplasm –Study design –Racial/ethnic minorities  Databases: –Medline –Cochrane –CINAHL

6. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Method  Inclusion criteria –RCT or CCT –Published 1986-2005 –Clinic-based –Study population > 50% minority or  results analyzed by race if population < 50% minority  Primary and secondary reviewer

7. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Conceptual Model

8. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Results  215 unique citations  154 eligible for full review  42 interventions –screening (36) –diagnosis (5) –treatment (2)  Intervention targets –patients (20) –patients & providers (18) –providers (4)

9. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Screening  I. Patient-targeted Interventions –Reminder-based  More successful at increasing mammography among women with higher educational attainment and previous mammography –Culturally sensitive  Increased mammography and breast self exams among Hispanic and Black women –Multifaceted  Increased mammography regardless of race, ethnicity, education, income

10. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Screening  II. Patient- & Provider-targeted Interventions –Reminder-based  More effective at increasing mammography than patient-targeted interventions alone  Effective even after out-of-pocket mammography cost removed  More impact on mammography than on clinical breast exam

11. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Diagnosis Patient-targeted Case Management –Minimal Model  Outreach, planning, referral  Increased adherence to subspecialty appointments –Coordination Model  Above plus advocacy, casework, reassessment  Increased adherence to subspecialty appointments –Sociomedical Model  Above plus assistance with housing, work, food security, substance use, domestic violence, & mental health services  Increased biopsy rate and shortened time to biopsy  Increased adherence to subspecialty appointments

12. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Treatment Patient-targeted Case Management –Sociomedical Model  1st treatment within 30 days (62% vs. 40% ) (ns)  Median time to treatment (24 days vs. 29 days) (ns) Ell et al. Cancer Practice 2002;10(3):130-138

13. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Treatment Patient-targeted Case Management –Sociomedical Model  Breast conserving surgery (28.6% vs 18.7%) (p=.031)  Radiation therapy (36% vs. 19%) (p=.003)  Breast reconstruction (9.3% vs. 2.6%) (p=.054)  Normal arm function (93% vs 84%) (p=.037) Goodwin et al. Journal of the American Geriatric Society 2003;51:1252-1259

14. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago National Breast and Cervical Cancer Early Detection Program (NBCCEDP)  Federal program which funds breast and cervical cancer screening and diagnostic testing among uninsured and underinsured women  $192 million budget in 2002 1  292,601 mammograms in 2002 1 1 Ryerson & Major. National Breast and Cervical Cancer Early Detection Program: 1991-2002 National Report. 2005

15. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago National Breast and Cervical Cancer Early Detection Program (NBCCEDP)  In 2003, 42% of uninsured women reported having had mammography in previous two years 1  With 6.7 million uninsured women between the ages of 40-64 years, ~3.9 million women are eligible for NBCCEDP- financed mammography 2 2 DeNavas-Walt et al. Income, Poverty, and Health Insurance 2005 1 Nat Center for Health Statistics Health, United States, 2005

16. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) of 2000  Women diagnosed through NBCCEDP can receive treatment through the BCCPTA, a federal program which permits states to extend Medicaid benefits to uninsured women regardless of income or assets.  Focus group study in 2003 revealed knowledge of BCCPTA is limited 1  Increased publicity re. BCCPTA may lead to increased mammography among low-income women 1 1 Kenney et al. Hearing Their Voices, Kaiser Family Foundation, 2004

17. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Conclusions  Causes of racial & ethnic disparities in breast cancer mortality are several and include barriers to screening, diagnosis, and treatment  Multi-faceted interventions are the most effective at increasing mammography among women with lower incomes, lower education, or language barriers  More research is needed regarding interventions to improve treatment among racial/ethnic minority women

18. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Conclusions  With the large number of uninsured Americans, the NBCCEDP and BCCPTA provide much needed support for breast cancer screening & treatment  In the absence of substantive health insurance reform, additional resources should be dedicated to NBCCEDP, BCCPTA, and to interventions which address the range of barriers faced by racial & ethnic minority women

19. Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago Acknowledgments  Dionne Blackman, MD  Monica Peek, MD, MPH  Elbert Huang, MD  Marshall Chin, MD, MPH  Jeroan Allison, MD, MS –Special Issue Editor, Medical Care Research & Review. See October 2007 issue for the paper re. this study.