For the approximately one-quarter of American women who face a greater-than-average risk of developing breast cancer, interventions beyond an annual mammogram after age 40 can help reduce their risk of the disease or help detect it at earlier, more treatable stages. Depending on the factors specific to an individual woman with this elevated risk, medical guidelines may indicate that she should have more frequent breast exams by her doctor, begin mammography screening before she turns age 40, regularly obtain breast MRI scans in addition to mammograms, lose weight or take a medication such as tamoxifen. For women with an elevated risk of breast cancer, such cancer control interventions are critical to reducing their risk of dying from this disease.
Yet the limited data available indicate that the vast majority of women eligible for these interventions are not taking advantage of them, and there is very little evidence to explain why. Further, even less is known about what influences minority women at increased risk of breast cancer to follow their doctor’s recommendations for reducing their risks of this disease. A research scientist at the Institute for Health Research and Policy plans to fill this knowledge gap with a two-year grant from the National Cancer Institute (NCI).
Silvia Tejeda, who completed a post-doctoral fellowship funded by the NCI in 2011, is examining the knowledge, attitudes, beliefs and perceptions of risk for breast cancer among minority women and learning whether these change after their physicians tell them they face an increased risk of developing the disease.
Tejeda’s study supplements a larger research project that aims to detect breast cancer earlier and reduce its incidence among African-American and Latina women by identifying those at increased risk for the disease. For that study, Kent Hoskins, has developed an intervention that introduces a computer-based tool to help primary care physicians in community health clinics help identify women at risk for breast cancer and address this risk. The tool helps doctors assess a woman’s breast cancer risk, based on such factors as family history, reproductive history and lifestyle practices, and then tailor recommendations for surveillance and primary prevention according to her specific risk level, based on national guidelines. Following these guidelines, the physician may recommend starting breast cancer screenings at a younger age or more frequent screening, enhanced breast imaging with an MRI, risk reduction with selective estrogen receptor modulators (like tamoxifen) or referral to a geneticist to discuss DNA testing and preventive surgeries, depending on the patient’s risk.
Hoskins’s research is one of the key projects of the NCI-funded Center for Population Health and Health Disparities, based at IHRP.
Most women in the United States face a lifetime risk of one in eight chances of developing breast cancer. But 15 to 20 percent of American women face a moderate risk (say, one in five or six chances) for developing the disease over their lifetime, and that risk is doubled, tripled or quadrupled for five to ten percent of American women.
“We know that African American women and Latinas are at risk for more advanced disease and poorer survival rates for breast cancer,” Tejeda said. In Hoskins’s study, in which she’s a co-investigator, “we can potentially identify women at greater risk at the primary care level. So when they are diagnosed, if they are diagnosed, their breast cancer will be at an earlier stage, so we can treat them earlier.”
More than 800 women at moderate or high risk will be enrolled in Hoskins’s study, from which Tejeda will recruit 150 African-American women and 150 Latina women. Half will be at high risk for developing breast cancer in their lifetime and half at moderate risk. Tejeda will survey the women two weeks after the appointment at which they learned about their breast cancer risk.
Previous research indicates a physician’s recommendation is powerful, Tejeda said.
“We think in these populations women may have fatalistic attitudes and beliefs about breast cancer,” she said. “So if their doctor says, ‘You’re not going to die from this; there’s something we can do to reduce your risk,’ we believe these changes (in approach) can increase adherence” in screening recommendations and other follow-up care.
By identifying how doctors motivated their patients to follow their advice for increased care, this study will help “inform physicians and interventions on what to include and what type of conversation is needed between the physician and the patient,” Tejeda said.
Besides addressing these scientific questions, Tejeda’s $280,000 grant is intended to help establish her career as an independent researcher. It will allow her to enroll in classes and travel to conferences. She hopes this work will lead her to develop further interventions to reduce cancer disparities among low-income women, especially Latinas. To help her achieve that goal, she will work closely with another mentor, Melinda Stolley, a psychologist and associate professor of medicine who specializes in behavioral interventions among minority populations.
“I see myself as a behavioral interventionist,” said Tejeda, whose doctoral dissertation focused on mammography screening of Latinas in rural Washington state. “My interest has always been Latinas. Since I’m Mexican, it feels very appropriate to be working with this population.”