One in seven Colorado women will have breast cancer at some point in their lifetime. Breast cancer is the most common life-threatening cancer in Colorado women and the third leading cause of cancer death (after lung cancer and colorectal cancer). Despite these numbers, breast cancer mortality rates are actually declining in Colorado. Breast cancer mortality rates have decreased about 1% per year for Caucasian and Hispanic women, and about 7% per year for African American women. In 2007, the overall mortality rate had decreased 15% compared to the 2002-2006 time period. Compared to national rates, Colorado breast cancer mortality rates are 9% lower (Cancer in Colorado 1997-2007, Colorado Central Cancer Registry). According to the National Cancer Institute, approximately 63 percent of all American Indian (AI) and Alaska Native (AN) breast cancer patients are alive five years after diagnosis. This is the poorest five year relative survival of any ethnic and minority group in the United States.
During 2002-2006, Colorado's overall breast cancer incidence rates (new diagnoses) were 1% higher than national rates. For Hispanic women, the Colorado rate was 15% higher than the national rate, but for African American women the rate was 16% lower. In contrast to these findings, 2007 data showed a sharp increase (46%) in the incidence rate for African American women. National data for 2007 are not yet available so it is unknown whether a similar increase occurred nationally (Cancer in Colorado 1997-2007, Colorado Central Cancer Registry). Incidence for American Indian (AI) relys on national incidence data. More than half of the Colorado AI population is from Northern and Southern Plains, rates of breast cancers remain high in these populations.
According to the American Cancer Society, breast cancer is about 100 times less common among men than among women. For men, the lifetime risk of getting breast cancer is about 1 in 1,000. The number of breast cancer cases in men, relative to the population, has been fairly stable over the last 30 years. Men and women with the same stage of breast cancer have a fairly similar outlook for survival.
The breast cancer plan for Colorado has three objectives aimed at decreasing breast cancer morbidity and mortality for Colorado women and men. Objectives include increasing mammography screening rates, increasing compliance with complete diagnostic evaluation and supporting the development and implementation of cancer survivorship care plans. Each objective is discussed based on social determinants of health, evidenced-based interventions and community collaborations with potential impact for change. Social determinants of health are the economic and social conditions in which people live that have an effect on their health conditions. Examples of social determinants include factors such as race/ethnicity, educational attainment, income level, risky health behaviors, access to quality health care and the physical environment in which people live.
Detecting breast cancer early saves lives and increases an individual's treatment options. About 72% of Colorado women are detected at the in situ or localized stage of disease (before the cancer has spread beyond the breast). Regular screening with mammography can lead to early detection of breast cancers. According to 2008 Colorado Behavioral Risk Factor Surveillance System (BRFSS) data, 73% of Colorado women reported having a mammogram within the past two years. This percentage is the same as in 2006, up from 71% in 2004 and down from 74% in 2002.
Recent national studies indicate that racial/ethnic disparities in mammography use have largely disappeared and that emphasis on specific racial/ethnic minority populations for screening may no longer be warranted (Williams, 2002). National BRFSS data for 2008 show that about 79% of Caucasian women have had a mammogram in the past two years, compared to 82% of African American women and 84% of Hispanic women. Colorado BRFSS data for 2008 show that about 70% of Caucasian women have had a mammogram in the past two years, compared to 72% of African American women and 67% of Hispanic women. These findings indicate that Colorado is screening fewer women than other states and that inequity for African American and Hispanic women exists.
Early detection of breast cancer has changed very little over the past decade for Colorado women. However, for African American and Hispanic women, the early detection rate is worse. Compared to Colorado's early detection rate of 72%, in 2007, 66% of breast cancers in Hispanic women were detected early, and 62% of breast cancers in African American women were detected early. For African Americans, this represents a decrease of 8 percentage points compared to the 2002-2006 time period (Cancer in Colorado 1997-2007, Colorado Central Cancer Registry).
Other social determinants have been associated with decreased screening rates, including low income, less than a high school education, lack of health insurance and reduced access to health-care (Crawford, Jones & Richardson, 2008, Harris, Miller & Davis, 2003, Schootman, Jeffe, Reschke & Aft, 2003, O'Malley, Earp, Hawley, Schell, Mathews, & Mitchell, 2001). According to Colorado BRFSS data from 2008, 56% of women with a household income of less then $25,000 (2009 Federal Poverty Guidelines place the poverty level at $27,075 for household of one person) had a mammogram within the last two years, compared to 66% of women with incomes between $25,000 and $49,999 and 78% of women with incomes above $50,000. Similarly, 53% of women report having had a mammogram with in the last two years have less then a high school education, 66% were high school graduates and 72% had some college or more (BRFSS, 2008). It is clear that many health inequities exist among Colorado women for breast cancer screenings; focus on these social inequities should remain a focus of the health-care system.
Follow-Up on Abnormal Findings
Decreasing the delay in diagnostic evaluation after an abnormal mammogram or clinical breast exam (CBE) will have positive effects on cancer outcomes attributed to earlier stage identification at the time of diagnosis (Jones, Dailey, Calvocoressi, Reams, Kasl, Lee & Hsu, 2005, Vourlekis, Ell & Pagett, 2005). In the U.S., approximately 8% of mammograms are abnormal and in Colorado's low-income, uninsured population, 10-24% of women require additional follow-up (Komen and WWC, 2009). Inadequate follow-up for abnormal cancer screenings may range from 18% - 39% of women (Jones et al., 2005). The only known source of baseline data on this objective for Colorado is for low-income, uninsured or under-insured women, ages 40-64 enrolled in the WWC program. In the 2009 fiscal year, 96% of women completed follow-up on abnormal breast findings within 60 days or less, compared to 93% from 2008, and 94% from 2007, and 93% from 2006.
Social Determinants Associated with Timely Follow-up on Abnormal Findings
Few studies have addressed social determinants associated with non-compliance on recommended follow-up. Jones et al. (2005) suggests that African American women are significantly less likely to receive adequate follow-up on abnormal mammograms. Other social determinants of inadequate follow-up on abnormal mammograms include lower educational level (Harris et al., 2003), lacking a usual provider for health-care and experiencing pain during the initial mammogram (Jones et al., 2005).
Breast Cancer Suvivorship
With the growing number of breast cancer survivors in Colorado (estimated at 45,000), the quality of care provided in cancer survivorship has gained recognition as an important component of the cancer continuum (Gilbert, Miller, Hollenbeck, Montie & Wei, 2008). Five-year breast cancer survival in Colorado women is 89% for all stages combined, but even at 10 years, 76% of women are still alive. For women diagnosed at the earliest stages, survival increases to 96% at 5 years and 83% at 10 years (Colorado Cancer Registry, 2009).
Many individuals diagnosed with breast cancer continue to face complicated care issues long after cancer treatment is complete (Miller, 2007). The current U.S. health care system is not routinely using or planning for coordinated follow-up care after cancer treatment is complete. The Institute of Medicine (IOM) recommends that every cancer survivor should have a "comprehensive care summary and follow-up plan" once their cancer treatment is completed (2005).
Social Determinants Associated with Cancer Survivorship Care Plans
Colorado breast cancer survival differences exist across racial/ethnic groups. For example, while 89% of Caucasian women survive five years, only 83% of Hispanic women and 81% of black women survive that interval. Even accounting for different stages of disease at diagnosis, Hispanic and black women have survival deficits. Whether early stage (localized) or later stage (regional), Hispanic survival is 3-10 percentage points worse than white survival and black survival is 5-9 percentage points worse (Cancer in Colorado 1997-2007, Colorado Central Cancer Registry).
These disparities may be explained to some extent by differences in breast cancer mortality rates. National data indicate that African American women have higher breast cancer mortality rates compared to white women (Jones et al., 2005). In Colorado, the mortality rates in 2007 were similar for African Americans and Caucasians. Mortality rates for African American women have decreased substantially since the late 1990s in Colorado when mortality rates were 60% higher than Caucasians. The 2007 mortality rate for breast cancer among African American women was 22 deaths per 100,000 population compared to 20 for white women, and 12 for Hispanic women. For 2002-2006, the rate was 12 for Asian women and 9 for American Indian women (Health Statistics Section, CDPHE).
Furthermore, uninsured, African American, Hispanic and low-income individuals are less likely to receive recommended cancer care and experience significant delays in completing cancer care. Several studies have identified patient, provider and health system barriers (Schwaderer et al., 2008; Wells et al., 2008) including high out-of-pocket payments, lack of health insurance, ignorance of available resources, and poor social support (Petereit et al., 2008; Schwaderer et al., 2008). There is also some evidence showing that physicians provide less informational support to minority women with breast cancer. These women have less access to cancer support groups and have the most difficulty understanding information related to their breast cancer diagnosis (Janz et al., 2008).