Misperceptions of Breast Cancer Etiology in Low-Income Women
Misperceptions of Breast Cancer Etiology in Low-Income Women
Our study identified numerous misconceptions among a small, predominantly African American cohort of low-income, urban women, all of whom had undergone mammography, regarding the etiology, progression, and clinical presentation of breast cancer. Our findings are consistent with past population-based surveys of women indicating that incorrect perceptions regarding breast cancer are widespread. Unlike other investigations, our sampling frame consisted solely of women who had undergone mammographic screening, suggesting that even women who have received and acted on the message regarding the importance of undergoing a mammogram may lack a correct understanding of the test's role in preventing advanced-stage cancer. It is important for clinicians to be aware that such misconceptions exist, given research that suggests that black women in particular are less likely than white women to be aware of the sensitivity and specificity of mammography and are less likely to be willing to continue to adhere to routine screening mammography after being called back for a false-positive result. Our findings suggest that there may be a need for more culturally targeted media campaigns that explain the benefits and limitations of screening mammography and the rationale for current screening strategies.
Current guidelines advocate a multipronged approach to reducing the incidence of advanced-stage disease by offering women tailored genetic counseling, targeted mammographic screening, and appropriate chemoprophylaxis based on each woman's risk profile. Because each of these approaches has potential risks and uncertainties, shared decision making is important. Indeed, the US Preventive Services Task Force specifies that for patients to engage in shared decision making they should "understand the risk or seriousness of the disease or condition to be prevented"; "understand the preventive service, including the risks, benefits, alternatives and uncertainties"; and "have weighed his or her values regarding the potential benefits and harms." To foster such understanding, clinicians must have an awareness of women's underlying preconceptions regarding breast cancer, and it is important for targeted educational interventions to be framed to address these attitudes and beliefs. Our findings suggest that participants may not have fully understood the potential benefits and harms of screening mammography before undergoing their examination.
Our observation that many focus group participants recognized the influence of heredity on breast cancer risk is encouraging, given research suggesting a strong association between black women's willingness to undergo BRCA1 and BRCA2 counseling and/or testing and their knowledge of cancer genetics. Black women are counseled and/or screened for this mutation at a significantly lower rate than the general population, even though numerous BRCA-associated breast cancers have been identified in black women. When embarking on such discussions, clinicians should keep in mind that past research suggests an association between high degrees of perceived susceptibility and decreased screening for breast cancer. Awareness of and sensitivity to these concerns are, therefore, of paramount importance when broaching the subject of personal cancer risk and screening preferences.
Our findings also suggest that some women who undergo mammography on doctor's orders are reluctant to find out their results or follow up. A body of research indicates that black and other ethnic minority women are at higher risk of delays in follow-up and increased time to diagnostic resolution after an abnormal mammogram when compared with white women. Although the reasons for these delays are multifactorial, studies have suggested that physicians are less likely to discuss treatment plans and prevention with black patients than white patients and that black women are at risk of having negative experiences during mammography screening and in health settings in general. Past investigations have also identified psychological factors, such as fatalism, medical mistrust, a low internal health locus of control, and a high spiritual health locus of control as major barriers to mammography screening.
Our findings highlight the importance of clinicians discussing in a culturally sensitive way breast cancer screening and the possibility of needing follow-up before ordering mammography. Lay health workers who are trusted in their communities also may serve as an effective means of disseminating messages regarding how breast cancer develops, the rationale for imaging to screen for nonpalpable tumors, and the importance of timely follow-up.
Our study had several limitations. Our methodology was qualitative; therefore, we are unable to generalize the results. In addition, we recruited only low-income participants from South Florida. It is possible that a study of more affluent women or women from a different location, with a higher level of health literacy, may yield different results. As previously noted, this is a secondary analysis; the primary purpose of the focus groups was to explore women's experiences learning of their mammogram results, not their beliefs about breast cancer per se. Despite these limitations, our findings provide insight into issues that must be considered when framing clinician–patient discussions about breast cancer screening and prevention.
Discussion
Our study identified numerous misconceptions among a small, predominantly African American cohort of low-income, urban women, all of whom had undergone mammography, regarding the etiology, progression, and clinical presentation of breast cancer. Our findings are consistent with past population-based surveys of women indicating that incorrect perceptions regarding breast cancer are widespread. Unlike other investigations, our sampling frame consisted solely of women who had undergone mammographic screening, suggesting that even women who have received and acted on the message regarding the importance of undergoing a mammogram may lack a correct understanding of the test's role in preventing advanced-stage cancer. It is important for clinicians to be aware that such misconceptions exist, given research that suggests that black women in particular are less likely than white women to be aware of the sensitivity and specificity of mammography and are less likely to be willing to continue to adhere to routine screening mammography after being called back for a false-positive result. Our findings suggest that there may be a need for more culturally targeted media campaigns that explain the benefits and limitations of screening mammography and the rationale for current screening strategies.
Current guidelines advocate a multipronged approach to reducing the incidence of advanced-stage disease by offering women tailored genetic counseling, targeted mammographic screening, and appropriate chemoprophylaxis based on each woman's risk profile. Because each of these approaches has potential risks and uncertainties, shared decision making is important. Indeed, the US Preventive Services Task Force specifies that for patients to engage in shared decision making they should "understand the risk or seriousness of the disease or condition to be prevented"; "understand the preventive service, including the risks, benefits, alternatives and uncertainties"; and "have weighed his or her values regarding the potential benefits and harms." To foster such understanding, clinicians must have an awareness of women's underlying preconceptions regarding breast cancer, and it is important for targeted educational interventions to be framed to address these attitudes and beliefs. Our findings suggest that participants may not have fully understood the potential benefits and harms of screening mammography before undergoing their examination.
Our observation that many focus group participants recognized the influence of heredity on breast cancer risk is encouraging, given research suggesting a strong association between black women's willingness to undergo BRCA1 and BRCA2 counseling and/or testing and their knowledge of cancer genetics. Black women are counseled and/or screened for this mutation at a significantly lower rate than the general population, even though numerous BRCA-associated breast cancers have been identified in black women. When embarking on such discussions, clinicians should keep in mind that past research suggests an association between high degrees of perceived susceptibility and decreased screening for breast cancer. Awareness of and sensitivity to these concerns are, therefore, of paramount importance when broaching the subject of personal cancer risk and screening preferences.
Our findings also suggest that some women who undergo mammography on doctor's orders are reluctant to find out their results or follow up. A body of research indicates that black and other ethnic minority women are at higher risk of delays in follow-up and increased time to diagnostic resolution after an abnormal mammogram when compared with white women. Although the reasons for these delays are multifactorial, studies have suggested that physicians are less likely to discuss treatment plans and prevention with black patients than white patients and that black women are at risk of having negative experiences during mammography screening and in health settings in general. Past investigations have also identified psychological factors, such as fatalism, medical mistrust, a low internal health locus of control, and a high spiritual health locus of control as major barriers to mammography screening.
Our findings highlight the importance of clinicians discussing in a culturally sensitive way breast cancer screening and the possibility of needing follow-up before ordering mammography. Lay health workers who are trusted in their communities also may serve as an effective means of disseminating messages regarding how breast cancer develops, the rationale for imaging to screen for nonpalpable tumors, and the importance of timely follow-up.
Our study had several limitations. Our methodology was qualitative; therefore, we are unable to generalize the results. In addition, we recruited only low-income participants from South Florida. It is possible that a study of more affluent women or women from a different location, with a higher level of health literacy, may yield different results. As previously noted, this is a secondary analysis; the primary purpose of the focus groups was to explore women's experiences learning of their mammogram results, not their beliefs about breast cancer per se. Despite these limitations, our findings provide insight into issues that must be considered when framing clinician–patient discussions about breast cancer screening and prevention.
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