Case Studies

Reducing Health Disparities: Breast Cancer Early Diagnosis

Contra Costa County, California has one of the highest rates of breast cancer in the country. The disease also starkly illuminates a health disparity between whites and African Americans. In Contra Costa, like the rest of the United States, white women are the most likely to get breast cancer but African American women have the highest mortality from the disease. Minorities have been less likely to have their breast cancer detected at an early stage, they frequently have less access to quality medical care, and as a result they are more likely to die from breast cancer than whites.

In 1992, only 44 percent of African American women with breast cancer in Contra Costa were diagnosed at an early stage, when the chance of cure is best, and Latinas were diagnosed early only slightly more often (58 percent). Seventy-two percent of Euro-American women in Contra Costa had their breast cancer diagnosed at an early stage. Late diagnosis and lack of access to quality medical treatment are the main causes of higher mortality for African American women.

Contra Costa Health Services identified breast cancer and the related disparity in health outcomes as a major priority for the department to address. It recognized that ending the disparity in outcomes for African American women in Contra Costa would require a community-wide, protracted effort involving a broad spectrum of strategies.

Contra Costa Health Services used the Spectrum of Prevention to address the problem.

Influencing Policy and Legislation:

In addition to the disparity in breast cancer early detection, access to quality health care had to be addressed as a policy issue. Contra Costa Health Services (CCHS) committed to providing treatment for all low-income, uninsured women in Contra Costa on an interim basis and to joining the statewide Breast and Gynecological Cancer Treatment Task Force to lobby for a state treatment program. In January 2002, after three years of lobbying by the Task Force, the California Breast Cancer Treatment Program was implemented and provides quality treatment for breast and cervical cancer for all unisured women in California, including undocumented women.

Mobilizing Neighborhoods and Communities:

To administer the state-sponsored Breast Cancer Early Detection Program, the county brought together an array of medical providers, agencies, health advocates and breast cancer survivors to form the Contra Costa Breast Cancer Partnership (CCBCP). To reach out to underserved communities, CCBCP then formed an African American Task Group, a Lesbian Task Force, a Latina Task Group and an Asian/Pacific Islander Task Group. The African American Task Group produced an attractive wall calendar using local breast cancer survivors as models. This calendar hangs on walls in offices and homes throughout the County and was featured in Contra Costa's segment of a satellite videoconference sponsored by the U.S. Department of Health and Human Resources' Bureau of Primary Health Care in October 2001. The calendar is beautifully photographed, depicting each month's model radiant with life and power. It proclaims to African American women that breast cancer does not have to mean death, and that women should get regular screening for breast cancer.

The African American Task Group also enlisted broader community involvement in a variety of ways including outreach to church congregations and door-to-door contact with residents and beauticians in neighborhoods.

Other innovations included outreach to the Lesbian community through a woman's softball team and the hosting of an annual picnic for breast cancer survivors and their families to celebrate the fight against the disease.

Changing Organizational Practices:

Local residents and members of the Partnership advised CCHS how to change their clinics to make them more accessible, welcoming and culturally appropriate. The health department also helped other agencies focus on resolving health disparities as an important part of their own missions. CCHS created a Patient Navigator Program, which facilitates breast health screenings for non-English speaking women and helps them "navigate" the often complex maze of health care services.

Fostering Coalitions and Networks:

Contra Costa Health Services played a leadership role in convening and mobilizing the many agencies and organizations that addressed this health disparity. One of the county's first efforts was to help form the Bay Area Cancer Coalition during the late 1980s. By 1992, the Coalition partnered with the Northern California Cancer Center to conduct the Breast and Cervical Cancer Intervention Study (BACCIS). This study targeted low-income, uninsured, ethnic women 40 years and older in San Francisco and in Contra Costa. BACCIS provided a vehicle for outreach into the city with the largest African American population in the county.

In 1995, CCHS became one of the few local health departments in California to participate in the state-funded Breast Cancer Early Detection Program (BCEDP). This program was instituted to provide free clinical breast exams, mammograms and additional diagnostic services to low-income, uninsured and underinsured women age 40 and over. To implement BCEDP, the county brought together an array of medical providers, agencies, health advocates and breast cancer survivors to form the Contra Costa Breast Cancer Partnership. The Partnership grew into a diverse coalition of nearly 400 breast cancer survivors, providers, advocates and community agencies.

The Partnership also created a clinical provider network to increase access to free or low-cost breast health services. This network includes regional clinics operated by CCHS. Linkages were also formed with American Cancer Society, the National Cancer Institute's Cancer Information Service, the Susan G. Komen Foundation, the county hospital and several private medical centers. Collaboration among a broad range of community organizations and agencies was a key to success.

Promoting Community Education:

One key barrier was the perception by many people that a diagnosis of breast cancer was a death sentence. As a result of the Partnership's culturally relevant commuity outreach, many women became more proactive about getting screened for breast cancer.The Task Groups reached into ethnic communities with culturally appropriate materials in many languages. The Partnership worked actively with the local news media to frame issues on breast cancer and educate the public through the press, including small ethnic papers. The African American Task Group also enlisted broader community involvement in a variety of ways including outreach to church congregations and door-to-door contact in neighborhoods. Finally, through BCEDP, CCHS was able for five years to distribute mini-grants for implementing breast health outreach and education. These grants went to diverse organizations, many of which would not have otherwise addressed breast cancer.

Strengthening Individual Knowledge and Skills:

The Breast Cancer Partnership worked with the county TV station to produce an instructional video on breast self-examination, and the video aired numerous times on cable TV systems countywide. The Partnership's African American Task Group hit the streets to knock on doors and tell other women about the issues of breast cancer, how they affected African Americans and what to do about it. The Asian/Pacific Islander Task Force developed culturally appropriate breast health workshop materials in Vietnamese and Lao/Mien languages and gave subsequent workshops. The work of the Latina Task Group ultimately resulted in the development and implementation of the county's Patient Navigator Program, which helps low-income, non-English speaking women navigate the often complex maze of health screening services.

In 1992, 44% of African Americans had their breast cancer diagnosed at an early stage, and 72% of Euro-Americans were diagnosed early.

By 1997, 72% of Euro-Americans were still diagnosed early, and 72% of African Americans likewise had their cancer diagnosed at an early stage. Improvements were also made among Latinas, but the numbers were not large enough for statistical significance.

By January 2002, advocacy from the Contra Costa Breast Cancer Partnership and others led to a state-funded Breast and Cervical Cancer Treatment Program to provide treatment for all uninsured women (including undocumented) in California for breast and cervical cancer.

Lower breast cancer mortality rates are not evident yet and will lag behind improved diagnosis statistics by 5 to 10 years. However, eliminating the disparity in early diagnosis and providing access to quality treatment for all women will result in lower mortality from breast cancer for African American women in the years to come.

Early detection and access to treatment will be the key in lowering breast cancer mortality rates for all women. This success demonstrates that health disparities are not some inalterable fact of nature. Health disparities have causes, those causes can be identified, and with persistent, community-wide effort, health disparities can be eliminated.

Contact Wendel Brunner, MD. 925-313-6712 for more information.

Content provided by the The Community Wellness & Prevention Program of Contra Costa Health Services.