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Recommendations
For the Federal Goverment | For
the State Government | For Local Governments | For Individuals
Recommendations for the Federal Government
- Increase federal funding through the National Institutes of Health
(NIH) to promote greater research into the prevention of breast cancer.
- Increase funding for research into the causes of disparities in
breast cancer incidence and outcomes among the different ethnic groups.
Increased research must address the economic, social and cultural
factors that interfere with access to modern, curative therapies,
delivered in a timely fashion so as to maximize their benefit. Particular
attention should be paid to the higher risk and mortality in younger
African-American women.
- Increase funding aimed at eliminating barriers to screening for
breast cancer for all women, especially those groups with the lower
utilization of these services and more adverse outcomes after treatment.
Hispanic women in our study reported more barriers to access for
screening and had lower rates of mammography.
- Recommend that women at high risk consider screening before age
40. African-Americans, Ashkenazi Jews, and women with a strong family
history of breast cancer are at potentially higher risk and may warrant
earlier screening than the general population. These screenings should
remain available and insurable.
- Provide guidance to state and local governments to assist them
in the publication and distribution of informational materials so
that women can better understand that the majority of breast cancer
cases occur among women who have no family history of breast cancer.
All women need to understand the importance of yearly screening mammograms
beginning at age 40, as well as other measures important in limiting
risk. Information should highlight differences among ethnic groups
with regard to breast cancer risk. Women surveyed uniformly overestimated
the role of family history and genetics in breast cancer, which may
adversely affect many women’s screening behavior. EHHI’s
study showed that if women where made aware that over 80% of all
breast cancers occur in women with no family history, they would
be more vigilant about mammographic screening.
- Expand the effort to identify or exclude causal roles for a variety
of environmental contaminants in breast cancer. Increased effort
should be directed to assessing exposures that occur both during
the prenatal period, as well as in early childhood and adolescent
years, in relationship to breast cancer risk.
Recommendations for the State Government
- States should provide information about known risk
factors for breast cancer to allow women to assess
their own relative risks. Materials should describe
prevention strategies and how to access screening
opportunities within the state.
- States should establish and regularly update a
website that provides information about the known
and suspected risk factors for breast cancer. The
website should include:
- The number of women diagnosed with the disease,
both nationally and within each state, updated
on an annual basis. Data should include ethnic
differences within those statistics;
- How women can reduce their risk factors for
breast cancer within their control;
- How and where women can access screening opportunities
within each state.
- States should provide free or limited-cost (by
sliding scale) counseling and breast cancer screening
services targeted to minorities and the uninsured.
These services should be available at convenient
locations and times to ensure accessibility for women
facing economic and social barriers. Innovative efforts
to partner with not-for profit organizations, corporate
and local businesses, as well as the medical community,
should be encouraged to widen access to these services.
- States should undertake a broad public health campaign
targeted to enhancing women’s understanding
of breast cancer risks to increase women’s
utilization of screening tests. Women in this survey
uniformly overestimated the role of family history
and genetics in breast cancer. This overestimation
may adversely affect many women’s screening
behavior. When women were made aware that more than
80% of all breast cancers occur in women without
a family history, they reported that they would be
more vigilant about mammographic screening. States
should use the media to publicize this fact, along
with other breast cancer prevention strategies. EHHI’s
study showed that the majority of women surveyed
said they obtained their information about breast
cancer from media sources.
Recommendations for Foundations
- Both increased funding and education are needed
to address the disparities in both breast cancer
incidence and mortality in the minority community,
particularly among young African-American women.
- Women uniformly overestimate the role of family
history and genetics in breast cancer, which may
adversely affect many women’s screening behavior.
EHHI’s study shows that women would be more
vigilant about getting mammographic screening if
they were aware that more than 80% of all breast
cancers occur in women without a family history of
the disease. This fact needs to be publicized.
- Assist in the dissemination of information about
breast cancer to women at high risk for the disease,
including African American women, Ashkenazi Jews,
and those with a strong family history of the disease.
Women in high-risk groups need to be better informed
of their risk of early-onset breast cancer so they
can consider screening before age 40. Mammographic
screenings should remain available and insurable
for these vulnerable groups.
- Increase funding for research into effective treatments
for breast cancer in all women, paying particular
attention to African-American women and other at-risk
minority populations.
- There is a growing need for research and education
efforts devoted to lifestyle factors that may contribute
to adverse breast cancer outcomes. The growing obesity
epidemic in early childhood, adolescence, and young
adulthood is a critical influence in breast cancer
development and outcome, and should be a priority
for research and intervention. Partnerships among
organizations can broaden these efforts and serve
as models for the governmental, corporate and the
not-for-profit community.
- The majority of women get their breast cancer
information from the media. Given the many areas
of misunderstanding about breast cancer among the
surveyed women, there is a great need for wider dissemination
of accurate information through media sources. Foundations
can be helpful in supporting these educational efforts.
- Access to breast cancer screening should be improved.
Women would also benefit from better education about
the critical need for timely screenings and the importance
of yearly follow-up exams for all women, irrespective
of level of risk, beginning at age 40. Foundations,
in cooperation with the medical community, can offer
significant support for these activities.
Recommendations for the Medical Community: Institutions, Physicians and Healthcare Providers
- Healthcare providers and institutions must focus their educational
efforts on emphasizing the importance of screening for all women,
paying particular attention to vulnerable populations.
- Healthcare institutions should educate primary care providers,
including internists, family practitioners, gynecologists, and physicians
in training—as well as nurses working with minority populations—about
the higher incidence of breast cancer among younger African-American
women who have a higher risk of more aggressive cancers. The critical
need for patient follow-up, appropriate screenings, and lifestyle
interventions cannot be overemphasized.
- Institutions should maximize continuity of care for women who
lack a single primary care provider. Fragmentation of care for minority
women remains a significant barrier that reduces the likelihood of
timely and appropriate care.
- To limit barriers to screening and treatment, institutions should
strongly consider the use of patient “navigators” who
can facilitate timely follow-up studies and care involving multiple
practitioners and services.
- African-American women should be educated about their higher risk
for early-onset breast cancer and the critical importance of early
detection through mammographic screening. Educational efforts could
be facilitated by African-American groups, including the National
Medical Association (NMA) and the NAACP, as well as local community
and church-affiliated organizations. The goal should be to encourage
understanding of breast cancer risk factors and the benefits of early
detection in improving cancer survival. Medical institutions should
partner with community organizations in these efforts.
- Assure the timely start of adjuvant therapy for early-stage breast
cancer, including chemotherapy in the most effective dose and schedule;
hormonal treatments when appropriate; and localized breast irradiation
in the appropriate setting. Healthcare providers and institutions
should make every effort to educate minority populations, in particular,
about treatment benefits, while limiting barriers (social, economic,
educational or geographic) that may impair full and timely compliance
with these important therapies.
- Women should be apprised of the potential benefits of breast-feeding
and, whenever possible, be encouraged to breast-feed for at least
six months, in line with the American Academy of Pediatrics recommendations.
African-American women, who are at higher risk for premenopausal
breast cancer, but whose breast-feeding rates are lower, should be
made aware of the the protective effects of breast-feeding.
- Institutions should recognize the barriers to care represented
by the costs incurred by low-income women for screening, transportation
and childcare needs, as well as the outof- pocket expenses for treatment.
This is particularly problematic for women requiring on-going chemotherapy
and radiation with multiple visits to a variety of service providers.
- Additional resources and education should be devoted to systems
that facilitate rapid and complete follow-up after abnormal tests
and studies.
- Minority women are more likely to receive care that does not reflect
standards of the 2000 National Comprehensive Cancer Network. All
institutions should strive to provide care in accordance with evidence-based
guidelines for all patients diagnosed with breast cancer.
- Increased research should be devoted to the role of genetic risk
factors in breast cancer within the minority community.
- Institutions and practitioners must be knowledgeable about modifiable
breast cancer risk factors, including obesity, inactivity, alcohol
consumption and hormone replacement therapy, in order to counsel
patients about healthy lifestyles. Physicians need to be aware of
the role of excessive weight in adverse outcomes. Most research indicates
that physician recommendations about diet, exercise and weight control
are important in ensuring compliance.
- Multiple programs have been instituted to provide financial assistance
to low-income women, such as the National Breast and Cervical Cancer
Early Detection Program (NBCCEDP), the Breast and Cervical Cancer
Prevention Act of 2000, and the Avon Foundation’s AVONCares.
These and similar programs should be accessed wherever possible to
help disadvantaged populations.
Recommendations for Individuals
- Women should follow recommended guidelines for
mammographic screening, including follow-up studies
on a regular basis. This is particularly important
for African-American women who are, according to
our survey, largely unaware of their higher risk
for earlyonset breast cancer. Mammographic screening
at a younger age should be considered for this group.
- In addition to African-American women, others at
high risk, such as those with a strong family history
and those with the BRCA-1 or BRCA-2 gene, should
consider obtaining a screening mammogram before age
40. They should also consider MRI screening at appropriate
intervals based on their physician’s recommendations.
- Women should avoid weight gain in early adulthood
by eating a healthy diet, rich in vegetables and
fruit, low in saturated fat, with a moderate intake
of monounsaturated fat (olive and canola oils), along
with regular exercise and physical activity. Avoiding
weight gain is crucial for all women, but is of particular
concern for African-American women, in whom increased
body weight may contribute to their adverse breast
cancer outcomes.
- Beginning in childhood, parents should foster a
healthy diet and include regular exercise for their
children. Avoidance of obesity and providing physical
activity is critical.
- Women should avoid the use of long-term HRT, particularly
combinations of estrogen and progestins.
- Women at higher risk for breast cancer should limit
alcohol intake to one to two drinks per week. If
women consume alcohol on a regular basis, they should
consider taking a daily multivitamin containing folic
acid.
- Women at high risk should exercise at least four
to five times a week.
- Women at significantly higher risk, such as those
with a family history or prior benign breast disease,
should discuss with their physicians the option of
preventive medications, such as tamoxifen, or other
hormonal treatments. In many cases, the benefit of
these agents may significantly exceed their risk.
Because EHHI’s survey showed that most women
are unfamiliar with this option, greater effort should
be made to explain the potential benefits of Selective
Estrogen Receptor Modulator (SERMs). Recent data
support the use of the alternative SERM agent raloxifene
(Evista), which provides benefits similar to tamoxifen
in reducing breast cancer risk, while also improving
bone density. Raloxifene has been shown to cause
fewer adverse effects, including an absence of increased
endometrial cancer risk, lower risks of blood clots
and strokes, and lower rates of cataract formation.
Because of its improved risk profile, many women
may find raloxifene a more acceptable alternative
to tamoxifen.
- Because we do not know the exact interplay between
environmental contaminants and breast cancer, women
should avoid exposures to carcinogens and endocrine
disrupters. Exposures to pesticides and other chemicals
should be avoided, especially during vulnerable periods
of growth, such as pregnancy, early childhood and
adolescence. Until there is more data about the role
that chemical exposures play in breast cancer incidence,
reducing pesticide and chemical exposures will remain
the most prudent course of action.
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