Disseminating Information about Breast Cancer Prevention to African American Women Chanita Hughes Halbert, Ph.D. Center for Community-Based Research and Health Disparities Department of Psychiatry University of Pennsylvania Supported by AHRQ grant #R18HS19339

Breast Cancer Facts and Figures A leading cause of cancer among women in the US White women are more likely to develop breast cancer, but African American women are more likely to die from this disease

Knowledge about Breast Cancer in African American Women Sample is 110 African American women recruited from community resources.

Knowledge about Breast Cancer in African American Women Sample is 110 African American women recruited from community resources.

Knowledge about Breast Cancer in African American Women 23% of women did not know if being hit in the breast increased women’s chances of developing breast cancer 27% of women did not know if having breast surgery was a risk factor for disease Sample is 110 African American women recruited from community resources.

Physical Activity Levels and Breast Cancer Risk in African American Women 19% Reduced Risk 16% Reduced Risk Highest Risk 25% Reduced Risk Bernstein et al., JNCI, 2005

Nutrition Guidelines for Cancer Prevention Eat a healthy diet, with an emphasis on plant sources. Choose foods and beverages in amounts that help to achieve and maintain a healthy weight. Eat 5 or more servings of a variety of vegetables and fruits each day. Choose whole grains rather than processed (refined) grains. Limit consumption of processed and red meats.

Guidelines for Breast Cancer Early Detection Yearly mammograms starting at age 40 Clinical breast exam (CBE) every 3 years for women in their 20s-30s American Cancer Society

Medications to Reduce Risk of Breast Cancer Two medications decrease the risk of invasive breast cancer for women who have never had breast cancer before and have an increased risk of disease and low risk for adverse events Raloxifene: Only for women after menopause Tamoxifen: For women before and after menopause

Reducing the Risk of Breast Cancer With Medicine A Guide for Women

Evidence of a Digital Divide Percent who say they…AllWhiteAfrican American Hispanic Use the Internet or at least occasionally 84%87%80%72% Earn less than $40,000 annually Earn $40,000 or more annually Have a computer at home86%89%78%81% Earn less than $40,000 annually Earn $40,000 or more annually Have a high speed Internet connection 72%77%63%56% Earn less than $40,000 annually Earn $40,000 or more annually Kaiser Family Foundation, Race and Recession Survey, 2011

Evidence of a Digital Divide: Computer Use to Access Health Information Percent who say they have ever used the Internet to access health information. AllWhiteAfrican American Hispanic All60%65%56%43% Annual household income Earn less than $40,000 annually Earn $40,000 or more annually Health insurance status (less than 65 years old) Insured Uninsured51**4636 Kaiser Family Foundation, Race and Recession Survey, 2011

Exposure to NIH Sample is 148 African Americans recruited from an academic health system.

Community-based strategies for disseminating information about breast cancer prevention may overcome the racial digital divide.

Specific Aims To evaluate uptake of a community-based strategy for disseminating CERs about breast cancer prevention to African American. To evaluate the impact of evidential versus non-evidential content about breast cancer prevention on psychological and behavioral outcomes. To identify mechanisms that lead to changes in psychological and behavioral outcomes.

Hypotheses Participation in a community forum will be higher among women with greater SES, those who have a family history of breast cancer, and women who have more positive beliefs about research. Women who receive evidential content will report greater knowledge about breast cancer risk factors and prevention strategies, will be more likely to discuss breast cancer prevention strategies with their individuals in their social and medical network, and will report greater reductions in distrust of medical research compared to those who receive non-evidential content.

Study Design and Population Phase 1: Qualitative methods (focus groups) to understand responses to the evidential and non- evidential content Phase II: Randomized trial comparing responses to evidential and non-evidential content about breast cancer prevention Study Population: African American women ages who do not have a personal history of breast cancer Conceptual Model: RE-AIM

Community-Based Participatory Research (CBPR) Community-based participatory research (in health) is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community (health) Enhance the value and applicability of research to all potential users through shared learning, decision-making, and ownership of research activities and products Increase the community’s ability to address its own problems and is intended to leave something positive after the project is completed

SWACHPC NBLIC CCCDCPenn Executive Council Intervention Development Communication & Outreach Risk EducationNavigation West Philadelphia Consortium to Address Disparities

Interventions Evidential content –Breast cancer and risk factors in African American women –Progress has been made in terms of breast cancer survival among African American women –Behavioral and medical prevention strategies –Medical strategies have risks and benefits –It is important to talk about breast cancer prevention with a health care provider Non-evidential content –General information about breast cancer, risk factors, and behavioral and medical prevention strategies

Outcomes Uptake of education program Trust in health care system Communication with health care providers Knowledge and saliency about breast cancer

Raloxifene (Evista) Tamoxifen (Novaldex) Treatment Recommendation After Menopause Before and After Menopause Breast Cancer Risk Reduction 30% - 68% reduced risk of invasive breast cancer Mortality Unclear if reduces the risk of dying from breast cancer Side Effects Thromboembolic Events (Blood Clotting) Endometrial Cancer Cataracts Compare Raloxifen and Tamoxifen

Preliminary Responses to the Interventions Increased awareness about medical options for breast cancer prevention Greater knowledge about risk factors for breast cancer (some women did not know their BMI) Questions about the source of information Concerns about the lack of African American participation in clinical trials Belief that lack of exposure is the primary barrier to limited African American participation Intentions to discuss breast cancer and prevention strategies with health care providers Start or continue early detection

“I plan to increase physical activity, watch my diet, and try to lose about 20 pounds.” “If a clinical trial for breast cancer were available, I would consider being a participant.” “I will talk to my doctor about this.” “…be well informed about breast cancer and ask about surveys and clinical trials.”

Future Directions Continue recruitment to achieve accrual goals Evaluate uptake of community education program Assess the impact of evidential versus non- evidential content on psychological and behavioral outcomes Intervention scale up and dissemination

Collaborators Katrina Armstrong, MD Scarlett Bellamy, ScD Vanessa Briggs, RD, MBA (HPC) Ernestine Delmoor, MPH (NBLIC) Susan Domchek, MD Jasmine McDonald, PhD Benita Weathers, MPH Janet Weiner, MPH Chanita Hughes Halbert, Ph.D., Principal Investigator