1. Breast Cancer Prevention for the Rural Healthcare Provider
A CME workshop presented by
Introduction
This slide is used to test projector function and focus. It can serve as a backdrop while the speaker is being introduced, and can also be displayed while the speaker makes opening comments.

2. Workshop Learning Objectives
Assess breast cancer risk for individual women patients.
Identify patients for whom breast cancer risk reduction is feasible and should be considered.
Describe the reduction in breast cancer risk in older women being treated for osteoporosis with Selective Estrogen Receptor Modulators (SERMs)
Analyze the risks and benefits of SERMs in breast cancer prevention.
Introduction
This Continuing Medical Education program is a workshop accredited by The University of Illinois College of Medicine and The Illinois Critical Access Hospital Network.
The Learning Objectives for these materials are:
Assess breast cancer risk for individual women patients.
Identify patients to whom breast cancer risk reduction is feasible and should be considered.
Describe the reduction in breast cancer risk in older women being treated for osteoporosis with Selective Estrogen Receptor Modulators (SERMs)
Discuss with menopausal patients the risks and benefits of selective estrogen receptor modulators (SERMs) and a comparison to hormonal replacement therapy (HRT) and no pharmacologic intervention.

3. Epidemiology of Breast Cancer
Most common cancer in women.
Second only to lung cancer as cause of cancer-related deaths in women.
One women diagnosed every 3 minutes and one women dies of disease every 13 minutes.
In 2006, over 200,000 women were diagnosed with invasive breast cancer.
A woman’s lifetime risk for developing breast cancer is 12.5% (1 in 8).
Epidemiology
Breast cancer is the most common cancer in women. Breast cancer is second only to lung cancer as cause of cancer-related deaths in women. Breast cancer statistics are sobering: in the U.S., a woman is diagnosed with breast cancer every three minutes, and one woman dies of this disease every 13 minutes. In 2006, over 200,000 women were diagnosed with invasive breast cancer; over 60,000 were diagnosed with breast cancer in situ. A woman’s lifetime risk for developing breast cancer, assuming she lives at least 80 years, is 12.5% (1 in 8). Because of early detection, increased awareness, and improved treatment, the mortality rate from breast cancer has declined (as measured from 1975 to 2003).   

4. Risk Factor for Breast Cancer
Ethnic and Familial
Hormonal and Reproductive
Dietary/Lifestyle
Risk Factor Assessment
Risk Factors for Breast Cancer
A fundamental component in screening for and early detection of breast cancer is identifying those who are at the highest risk for developing the disease. The following slides will discuss various risk factors associated with breast cancer, including ethnic and familial risk factors, hormonal and reproductive risk factors, and dietary and lifestyle risk factors. We will also discuss several tools used for breast cancer risk assessment.

5. Ethnic Variations in Breast Cancer Risk
Rate of breast cancer stratified by race/ethnicity
Race/Ethnicity
Rate of breast cancer occurrence
Caucasian
141 per 100,000
African American
119 per 100,000
Asian American/Pacific Islander
97 per 100,000
Hispanic/Latina
90 per 100,000
American Indian/Alaska natives
55 per 100,000
Ethnic Variations in Breast Cancer Risk
Breast cancer rates differ significantly by ethnic background, a disparity which may be attributed to factors associated with lifestyle and socioeconomic status (see slide for exact numbers). Also, ethnic minorities present with more advanced stages of breast cancer and have shorter survival following diagnosis. According to the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) program, average mortality rates from 1992 to 1998 per 100,000 women diagnosed with breast cancer were 31 for African-American women, 24.3 for Caucasian women, 14.8 for Hispanic women, 12.4 for American Indian women, and 11 for Asian/Pacific Islander women. One possible explanation for this trend is more advanced stage at diagnosis combined with higher stage-specific mortality.

6. Average lifetime risk of breast cancer %
Familial Risk Factors
Two- to three-fold increased risk for women whose first- degree relative was diagnosed with breast cancer.
The risk declines significantly if only second-degree relatives are affected.
Risk for all women compared to those with a family history
% of population
% of all breast cancer
Average lifetime risk of breast cancer %
General population 90
80-85
11-12
Family history of breast cancer
5-10
15-20
20-25
Positive for BRCA1 or BRCA2 mutations
0.1
5-6
65-85
Familial Risk Factors
Most studies on familial risk of breast cancer have demonstrated a two- to three-fold increased risk for women whose first-degree relative (mother, sister, daughter) was diagnosed with breast cancer. The risk declines significantly if only second-degree relatives (grandmothers, aunts, grand-daughters) are affected.
While only 5-6% of all breast cancers are directly attributable to inheritance of a breast cancer susceptibility gene such as BRCA1 or BRCA2, the risk associated with genetic mutation is high. A woman with a mutation in BRCA1 or BRCA2 has an estimated life-time risk of developing breast cancer as high as 85%.

7. Reproductive/Hormonal Risk Factors
Nulliparity
Early menses (< age 12)
Late menopause (> age 55)
First full-term pregnancy after age 35
Use of oral contraceptives
Before first full-term pregnancy
Use for longer duration in BRCA mutation carriers
Use of hormone replacement therapy
Reproductive and Hormonal Risk Factors
Several hormonal and reproductive risk factors are associated with breast cancer, including age of menarche and menopause, childbirth, breastfeeding, and use of exogenous hormones. Nulliparous women are at increased risk of breast cancer compared to parous women. Women who experienced menarche at 11 years of age or younger have approximately 20% greater chance of developing breast cancer than women who experience menarche at 14 years of age or older. Women with late menopause (>55 years of age) also experience increased risk. Women who experience childbirth have a transient increase in risk, followed by a long-term reduction in risk. The age of the woman at childbirth also affects risk. In one study, women who experienced a first full-term pregnancy before age 20 were half as likely to develop breast cancer as nulliparous women or women whose first full-term pregnancy was at 35 years or older. The use of exogenous hormones has also been associated with an increased risk of breast cancer. Use of oral contraceptives is associated with an increased risk of premenopausal breast cancer, especially in women who use them prior to their first full term pregnancy. There is some evidence to suggest that oral contraceptive use may increase risk in some patients with a BRCA mutation, especially when used for a long duration (>5 years) in women prior to their first full term pregnancy. The  use of injectable or implantable progestin-only contraceptives in women aged years has not been associated with an increased risk of breast cancer. For women taking hormone replacement therapy, the Women’s Health Initiative (WHI) study showed that the relative risk of breast cancer was increased in women taking combined estrogen/progesterone for an average of 5.2 years compared to those receiving placebo. However, the use of unopposed estrogen in women with prior hysterectomy did not increase the incidence of breast cancer compared to placebo.

8. Dietary/Lifestyle Risk Factors
In post-menopausal women:
Higher weight
Higher body mass index (BMI)
Alcohol use (<2 drinks per day)
Regular exercise associated with a decreased risk, but lack of exercise not associated with an increased risk
Exposure to ionizing radiation
Before 40 years of age
Exposure between 10 and 14 years of age most critical.
Dietary and lifestyle risk factors
Dietary and lifestyle risk factors may be associated with the development of breast cancer. Among post-menopausal women, higher weight and body mass index (BMI) are associated with an increased risk of breast cancer. Alcohol consumption (more than 2 drinks per day) has been associated with a moderate increase in risk, but no such association has been proven for cigarette smoking. Although regular exercise is associated with a decrease in breast cancer risk, lack of exercise has not been associated with an increase in risk. Exposure to ionizing radiation before age 40 is also well recognized as a risk factor, with exposure between 10 and 14 years of age being most critical.

9. Risk Factor Assessment
Important for healthcare professionals to identify high risk factors:
Previous medical history of breast cancer.
History of lobular carcinoma in situ or ductal carcinoma in situ.
Family history of breast cancer.
Presence of BRCA 1 and 2 mutations.
In the absence of personal or family history, the presence of multiple risk factors can result in an elevated risk
Risk Factor Assessment
When discussing breast cancer risk with patients, it is important for healthcare providers to remember that some risk factors are more closely linked with the development of breast cancer. A previous medical history of breast cancer presents the highest level of breast cancer risk, followed by a history of lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS). In the absence of a personal history of breast cancer, the highest risk of developing the disease is found in those women with a family history of breast cancer and the presence of BRCA1/2 mutations. Even in women without previous medical or family history of breast cancer, the combination of multiple factors can cumulatively result in a significantly elevated risk of breast cancer. Several risk assessment tools are currently available to evaluate a women’s likelihood of developing breast cancer, with the Gail model being the most commonly recognized and used.

10. The Gail Model Internet-based tool
Projects a women’s estimated risk of breast cancer over a 5-year period and over her lifetime.
Includes assessment of:
Age and race
First-degree relative history
Hormonal factors
Does not take into account:
Personal history of cancer,
Second degree relative history of breast cancer
Family history of breast cancer before age 50
Family history of bilateral disease and ovarian cancer
BRCA1/2 mutations
The Gail Model
The Gail model is an internet-based tool developed by the NCI and the National Surgical Adjuvant Breast and Bowel Project (NSABP) Biostatistics Center. This tool allows healthcare providers to project a woman’s individualized estimate of risk for invasive breast cancer over a 5-year period and over her lifetime (to age 90). The Gail Model does have a number of limitations; this assessment does not take into account a woman’s personal history of cancer, family history of breast cancer in second degree relatives, family history of breast cancer before age 50, family history of bilateral disease, family history of ovarian cancer, or specific genetic predispositions such as mutations in BRCA1/2. It does include other risk factors such as age and race, family history of first degree relatives, and hormonal factors. The  risk projections assume that a woman is receiving regular clinical breast exams and screening mammograms. Once the provider answers the questions, the Gail program can provide an individual’s risk estimate for a 5-year period. The program also compares this risk to that of a woman of the patient’s age who is at average risk for breast cancer.

11. The Gail Model Example
Patient background: Lucy is a 34 year-old female whose mother had breast cancer.
Age at Menarche 12
Age at first live birth
Nulliparous
# of biopsies
atypical hyperplasia
First degree relatives 1
Race
Caucasian
5-year Risk
0.4% (Average risk 0.2%)
Lifetime Risk
17.2% (Average risk 12.6%)
The Gail Model
This slides provides an example of the Gail Model. The Gail Model can be found on the internet at:
The Gail Model is available at:

12. Pedigree Assessment Tool
Useful in identifying those individuals most at risk for hereditary breast cancer.
More information available at:
Pedigree Assessment Scoring System
Diagnosis
Points assigned
Breast cancer at age 50 or higher 3
Breast cancer prior to age 50 4
Ovarian cancer at any age 5
Male breast cancer at any age 8
Ashkenazi Jewish heritage
Pedigree Assessment Tool
Another model called the Pedigree Assessment Tool was recently published. This tool was designed for use by non-specialists to assist in providing breast cancer risk assessment in a primary care setting and is especially useful in identifying those individuals most at risk for hereditary breast cancer.  More information on this tool is available at: The scoring system used for this tool is also provided here.

13. Prevention Primary prevention Secondary prevention Tertiary prevention
Modifiable risk factors
Chemoprevention
Genetic screening
Secondary prevention
Self breast exam
Clinical breast exam
Mammography
Tertiary prevention
Prevention
While some breast cancer risk factors such as age are unavoidable, there are several measures women can take to reduce the risk of developing breast cancer. Several screening options are available to help detect cancers at early stages, when treatment outcomes are more favorable. The following slides will review information on primary prevention,, secondary prevention, and tertiary prevention.

14. Primary Prevention: Modifiable Risk Factors
Non-modifiable risk factors
Use of hormone replacement therapy
Obesity
Physical activity
Alcohol use
Breastfeeding
Pregnancy (number, age, etc)
Age
Gender
Race/ethnicity
Age of menarche/menopause
Personal history of breast cancer
Familial history
Genetic mutations
Primary Prevention: Modifiable Risk Factors
Educating women about behaviors aimed at changing modifiable breast cancer risk factors can help them take charge of their own health. While many risk factors such as age, gender, race/ethnicity, and family history are predetermined, many risk factors can be favorably impacted by simple lifestyle changes. Engaging in regular physical activity, maintaining a healthy weight, limiting alcohol use, and limiting the use of hormone replacement therapy all help minimize a woman’s risk.

15. Primary Prevention: Chemoprevention
Selective estrogen receptor modulators (SERMS).
Tamoxifen
FDA approved for risk reduction of breast cancer in high-risk women.
Raloxifene
The FDA Advisory Committee recently recommended approval of Raloxifene for breast cancer risk reduction (July 2007).
Only recommended for high risk women, not those with low or average risk.
Primary Prevention: Chemoprevention
Some high-risk patients may further reduce their risk of breast cancer by chemoprevention with selective estrogen receptor modulators (SERMs). The two SERMs currently available are tamoxifen and raloxifene. Tamoxifen is the only FDA approved agent for risk reduction of breast cancer in high-risk women. Raloxifene, another selective estrogen receptor modulator, is currently FDA approved for the treatment and prevention of osteoporosis in post-menopausal women. The FDA Advisory Committee recently recommended approval of Raloxifene for breast cancer risk reduction (July 2007). Evidence does not currently support the use of chemoprevention in women with low or average risk of breast cancer.

16. Chemoprevention: Tamoxifen
The Breast Cancer Prevention Trial (BCPT)
50% reduction in the incidence of breast cancer after receiving tamoxifen for 5 years.
Other studies
Statistically significant reductions in the incidence of contralateral breast cancer in those treated with tamoxifen.
Side effects:
Increased risk of endometrial cancer and thrombosis
Hot flashes.
Chemoprevention: Tamoxifen
The Breast Cancer Prevention Trial (BCPT) demonstrated a significant reduction (50%) in the incidence of breast cancer in women who received tamoxifen for five years. Also, several studies in women with breast cancer demonstrated statistically significant reductions in the incidence of contralateral breast cancer in those treated with tamoxifen. Serious side effects associated with tamoxifen include increased risk of endometrial cancer and thrombosis; many patients also experience hot flashes.

17. Chemoprevention: Raloxifene
Multiple Outcomes of Raloxifene Evaluation (MORE)
76% reduction in invasive breast cancer compared to placebo when treatment continued for a median of 40 months.
Side effects:
Thrombosis
Hot flashes
STAR Trial
Raloxifene as effective as tamoxifen in reducing risk of invasive breast cancer.
Raloxifene had a lower risk of thromboembolic events and cataracts, but a nonstatistically significant higher risk of noninvasive breast cancer compared to tamoxifen.
Chemoprevention: Raloxifene
The effect of raloxifene on breast cancer reduction was first investigated during the Multiple Outcomes of Raloxifene Evaluation (MORE) trial. The primary endpoint of the study was reduction and/or prevention of osteoporosis in post-menopausal women; breast cancer prevention was a secondary endpoint. Results from this study demonstrated a 76% reduction in invasive breast cancer compared to placebo when treatment continued for a median of 40 months. Unlike tamoxifen, raloxifene has not been associated with an increased risk of endometrial cancer but is associated with a similar increased risk of thrombosis and hot flashes. A head to head comparison study of tamoxifen to raloxifene was recently published and showed that raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer. The study also demonstrated that raloxifene had a lower risk of thromboembolic events and cataracts but a nonstatistically significant higher risk of noninvasive breast cancer compared to tamoxifen.

18. Primary Prevention: Genetic Screening
Family history patterns associated with increased risk for inherited BRCA mutations in non-Ashkenazi Jewish women:
1st degree relative with a known BRCA mutation
Two 1st degree relatives with breast cancer, one who received the diagnosis at age 50 or younger
Three or more 1st or 2nd degree relatives with breast cancer regardless of age at diagnosis
Combination of both breast and ovarian cancers among 1st and 2nd degree relatives
1st degree relative with bilateral breast cancer
Combination of two or more 1st or 2nd degree relatives with ovarian cancer
1st or 2nd degree relative with both breast and ovarian cancers
Breast cancer in a male relative
Primary Prevention: Genetic Screening
Because the presence of BRCA1 and BRCA2 mutations increases a woman’s lifetime risk of developing breast cancer, testing and identifying these mutations in women with a strong family risk of the disease can help facilitate early detection. The chance that a woman carries the genetic mutation is rare, with only 5-6% of all breast cancers associated with an inherited mutation. However, familial history patterns associated with BRCA mutations can facilitate the decision to test. The U.S. Preventive Services Task Force recommends against testing for genetic mutations in women without these family history patterns.

19. Primary Prevention: Genetic Screening
Options for women who test positive BRCA mutations:
Prophylactic mastectomy and oophorectomy.
Increased surveillance, including:
Clinical breast exams 2-4 times per year.
Monthly self breast exams.
Annual mammograms starting at age 25.
Twice yearly ovarian cancer screening with ultrasound beginning at age 35.
Chemoprevention with SERMs.
Primary Prevention: Genetic Screening
Options available for women who test positive for a BRCA mutation include prophylactic mastectomy and oophorectomy to reduce the risk of breast cancer (90% and 50%, respectively); increased surveillance, including clinical breast exams 2-4 times per year, monthly self breast exams, annual mammograms starting at age 25, and twice yearly ovarian cancer screening with ultrasound beginning at age 35; and chemoprevention with SERMs.

20. Secondary Prevention: Self Breast Exam (SBE)
Noninvasive screening test.
Clinical evidence does not show clear benefit.
Patient and healthcare professional should discuss.
Women should be told to report any changes or abnormalities.
Secondary Prevention: Self Breast Exam
Many healthcare advocates support self breast examination (SBE) as a noninvasive screening test that can help women feel in charge of their health. However, clinical evidence fails to show a clear benefit to performing an SBE. Several randomized clinical trials indicate that the practice of regular SBE by trained women does not reduce breast cancer mortality, and several evidence-based reviews concluded that clinical evidence does not support the use of SBE. In fact, the Cochrane group viewed SBE as causing more harm than good by increasing the number of biopsies performed. A thorough discussion of this activity and the accompanying research data should be held between the patient and her provider. It is important that women are sensitized to immediately alert their primary health care provider if, in any event and by any means, they notice a change in their breast.

21. Secondary Prevention: Clinical Breast Exam (CBE)
Approximately 5% of breast cancers identified by CBE alone.
54% Sensitivity
94% Specificity
No clinical trial exist comparing CBE alone to no screening.
Secondary Prevention: Clinical Breast Exam
As with the SBE, there is much debate regarding the efficacy of the clinical breast exam (CBE). Researchers estimate that approximately 5 percent of breast cancers are identified only by clinical breast examination, with pooled data estimating 54 percent sensitivity and 94 percent specificity. In a large community study, only 4 percent of women with an abnormal CBE were eventually diagnosed with breast cancer. No clinical trials exist comparing CBE alone to no screening, so it is difficult to assess the absolute effectiveness of this technique.
Bobo JK, et al. J Natl Cancer Inst. 2000;92(12):

22. Secondary Prevention: Screening Mammography
Recommendations for mammography screening
Age to start screening (yrs.)
Interval of screening (yrs.)
Organization 40 1
National Comprehensive Cancer Network
American College of Radiology
American Medical Association
American Cancer Society
1-2
American College of Obstetricians and Gynecologistsa
National Cancer Institute
US Preventative Services Task Force
American Academy of Family Physicians
50b
American College of Preventive Medicine*
a: 1-2 years for women years, 1 year for women >50 years; b: age 40 for high risk women; * the ACPM policy is currently under review.
Secondary Prevention: Mammography
Routine screening with mammography is generally recognized as a valuable tool for improving early detection and decreasing mortality from breast cancer. Numerous studies demonstrate the ability of mammography to detect breast cancer before it becomes clinically evident. Most North American medical organizations support the use of mammography for screening at 1-2 year intervals, beginning at age 40.
There is some debate regarding when to stop screening. While mammography has been shown effective in the early detection of breast cancer in women 40 to 74 years of age, the benefits of mammography for women over 75 years of age is unknown because few clinical trials have included women older than 74 years. Because breast cancer risk is high after age 70, older women would certainly seem to continue to benefit from yearly mammograms. The reality for many older women is that breast cancer becomes one of many competing health issues where the risk of dying from other health conditions may be much higher than the risk of dying from breast cancer. The older woman and her healthcare professional need to carefully weigh the risks and benefits of continued mammography screening.

23. Secondary Prevention: Other Modalities
Ultrasound
MRI
Recommended as annual screening tool for women who:
Have a BRCA 1 or 2 mutation.
Have a first-degree relative with a BRCA 1 or 2 mutation and are untested.
Have a lifetime risk of breast cancer of percent or more using standard risk assessment models.
Received radiation treatment to the chest between ages 10 and 30, such as for Hodgkin Disease.
PET
Ultrasound is accepted as the most useful adjunct to mammography for the diagnosis of breast abnormalities, but has limited value as a stand-alone screening tool. It can effectively differentiate cystic masses from solid masses and is often used to guide needle aspirations. Ultrasound is especially effective for younger women with dense breasts. Its use in women with fatty breasts yields a higher rate of false negatives compared to mammography.
Magnetic resonance imaging (MRI) and positron emission tomography (PET) have proven effective in imaging suspected growths in the breast. MRI scans are especially effective in pre-surgical planning, but may be useful as an adjunct to mammographic screening in woman at very high risk of breast cancer. The American Cancer Society recently released guidelines outlining the use of MRI as an annual screening tool in specific high risk women (Table 7). PET scans can distinguish malignant from benign disease and have excellent sensitivities and specificities, but cost prohibits their use as breast cancer screening tools; currently, they are used mainly for diagnostic situations.

24. Tertiary Prevention Cancer treatment-related complications
Early complications
Wound infection
Shoulder immobility and neuropraxia
Skin desquamation
Acute toxicities of chemotherapy
Febrile neutopenia
Early lymphedema
Late Complications (rare)
Tissue fibrosis
Chemotherapy-induced heart disease
Myelodysplasias
Late-onset lymphedema
Psychological and possible intellectual effects
Endocrine therapy
Tamoxifen
Endometrial cancer
Vaginal bleeding
Thromboembolic events
Aromatase inhibitors
Decreased bone density
Myalgias and arthralgias
Tertiary Prevention
After diagnosis of breast cancer, the cancer care of most patients involves an oncologist. However, once a cancer treatment regimen is complete, the oncologist may continue to provide follow-up, but more likely the patient returns to her primary care provider. A typical treatment regimen of surgery, chemotherapy, and radiation can span 6-12 months, with many patients receiving endocrine therapy for an additional 5-10 years. During the first year, patients usually have frequent follow-up with oncologists; after this, the primary care provider often monitors closely for treatment-related complications

25. Tertiary Prevention Continue preventive screening.
No long-term survival benefit seen with intensive follow-up vs. routine mammograms and physical exams.
Continue ongoing primary care and screenings for other cancers (i.e.. Colon cancer).
Provide psychosocial support, education, and resource materials.
Encourage exercise and weight loss (if applicable).
Tertiary Prevention
Primary care providers should continue preventive screening to observe for metastasis of breast cancer or occurrence of new cancers. Regarding the type of screening, clinical trials comparing intensive follow-up with bone scans, CT scan, and laboratory tests versus an annual mammogram plus bi-annual physical exams demonstrated no survival benefit for intensive follow-up. Since most breast cancer patients are long-term survivors, ongoing primary care and standard screening for other cancers (e.g. colonoscopy) are essential to future health.
Primary care providers can play an important role in the patient’s follow-up care by offering invaluable psychosocial support and providing education and resource materials about reducing the risk of cancer recurrence. During the initial treatment period and throughout the follow-up period, many cancer survivors experience depression and anxiety. Weight gain is also common, and may contribute to body image changes resulting from cancer-related treatments. Encouraging a patient to begin or continue exercising can have a two-fold effect: helping a patient maintain or even lose weight and lessening the symptoms of fatigue, depression, and anxiety.

26. Special Issues for Rural Providers
Compared to urban counterparts, the rural population:
Is generally older, poorer, and less educated.
Has fewer physicians and hospitals per capita.
This disparity results in:
Lower level of patient-reported health status.
Less confidence in being able to obtain needed care.
Fewer physician visits.
The need to travel farther to obtain care.
Special Issues for Rural Providers
The rural population is generally older, and on average poorer and less educated, than their urban counterparts. Rural areas have fewer physicians and hospitals per capita compared to urban regions. This disparity often results in a lower level of patient-reported health status, less confidence in being able to obtain needed care, fewer physician visits, and the need to travel farther to obtain care. Also a rural resident is more likely to have their primary care provided by a nurse practitioner or physician assistant.

27. Poverty in Rural Regions
Percentage of population living in poverty stratified by geographic location
Geographic location
% of population living in poverty*
Urban population
13.8%
Rural adjacent population
15.8 %
Rural non-adjacent population
22.5%
*Poverty is defined as household income below the 100% of the 1997 federal poverty level; specific numbers can be found at
Poverty in Rural Regions
Little information is available on breast cancer statistics in urban women compared to rural women. Research suggests that income correlates with health status and access to care. The 1997 National Survey of America’s Families (NSAF) interviewed residents in 44,000 households (both children and adults) to gather demographic and geographic data to assist policy-makers in designing health policies. The NSAF found that 22.5% of the population living in rural areas lived in poverty compared to 13.8% of the urban population. They defined geographic regions as 1) Urban - the resident’s county encompassed a metropolitan area; 2) Rural adjacent - the resident’s county was contiguous with a metropolitan area; and 3) Rural non- adjacent - the resident’s county was not contiguous with a metropolitan area.
Ormond B, et al. A Rural/Urban Differences in Health Care Are Not Uniform Across States. New Federalism: National Survey of America's Families [Number B

28. Barriers Facing Rural Providers
Negative patient attitudes about mammography.
Fear of pain, discomfort, and anxiety.
Cultural/racial norms and attitudes about disease processes.
Screening rates lower in women with no high school diploma or GED.
African-American and Hispanic women have fewer baseline and routine mammograms.
Barriers Facing Rural Providers
Rural providers face an inordinate number of patient-related barriers to providing the necessary screening for breast cancer prevention. Many patients avoid regular mammograms because of fear of pain, discomfort, and anxiety. Therefore, providers may need to spend additional time educating patients about the recommended frequency of mammograms and discussing negative misconceptions regarding the test. Providers must also be sensitive to cultural and racial issues and may need to target certain patients for more aggressive follow-up.
In general, mammography screening rates are lower among women with no high school diploma or GED. In addition, African-American and Hispanic women undergo fewer baseline and routine mammography screenings and have a more advanced stage of disease at diagnosis than Caucasian women. Caucasian women have the highest incidence of breast cancer; however, African-American, Hispanic, American Indian, Alaskan native, and Asian-American women have higher death rates from the disease.

29. Barriers: Health Insurance
Percentage of patients uninsured:
14.3 percent of urban residents
17.5 percent of residents in rural adjacent counties
21.9 percent in rural non-adjacent counties
Significantly more women with insurance received regular mammograms than did those without insurance (60% vs. 33%, respectively).
The National Breast Cancer and Cervical Cancer Early Detection Program
Barriers: Lack of Health Insurance
The proportion of the non-elderly population covered by private health insurance (predominantly employer-sponsored coverage) fell as county of residence becomes more remote; although, in some areas Medicaid coverage helped offset this short-fall. The percentage of those who were uninsured by private insurance or public coverage was 14.3 percent of urban residents, 17.5 percent of residents in rural adjacent counties, and 21.9 percent in rural non-adjacent counties. Rural residents had less employee-sponsored insurance, in part due to a higher percentage of family-owned businesses, lower wages, and self-employment. Lack of insurance has been directly linked to decreased healthcare access, particularly annual screening mammograms. Not surprisingly, significantly more women ages with insurance received regular mammograms than did those without insurance (60% vs. 33%, respectively).
Without a means to pay for preventive care, many patients simply neglect this important health measure. The National Breast Cancer and Cervical Cancer Early Detection Program helps women in need obtain important cancer prevention screening by providing an array of services, including program management, screening and diagnostic services, data management, quality assurance and quality improvement, evaluation, partnerships, professional development, and recruitment. Visit the National Breast Cancer and Cervical Cancer Early Detection Program website to find resources in your state:
Ormond B, et al. New Federalism: National Survey of America's Families [Number B Smith RA, et al CA Cancer J Clin. Jan-Feb 2006;56(1):11-25.

30. Barriers: Screening Site Issues
Shortage of breast imaging specialists; however, new technologies may help:
Increase the accuracy of breast cancer detection.
Improve access to mammography.
Broaden the pool of medical personnel who can interpret mammograms.
Shortage of new visiting specialists
Rural Health Care programs help fund necessary telecommunications.
Barriers: Screening Site Issues
Another issue facing rural providers is a shortage of breast imaging specialists. However, new technologies may help increase the accuracy of breast cancer detection, improve access to mammography, and broaden the pool of medical personnel who can interpret mammograms. Although telemedicine and visiting specialists are essential to providing medical access in rural areas, there is a shortage of new doctors choosing to become visiting specialists. The Rural Health Care program supports health care providers serving rural communities by funding telecommunications services necessary for the provision of health care.

31. Barriers: Access Issues
Components of an office system for annual preventive care prompts and reminders
Determine the target women for breast cancer screening/preventive services
Computerized prompts through an electronic medical record (EMR) system
Flow sheets
Mailed or telephone reminders
Newsletters or educational materials
Brief telephone counseling for women who have not received a mammogram in the preceding 15 months.
Barriers: Access Issues
Finally, one of the biggest issues for rural providers is lack of regular health care access by the patient. When patients fail to schedule regular check-up visits and come in only when an acute issue develops, the provider must focus on acute conditions and symptoms in favor of preventive medicine. To help primary providers manage multiple clinical issues in a single office visit, an office-based system of prompts and reminders could be implemented. The components of a prompt system include: determining the target women for breast cancer screening/preventive services, computerized prompts through an electronic medical record (EMR) system, flow sheets, mailed or telephone reminders, newsletters or educational materials, and brief telephone counseling for women who have not received a mammogram in the preceding 15 months.

32. Improving Communications
Learn about your community. If you are new to the community, learn about the demographics of your population.
With your staff, decide on a realistic target and set a goal. For example, develop a plan to increase the mammogram screening of your target population by 20% in the next year.
Visit the women in your community at adult education classes, coffee shops, and other places where women are gathering. Put together a “Grab Bag” with handouts and important date reminders.
Improving Communications
By helping women recognize the importance of regular screening, identifying personal barriers that may hinder screening, implementing an office system of prompts and reminders, and increasing access to preventive care, rural primary care providers can increase the number of women receiving annual mammograms, and subsequently, reduce the mortality of breast cancer. The tips on this slide provide some ideas on how to better facilitate the communication between patients and their healthcare providers.

33. Improving Communications
Use the office staff to teach and help with follow-up. Ask them for ideas on how to reach out into your community.
Create a “reward” for repeat positive behavior or change in behavior. For instance, create a “Bring a friend to your mammogram” program.
Use the Pink Ribbon symbol to remind women how important screening is. Contact the Susan G. Komen Foundation and others who offer free Pink Ribbons.
Be visible. Health care providers are viewed as the experts, and when you speak, others listen and will know the message is important.
Improving Communications
This slide provides some additional tips for improving communications with patients. Remember that opening a dialogue with patients on breast cancer risk reduction and preventative measures is an important part of patient care.

34. Conclusions
Rural healthcare providers face challenges in addressing patient needs.
Acute issues vs. preventive measures.
Patient barriers
Assess individual risk factors
Discuss chemoprevention in applicable patients
Encourage regular screenings for all eligible patients.
Conclusions
Rural healthcare providers face enormous challenges in addressing all the needs of their patients. Often, they must focus on acute issues at the exclusion of preventive measures. However, because early detection of serious diseases such as breast cancer can drastically increase a patient’s chance of survival, it is essential that every effort is made to provide these needed services to each patient. By recognizing patient barriers and by assessing each patient’s individual risk factors, providers can begin to tailor preventive strategies to each patient. Encouraging regular screenings for all eligible patients, regardless of risk, will allow rural practitioners to provide the best standard of care for their patients, thereby improving their quality of life and promoting their continued health.

35. Breast Cancer Prevention: An AAFP-Accredited CME program
Allergic Rhinitis: diagnosis and treatment
Thank you very much for attending the workshop today. Does anyone have any questions?
Note to speaker: you will most likely need to reserve 5-10 minutes at the end of your presentation for questions.