Breast Cancer in Vulnerable Female Populations

FEMALE BREAST CANCER

Kennon H. McCollum

University of Alabama

Capstone College of Nursing

NUR 732: Population Health for the Advanced Practice Nurse

Spring 2012

Breast Cancer in Vulnerable Female Populations

Breast cancer in women remains a major health care concern for the United States (U.S.). In the year 2012 it is expected that approximately 226,870 new cases of invasive breast cancer and 63,300 new cases of carcinoma in situ (CIS) of the breast will be diagnosed in the U.S. (American Cancer Society, 2012a). At current incidence rates, approximately 12% or 1 in every 8 women in the U.S. will develop invasive breast cancer within their lifetime (Breastcancer.org, 2012a). Even though there has been a decline in the incidence of newly diagnosed cases of breast cancer of approximately 2% from 1999 to 2005, breast cancer remains the second leading cause of death in women and is surpassed only by lung cancer; and it is estimated that there will be approximately 39,510 deaths from breast cancer in 2012 (American Cancer Society, 2012b).

Women who are the most at risk of developing breast cancer are those who have an inherited familial risk such as deleterious mutations in either the BRAC-1 or BRAC-2 gene, are Caucasian, are obese, are over the age of 55, are exposed to certain environmental factors, and those who have had previous hormonal replacement therapy (Breastcancer.org, 2012b). Differences in race and ethnicity also influences a women’s likelihood of developing breast cancer since Caucasian women are more apt to be diagnosed with breast cancer than are African American, Hispanic, Latina, and Asian women, with African American women usually being diagnosed at earlier ages, and with more aggressive forms of breast cancer (Breastcancer.org, 2012b). All women are considered to be within a vulnerable population based on gender alone, but may also be considered to be within a vulnerable population because of age, race, ethnicity, genetics, disability, or other modifiable factors such geographic locale or socioeconomic status. Vulnerable populations are defined as particular social groups with increased morbidity and mortality which is the result of various factors such as low socioeconomic status, high relative risk, and lack of adequate environmental resources (Flaskerud & Winslow, 1998a). One example of this may be women living in neighborhoods with lower mean incomes. Lower income women are more likely to have advanced-stage breast cancer at the time of diagnosis, worse breast cancer outcomes, and seek treatment for breast cancer later than women with higher mean incomes (Echeverria, Borrell, Brown, & Rhoads, 2009).

In addition to population vulnerability, there are also disparities that exist in today’s healthcare system that have an effect on the treatment that women receive for breast cancer. Haggstrom, Quale, & Smith-Bindman (2011) report that African-American and Hispanic women are significantly less likely to receive adequate care than are Caucasian women for breast cancer, and the Asian / Pacific Islander women receiving adequate care was similar to Caucasian women (Haggstrom & Doebbeling, 2011). Their study also concluded that; (a) women who were diagnosed from 1997-1999 and were African-American were less likely than Caucasian women to receive adequate care; (b) women ages 75-79 years were less likely to receive adequate care compared with women ages 66-69; and (c) women from rural areas were less likely to receive adequate care as compared to women in urban settings (Haggstrom, Quale, & Smith-Bindman, 2005). Studies such as these serve only to remind us that that the quality of breast cancer care is often lower among certain vulnerable populations than others, and that changes are needed to end disparity.

The purpose of this paper will be to discuss how race, poverty, social isolation, limited resources, and lack of access to healthcare have an integral effect on the outcomes of breast cancer in the vulnerable population of women, and will discuss how patient centered risk reductions should become an area of focus for improvement in regards to breast cancer care. This paper will also discuss how the tenets of the Vulnerable Populations Conceptual Model (VPCM) of care can be applied to vulnerable populations of women with breast cancer concerns in hopes of improving overall community health.

Demographic Characteristics of U.S. Women and Female Breast Cancer

Gender and Race and Age

According to the 2010 U.S. census, there are approximately 156,964,212 females that comprise 50.8% of the total population (U.S. Census Bureau, 2011a). In 2011 there were 230,480 new cases of invasive breast cancers, 57,650 cases of CIS, and 39,520 deaths attributed to female breast cancer (American Cancer Society, 2012b). In examining female breast cancer from 2004-2008 is noted that the median age at diagnosis was 61 years of age, and white females were diagnosed at 124 cases per 100,000 women as compared to 119 cases per 100,000 women for African American women, 94 cases per 100,000 for Asian women, and 92 cases per 100,000 for Hispanic women respectively (National Cancer Institute, 2011).

Marital Status

In review of the literature in regards to the differences in the incidence of breast cancer that may exist between single females, married females, and divorced females not much data exists. Hems & Stuart (1975) conducted research to determine if variation in the incidence of breast cancer was noted between single women and married women and concluded that age specific breast cancer rates for single women showed the same variation by country, social class, urban-rural areas as did the corresponding rates for married women (Hems & Stuart, 1975).

Income and Education Levels

The average per capita income noted in the 2010 census was approximately $27,334.00 with the median household income of approximately $51, 914.00, and there was approximately 13.8% of the population living below the national poverty levelof $11,139 per person (U.S. Census Bureau, 2011b). The median annual income for full-time employed, year-round women workers in 2009 was $36,278 (U.S. Census bureau, 2010d). The 2010 census also revealed that in females who were living above the national poverty level there were; (a) 9,873,579 women who had less than a high school education; (b) 24,997,608 women who were either high school graduates or had an equivalent diploma; and (c) 28,107,300 women with a bachelors degree ore higher (U.S. Census Bureau, 2011d). In the same year,the number females who were living below the national poverty level were; (a) 4,282,216 women who had less than a high school education; (b) 4,435,438 women who were either high school graduates or had an equivalent diploma; and (c) 1,353,878 women with a bachelors degree ore higher (U.S. Census Bureau, 2011d).

Geographic Density of Female Breast Cancer

In examining the U.S. population, the states with the highest incidences (124.9 to 139.2 cases per 1000, 00 women) of female breast cancer are: Connecticut, Delaware, District of Columbia, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, Oklahoma, Oregon, Rhode Island, and Vermont; and the states with the highest death rates (24.4 to 31.5 cases per 100,000 women) from female breast cancer are: Alaska, Arkansas, Delaware, District of Columbia, Illinois, Kentucky, Maryland, New Jersey, North Carolina, Ohio, Oklahoma, Vermont, and Virginia (Centers for Disease Control, 2011).

Relative Trends in Female Breast cancer

In looking at relative trends in female breast cancer it is noted that from 1998 to 2007 in the U.S. the incidence of invasive breast cancer has; (a) declined by 1.3% per year among women; (b) declined by 1.4% per year among white women; (d) remained unchanged among African America women; (d) declined by 0.9% per year among Hispanic women; (e) declined by 1.0% per year among American Indian/Alaska Native women; and (f) remained unchanged among Asian/Pacific Islander women (Kohler et al., 2011). Trends as they relate to mortality from 1998 to 2007 in the U.S. show that deaths from breast cancer have; (a) declined by 2.0% per year among women; (b) declined by 2.0% per year among white women; (c) declined by 1.4% per year among black women; (d) declined by 1.9% per year among Hispanic women; (e) remained unchanged among American Indian/Alaska Native women; and (f) declined by 1.0% per year among Asian/Pacific Islander women (Kohler et al., 2011). This data suggest that women in the U.S. who are diagnosed and who die with female breast cancer has decreased by overall by approximately 2%, and most notably has done so in Caucasian women. As public awareness of female breast cancer expands, and public advocacy groups become more visible and active within communities, breast cancer resources for these women are also expanding.

The Vulnerable Populations Conceptual Model

The Vulnerable Populations Conceptual Model (VPCM) by Flaskerud & Winslow (1998) hypothesizes that interrelationships among resource availability, relative risk, and health status have an influenceon the health of both individuals within a community and the community itself. Within the VPCM resource availability pertains to certain socioeconomic and environmental resources such as income, jobs, education, housing, availability of health care, quality of health care, and patterns of family and community life(Leight, 2003). The model further postulates that individuals will likely be exposed to risk factors as the result of lifestyle behaviors, personal choices, and exposure to stressful events, and also states the individuals may possess some degree of inherent risk based upon age, gender, race, and ethnicity(Leight, 2003). The availability of resources and the exposure to risks ultimately have either a positive or negative effect on health status which is operationalized through the concepts of morbidity and mortality which serve to represent the concept of health status (Flaskerud & Winslow, 1998b). The VPCM of care has been applied to rural health populations and other at-risk populations for the purpose of improving the overall health status ofa variety of vulnerable communities in the U.S., and can be also be applied to female breast cancer as a vulnerable population.

Resource Availability

Resource availability is one of the major tenets of the VPCM. Resources can be either social or environmental resources, and as resources are increased, relative risk which is the likelihood of developing disease, tends to decrease. Examples of social resources are poverty, limited or low financial resources, inadequate health insurance coverage, decreased or limited education, and limited access to health care (Sebastian, 2012). Research has repeatedly shown that impoverished, rural, low income, low education women, who live in areas where access to health care is limited, are less likely to be screened for breast cancer than suburban women with higher incomes, education, and adequate financial resources(Goldman et al., 2008). Data from the Behavioral Risk Factor Surveillance System (BRFSS) surveys contained in the 2000 census suggested those with annual household incomes of less than $15,000,less than a high school education, are less likely to have had a mammogram than more affluent, and higher educated women(Centers for Disease Control and Prevention (CDC), 2005).Increasing mammography resources for these at-risk individuals would improve the health status of women vulnerable to female breast cancer.

Relative Risk

Aday (1994) summarizes that the notion of risk relates to the concept of vulnerability, and implies that everyone is potentially vulnerable, which means to be at risk. Relative risk is the idea that there is the risk of an event occurring, or of developing a disease, or having an undesired outcome relative to exposure to certain associated risk factors. As risk exposure increases the relative risk also increases, and for individuals with poor social status, low social capitol, and deficient human capitol the consequences of risk exposures are often poor physical, psychological, and social health (Aday, 1994). Risk factors can be classified into either socioeconomic risk factors or environmental risk factors, and in terms of female breast cancer, risk factors may include genetic susceptibility, familial history, advanced age, poverty, race, low socioeconomic resources, low literacy levels, rural location, and even occupational and environmental exposure (Breastcancer.org, 2012c). Lack of resources as for this vulnerable population when combined with increased risk exposure may increase the relative risk of developing female breast cancer, which ultimately affects the overall health status of the individual and community by increasing morbidity and mortality.For this reason, risk reduction in addition to improved resource availability for breast cancer detection, treatment, and care should remain a primary focus for population-focused nursing initiatives.

Health Status

Vulnerable populations often share similar developmental and physiological characteristics that predispose the group to certain risk. Risk exposures that alter physiologic and developmental norms caused by vulnerability are associated with declined health status within populations (Sebastian, 2012). Measurable indicators of health status within a community are morbidity and mortality (Leight, 2003). Determinants of health status within these populations are notable improvements in normal physiologic and developmental function which often corresponds to reductions in morbidity and mortality (Sebastian, 2012). As resource availability increases, and relative risk declines, health status should reflect improvements in individual and community health determinants (Leight, 2003). In discussing breast cancer in vulnerable females, adherence to quality indicators remains important in order to achieve disease-specific outcomes for these vulnerable patients. Quality indicators established by National Initiative for Cancer Care Quality (NICCQ) that are specific to breast cancer can used to measure the health status within communities (Chen et al., 2011).

Conclusions

The VPMC is a very complex and multidimensional model which contains three interrelated concepts which are those of resource availability, relative risk, and health status. Women in general who are themselves a vulnerable population based upon gender alone are faced with limited resources for the detection, treatment, and follow-up care of female breast cancer. Though the incidence of female breast cancer has declined slightly in previous years, it still remains the second leading cause of death for women, surpassed only bylung cancer. Women who comprise slightly more than one half of the U.S. population remain at risk for this disease. Disparities in the early detections, effective treatment, and access to healthcare in regards to female breast cancer remain problematic for all women in America. Race, age, geographic locale, lower socioeconomic standing, poverty, and lower education levels all serve as barriers to resource availability in the care of women who may develop, and those who have been diagnosed with female breast cancer. The Vulnerable Populations Conceptual Model of care remains a valid framework for which these disparities and risk factors can be evaluated, improved, and admonished. The population-focused nurse through scientific research, direct clinical intervention, patient advocacy, and policy analysis and development can effectively improve resources, lower the relative risk for women in America, and improve the overall health status of communities and populations in regards to female breast cancer.

References

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Sebastian, C. A., (2012).Vulnerability and vulnerable populations: an overview. In M. Stanhope & J. Lancaster (Eds.), Public health nursing: population-centered healthcare in the community. 8th ed., pp 718-735). Maryland Heights, MO: Elsevier Mosby.

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United States Census Bureau (2011d). Poverty status in the past 12 months of individuals by sex by educations attainment. Retrieved from

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