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Implementing Recommendations for the Early Detection of Breast and Cervical Cancer Among Low-Income Women

Implementing Recommendations for the Early Detection of Breast and Cervical Cancer Among Low-Income Women

Although the causes and natural histories of breast and cervical
cancer are different, the public health responses to these diseases
have been similar. Early detection of breast cancer and primary
prevention of cervical cancer are possible through community-based
screening programs; however, early detection of both breast and
cervical cancer is less common among low-income women (defined as up
to 250% of poverty level, depending on family size). This report
presents morbidity and mortality data regarding breast and cervical
cancer, screening recommendations, an update on the National Breast
and Cervical Cancer Early Detection Program (NBCCEDP), and
recommended priority activities for the NBCCEDP. The NBCCEDP is a
major public health effort to increase breast and cervical cancer
screening among uninsured, low-income women.

Scope of the Problem

Breast Cancer

Among women in the United States, breast cancer is the most commonly
diagnosed cancer and remains second only to lung cancer as a cause of
cancer-related death. The American Cancer Society (ACS) estimates
that 182,800 new cases of female breast cancer and 41,200 deaths from
breast cancer will occur in 2000. In 1996, data from the
Surveillance, Epidemiology, and End Results (SEER) Program of the
National Cancer Institute (NCI) indicated that the incidence of
breast cancer increased 25.3% between 1973 and 1996 (Figure
1
). Most of the increase occurred from 1973 to 1991; incidence
rates remained stable from 1992 to 1996.

In 1996, the incidence rate for breast cancer was 110.7 cases per
100,000 women, a 29.6% increase since 1980. In addition, in 1996, the
case-fatality rate for breast cancer was 24.3 per 100,000 women, a
4.5% decrease since 1992, representing the first sustained decline in
breast cancer–related mortality since 1973 (when SEER
surveillance for breast cancer began). Although the percentage
increases in incidence from 1973 to 1996 were similar among black and
white women, the percentage decrease in mortality from 1992 to 1996
was substantially greater among white women than black women.

Overall, from 1992 to 1996, breast cancer incidence rates were higher
among white women (113.1 per 100,000) than black women (100.3), but
breast cancer death rates were lower among white women (25.1) than
black women (32.0). Furthermore, these race-specific differences in
rates varied by age.

Among women aged < 50 years, the incidence rate for black women
(32.7) was higher than that for white women (31.1). Among women aged ³
50 years, the rate was higher for white women (365.8) than for black
women (308.7). The death rate among women aged < 65 years
was higher for black women (20.4) than for white women (14.3).
Although the death rate among women aged ³ 65
years was higher for white women than for black women before 1987,
recent data indicate that the death rate among this age group is
higher for black women (130.9) than for white women (124.0). On the
basis of SEER data for 1988 to 1992 (the most recent data available),
incidence rates were highest for white (145.7), Hawaiian (105.6), and
black women (95.4), and lowest for Korean (28.5), American Indian
(31.6), and Vietnamese (37.5) women. Incidence rates among white,
non-Hispanic women were four times higher than among Korean women.

Stage-specific survival rates among women with breast cancer have
increased slightly since the 1970s. The overall 5-year survival rates
for women from 1989 to 1995 were 86% for white women and 71% for
black women. Survival was greatest at the earliest stage of disease.
Age-specific survival rates were similar for white and black women.
One explanation for the disparity in race-specific survival rates is
that white women, on average, seek medical care for tumors at an
earlier stage of disease than black women. However, the interim
between symptom recognition and medical consultation does not appear
to account for these race-specific differences in survival rates or
stage at diagnosis of breast cancer.

Limited data are available regarding survival for other ethnic groups
in the United States. In a study of stage at diagnosis and tumor
histology among white and Asian women, the 5-year survival rate at
all stages was higher among Asian women than among white women. In
addition, based on data from another study, the survival rate among
Hispanic women is similar to the rate among white women in the United States.

Cervical Cancer

Since the 1950s, the incidence of invasive cervical cancer and
mortality from this disease has decreased substantially. In large
part, the decline has been attributed to widespread use of the
Papanicolaou (Pap) test—a highly effective preventive measure.
However, the rate of decline in invasive cervical cancer has slowed
since the early 1980s and appears to have stabilized in recent years (Figure
2
). The ACS projects that approximately 12,800 cases of invasive
cervical cancer will be diagnosed and that approximately 4,600
cervical cancer deaths will occur in the United States in 2000. From
1992 to 1996, the incidence rate at SEER sites was 7.9 cases per
100,000 women, and the death rate for cervical cancer was 2.8 per
100,000 women.

On the basis of SEER data, both incidence and death rates for
cervical cancer vary among racial/ethnic groups. The incidence rate
for cervical cancer is highest among Vietnamese women (43.0), and the
death rate for cervical cancer is highest among black women (6.7).
The incidence rate among black women (11.2 per 100,000) is
approximately 50% higher than among white women (7.3). Death rates
among black women (5.9) are approximately twice as high as those
among white women (2.4). Although the disparities in rates between
blacks and whites have declined since 1990, differences in rates
persist. This persistent disparity has been attributed to several
factors, including differences in the prevalence of risk factors for
cervical cancer; differences in screening, diagnostic evaluation, and
treatment; and differences in the stage of disease at diagnosis.

Race-specific differences in incidence and death rates for cervical
cancer also varied by age. From 1992 to 1996, among women aged <
35 years, the rate of invasive cervical cancer among black women was
lower than the rate among white women. However, in older age groups,
incidence rates among white women fluctuated between 13 and 15 per
100,000 women, whereas rates among black women tended to increase
with age to approximately 32 per 100,000 for those aged ³
75 years. Among both black and white women, death rates for cervical
cancer increased with advancing age; however, rates were
substantially higher for black women aged > 40 years than for
white women the same age. Regardless of race, most cervical cancer
deaths occur among women aged ³ 50 years.

For women in whom invasive but localized (ie, stage I) cervical
cancer has been diagnosed, the 5-year relative survival rate is
approximately 90%. In contrast, for women with advanced invasive
cervical cancer (beyond the cervix and pelvis [ie, stage III and IV,
respectively]), the 5-year relative survival rate is approximately
12%. As with breast cancer, diagnosis of invasive cervical cancer in
black women usually occurs at a later stage of disease compared with
white women. Moreover, 5-year relative survival rates for local and
regional stages are lower for blacks than for whites.

Etiologic Factors

Breast Cancer

The risk for breast cancer increases with advancing age. Other risk
factors include personal or family history of breast cancer, history
of certain benign breast diseases, early age at menarche, late age at
menopause, exposure to ionizing radiation, obesity, white race,
nulliparity, late age at first birth, nodular densities on mammogram,
higher socioeconomic status, and residence in urban areas of the
northern United States. Less clearly established risk factors include
the duration between menstrual periods, use of oral contraceptives,
use of replacement hormones (estrogen), height, alcohol consumption,
and not breast-feeding.

Studies of immigrants to the United States suggest that environmental
factors rather than genetic factors are responsible for variations in
breast cancer rates among countries. For example, the rate of breast
cancer among first-generation Japanese-American women is only
slightly higher than the rate among their mothers, but the rate among
their daughters is considerably higher.

No primary prevention measures suitable for use in the general
population have been established for breast cancer. Preliminary
results from clinical trials among high-risk women regarding the use
of the drug tamoxifen (Nolvadex) indicate a 45% decline in incidence
from its use. Although side effects and the potential development of
other neoplasms are associated with tamoxifen use, other medications
in its class might offer even greater benefits in breast cancer
treatment. The Study of Tamoxifen and Raloxifene (STAR) trial is
underway to evaluate tamoxifen vs raloxifene (Evista) and the
potential for reducing the incidence of breast cancer in high-risk
postmenopausal women.

Cervical Cancer

The risk for cancer of the cervix has been associated with several
factors, including infection with certain types of human
papillomavirus (HPV), early age at first intercourse, multiple male
sex partners, a history of sexually transmitted diseases, smoking,
certain nutritional deficiencies, and low socioeconomic status. HPV
infection is widely accepted as the cause of most squamous cell
cervical cancers, and the sexual practices listed are
well-established risk factors for the disease; however, the role of
other demographic and behavioral factors is less clear.

Black, Hispanic, or American Indian race/ethnicity is considered a
risk factor for cervical cancer because rates of detection and death
from cervical cancer are higher among these women. However, some of
the racial/ethnic differences in cervical cancer rates can be
explained by the strong inverse association between socioeconomic
indicators and the risk for invasive cervical cancer. This increased
risk could be associated with differences in access to care and
cultural behavior.

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