Abstract
Background
Breast cancer is Asian American women’s most frequently occurring cancer.
Methods
Asian American women completed breast cancer-related baseline surveys for 2 studies 5 years apart.
Results
Statistically significant and rapid improvements in knowledge and screening practices were seen between the 948 participants in the first study (1995) and the 1540 participants in the second study. This increase paralleled the reported climb in early detection rates among Asian American women.
Conclusions
The data document the achievement of a tipping point in breast cancer screening rates with culturally and linguistically focused education programs and increased access to screening among disadvantaged women.
Breast cancer is the most frequently occurring cancer among women living in the United States. Asian American women have the lowest breast cancer incidence rates, but their likelihood of developing breast cancer increases with the length of time that they have lived in the United States. Hence, that low incidence rate is anticipated to increase as Asian American women’s residency in the United States extends.1,2 Further, as the Asian population’s average age has risen, so has its breast cancer incidence. Between 1988 and 2002, the breast cancer incidence among Asian American women increased from 77.7 per 100,000 to 92.9 per 100,000, whereas a decrease in incidence was noted when all women were grouped together (from 135.5 per 100,000 to 126.7 per 100,000). Asian women have also had lower breast cancer mortality rates than other groups, but during that same time period, their mortality rate increased from 14.0 per 100,000 in 1988 to 14.7 per 100,000 in 2002,3 whereas the mortality rate among women of all races combined decreased from 32.4 per 100,000 women in 1988 to 23.2 per 100,000 in 2002.3
Such data highlighted the need to promote breast cancer education and screening among Asian American women if a rise in mortality rates were to be prevented. Of equal concern was the data that showed Asian American women had the lowest rate of breast cancer early detection.4,5
Given the life-saving value of early breast cancer detection and the economic barriers to screening, the California legislature created the 1993 Breast Cancer Act. Effective July 1994, this funded mandate provided low income women throughout California with free access to breast cancer screening. It also funded a series of breast cancer education programs throughout the State.
In this article, we examine changes in the knowledge, behaviors, and attitudes of 2 convenience samples of Asian women who participated in separate evaluations of the Asian Grocery Store-Based program.
MATERIALS AND METHODS
Data collection was accomplished through the Asian Grocery Store-Based Cancer Education Program, a campus-community partnership with the Moores University of California, San Diego (UCSD) Cancer Center as the campus partner and over 2 dozen Asian grocery stores throughout San Diego County as the community partners. UCSD recruited bilingual, bicultural Asian American university students to work as the program’s breast cancer community health educators in salaried and service learning positions. They personalized breast cancer public health messages to large numbers of Asian American women for whom language, culture, and transportation barriers might limit access to information and screening.6–14
Asian grocery stores were asked to partner with the university because they were perceived to be venues where Asian women repeatedly spent a considerable amount of discretionary time. In addition, Asian women of diverse acculturation levels, linguistic preferences and proficiencies, and socioeconomic status could be easily reached at the Asian grocery stores.6–14
The Asian grocery-store-based education programs were designed as brief interventions to heighten breast cancer awareness, to stimulate and motivate the women to gather additional information, and to get screened if they were not already adhering to the mammography and clinical breast exam guidelines. Over the duration of the studies, breast self-exam screening was gradually losing favor, but adherence continued to be evaluated because the final conclusions regarding breast self exam had not been established.15
Posters in various Asian languages and country-specific visual icons helped to attract shoppers; small tokens of appreciation (eg, small candles, small vases, sunscreen samples) were given to women who agreed to participate in the study. Once trained, health educators rotated their education sessions among the Asian grocery stores and varied the times and days of the outreach events to increase sample diversity.
From 1995 to 1998, women (N = 1202) were recruited to a demonstration project (Study 1) to evaluate the feasibility, viability, and acceptability of Asian grocery stores as sites for delivering breast cancer information.6–14 Women verbally consented and completed a baseline survey in their preferred language (Institutional Review Board [IRB] approved). Based on the success of the demonstration project, an IRB-approved, randomized controlled trial (Study 2) was conducted at the Asian grocery stores from 2000–2004 (N = 1687). In this article, we compare the baseline data between Study 1 and 2.
Description of the Sample
Participants self-identified as being female, of Asian descent, and at least 20 years of age. Whereas Study 1 focused on the 6 largest Asian ethnic groups (Chinese, Filipino, Southeast Indian, Japanese, Korean, and Vietnamese), Study 2 was focused on the 4 Asian communities that Study 1 had shown to have the lowest adherence rates to recommended screening guidelines (Chinese, Filipino, Korean, and Vietnamese). Only the Study 1 participants (n = 948) from those 4 groups were included in this study with the 1540 participants from Study 2.
Of the women who reported their age (85% in Study 1; 94% in Study 2), the ages ranged from 20 to 86 years for Study 1 and from 20 to 101 for Study 2, with 46% of those in Study 1 and 73% of those in Study 2 being aged 40 and older (Table 1). This age shift from Study 1 to Study 2 (χ21 = 124.9, P = 0.05) reflected the methodologic shift to overrecruiting women aged 40 and older in Study 2 because of breast cancer’s increasing risk with age.
TABLE 1.
Sociodemographic Characteristics by Study Group of Women
| Study 1* | Study 2† | ||
|---|---|---|---|
| Characteristic | n (SD) | n (SD) | P Value |
| Age, y | |||
| Mean (SD) | 42.4 (11.7) | 48.5 (12.0) | <.001 |
| Mode | 45 | 48 | |
| Median | 41.0 | 48.0 | |
| Range | 20–86 | 20–101 | |
| n (%) | n (%) | χ2 | |
| Age groups | |||
| 20–39 y | 369 (39) | 338 (22) | 1.40 |
| 40–49 y | 242 (26) | 466 (30) | 70.87‡ |
| 50+ y | 191 (20) | 652 (42) | 252.10‡ |
| Unspecified | 146 (15) | 84 (6) | 16.71‡ |
| Full Sample | 948 (100) | 1540 (100) | 212.20‡ |
| Ethnic group§ | |||
| Chinese | 302 (32) | 390 (25) | 11.19‡ |
| Filipino | 248 (26) | 418 (27) | 43.39‡ |
| Korean | 123 (13) | 376 (25) | 128.28‡ |
| Vietnamese | 275 (29) | 356 (23) | 10.40‡ |
| Full Sample | 948 (100) | 1540 (100) | 55.53‡ |
| English as the native language | |||
| Chinese | 16 (2) | 52 (13) | 12.55‡ |
| Filipino | 17 (2) | 102 (25) | 33.11‡ |
| Korean | 3 (1) | 49 (13) | 11.23‡ |
| Vietnamese | 3 (1) | 8 (2) | 1.23 |
| Total | 39 (4) | 211 (14) | 171.45‡ |
N = 948.
N = 1540.
For Study 1, the goal was to recruit the same portion of participants in each ethnic group.
For Study 2, the goal was to recruit equal sized ethnic groups with follow-up data rather than meeting the same proportions of participants as had been recruited in the earlier study.
Data Analysis
The data were analyzed using SPSS version 14.0 (SPSS, Inc., Chicago, IL). Mammography and clinical breast examination (CBE) data analysis excluded participants younger than 40 years of age. Statistical significance was determined by chi-square analysis, with a P ≤ .05 considered to be significant.
RESULTS
Evaluating Change
Changes in Baseline Breast Cancer Screening Rates from Study 1 to 2
Women showed statistically significant increases in adherence to recommended breast self-exam, CBE, and mammography screening guidelines from Study 1 to 2 (Tables 2 and 3). The increased screening rates were also noted for each of the 4 individual ethnic groups. A parallel statistically significant decrease was noted in the number of women who reported never having had a mammogram from Study 1 to 2 (Table 4).
TABLE 2.
Baseline Breast Self-Exam Screening Adherence Rates Increased Significantly from Study 1 to Study 2 Among all Ethnic Groups and Ages (P < .05)*
| Age 20– 39 y |
Age 40– 49 y |
Age 40 y and Over |
Age 50 and Over |
|||||
|---|---|---|---|---|---|---|---|---|
| Ethnic Group | n | % | n | % | n | % | n | % |
| Chinese (Study 1) | 141 | 27 | 65 | 25 | 120 | 28 | 55 | 33 |
| Chinese (Study 2) | 96 | 62 | 120 | 59 | 275 | 64 | 155 | 67 |
| χ2 | 28.13 | 20.21 | 41.79 | 19.70 | ||||
| Filipino (Study 1) | 72 | 46 | 75 | 48 | 137 | 49 | 62 | 50 |
| Filipino (Study 2) | 53 | 74 | 120 | 83 | 342 | 84 | 222 | 84 |
| χ2 | 9.63 | 27.31 | 62.18 | 31.84 | ||||
| Korean (Study 1) | 59 | 32 | 27 | 22 | 51 | 26 | 24 | 29 |
| Korean (Study 2) | 117 | 52 | 140 | 63 | 234 | 62 | 94 | 61 |
| χ2 | 6.29 | 15.19 | 22.55 | 7.63 | ||||
| Vietnamese (Study 1) | 84 | 20 | 66 | 33 | 109 | 32 | 43 | 30 |
| Vietnamese (Study 2) | 71 | 48 | 85 | 53 | 261 | 60 | 176 | 64 |
| χ2 | 13.32 | 5.79 | 24.22 | 15.74 | ||||
| Full Sample (Study 1) | 356 | 30 | 233 | 34 | 417 | 36 | 184 | 38 |
| Full Sample (Study 2) | 337 | 57 | 465 | 65 | 1112 | 69 | 647 | 71 |
| χ2 | 52.23 | 60.44 | 137.07 | 69.90 | ||||
The numbers represent only women who provided valid data for these questions.
TABLE 3.
Baseline Adherence to Clinical Breast Exam and Mammography Screening Guidelines Increased Significantly Among and all Ethnic Groups and Ages (P < .05)*
| Annual Clinical Breast Exam Age 40 y and Over |
Annual Mammogra phy Age 40 y and Over |
Annual Mammogr aphy Age 50 y and Over |
||||
|---|---|---|---|---|---|---|
| Ethnic Group | n | % | n | % | n | % |
| Chinese (Study 1) | 120 | 53% | 120 | 34% | 55 | 35% |
| Chinese (Study 2) | 275 | 90% | 275 | 83% | 155 | 83% |
| χ2 | 68.89 | 89.64 | 46.24 | |||
| Filipino (Study 1) | 137 | 48% | 137 | 53% | 62 | 58% |
| Filipino (Study 2) | 344 | 90% | 345 | 86% | 224 | 88% |
| χ2 | 103.12 | 60.01 | 28.72 | |||
| Korean (Study 1) | 51 | 49% | 51 | 22% | 24 | 29% |
| Korean (Study 2) | 232 | 86% | 234 | 77% | 94 | 90% |
| χ2 | 35.48 | 58.05 | 41.76 | |||
| Vietnamese (Study 1) | 109 | 54% | 109 | 39% | 43 | 33% |
| Vietnamese (Study 2) | 262 | 89% | 261 | 84% | 177 | 89% |
| χ2 | 55.63 | 75.21 | 62.99 | |||
| Full Sample (Study 1) | 417 | 52% | 417 | 39% | 184 | 47% |
| Full Sample (Study 2) | 1113 | 89% | 1115 | 83% | 650 | 77% |
| χ2 | 260.69 | 269.98 | 173.10 | |||
The numbers represent only women who provided valid data for these questions.
TABLE 4.
Women who Reported Never Having had a Mammogram at Baseline Decreased Among all Ethnic Groups and Ages (P < .05)*
| Women Age 40–49 y |
Women age 40 y and Over |
Women Age 50 y and Over |
||||
|---|---|---|---|---|---|---|
| Ethnic Group | n | % | n | % | n | % |
| Chinese (Study 1) | 65 | 66% | 120 | 66% | 55 | 66% |
| Chinese (Study 2) | 120 | 18% | 275 | 18% | 155 | 17% |
| χ2 | 42.31 | 89.64 | 46.24 | |||
| Filipino (Study 1) | 75 | 52% | 137 | 47% | 62 | 42% |
| Filipino (Study 2) | 121 | 18% | 345 | 14% | 224 | 12% |
| χ2 | 24.70 | 60.01 | 28.72 | |||
| Korean (Study 1) | 27 | 85% | 51 | 78% | 24 | 71% |
| Korean (Study 2) | 140 | 32% | 234 | 23% | 94 | 10% |
| χ2 | 26.38 | 58.05 | 41.76 | |||
| Vietnamese (Study 1) | 66 | 56% | 109 | 61% | 43 | 67% |
| Vietnamese (Study 2) | 84 | 25% | 261 | 16% | 177 | 11% |
| χ2 | 15.04 | 75.21 | 62.99 | |||
| Full sample (Study 1) | 233 | 61% | 417 | 60% | 184 | 59% |
| Full sample (Study 2) | 465 | 24% | 1115 | 17% | 650 | 13% |
| χ2 | 93.56 | 269.98 | 173.10 | |||
The numbers represent only women who provided valid data for these questions.
Anticipating Future Programmatic Content and Structure
Women’s Perceptions of the Adequacy of Their Breast Cancer Knowledge
To help the research team plan future interventions, women were asked about their perceptions of the adequacy of their current breast cancer knowledge (Table 5). Less than half of the women in Studies 1 and 2 reported feeling that they possessed sufficient knowledge, and there was no significant difference from Study 1 to 2. When participants were compared by ethnic subgroup, Korean women reported a statistically significant increase in the perceived adequacy of their breast cancer knowledge by Study 2, whereas Chinese women reported a statistically significant decrease in the adequacy of their breast cancer knowledge at Study 2.
TABLE 5.
Differences in Knowledge Preferences by Cultural Subgroups*
| Sufficient Knowledge About Breast Cancer |
Prefer to get New Health Knowledge by Mail |
Prefer to get New Health Knowledge by Telephone |
Prefers to get New Health Knowledge Both Ways |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Ethnic Group | n | % | n | % | n | % | n | % | ||||
| Chinese Study 1) | 184 | 57% | 302 | 74% | 302 | 19% | 302 | 13% | ||||
| Chinese (Study 2) | 355 | 47% | 379 | 79% | 379 | 44% | 379 | 22% | ||||
| χ2 | 4.36† | 2.10 | 46.52† | 9.46† | ||||||||
| Filipino (Study 1) | 182 | 47% | 248 | 68% | 248 | 30% | 248 | 23% | ||||
| Filipino (Study 2) | 372 | 51% | 409 | 78% | 409 | 61% | 409 | 39% | ||||
| χ2 | 0.53 | 8.91† | 57.98† | 17.24† | ||||||||
| Korean (Study 1) | 81 | 25% | 123 | 76% | 123 | 34% | 123 | 28% | ||||
| Korean (Study 2) | 303 | 48% | 366 | 76% | 366 | 48% | 366 | 24% | ||||
| χ2 | 14.37† | 0.03 | 7.52† | 0.64 | ||||||||
| Vietnamese (Study 1) | 200 | 49% | 275 | 52% | 275 | 39% | 275 | 29% | ||||
| Vietnamese (Study 2) | 303 | 51% | 345 | 72% | 345 | 77% | 345 | 48% | ||||
| χ2 | 0.22 | 26.86† | 91.71† | 23.82† | ||||||||
| Full Sample (Study 1) | 647 | 48% | 948 | 66% | 948 | 30% | 948 | 22% | ||||
| Full Sample (Study 2) | 1333 | 49% | 1499 | 76% | 1499 | 57% | 1499 | 33% | ||||
| χ2 | 0.45 | 29.50† | 176.62† | 34.02† | ||||||||
The numbers represent only women who provided valid data for these questions.
Chi-square indicates significant differences between the Study Groups, P < .05.
Women’s Reported Preferences for Receiving Future Health Information
To facilitate addressing identified needs for additional information, women were asked to indicate their preferences for how they would like to receive future health information and could select either by mail, by telephone, or both. Receiving information by mail was the participants’ clear preference, with two thirds of the women indicating that they preferred to receive their future health information by mail in Study 1 and three fourths by Study 2 (P < .05). This shift reflected changes seen mostly among Filipino and Vietnamese women.
The frequency with which women opted to receive their health information by phone also increased significantly, a finding that was consistent among all 4 ethnic subgroups (Table 5). In Study 1, less than one third of the women preferred to receive health information by phone; by Study 2, over 50% of women preferred to receive their health information by phone. Between those 2 groups was a smaller group of women who selected both mail and phone, 22% for Study 1 and 33% for Study 2, respectively (P < .05). This shift was significant for every ethnic group except Korean women.
DISCUSSION
Consistent with the findings from Study 1, previous studies had also shown that Asian American women engaged in breast cancer screening at suboptimal rates.16–18 In Study 1, screening rates were far below the 70% goal then set in the National Cancer Institute’s and the American Cancer Society’s Year 2000 Goals, suggesting a cohort at significant risk of late stage breast cancer detection.4,19–22
These data raised grave concerns for Asian American women’s breast cancer related risks because adherence to screening guidelines has been consistently correlated with early stage detection, which has, in turn, been correlated with increased survival rates.23–25 In California, such findings prompted interventions directed at Asian American women through California’s Breast Cancer Early Detection Program, Komen for the Cure, the American Cancer Society, and the National Cancer Institute.
The cumulative outcome of this plethora of media campaigns and public health programs directed toward Asian American women may have increased their awareness of the need for screening and contributed to the dramatic shift in screening rates seen by Study 2.26, 27 This occurred across the sample as a whole as well as across all 4 ethnic subgroups studied.
These shifts are consistent with shifting increases in earlier stages of breast cancer detection more recently reported by the California Cancer Registry.28 According to the data in the California Cancer Registry, the early stage detection among Asian American women has steadily improved to the point that Asian American women surpassed Hispanic American women’s early detection rates in 1994, equaled African American women’s rates in 2001, and surpassed white women in 2003.29
This study suggests that many Asian American women realize they need more breast cancer information and offers several information delivery strategies. The women’s preferences to receive information by mail or phone or both suggest educational strategies that might be employed. The Asian grocery stores clearly offer an additional, well-tested strategy.
A key strength of this campus community partnership with Asian grocery stores was the diversity of the women reached and the greater likelihood that they may be underserved, from a medical and public health perspective. Most reported preferences for using a language other than English: Study 1 (96%) and Study 2 (86%). This characteristic increases their risk of barriers to accessing information and services.
A limitation of this study was that the 2 studies data were drawn using convenience samples and may not be representative of all Asian American women. Further, at the time of this survey, standardized instruments that might have been appropriate for this study’s focus were either not available or had not been validated for Asian American women. It was also not possible to verify the participants’ self-reported screening adherence data due to the monetary limitations of this study.
In spite of these limitations, the statistically significant increase in reported adherence to screening guidelines from Study 1 to Study 2 suggests that women at least knew the “socially desirable responses” they should be giving by Study 2, and this shift was parallel to the shift toward increased rates of early breast cancer detection being reported in the California Cancer Tumor Registry. Thus, for 4 Asian groups included in this study, the data offer additional insight into the breast cancer knowledge, attitudes, and behaviors of this cohort of Asian American women.
CONCLUSION
The findings reported from this data analysis, in combination with the decreasing numbers of Asian women being reported by the California Cancer Registry to have been detected with late stage breast cancer, suggest that the efforts of public and private organizations and individuals are making a significant, positive impact on improving the breast health of Asian American women. Vigilance is still warranted, however, since as Asian women’s tenure in the United States extends, so too will their risk of developing breast cancer, making it essential that health care providers across the state continue their efforts to reach Asian American women with information and screening appointments plus prompt follow-up appointments when abnormal breast changes are detected.
ACKNOWLEDGEMENTS
This project was funded by a series of grants. The primary funding for this project was from the San Diego Affiliate of the Susan G. Komen for the Cure and the California Breast Cancer Early Detection Program. Additional funding was provided by the National Cancer Institute’s R25-CA65745, the Cancer Center core grant 5 P30 CA023100, and the Minority Institution/Cancer Center Partnership Program grants U56 CA92079 and U56 CA92081 as well as the National Institutes of Health’s Division of National Center on Minority Health and Health Disparities EXPORT grant P60MD00220. This article’s contents are the sole responsibility of the authors and do not necessarily represent the official beliefs of the funding agencies. The authors also wish to thank the American Cancer Society, the National Cancer Institute, and the San Diego Union of Pacific Asian Communities for their guidance and generous contribution of printed educational materials. Dozens of Asian American students volunteered to assist with both of the studies presented in this article. Their dedication to serving their community is to be commended.
Footnotes
The preliminary data on which this article is based were presented in the poster session at the 2007 annual scientific meeting of the American Association for Cancer Education in Birmingham, Alabama.
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