Women’s Understanding of Windows of Susceptibility and the Role of the Environment in Breast Cancer Risk

Abstract

Emerging evidence suggests women who are exposed to harmful environmental exposures, especially during certain critical periods across the lifespan, may increase their breast cancer risk. Such windows of susceptibility (WoS) occur throughout a woman’s lifetime, during which she is especially vulnerable to the effects of harmful environmental exposures. This interaction makes the reduction of harmful environmental toxicants during those time periods a priority for community health promotion. Communicating about environmental exposures and their impact on women’s health requires an assessment of sensemaking around, and understanding of, the link between breast cancer and the environment. To that end, focus groups were conducted to assess the themes that emerge when women make sense of a) their own breast cancer risk, b) the environment-cancer connection, and c) WoS. Results provide insight into how women understand these issues which can inform messaging strategies focused on reducing harmful environmental exposures. Implications are discussed within the context of communication efforts tailored to educate women, particularly mothers with daughters in the prepubertal and pubertal WoS who are particularly vulnerable to harmful environmental exposures.

Many factors influence the risk of developing breast cancer, however, expert agencies widely recognize the role of the environment and one’s lifestyle in the development of cancer [1,2]. For instance, the Breast Cancer and the Environment Research Program (BCERP) has identified endocrine disrupting chemicals individuals interact with on a daily basis that can increase one’s risk of developing breast cancer later in life.

These expert agencies have more recently identified periods in a woman’s lifespan when these endocrine disrupting chemicals can have a particularly pronounced effect on cancer risk, called windows of susceptibility (WoS). These WoS are characterized by changes in a woman’s mammary tissue that leaves breast cells particularly susceptible or vulnerable to damage from endocrine disrupting chemicals, which may lead to breast cancer development later in life [3, 4]. Translation of these findings is key in order to put this information into the hands of the public and to generally promote risk reduction activities. However, before strategic communication programs and initiatives can be developed, it is necessary to understand the gap between how women think about the breast cancer and environment connection and what expert agencies believe the public should know [5]. This study aims to capture how women think about their own risk of breast cancer and the cancer-environment connection, as well as to begin to uncover sense-making mechanisms around WoS.

Breast Cancer and the Environment

Breast cancer was estimated to kill 42,170 U.S. women in 2020 [6]. Although women tend to be aware of breast cancer and the importance of regular cancer screening detection [4], a stronger focus on risk reduction and precaution is needed for prevention practices to be well-known and effective. Breast cancer research has improved understanding of different factors influencing lifetime cancer risk, such as girls’ earlier onset of puberty which is an increasing trend in the U.S. [7]. This increased risk is in part due to the extended time spent in vulnerable developmental periods called WoS [4,8]

Windows of susceptibility.

WoS refer to specific time frames across the life span where women are susceptible to increased breast cancer risk related to environmental exposures [3]. There are seven breast cancer WoS: in-utero, neonatal, pre-pubertal, pubertal, pregnancy, lactation, and menopause [9]. During these times in a woman’s lifespan, she is more vulnerable to the impact of environmental toxicants due to an increased rate of physical changes [3]. These rapid changes increase breast cell susceptibility to damage from environmental toxicants as the cells undergo proliferation and differentiation. Adolescent women are especially vulnerable during puberty as the associated volume of breast tissue proliferation increases the chance that breast cells will be adversely affected by endocrine disrupting chemicals [10]. Thus, avoiding environmental toxicants is important during WoS, especially pre-puberty and puberty. Women, as well as the caregivers of girls within the early WoS, need to be aware of the risk associated with environmental exposures so they can implement appropriate risk-reducing actions.

Translating Research on the Cancer-Environment Connection

The primary mission of the BCERP is to understand and communicate about the link between breast cancer and the environment. With funding from both the National Institute of Environmental Health Sciences and the National Cancer Institute, this collaboration brings together biologists, epidemiologists, breast cancer advocates, and communication scientists to research, translate, and disseminate findings pertaining to endocrine disrupting chemicals’ effects on women’s breast cancer risk [11,12].

A primary goal of the BCERP is outreach and engagement to effectively communicate scientific findings pertaining to environmental risks of breast cancer to lay audiences. As the BCERP continues to work toward this goal, such efforts should be informed by how audiences already think about these topics, as well as potential barriers and facilitators to engaging in any recommended behaviors [13] and gaps between expert expectations and community sensemaking [5].

In planning communication interventions, the focal audience’s baseline understanding must be assessed, in addition to understanding how that diverges from the standpoint of experts and intervention planners [5]. Messages to promote awareness or encourage risk reduction behaviors must address the linguistic and psychological standpoints of the audience, especially in the context of women’s health, in order to be effective. To date, focus group research has found that women are often uncertain about environmental links to breast cancer risk [13]. Other formative research methods such as investigation into memorable messages about breast cancer have identified content and sources surrounding messages about breast cancer risk [14,15]. In addition, both news source analyses [16] and message testing studies [17] have been employed to better understand how information linking environmental factors and breast cancer risk resonates with lay audiences.

Although some formative research has been conducted, BCERP researchers have yet to fully address the diverse needs and baseline understanding of lay audiences when addressing the link between environmental exposures and breast cancer risk. The WoS concept is especially important moving forward as it is a complex idea with major, long-term impacts on women as they are exposed to both small and large-level exposures that build up over their lifetimes. The current focus group study aims to answer the key questions of:

• RQ1: What themes emerge when women make sense of a) their own breast cancer risk, b) the environment-cancer connection, and c) WoS?

Method

Participants and Recruitment

Data were collected via 19 focus groups (N = 122 women) across five sites in Massachusetts, Michigan, and New York. Convenience sampling was used to recruit participants through community partners, including community stakeholder contacts, a health education conference, a community nutrition class, newspaper advertisements, a community research pool sponsored by an academic institution, email to nonprofit organization leaders, and an email listserv. Eligibility criteria included being female and aged 18 years or older. Participants predominately identified as White (80.7%) and the average participant age was 44.22 years (SD = 13.38). A slight majority of participants reported having a family breast cancer history (54.78%), but not a personal history (54.76%). A summary of participants’ demographics can be found in Table 1.

Table 1.

Participant demographics (N=181 women).

Age
Age range	18 – 76
Mean age	44.75 (SD=16.13)
Number of children cared for
0	54 (29.8%)
1	13 (7.2%)
2	34 (18.8%)
3	20 (11.0%)
4+	5 (2.8%)
No response	55 (30.4%)
Personal breast cancer history
Yes	55 (30.4%)
No	70 (38.7%)
No response	56 (30.9%)
Family breast cancer history
Yes	71 (39.4%)
No	52 (28.7%)
No response	58 (32.0%)
Race/Ethnicity
African American	26 (14.4%)
Asian/Pacific Islander	30 (16.6%)
Caucasian	90 (49.7%)
Hispanic	25 (13.8%)
Multiracial	3 (1.7%)
Native American	1 (0.6%)
Other	4 (2.2%)
No response	2 (1.1%)
Income
Less than $30,000	27 (14.9%)
$30,000 – $39,999	13 (7.2%)
$40,000 – $49,999	18 (9.9%)
$50,000 – $59,999	16 (8.8%)
$60,000 – $69,999	20 (11.0%)
$70,000 or more	76 (42.0%)
No response	11 (6.1%)
Education
Some high school	22 (12.2%)
High school diploma/GED	6 (3.3%)
Some university/college	31 (17.1%)
Vocational/technical degree or certification	17 (9.4%)
Community college	15 (8.3%)
4-year university	36 (19.9%)
Master’s degree	44 (24.3%)
Doctoral/Professional degree	8 (4.4%)
No response	2 (1.1%)

Procedure

Focus groups were conducted by the first author, as well as breast cancer advocate and health educator partners trained in focus group methodology as part of this project. These data are a subset of a larger project wherein each focus group lasted between 75 and 90 minutes and followed the same moderator guide questions regarding breast cancer and the environment. Location of focus groups varied within and between sites, though all consisted of 6–13 participants and took place in conference room style settings, with audio recording that was later professionally transcribed verbatim and de-identified. Upon arrival, participants were greeted and introduced, completed informed consent, and provided a seat and name tag. All focus groups included an icebreaker activity, followed by the larger discussion led by a trained moderator.

Moderator Guide

The research questions, and thus the moderator guide, were shaped by the needs of the community partners, breast cancer advocates, and researchers collaborating on this project. These issues included 1) how women thought about their breast cancer risk, 2) women’s understanding of the breast cancer and environment connection, 3) how women reacted to the concept of WoS, as well as other topics not reported here, including sense-making around breast density and women’s legislative priorities around regulation of environmental exposures. Only those data regarding women’s concerns about breast cancer and its connection to the environment (defined for participants as “substances in the air, food and drink, and things put on one’s skin”) are presented here. The relevant section of the focus group protocol can be found in the Appendix.

Data Analysis

For all analyses, the unit of analysis was the turn of talk. Development of the coding scheme was driven by the research questions and moderator guide, and additional themes that emerged across focus group discussions. After focus group recordings were transcribed and de-identified (N = 2,805 turns at talk), three researchers reviewed each transcript and iteratively identified overarching themes to code based on coder notes and field notes taken during individual focus groups. Coder reliability was calculated before and after independent coding (n = 111 turns of talk from one focus group and n = 210 turns of talk from another focus group from a distinct physical site). At the initial reliability calculation, coders achieved high reliability (percent agreement = 99.8%), as well as at post-coding reliability (percent agreement = 99.6%). The remaining 16 focus groups and their respective units were split between two coders (n = 981 and n = 1,503 turns at talk, respectively).

Results

A total of 14 emergent themes were identified in these data that totaled 643 turns of talk overall for the topics reported here. These are organized under three general thematic categories reflected by research question 1: breast cancer risk, environmental exposures, and WoS. Table 2 provides the number of each type of comment along with exemplary phrases from focus group participants that illustrate subareas of each of the three main categories.

Table 2.

Exemplary phrases from focus group participants

Main Theme	Subtheme	Description	N/%	Examples of comments from focus groups
1. Breast Cancer Risk			57 turns of talk/9% of total
	Family History and Concern
		Concern about own cancer risk because of family history	20, 35.1% of category	“I think the biggest factors honestly when it comes to breast cancer is of course heredity because when you have that in the family and most of the time that’s why it’s so important to know your family history”
	Peer Cancer History and Concern
		Increased concern due to a peer having had breast cancer	6, 10.5% of category	“I have a friend that, although she has absolutely no history of cancer whatsoever, she got breast cancer. That was a little bit concerning.” “people all around me are being so affected by it.”
	Lack of Concern from Lack of History
		Lack of concern due to lack of family history	10, 17.5% of category	“don’t really think about it just because honestly I don’t have a history of it in my family. Nobody’s had it.”
	Lack of Concern from Routine Screening
		Lack of concern from routine screening	6, 10.5% of category	“like if I take care of myself and if I go for my regular mammograms and I get all the proper prevention or maintenance, then I’m okay”
2. Environmental Exposures and Breast Cancer Risk			419 turns of talk/ 65% of total
	Food Production
		GMOs/pesticides/chemicals	100, 23.9%	“Plastics and BPA and things like that. I read something about that when I was pregnant and they came out with BPA-free bottles and things.” “fruits and vegetables are a risk for us. Farmers put so many steroids and stuff in them and pesticides and things like that. It’s got to do something to you.”
	Cosmetics
		Cosmetic products increase cancer risk	99, 23.6%	“…a lot of the time the biggest factor is the stuff you’re putting on your body. All these companies are adding in so many of these chemicals that haven’t been properly researched to see what they actually do and how dangerous they are.” “I’m familiar with deodorants and the link between them and breast cancer, or at least I’ve heard that before.”
	Cleaning Products
		Household products increase cancer risk	50, 11.9%	“…heard something in a health podcast that said something about inhaling ammonia or the things you use to clean your bathroom and that may be a thing promoting cancer.”
	Fatalism and Communicative Barriers
		Cancer is inevitable	17, 4.1%	“…at the mercy of the products and the government and regulations and rules and laws.” ““lack of education or even mis-education too. I know that when I had my breast reduction no one told me that I would be more susceptible to cancer because I had foreign objects in me because that’s what they do.”
	Family History
		Genetics more risk than environment	37, 8.8%	“I don’t know if there actually is something in the environment because you have some people who eat healthy and do all the right things but still get cancer. I think if your body has that gene, that’s what matters.”
3. WoS Perceptions			164 turns of talk/26% of total
	Windows Identified
		Accurate identification	109, 66.5%	“Children are at risk because your body is developing and you’re going through a lot of changes very quickly and so if you’re exposed to chemicals it can create a lot of different dynamics in your body.” “Elderly people are more vulnerable to most things, so they’re probably more at risk of cancer.”
	Immunity, Stress, and Cancer Risk
		Stress/age	38, 23.2%	“It could be if your immunity is suppressed because you’re not healthy or stressed out from work, that could make these things matter more.” “babies are more at risk when they’re first born because their immune system isn’t developed yet.” “When you get older, you don’t have that strong of an immune response so that puts you more at risk.” “I think people who are already sick and fighting something off where their immune system might be suppressed already; that increases your risk.” “It’s when you’re under stress that you’re susceptible. I think that’s what caused my cancer, not diet” “well she was so overworked and not taking care of herself, so I know it was that stress that caused her cancer”
	WoS and Cancer Concern
		WoS increased concern	11, 6.7%	“Now that we’re talking about this, it makes me a lot more worried about cancer and what I’m putting in my body.” “makes me think a lot more and I guess I need to look up a lot more information and figure out how this works.”

Breast Cancer Risk

The first theme of the focus group discussions concerned participants’ own cancer risk reduction (n = 57 turns of talk, 9% of total comments). This included subthemes of expressions of concern 1) because of one’s family history of breast cancer and 2) due to a peer having had breast cancer. For instance, a number of women expressed that they noticed others like them developing breast cancer as they aged, which made them more concerned for their own risk. This came across with one participant saying they “have a friend that although she has absolutely no history of cancer whatsoever she got breast cancer. That was a little bit it was concerning. She’s exactly my age.” Another said that “it seems that the older I get the more I hear about my friends having it and I’m like … is this going to happen to me as I get older?”

Also included are subthemes that reflect not being concerned about one’s breast cancer risk 3) due to a lack of family history and 4) due to partaking in routine cancer screening (e.g., mammography). For example, one participant outright stated they “don’t really think about [breast cancer] just because, honestly, I don’t have a history of it in my family.” Here, women discounted a need to worry about breast cancer and its potential risks in the environment because of no apparent genetic predisposition. Another, noting that they get screened regularly so they do not think much about cancer, said: “I go to my doctor on a regular basis, I get yearly exams, my mammograms. I think maybe it’s the comfort and they’re always coming back negative… it’s not a huge concern for me.” This suggests possible complacency regarding breast cancer risk, which may be a barrier to cancer education.

Environmental Exposures and Breast Cancer Risk

The second general thematic category identified how participants thought about the breast cancer and environment connection and what environmental exposures they believed affected cancer risk (n = 419 turns at talk, 65 % of total comments). This included subthemes of perceived cancer risk from 1) aspects of food production, chemical additives, and storage), 2) cosmetic product additives (parabens and phthalates) and types (lotions and deodrants), and 3) cleaning/household products (such as bleach) use and inhalation. After being prompted about exposures, some noted an awareness of “the food we eat and the stuff we put in our bodies” or others saying they “try to buy organic [food products] because I know it’s better for our health.” Many viewed organic products as being inherently healthier, and thus less likely to increase cancer risk, while seeing processed or GMO foods as having some inherent cancer risk. Other food-related concerns addressed food and drink packaging, such as when one participant said they made efforts to use BPA-free water bottles or tried to use glass containers to avoid the risk that came from sources such as “the chemicals in water bottles.” Then, especially when learning that exposures included things put on one’s skin, women shared concerns around cosmetic and personal care products, such as shower gels, sunscreen, and especially deodorants. Participants explicitly named parabens and cosmetics more generally, noting that products marketed to women “have a lot of the nasty stuff [in them] that gets us sick.”

In addition, some women espoused 4) cancer fatalism, or the sense that cancer is inevitable or that if someone is meant to get cancer, there is nothing that can be done to avoid it [18], and 5) that family history as a greater cancer risk than environmental exposures. In addition to a general sense that things in the environment seemed outside of one’s control, some women focused on a belief that individual behaviors did not matter and that they were “at the mercy of the products and the government and regulations and rules and laws.” Some also felt women were at risk when they were not given enough information about their breast health, being put at risk by things outside of their control. For example, one participant said cancer risk came from a “lack of education or even mis-education too.” Lastly, and posing a barrier to education on environmental breast cancer risks, participants continued to discuss genetics or family history as a risk, in some cases discounted environmental risks, such as when one said: “I don’t know if there actually is something in the environment because you have some people who eat healthy and do all the right things but still get cancer. I think if your body has that gene, that’s what matters.”

WoS Perceptions

The third and final thematic category within these data included participants discussing their perceptions of WoS (n = 164 turns of talk, 26% of total comments). The subthemes included are 1) accurate identification of breast cancer WoS, 2) whether they had heard of WoS, 3) whether they were more concerned about breast cancer after discussing WoS, 4) identification of being under stress or having a compromised immune system at time periods of elevated cancer risk, and 5) identification of other unrelated periods of increased breast cancer risk. Of the WoS identified for breast cancer, participants discussed being elderly or menopausal, just after birth (neonatal), and when going through puberty and adolescence. The in-utero window was mentioned to a lesser extent, and lactation was only discussed as it relates directly to cancer risk and not that exposures have an elevated impact during that time. The menopausal window was only referred to in terms of becoming elderly, such as when a participant said “Elderly people are more vulnerable to most things, so they’re probably more at risk of cancer.” Additionally, some discussed general times when breast cells and the body are developing as times when risk is increased. This was exemplified through comments like “Children are at risk because your body is developing and you’re going through a lot of changes very quickly and so if you’re exposed to chemicals it can create a lot of different dynamics in your body.” This reflects a somewhat intuitive understanding of the logic behind why WoS are relevant to cancer risk.

Outside of references to the actual WoS, women made connections to the immune system and stress affecting how susceptible one is to cancer risks. For instance, women made comments such as, “It could be if your immunity is suppressed because you’re not healthy or stressed out from work, that could make these things matter more.” Relatedly, women made connections to levels of stress: “It’s when you’re under stress that you’re susceptible … [my friend] was so overworked and not taking care of herself, so I know it was stress that caused her cancer.”

Finally, several participants stated that hearing about WoS made them more concerned about breast cancer and the risk associated with environmental exposures Some explicitly stated they were more concerned: “Now that we’re talking about this, it makes me a lot more worried about cancer and what I’m putting in my body.” Others suggested a behavioral response to learning about WoS, with a participant saying that learning about it “makes me think a lot more and I guess I need to look up a lot more information and figure out how this works.” Few women said they had heard of the concept prior to the focus groups, but were uncertain of how it applied to breast cancer.

Discussion

Breast cancer continues to be prevalent in the U.S., with more than 276,000 new cases expected among women in 2020 [6]. Breast cancer risk reduction efforts need to reach women early in life to protect them against environmental risk factors, particularly during WoS. With new findings on environmental exposures, communication strategies to reach audiences need to be identified that address gaps between what expert agencies believe the public should know and the ways in which the public understands the breast cancer and environment connection [5]. The present focus group data identify lay understanding of the breast cancer and environment connection, especially related to WoS, which is important when tailoring risk reduction message content to women. Evidence here suggests women generally understand that the environment has a role in breast cancer risk, though there remains a preoccupation with family history and cancer detection above prevention and risk reduction, as well as potential misunderstandings when it comes to the concept of WoS and breast cancer.

Despite a wide acceptance of the environment’s role in breast cancer risk, many of the women in these focus groups still named genetics or family history as a major risk factor of breast cancer. In fact, in some cases, women reported being concerned because of a family connection, and not being concerned when there was no family breast cancer history. Some of the women also noted that their peers had breast cancer, especially when at younger ages, as something that elevated their concern regarding their own breast cancer risk. This reflects an explanation for why breast cancer risk reduction messaging may be discounted, such that breast cancer may be viewed as a psychologically distant event [19]. In this case, psychological distance refers to a phenomenon in which a disease like breast cancer is perceived as something not likely to affect oneself due to its abstract, long-term, or otherwise irrelevant nature. Relatedly, this may resemble women holding a “gist” representation of breast cancer risk [20], wherein a vague or abstract mental image of breast cancer risk entails a genetic component, where women without a family history discount breast cancer as concerning because they themselves have not met the sole, simple inclusion criterion. Gist representations can be powerful in predicting habitual behavior, making it possible for belief systems to complicate risk reduction messages.

As for specific environmental breast cancer risks, the women in these focus groups largely concentrated on cosmetics. While food production was discussed broadly, the conversation around cosmetics concerned specific topics that reflected greater salience and perhaps a more nuanced understanding of risk. In fact, some women referenced specific chemicals found in cosmetic products like parabens and phthalates, as well as general terms, such as “fragrance,” when discussing connections to breast cancer risk. Some even made connections to emerging risks studied by tthe BCERP, including some sunscreens and the additive benzophenone-3, otherwise known as oxybenzone [21]. This suggests a more nuanced understanding of “emerging” risk information regarding breast cancer, meaning future breast cancer risk reduction messages may not need to assume a complete lack of knowledge on exposures that may come from cosmetic and personal care products [22]. A future avenue of research should examine these perceptions and understandings more directly, as well as sources within and tangential to the beauty and cosmetic industry that may convey relevant information to shape risk perceptions. In addition to cosmetics, aspects of food production emerged throughout the focus groups, including discussion about food packaging, pesticides, and GMOs as well as chemicals in household cleaning products.

Participants also largely focused on what they believed was the role of stress and one’s immune system in the cancer and environment connection. It is the case that long-term psychosocial stressors during childhood have the potential to affect onset of puberty (e.g., [23]), and thus could induce a WoS earlier in life with its associated increase in exposure to environmental risks

Almost none of the women in these focus groups had heard of the WoS concept, especially as it applies to breast cancer risk. Despite this, many of the participants offered intuitive interpretations of the concept and possible “windows” that on the surface reflected the logic behind WoS as a developmental period in one’s life that is characterized by rapid breast cell division and proliferation [3], which leaves these cells particularly susceptible to damage from environmental toxicants. Of the actual windows identified for breast cancer, participants discussed being elderly or menopausal, just after birth (neonatal), and when going through puberty and adolescence. The in-utero window was mentioned to a lesser extent, and breastfeeding/lactation was only discussed as it relates directly to cancer risk and not that exposures may have an elevated impact during that time. The menopausal window was not directly discussed, but was referred to in terms of becoming elderly. Also, some participants discussed general times when breast cells and the body are developing as times when risk is increased. Notably absent from these seemingly intuitive understandings of WoS, however, was discussion of the interaction of WoS and environmental exposures Participants also made comments suggesting environmental exposures are more likely to promote cancer when one’s immune system is compromised. Some connected early childhood or being elderly to increased risk because of one’s immune response. Others suggested one’s body might “fight off” environmental toxicants if it is healthy or responsive enough.

The final subtheme reflected participants saying that hearing about WoS made them more concerned about breast cancer and the risk associated with environmental exposures. Very few participants said they had heard of the concept prior to the focus groups, and they were uncertain of how the concept applied to breast cancer. As evidenced by these focus group data, introducing and elaborating on the concept of WoS may provide an opportunity to raise women’s concern about breast cancer and associated risk reduction activities even if there is not a history of breast cancer in their family. It may be that learning about WoS and how exposure to environmental toxicants can elevate one’s breast cancer risk brings breast cancer psychologically closer and makes it something a woman is more likely to act upon.

Implications for Cancer Communication

With the continued prevalence and impact that breast cancer has in the United States, it is imperative that efforts are made to accurately inform the public about breast cancer and the various ways breast cancer risk is impacted. The present findings address numerous issues in current cancer communication trends. It appears that women’s sensemaking around WoS and the cancer-environment connection is aligned with expert cancer control agencies. This is especially the case in terms of risks posed by cosmetics, food packaging, cleaners, and other household products, but senseaking diverges in other places. Namely, women appear to miss logic intended by expert agencies in making sense of WoS, for instance, by relying on a mental model for breast cancer that resembles infectious diseases (e.g., one’s immune system or stress response contributing to cancer risk). Cancer communication around this topic must address the possibility that women’s current sensemaking will interact with messaging and potentially lead to further divergence in what cancer control agencies intend to convey, while also being inclusive of women’s baseline consideration of environmental risks that should be built upon or reinforced.

One issue raised by the current findings is the inherent need to correct individuals’ misunderstanding of WoS. Although WoS are described as periods in which cell growth and hormonal development occur at a very fast pace, leaving the body more vulnerable to mutations and cancer [3], lay individuals do not appear to fully grasp or comprehend what WoS are and exactly why they are of importance. For example, participants were highly unlikely to have heard of WoS, especially as the concept pertains to breast cancer. Some connected different points in life to increased breast cancer risk, but discussions were vague. Individuals explained that being elderly was a WoS, not because of cell growth or hormonal development, but simply because of age and the potential for a compromised immune system. Future efforts in cancer communication would benefit from correcting misperceptions of WoS by providing information that explains exactly what WoS are and how the body interacts with chemicals during these times. This information will inform lay publics about how to take precautions during the WoS when their body is at a heightened risk of developing abnormalities.

As cancer communication continues to provide information relating to cancer risk, it is apparent that one area where such communication should be bolstered is in the realm of family history of cancer. Although cancer control research demonstrates family history is not necessarily the largest determinant of one’s cancer risk (e.g., [24]), the current findings show that women are increasingly worried about breast cancer due to family history and genetics. Additionally, participants expressed heightened worry about breast cancer risk if someone they knew (outside of their family) had an experience with breast cancer. As communication surrounding cancer continues to develop, it is important that cancer communication reiterates that one’s family history is not the sole determinant of breast cancer risk. Additionally, information on precautionary actions should be released to help inform lay publics on breast cancer risk.

In addition to family history, the idea that cosmetics influence breast cancer risk was discussed in all focus groups. Focus group participants appeared to narrow in on cosmetics specifically, which indicated that the issue of the presence of chemicals in cosmetics is not foreign to them. Given the substantial number of participants who believed or had heard of cosmetics being linked to breast cancer risk, this may be an area to “piggy-back” from to highlight other areas of importance for cancer risk-reduction techniques. As cosmetics already appear to be a known issue among participants, highlighting the connection between cosmetics and breast cancer, along with other breast cancer risk-reduction information, may help increase knowledge and awareness around lesser known breast cancer information, like WoS or other exposures.

Last, cancer communication should focus on correcting misperceptions about how cancer is developed. Participants from all focus groups discussed their ideas around breast cancer, often referring to endocrine disruptors as being similar to influenza, in which such chemicals seep into your body through contact, only affecting people if their immune system is not strong enough to fight off the endocrine disruptors. This idea is incorrect, and cancer communication can correct such misperceptions by highlighting ways in which cancer is developed to help alleviate any stress or fear from the public.

Limitations and Future Directions

Participants were recruited as a part of a larger BCERP study, and current data are only a subset of the transcribed data set. While these data provide robust insights into how women think about breast cancer and the environment, data are not generalizable across all women. Additionally, participants in these focus groups tended to be Caucasian and from upper middle-class socioeconomic status, which also limits generalizability of findings.

Future work related to this research should assess the effects of learning about WoS in the context of breast cancer and environmental risks. Future research may test these propositions in experimental settings to examine motivational and behavioral consequences of different information when participants hold only gist representations about genetic predisposition and cancer risk, for example. Given this topic is a continuing priority for cancer control research [4], experimental evidence is necessary to better inform cancer communication research and practice. For example, an experiment exposing women to breast cancer risk reduction messages with and without information on WoS could capture the extent to which including that information affects relevant risk perceptions and concern about breast cancer and intent to take actions to mitigate the threat. Other research should further explore women’s beliefs regarding topics such as environmental toxicants in cosmetics and personal care products. These issues are the focus of BCERP research and other cancer control activities, but there appear to be sources within women’s information ecosystems that contribute to a detailed understanding of health risks inherent to some cosmetics and personal care products. Further research is needed to better understand these beliefs and delineate the aspects of one’s information ecosystem that might shape these beliefs accurately and inaccurately so that communication and education efforts for lay audiences can have increased effectiveness. As noted previously, communicating about environmental exposures and their impact on women’s health requires an assessment of sensemaking around, and understanding of the link between breast cancer and the environment. One example of an important use for this base of knowledge is in training pediatric health care workers on how to integrate prevention information into well-child checks for caregivers and young girls. Such a project has been completed resulting in a three-hour Continuing Medical Education training which focuses on WoS and avoidance of potential environmental contanimants [25], some content of which was based on the findings here.

Appendix

Focus Group Moderator Guide

Today we are going be discussing breast cancer and the environment. Again, there are no right or wrong answers – we are looking for your thoughts, insights, and opinions. So, let’s get started.

1. There are lots of things to worry about in our lives in general and related to our health. How does breast cancer rank for you in terms of your overall level of worry? Please explain.

2. When you think about breast cancer, what are the major risk factors that might contribute to someone getting breast cancer?

   1. Are there any other factors that you think might increase someone’s risk of breast cancer?
   2. We are also going to be talking about environmental exposures – so my next question for everyone is when you think of environmental exposures, what comes to mind?

      1. If you had to define it for someone, what would you say?
3. For our purposes today, we are going to define environmental exposures as “contact with substances, such as chemicals or small particles, through the air we breathe, the food we eat, the water we drink, and things we touch and put on our skin.”

   1. Now that you know how we are defining environmental exposures, what types of specific concerns do you have about environmental exposures and breast cancer?
   2. Do you think that chemical exposures can increase the risk of breast cancer? What kind of chemicals are you concerned about – please name them if you can?

      1. How concerned are you about chemicals in food and everyday products?
      2. Which chemicals or products in your home concern you?
      3. Are there certain health effects that concern you?
   3. Throughout one’s lifespan, when are individuals vulnerable to chemical exposures?

      1. Are there times when one might be more vulnerable to chemical exposures? When might these times be?
      2. What would you call this time frame of high risk?
      3. Have you ever heard/seen the term Window of Susceptibility as it relates to breast cancer? What does it mean to you?