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DECEMBER, 2007 « THR JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION fy Volume i8 Number 2 , . Promoting Breast Health among Women in the U.S. Virgin Islands: A Focused Study of the Needs of Caribbean Women Sandra Underwood, RN, PhD, FAAN Edith Ramsay Johnson, RN, EdD Gloria Callwood, RN, PhD Edris E. Evans, RN, BSN ry . Alina Matthew, SN, Casandra Scotland-Brooks, SN, Ch LeFlore, SN, Dionne Williarns, SN, Harticia Samuels, SN, Jahtara Francis, ole Heskey, SN, Rachel D’Abreau, SN, Rashima Fleming, SN, Stacey Penn, and Yvette Scarbriel, SN . from the National Institutes of Health, National Center on ) and the National Office of the Susan G. Komen Breast Clinkscales, SN, Martha Joseph, SN, Nihj SN, Tameka A. Browne, SN, Tiffany Donastorg, SIN, Acknowledgements: This study was supported by a grant Minority Health and Health Disparities G? R24-MD0011231 Cancer Foundation Small Grants Program (#05-016-OH). Abstract: Breast cancer is the number one cause of cancer death among women in the United States Virgin Islands. Consequently, the Bureau of Health has identified breast cancer asa pr rity health concern. Within the medical conmunlty, increasing emphasis ts being placed on the iniportance of hereditary, faritilial, environ mental, and behavioral risk factors to breast cancer control, Little research has been conducted regarding these factors, however, fo explore their influence ot breast cancer detection and breast canoer riskmanasement. This report highlights the outcontes of q study undertaken to explore the associations between breast cancer risk, risk assessment, risk communication, screening, and receptivity to the management of breast cance? risk artong women from the Untted States Virgin Islands. Results of this study sug- gest a need within the territory to expand the systems that are responsible for monitoring and reporting breast cancer trends; forums to discuss concerns of women relative to breast health; forums to discuss communication with health-care providers; and, esearch efforts that address breast cancer detection and control among woinen in the United States Virgin Islands. Key Words: adult, African-American women, breast cancer, cancer screening, female, guidelines adherence, minority-women, risk assessntent, risk communication, risk management Introduction Breast cancer detection and control has been identified asa national health concern by the Untted States Depart: Sandra Millon Underwood, RN, Scholaz, Professor University of Wisconsin Milwaukee, Edith M. Ramsay-Johnson, RN, EAD, is a Frofeszos, Division 9 St. Thomas, V100802. Gloria Cailwood, RN, PhD, is a Dean and Professor, St. Thomas, VI 00802. Hdeis B, Evans, RN, BSN, is a Clinical Instructor, Division o ‘V1. 00802, Address Requests for Re waukee, School of Nursing, FO, Box 418, antal Hanley, SN, Damali Johnson-Harrigan, SN, Devatie SN, Jamela Arthur, SN, Jowana ment of Health and Human Services (USDHHS, 2000), the National Cancer Institute (Ries, Harkins, Krapcho, Mariotio, Millex, Feuer, et al., 2006), and the National Cen- ter for Health Statistics [NCHS] (NCHS, 2006). Consequently, numerous initiatives have been under- taken to track trends in breast cancer morbidity and mortality, to increase breast cancer awareness, to improve breast cancer screening, to improve treatment and ensure access to breast cate for women in need throughout the United States. These efforts have reached and impacted, in one way or another, the greater majority of women throughout the United States, However, the extent to which the initlatives reach and impact the women who reside in the organized territories of the United States appears to be limited. Breast cancer is the second most common cause of can- cer death among women throughout the United States (American Cancer Society, 2007), However, within the United States Virgin Islands (USVI), breast cancer is the number one cause of cancer death among women (USVI Department of Health, 2003). The United States Virgin Islands is an organized, unincorporated territory of the United States in the Atlantic Ocean and the Caribbean Sea, about50 miles east of Puerto Rico. The manner and extent to which data relative to the breast cancer mortality in the USVI is collectad, analyzed, and reported makes it diffi- cult to compare data reflective of breast cancer mortality among women in the USVI with data reflective of breast cancer mortality of women from other states and territo- ries, Nevertheless, the USVI Bureau of Health has identified PhD, FAAN, fs an American Cancer Society Oncology Nursing Professor, Northwestern Mutuel Life Research School of Nursing, Milwaukee, WI5$201, . f Nursing Education, University of the Vizgin Islands, #2 John Brewers Bay, Division of Nursing Education, University of the Virgin Islands, #2 John Brewers Bay, f Nursing Education, University of the Virgin Islends, #2 John Brewer's Bay, St. Thomas, rints and Correspondence tot Sandra Millon Underwood, RN, PhD, FAAN, Bofessoy, University of Wisconsin Mil- Milwaukee, WI 53201, Emil: underwoo@uwmedu 63 NAL BLAck Nurs&s ASSOCIATION ° DECEMBER, 2007 Pg Tue JOURNAL OF THE Natio regional trends in breast cancer mortality among women in the U.S. Virgin Islands to be a priority health concern (USVI Department of Health, 2003). Breast Cancer Risk and Breast Cancer Risk Communi- cation While the exact cause of breast cancer is not known, several factors that influence a woman’s risk of devel- oping breast cancer have been identified (American Cancer Society [ACS], 2007; Smith, Cokkinides, & Eyre, 2007). The factors known to increase & woman's risk of devel- oping breast cancer include age, race, reproductive and mens trualhistory, history or hormone use, personal his- tory of breast cancet, family history of breast cancer, genetic alterations, radiation to the chestatan early age, and cer: , tain breast conditions. The factors identified as causing the most significant risk arg first-degree family history of pre-menopausal bilateral breast cancer or pres menopausal breast cancer, first-degree family history of breast and ovarian cancer, evidence of the susceptibility gene BRCA1/BRCAZ, & personal history of Jobular car- cinoma in-situ, breast atypical hyperplasia, and mammographic density occupying > 75% of the breast yolume (see Table 1). Identifying risk factors that are associated with breast - cancer is an essential component of quality breast care. Breast care specialists suggest that, before making Teo ommendations regarding breast cancer screening, health-care providers engage them in discussions about factors that could contribute to their breast cancer zisk. Determining the presence or absence of breast cancer risk factors can help health-care providers to make reconr mendations to women relative to the optimal type of breast cancer screening and to make recommendations relative to managing their breast cancer risk, Breast Cancer Risk Assessment Several tools have been developed to help health-care ‘providers evaluate breast cancer risk. Included among them are the Gail Model, the Claus Model, and the fami- ly health history. The Gail Model has been validated as a predictor of breast cancer risk in women who adhere to togular mammography screening (Bondy, Lustbader, Hal- abi, Ross, & Vogel, 1994; Speigelman, Colditz, Hunter, Hertzmark, 1994), The Gail Model, whichis based on data « derived from the Breast Cancer Detection and Demon- stration Project (Andrews, Fullerton, Holtzman, & Motulsky, 1994), estimates a woman's risk of developing breast cancer by analyzing her age, the number of first- degree relatives with breast cancer, the age of menatche, the age of first live birth, and the number of breast biop- sies. The Gail Model does not take into account the ages at which affected relatives were diagnosed with breast cancer, bilateral breast cancer, a family history of ovarian cancez, second-degree relatives with breast caticer, any . history of breast cancer on the father’s side of a woman's family, or known BRACA1 or. BRACAZ mutations. As a resuilé, the Gall Model can under-predict breast cancer tisk in wornen who have one or more of these factors and can Volume 18 Number 2 "Table 1. Risk Factors Associated with Breast Cancer Weak risk factors + Family history of postmenopausal breast cancer, except if associated with male breast cancer + bilater- al disease . * High socioeconomic status : @ Nulliparity ' » Later age at first birth (> 30 yx vs > 20 yr) « Later age at menopause (> 55 yr vs > 4 yx) + Early age at menarche (< 1] yr vs > 15 yt) e Postmenopausal obesity ® Alcohol consumption * Diet « Hormone replacement therapy (long term usage) Moderate risk factors ® Older age » North American and Northern European residence ¢ Family history of pre-menopausal breast cancer * Personal history of breast cancer ¢ Breast hyperplasia without atypla + Mammographic density occupying >50% of the breast volume Strong risk factots é Family history of pre-menopausal bilateral breast. cancer Or presmenopavss breast cancer in mother, grandmother sister, daughter and aunt or breast cancer and ovatian cancer in mother, grandmother, sister, autit » Evidence of susceptibility gene BRCA1/BRCA2 » Pergonal history of lobular carcinoma in sits « Breast atypical hyperplasia ° Memmogrephic density occupying > 75% of the breast volume overestimate breast cancer risk in young women who do not have atinual mammograms, Using the Gall Model, projections for women. of African-American, Hispanic, and other racial and ethnic descent are subject to greater uncertainty than projections for White women. The Claus Model is used to evaluate breast cancer risk among women with a family history of breast cancer. "the Claus Model, which is based on empirical data fom the Cancer and Steroid Hormone Study (Claus, Risch, & Thompson, 1994), assumes that inherited risk is attrib- uteble to an atitosomal dominant mutation with high penetrance. The breast cancer risk is estimated based on a womat’s current age, the number of first-degree and second-degrerelatives with breast cancer, and their age of onset. The Claus Model provides breast cancer risk estimates for women with a positive family history of breast cancer, however, itis not recommended for use in women who have three or more relatives with breast BA DECEMBER, 2007 » THR JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION Volume 18 Number 2 cancer. in addition, because the Claus Model does not take into account other breast cancer risk factors, it may understimate the risk in women with behavioral risk factors or re p roductive histories that increase their breast cancer risks. The family health history has also been shown, to be a useful tool for evaluating ‘a woman's breast cancer risk (Hoskins, Zwaagstra, & Ranz, 2006). The family health history can be used to construct a pedigree that identifies breast and ovarian cancer (as well as other health condi- Hons), environmental factors, and health behaviors common within a family. The pedigree, along with other breast cancer risk assessment tools, can then be used by health-care providers to counsel women about breast can- cer screening and about ways to be proactive in the management of their breast cancer risk. Breast Cancer Screening and Breast Cancer Risk Man- agement Breast cancer screening has been shown, to contribute significantly to reductions in breast cancer mortality (Gotzsche & Olsen, 2000; Tabar, Vitak, Chen, Yen, Duffy, & Smith, 2001; Humphrey, Helfand, Chan & Woolf, 2002; Duffy, Tabar, Chen, Holmgvist, Yen, Abdgalah, et al, 2002; CDC, 2003; Tabar, Yen, Vitak, Chen, Smith & Duffy, 2003; Swan, Breen, Coates, Rimer, & Lee, 2003). Several -eancer socletes have proposed breast cancer screening recommendations for asymptomatic women with an average risk of developing breast cancer, Most recom mend that asymptomatic women at average risk for developing breast cancer have regular clinical breast examinations beginning at 20 years of age and have an annual screening mammogrepay beginning at 40 years of age (Smith, Cokkinides, & Byre, 2007;'Komen, 2007), Similar recommendations have been proposed for women at increased risk for developing breast cancer. Recom- mendations for women at increased risk for developing breast cancer include semiannual clinical breast éxami- nation starting at 25 years of age, annual mammograms starting at 40 years of age or 5 to 10 years prior to the earliest breast cancer in their family (elthough not before 25 years of age), and, the consideration of investigational imaging and screening studies. Given that research sug- gests that breast cancer risk may be effectively reduced using preventive drug therapy, prophylacticemgery, and behavioral modification, it is recommended that women at increased risk have discussions with their health-care providers about thelr risk and the use of breast cancer risk reduction strategies (Smith, Cokkinides, & Byre, 2007; Komen, 2007) (see: Table 2). Purpose of the Study Within the scientific, medical, and lay literature, increas- ing emphasis is being placed on the relevance of hereditary, familial, envizonmental, and behavioral risk factors to breast cancer detection and breast cancer control. How- ever, in spite of the importance of breast cancer tisk assessmentand risk communication to quality breast care, Table 2, Risk Specific Breast Cancer Screening Recom- mendations (ACS, 2007) __ Recommendations for Women at Average Risk for Devel- oping Breast Cancer v Yearly mammograms are recommended starting at age 40 and continuing for.as long as a woman, isin good health. ¢ Clinical breast exam should be part of a periodic health exatn, about every 3 years for women in their 20s and 30s and every year for women 40 and over. * Women should know how their breasts normally feel and report any breast change promptly to their health care providers. Recommendations for Women at Moderate Risk for Developing Breast Cancer + Clinical breast examination, semiannually starting at age 25 + Annual mammogram starting at age 40 or 5 to 10 yeats prior to the earliest breast cancer in the family (although not before age 25) » Discuss the benefits and limitations of adding MRI acreenirig to their yearly mammogram with primary care provider * Consider investigational imaging and screening studies Recommendations for Women at High Risk for Devel- oping Breast Cancer * Clinical breast examination, semiannually starting at age 25 + MRI and a mammogram evety year « Consider investigational imaging and screening studies little research has been undertaken to explore thelr influ- ence on breast cancer detection and breast cancer risk management. The Bureau of Health inthe USVI hasiden- tified trends in breast cancer mortality among women in the USVI to be a priority health concern (USVI Depatt- ment of Health, 2003). The USVI has long been an organized, unincorporated territory of the United States. However, few efforts have been undertaken by researchers from within or beyond the territory to examine the breast health practices of these women. A study to explore asso- eiations between breast cancer risk, breast cancer risk assessment, breast cancer risk communication, breast cart- cer screening, and receptivity to the medical management of breast cancer risk among women from the USVI was therefore proposed. The study, which was undertaken by researchers, faculty, and students from the USVI School of Nursing, was designed in an effort to: 1. Assess the breast cancer risk perceptions and projected breast cancer risk of women in the USVI; 2. Assess the degree to which women in the USVI discuss their family health history, breast cancer risk, and breast cancer risk management with health-care providers; 55 NAL BLACK NURSES ASSOCIATION * DRCEMABER, 2007 a THE JOURNAL OF THE NATIO 3, Assess the breast cancer screening practices and recep- tivity to medical management of breast cancer risk of women in the USVI; and,‘ ° ; 4, Ascess the extent to which perceived risk, projected risk, risk assessment, and provider communication influ- enced the breast cancer screening practices and receptivity medical management of breast cancer risk among women in the USVI. A xnultidimensional breast cancer screening and risk management framework was used to guide the design of . the study. Incorporated in the framework were constructs reflective of breast cancer risk, breast cancer risk assess- ment, breast cancer risk communication, breast cancer screening, and breast caricer risk management. In apply- ing the framework in this study, the independent variables were breast cancerrisk, breast cancerrisk assessment, and ‘breast cancer risk communication. The dependent vari- ables were self-reported use of breast cancer gcreenirig (Le., breast self-examination, clinical breast examination, and mammography screening) and receptivity to the med- ical management of breast cancer risk (e., behavioral modification, radiology, sumgery, pharmacologic inter- vention, arid clinical trials) (see Figure 1). Figure 1. Study Framework Breast Breast Cancer Risk |, | Risk Appropriate Cancer 1{7"} communtcated Brezst Cancer Risk Scregning/Risk Breast Assessed Management Cancer Lspo{ Breast Gantcer Hisk }— Risk Breast | | Not Communicated A“ FiskAopopt] Factors Cancer ‘ Breast Gancer Risk Not “pe| Soreening/Risk Assessed Management Metheds Study Design, Target Sample, and Recruitment This cross-sectional exploratory study was conducted through the Exploratory Center at the Schoo} of Nursing at the University of the USVI. A putposive sample of women from St. Croix, St. Thomas, and St. John Island, who were 30 years of age and older and who had never been diagnosed with breast cancer, were recruited to the study. These women were recruited by the investigators and trained student assistants from the University of the Virgin Islands School of Nursing using flyers, directed mailings, word of mouth, and referrals. ' During the process of recruitment, prospective partici- pants were given an informational letter that described the study purpose and procedure. Prospective partici- pants were informed that the study would require that they participate in a 45 to 60 minute interview during which they would be engaged in a discussion about breast cancer and their breast health practices. Prospective pare ticipants were informed that the information they shared Volume 18 Number 2 during the interview would be recorded by the investi- gators and research assistants on data collection sheets, . Prospective participants were informed that no names or identifiers that could link them to the data would be record- ed on the data collection sheets and that thei respons¢s would be confidential. Prospective participants were informed that the findings would be used to design breast - cancer education and outreach programs for women with- in the USVI. A total of 178 women from the USVI volunteered to participate in the study, Instrumentation A focused interview guide was used to facilitate a dia- log with the study participants about breast caticer, breast cancer Msk, breast cancer risk communication, and breast carepractices. Included in the interview guide wereitems relevant to perceived breast cancer risk, projected breast cancer Msk, breast cancer risk assessment, breast cancer risk communication, breast cancer screening, breast can- cer risk management, and family health history. This focused interview guide wag developed by the investt- pators and it incorporated items from the literature. Perceived Health Status and Breast Cancer Risk, Three items was incorporated in the interview to elicit data from the study participants reflective of their perceived breast cancer risk, One item asked women to respond to a state- ment about their health status, one item asked women. to ‘respond to a statement about their concerns about breast cancer, and another asked women to respond to a state- ment about thelr perceived risk of developing breast cancer compared with that of the average woman. Projected Breast Cancer Risk, Seven items were incor- porated in the interview to elicit data from the study participants reflective of their 5-year and lifetime pro- jected breast cancer risk, Among them were forced choice . tems specific toage, race, number of first-degree relatives with a history of breast cancer, age at first live birth or nul- liparity, age. at menarche, number of breast blopsies, and history of atypical hyperplasia. Breast Cancer Risk Assessment, Six items were incor- porated in the interview to elicit data to evaluate the extent to which health-care providers collected histoti- cal information from the study participants regarding breast cancer risk. Breast Cancer Risk Communication, Eight items were incorporated in the interview to elicit data to evaluate the extent to which health-care providers discussed lmeast cancer and breast cancer risk with the study participants, Breast Cancer Screening. Ning items were incorporat- ed in the interview to elicit data to evaluate the regularity of mammography, clinical breast examination, and beast self-examination. Receptlvity to Breast Cancer Risk Management. Ten items were incorporated in the interview to elicit data to _ evaluate the receptivity of the study participante to increased surveillance, médical intervention, surgical inter- 5S DECEMBER, 2007 * Volume 18 Number 2 vention, and behavioral modification and clinical trials to manage breast cancer risk. Family Health History. A faraily cancer history sum maty table was used to gather information regarding the cancer history of the study particlpants’ first-clegree and second-degree relatives. Personal Characteristics. Ten items were jncluded in the interview to elicit data reflective of gender, age, edu- cation, income, marital status, employment status, corre, insurance status, finances, and perceived health status. Validity and appropriateness of the interview guide for use among the targeted population was assessed by a panelof experts, including two nursing faculty, two breast carenurée clinicians, and two breast cancer survivors, prior to beginning the stu dy, Data Analysis Information shared by the study participants during the interview was recorded on data collection sheets, coded, and entered into a computerized database and analyzed in two phases using the Statistical Package for the Social Sciences (SPSS, 2007). During Phase J, data that was reflective of the demographic, breast cancer tisk, breast cancer risk assessment, breast cancet risk com- munication, and breast cancer risk management, the characteristics of the study participants were analyzed using descriptive statistics (frequencies, means, standard deviations, ranges). Later analyses, Phase Il, used descrip- tive and inferential procedures to describe the associations between breast cancer risk, breast cancer risk assessment, breast cancer risk communication, and breast cancer screening and receptivity to medical management of breast caticer risk. ; Protection of Human Subjects The study was submitted for review and approval to the Institulonal Review Board for the Protection of Human Subjects of the University of the Virgin Telands and the University of Wisconsin Milwaukee, Approval of thestudy by both Institutional Review Boards was obtained before the study was inltiated. Results Demographic Profile Shady participants wete profiled by age, marital status, education, employment status, income; finances, and health insurance status. The ages of the women involved inthestudy ranged from 30 to 74 years ofage, with a mean of 44.47 years (SD = 10.805). Most of the women were sin- gle, high school graduates, employed full-time, and had access to health insurance, While most of the women _ involved in the shidy reported annual household incomes greater than $35,000, 46.6% (n = 83) reported that they were “living check to check” and 14.6% (a= 26} reported that they “needed financial help with the costs of living” (see Table 3). Tuk JOURNAL OF THR NATIONAL BLACK NURSES AssOciaTION [@ Breast Cancer Risk Profile In an effort to obtain baseline data reflective of perceived and projected breast cancer risk, the study participants were asked to respond to a series of questions related to ereptions of their health status, perceptions of their health risk, concern about developing breast cancer, pét- sonal and family history of cancer, childbearing history, menstrual history and history of atypical hype Jasia. When asked to describe their health status, 13.5% id = 24) responded “excellent,” 70.8.1% (n='126) responded “good,” 11.8% (n = 21) responded “fair,” and 1.7% (n =3) respond: ed “poor.” When asked if they ever think about their own risk of developing breast cancer 36.5% (rt = 65) respond- ‘ad “often” and 23.0% (1=41) responded “rarely ornever” When asked to comment about their perceive breast cati- cer risk compared to that of the average women, 60.7% (n = 108) Indicated that they perceived thelr risk to be Megs” than that of the average woman and 6,8% (n = 12) indicated that they perceived their risk to be “higher” that that of the average woman, As shown in Table 4, several of the women involved in _ the study had risk factora that could place them at inc risk for developing breast cancer. Twenty-two perent of the women (1 = 40) reported that one of mote Of thelr maternal or paternal family members had a his- tory of breast cancer. Five percent of the women (7 = 9) reported that a maternal or paternal family member had a history of ovarian cancen Twenty-five percent of the women (t= 44) reported that they had no children or that thelr first child was born after the age of 30. Twenty-two percent of the women (n = 39) reported that they began menstruating at 11 years of age or younger. Seventeen per cent of the women (# = 30) reported having had an abnormal mammogram or breast ultrasound, and twelve erant ofthe women (= 21) reported having had Lreast biopsies (see Table 4). Projected breast cancer risk was estimated for women involved in the study who were 35 years of age and older using the model proposed by Gail, Among the women involved in the study who were 35 years of age or older, 87.9% (n = 116) were projected to have an “avetage risk” for developing breast cancer, 7.6% (n + 10) were project- ed to havea “moderate risk” for developing breast cancer, and 4.5% (4 = 6) were projected to have a “high risk” for developing breast cances, Breast Cancer Risk Assessment and Breast Cancer Risk Communication ' Identifying the factors that are associated with the devel- opment of breast cancer is an essential component of quality breast care, given that this information can help providers make appropriate recommendations regarding screening and breast care. Several items were incorporated into the interview guide to assess the extent to which breast can- cerrisk was assessed atid breast cancer risk was discussed with the women by their health-care providers. Included were questions that related to the co lection of informa- tion about personal and family health history, gtiestions 57 1. BLACK NURSES ASSOCIATION ¢ DECEMBER, 2007 yg Tue JOURNAL OF THE NATIONA Volume 18 Number 2 Table 3, Demographic Profile of the Study Patticipants (V = 178) Characteristics nt %. Age (years) . 50-39 75 427 40-49 45 25.3 50-59 AQ ’ 22.5 60-69 16 9.0 70 + 1 0.6 Highest educational level Elementary 12 6.7 High school ‘79 44,4 College or technical school * 70 39.3 Graduate school 14 79 Marital status Never married 70 39.3 Married 61 34.3 Separated 7 39 Divorced 17 9.6 Widowed 10 5.6 Partnered Bb 7.3: Employment status ‘ Hinployed full time 182 74.2 Employed patt time 13 7.3 Unemployed and looking for work 5 2.8 Unemployed and not looking for work 28 Home maker . 8 45 Student 5 2.8 Ratired 6 3.4 Disabled, not able to work 2 LA Other yd 11 Yearly household income , $75,000 or more 13 7.3 $56,000 to $74,999 28 15.7 $35,000 to 49,999 38 21.3 $25,000 to $34,999 36 20.2 $20,000 to $24,999 al IL.8 $15,000 to $19,999 10 5.6 $10,000 to $14,999 5 2.8 Need heFinances Need help with costs of living ' 26 14.6 Live check to check with debt + Ad 24.7 Live check to check with little to no debt 39 21.9 Living comfortably 58 82.6 Living with no financial difficulties 10 5.6 Health Insurance Status, Individual plan paid by the study participant 17 9.6 Group plan through an employer, union, etc, 56 31.5 Government health plan 59 33.1 Medicaid 3 17 Medicare ‘3 L7 No insurance * 40 22.5 thatrelated to collection ofinformation aboutpersonaland . family history of breast cancer, atid questioris about dis- cussions with health-care providers about breast cancer, breast cancer risk, and breast cancer screening. Data analysis revealed that historical information rela- tive to personal and family health was not routinely collected from the women involved in the study. Sixty- seven percentofthe women (4 = 120) involved in thestudy 58 DECEMBER, 200 7» THE JOURNAL OF THE NATIONAL BLACK Nurses Association Volume 18 Number 2’ Table 4, Cancer Risk Profile of the Study Participants (V = 178) Characteristics i % Family history of cancer Maternal history of cancer 68 38.2 Paternal history of cancer 43 . 24,2 Maternal or paternal history of cancer 86 43.3 Family history of breast cancer Before menopause 17 . 96 After menopause 25 14.0 Family history of ovarian cancer 9 5.1 Childbearing history No children 4 2.72 | First child born at 30 < years of age 44 9,86 Menstrual history Menstrual cycle began < 12 37 21.39 History of abnormal mammogram or breast ultrasound 30 . 17.24 History of breast biopsy 2° 1.19 Five year breast cancer risk” Average Ti6 87.9 Moderate 10 7.6 High . 6 45 dures described in the Gail Model for study participants * Five year breast cancer risk was calculated using proce > 85 years of age. reported that historical information about their personal health and family health was collected prior to their last physical examination. Among those reporting the collec- tion of higtorieal health information, 87.5% (7 = 105) indicated that they were asked questions about theit fam- ily history of breast cancet. Howevel, significantly fewer reported having had discussions with providers about breast cancer risk factors and their breast caner risk. Forty- four percent (n = 53) of these women indicated that they were asked questions abottt thei menstrual history, child- bearing history, history of abnormal mammograms, and history of biopsies. Forty-six percent (n = 82) of these women reported having had discussions with their providers about their projected breast cancer risk. When women involved in the study were asked about discussions they had had with health-care providers about breast cancer screening, 52.8% (n= 94) reported having discussed clinical breast examination and 77.5% (4 = 138) of the women reported having had discussions about breast self-examination. Among those under 40 years of age, 28.9 % (t= 22) reported having had discussions with health-care providers about mammography screening. Among those 40 years of age and older, 92.2% (4 = 102) reported having had discussions with health-care providers about mammography screening. Breast Cancer Scteening Practices A review of the study data suggested that the greater majority of the women involved inthe study did not com- ply with recommended breast cancer screening guide- - lines, Among the women from 30 to 39 years of age, 28.9% (= 22) reported that they examined their breasts month- ly and 47.4% (# =36) reported that they had received & breast examination by a physician or mutse practitioner within the past year, Among women 40 years of age and older, 29.4% (n = 30) reported that they examined their breasts monthly, 66.7% (n = 68) reported that they had received a breast examination by a physician or nurs¢ practitioner within the past year, and 47.1% (4 =48) repore ed having obtained a mammogram with in the past year The guidelines proposed by the American Cancer Soci ety (Smith, Cokkinides, & Eyre, 2007) and the Susan G, Komen Foundation for the Curel were used to assess the overall complance with breast cancer screening recom- jnendations. Women from 30 to 39 years of age and older with an “average” projected risk for developing breast cancer were desmed to be compliant if they reported breast _ self-examination and clinical breast examination screen- ing consistent with the guidelines of the Americart Cancer Society and the Susan G. Komen Foundation forthe Cure, Women 40 years of age and older with an “average” pro- jected risk for developing breast cancer were deemed to be compliant ifthey reported breast self-examination, clin- ical breast examination and mammography screening consistent with the guidelines of the American Cancer Society and the Susan G. Komen Foundation for the Cure. Women 40 years ofage and older whose projected risk for developing breast cancer was “moderate” or “high” were 59 Al OF THE NATIONAL BLACK NURSES ASSOCIATION ° DECEMBER, 2007 deemed to be compliant if, in addition to reporting breast cancer screening consistent with the published guidelines, they indicated that they had discussed their breast can- cerrisk and breast cancer screening with thelr health-care provider, Seventeen percent of the women with az aver age risk for developing as being’ compliant with breast cancer screening recorm- mendations. Twenty-five percent of the women witha moderate/high risk for developing breast cancer (a= 4) were ascessed as being compliant with breast cancer ecreen- ing recommendations. Receptivity to Medical Management of Breast Cancer Risk Inan effort to determine the receptivity to medical man- agement of their breast cancer risk, woment participating in the study were asked if they would be willing to con- sider genetic testing, increased surveillance, and medical intervention if they were found to have a significant risk for developing breast cancer, Seventy-one percent of the women involved in the study (# = 126) reported that they ‘would be willing to undergo genetic testing. Among women indicating a willingtless to undergo genetic coun- séling and testing, 76.2% (1 = 96) reported that they would be willing to undergo more frequent breast examinations, and. 50% (x = 63) reported a willingness to undergo drug therapy. In addition, 31.7% (1 = 40) reported a willingness to undergo surgical intervention, 69.8% (1 = 88) reported a willingness to undergo behavioral modification, and 44.4% (i = 56) reported a willingness to participate ina breast cancer risk management clinical trial. Influence of Perceived Risk, Projected Risk, Risk Assess- ment, atid Provider Communication on Breast Cancer Screening and Receptivity ta Breast Cancer Risk Man- agetent During the second phase of the data analysis, eforts were undertaken to determine the influences of perceived risk, projected risk, risk assessment, and provider com- munication on the study participants’ breast cancer screening practices and receptivity to breast cancer risk management. Participants were stratified by paceived risk, projected risk, risk assessment, and provider com- munication. After which, chi square analyses were used to examine the influence of perceived risk, projected risk, risk assessment, and provider communication on the breast cancer ecreening practices and receptivity to breast can- cer risk management. Data analysis revealed that breast cancer screening prac- tices and receptivity to breast cancer risk management were not significantly influenced by perceived breast can- cer risk, projected breast cancer risk, or health assessment of the study participants. However, data analysis revealed that provider communication significantly influenced the breast cancer screening practices and receptivity to beast cancer risk management of the study participants. Study articipants who percelved themselves to be at increased risk for developing breast cancer were no more likely than those who perceived themselves to be at average or lower L ‘to report comp breast cancer (1 = 20) were assessed ‘investigators, faculty, Volume 18 Number 2 ‘risk to report compliance with breast cancer scteening re c- ommendations. Study participants with an average rojected risk of developing breast cancer were No More likely than those with a moderate or high projected risk Hance with breast cancer screening rec- ommendations. Study participants who reported that their ptoviders'collected detailed nformation about thelr pet- -sonal breast cancer risk were no more likely than those who did not to report compliance with breast cancer screen ing recommendations. However, the study participants who reported having had discussions with health-care providers about their breast cancer risk were more likely ompliance with breast self-examinations, clin- to report ¢ ical breast examination and mammography screening recommendations, In addition, the study participants who reported having had discussions with health-care providers about theit breast cancet risks were more likely to express a willingness to, consider risk management strategies. Discussion The U.S. Virgin Islands, after being “acquired” from Denmark, became an organized territory of the United States in 1917, According to the 2000 Census, there are nearly 108,612 residents in the U.S. Virgin Islands (U.S. Census, 2007). Approximately 95% of the USVI popula- tion lives on the islands of St, Thomas, St. Croix, and St. Johns. Its inhabitants, though they cannot vote in US. presidential elections, are citizens of the United States. The USVI Bureau of Health has identified regional trends in breast cancer mortality among women in the U.S, Vit- gin Islands to be a priority health concern (USVI Department of Health, 2003). This study provided the and students of the USVI School of Nursing, most of which are natives of the U.S. Virgin Islands, an opportunity collect empirical data that could be used to define the breast health, breast cancer detec- tion, and contro] care needs of women within the USVL In addition, it provided investigators, faculty, and stu- dents with information that could be used in planning future programs to address needs specific to the commu- nity, The reaults of this study should be interpreted as sug- gestive rather than strongly conclusive, The small sample size and the use of a purposefully non-probability select- ed sample of USVI women 30 years of age and older that had never been diagnosed with breast cancer limits the generalizability, of the findings of this study. Yet, in spite of these constraints, there are several finding of signifi- cance worth noting, The identification and review of reports of the Nation- al Cancer Institute (Ries, et.al, 2006), the American Cancer Society (ACS, 2007) and the National Center for Health Statistics (NCHS, 2006) include little data specific to the breast cancer incidence and mortality of women in the USVI, While the data limitations make it difficult to com- pare breast cancer trends among women in the USVI with women from other states and territories, it calls attention to the need for expanding the scope of systems that are 60 DECEMBER, 2007 © THE JOURNAL OF THE NATIONAL BLACK Nurses ASSOCIATION [4 Volume 18 Number 2 responsible for cancer surveillance within the United States and its organized territories. ' Smoking prevalence among native islanders in the USVI is far less fhan thatin the states (CDC, 2007). Consequently, unlike other states, lung cancer is not the number one cause of cancer death among women (USVI Department of Health, 2003). Findings revealed that while a signifi- cant proportion of women involved in the study reported risk factors that could place them at iricreased risk for developing breast cancer, most perceived their breast can- cer risk to be “lower than the average women.” Most of the women involved in the study reporied that iriforma- tion about their personal. health and their family health was collected prior to their last physical examination. While the greater majority reported that they had been asked about a family history of breast cancer, few report- ed that they had been queried about breast cancer risk factors related to their childbearing history, menstrual his- tory, and medical history. While discussions with health-care providers about breast cancer screening were noted by the women to be common, discussions with health-care providers about breast cancer risk were not. ‘The greater majority of the women involved in the study reported that they’were not in compliance with the rec- ommended breast cancer screening guidelines. However, careful review of the data revealed that women reporting having had discussions with health-care providers about their personal breast cancer risk were raore likely to report compliance with breast screening recommendations. In addition, women who reported having had discussions with health-care providers about their personal breast can- cer risk were more likely to express an interest in medical strategies for the management of breast cancer risk. Recommendations for Research, Practice, and Education Significant advances have been made over the pasttwen- ty years relative to breast cancerscreening, diagnosis, and control. Within scientific and medical communities itis generally believed that breast cancer could be controlled most effectively if screening, surveillance, and risk mai- agement strategies were effectively utilized. Data from this study suggests a need for the develop- ment of more focused programs of reseanh, education, ‘ and outreach to promote breast health among women in the USVI. Results of this study suggest that within the USVI there is a need to the enhance the systems respon- sible for monitoring and reporting cancer trends relative to cancer incidence, mortality, and survival within the ter- ritory; a need for forums for investigators, faculty, students, and the community to discuss the breast health needs and concerns of women across the territory; a need for edu- cational programming for women in the community that focuses on breast cancer, breast cancer risk, breast cancer screening, and breast cancer risk management; a need for educational programming for women in the comraunity that enhance communication with health-care provicers; a need for educational programming for women in the community that focus on the relationship between per- sonal health and family health; a need for training of health- care providers (i.e., physicians, nurse practitioners, oncology nurse specialists, etc.) relative to the assessment and communication of breast cancer risk; and, a need for the development of programs of research to address issues relevant to breast cancer detection and control among women in the USVI across the care continuum. Numerous initiatives have been undertaken to track trends in breast cancer morbidity and mortality, to increase b reast cancer awareness, to improve breast cancer scree n- ing, to improve treatment and to ensure access to breast care for women in need throughout the United States. Now is the time to ensure that similar efforts are under- taken to ensure that the same occurs for women in the USVI and other organized territories of the United States, References American,Cancer Society. (2007). Cancer Facts and Figures . 2007. Atlanta, GA: American Cancer Society. Andrews, L. B., Fullerton, J. B., Holtzman,N. A., & Motul- sky, A.G, (Bds,). (1994). Assessing genetic risk: Implications ‘or health and social policy. Washington, DC: National Academy of Science. Bondy, M. L., Lustbader, E. D., Halabi, $., Ross, E., & Vogel, V. G. (1994), Validation of a breast cancer risk assess- ment model in women with a positive family history. _ Journal of the National Cancer Institute, 86(8), 620-625. 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