Cancer cervical early sign

Black women in the U.S. have excess mortality from breast and cervical cancer, compared with white women. For 1996-1998, the age-adjusted breast cancer death rate among black women in the U.S. was 26.2/100,000, compared with 19.0/100,000 for white women. (1) For 1990-1994, the age-adjusted cervical cancer death rates were 5.9/100,000 for black women and 2.4/100,000 for white women. (2) Studies comparing rates of mammography screening and breast cancer mortality for black and white women in the early 1990s determined that less than 15% of the variance could be attributed to screening. (3) In 1998, the mortality rate from breast cancer was 40% higher among black women in Boston than among white women (Unpublished data, Boston resident deaths, Massachusetts Department of Public Health, analyzed by the Office of Research, Health Assessment and Data Systems, Boston Public Health Commission). For the time period 1995-1997, three times as many black women died from cervical cancer as white women. In Massachusetts, black women reported higher rates of breast and cervical cancer screening than white women on the Massachusetts Behavioral Risk Factor Surveillance Survey (BRFSS) (Unpublished 1992-1998 BRFSS data, Massachusetts Department of Public Health, analyzed by the Office of Research, Health Assessment and Data Systems, Boston Public Health Commission). The disparity in breast and cervical cancer deaths, therefore, does not appear to be solely attributed to lack of screening.

Several factors have been proposed to account for the disproportionately high rates of breast cancer deaths among black women. For example, McCarthy et al. reported that older black women have less regular mammography screening than older white women. (3) Factors that may contribute to higher death rates among black women are delayed diagnosis, differences in tumor biology, confounding comorbid and socioeconomic conditions, (4) and personal beliefs about cancer and mammography among black women. (5,6) Recent data suggest that black women have a higher incidence of and more aggressive breast cancers before the age of 40 than white women in the same age range. (7)

Cervical cancer disparities have been attributed to multiple factors. The lack of follow-up of abnormal Pap smears due to women's fear of cancer, concern for reproductive function, and fear of pain (8); logistical barriers (transportation, child care); and lack of understanding of the implications of abnormal results (9) are among the reasons cited for higher mortality from cervical cancer among black women than among white women.

Addressing high rates of breast and cervical cancer mortality among black women in Boston requires an understanding of the unique factors affecting Boston's black community as well as the institutions and systems in Boston. Racial and Ethnic Approaches to Community Health (REACH) 2010 is an initiative of the Centers for Disease Control and Prevention (CDC) aimed at eliminating disparities in health status between the white population and black, Latino, Asian, and Pacific Islander Americans and American Indians/ Alaska Natives in cancer, heart disease, infant mortality, HIV/AIDS, vaccinations, and diabetes. The goal of this initiative is to support community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities. In 1999, a coalition of community activists, public health officials, academicians, and others formed the REACH Boston 2010 Breast and Cervical Cancer Coalition to address the disproportionate rates of breast and cervical cancer deaths for women of African descent in Boston. The Boston Public Health Commission is the convening agency and was awarded a 12-month grant to support planning and development of a Community Action Plan to address breast and cervical cancer disparities. We report here on the outcomes of the planning year and on the development of the community-driven Community Action Plan.

FORMING A COALITION

Understanding the most appropriate ways to address racial/ethnic disparities in breast and cervical cancer death rates requires an understanding of factors that contribute to health disparities, including health system factors, health care policies and procedures, personal factors among women of color, provider factors and provider-patient interactions, social factors in the community, and other issues that go beyond mammography and Pap smear screening rates. To ensure that approaches to addressing breast and cervical cancer mortality reflected the realities of women from Boston's diverse black community, we developed a process to ensure involvement of a broad representation of community members, ranging from the women themselves to academic researchers.

In 1999, the Boston Public Health Commission, the health department of the city of Boston, convened key stakeholders to discuss their perceptions of the root causes of disparities in breast and cervical cancer mortality and to create a coalition representative of the diversity of the community. The initial meeting attendees represented members of a community coalition addressing disproportionately high rates of infant mortality in Boston's black community, academic researchers, public health workers, local and state public health officials, community health workers, women's advocates, cancer advocates, and social service providers. The community coalition addressing disparities in infant mortality was invited as a key stakeholder for several reasons. First, its members recognized that attention to a broad range of women's health issues was required to address persistent disparities in infant mortality and thus did not limit their attention to pregnant women. Second, the women participating in the infant mortality coalition overlapped with women who might be targeted for outreach related to cervical cancer, black women 18 to 45 years old. Finally, to be respectful of community women, the conveners believed that it was important to build on an already established coalition, recognizing its members' time and commitment. It is unrealistic to build separate coalitions for every health issue arising in the city.

To facilitate community members' participation in the Coalition, women representing the diversity of Boston's black community (including African American, Haitian American, Caribbean American, and African immigrant women) were identified and asked to serve as Cluster Leaders. Cluster Leaders are women from the community who agree to work a few hours a week reaching out to other black women in their neighborhoods, churches, and other community settings to educate them about disparities, to ask women their opinions about factors that contribute to breast and cervical cancer disparities, and to bring them into the Coalition as cluster members. Cluster Leaders participated in a leadership development training that focused on: education about breast and cervical cancer, leadership, outreach, community organizing, self-help approaches, and public policy. They also attend monthly Coalition Steering Committee meetings and report on what they have learned from their activities in the community. Cluster Leaders organize cluster meetings and encourage cluster members to bring others in to widen the circle of women involved in learning about breast and cervical cancer.

Early on, the Coalition developed and adopted a set of organizational principles designed to ensure a balance of power between the community members and institutional representatives (Figure 1). Coalition members, including institutional representatives, participated in several trainings on Coalition development, breast and cervical cancer risk factors and screening recommendations, proven strategies for increasing mammogram and Pap smear screening rates in black women, and cultural competence and ways of understanding and addressing racism. Results of a needs assessment and community mapping were shared with the Coalition members on an ongoing basis over the course of the first 10 months of the planning year. Coalition members participated in trainings on how to develop a Community Action Plan and a budget for the Plan; these trainings were based on the model described by Fawcett et al. (10)

Figure 1. REACH Boston 2010 Breast and Cervical Coalition: Organizational Principles

The Coalition will be governed by a steering committee, which is open to the following affiliated members:

* one representative from each of the original grant partner organizations;

* one representative from any interested organization/institution;

* Cluster leaders and Cluster members.

Principles of Participation

1. Steering committee members should be committed to the project and able to participate fully in the committee activities. Each Coalition steering committee member must sign (on behalf of his/her institution/organization) an affiliation agreement and agree to attend all member trainings.