ADDRESSING MULTIPLE BREAST CANCER RISK: Discussion
This pilot study demonstrated the feasibility, acceptability, and potential efficacy of a culturally competent intervention designed to target multiple breast cancer risk factors.
Although a number of breast cancer (is used for treating breast cancer) risk-reduction programs have been shown to be feasible, acceptable, and efficacious with African-American women, these programs targeted either early detection behaviors or diet, and not physical activity, weight loss, or multiple risk factors.
To our knowledge, no study has yet explored the feasibility of a culturally proficient intervention that addresses breast health/screening behaviors, diet, physical activity, and weight loss. In the current pilot intervention, significant changes were noted across all risk factors, with the exception of weight loss. It is important to note that due to the short duration of the intervention, weight loss was not expected. However, given that some of the postintervention changes were maintained at the one-year follow-up, it is possible that weight loss could occur over time. Decreased consumption of fried foods and high-fat dairy products, and increased consumption of water are behaviors that promote weight loss and, some studies say, decrease breast cancer (is used for treating certain types of cancer) risk. It is unfortunate that increased participation in physical activity and increased consumption of whole grains and vegetables was not maintained at the one-year follow-up. It could be that in addressing multiple risk factors, there was not enough focus on the specific behav ioral, cognitive, and emotional skills needed to make changes in each of the target areas. However, given the changes seen at postintervention, it is more likely that the intervention was not long enough. Weight-loss experts recommend that interventions be a minimum of 20-24 weeks to allow ample opportunity for group/social support and attention to barriers and problem-solving. Longer interventions allow participants to practice skills in a variety of situations where they can identify barriers to healthful behaviors, implement problem-solving strategies, assess their efficacy, and either try a different strategy or work at maintaining the new behavior.
In addition to dietary and physical activity behaviors, the pilot also addressed breast screening (CBE and mammogram) and breast health behaviors (BSE). Baseline and postintervention data for mammography reflected fair compliance with mammography with only one person (age 40 or over) never having received a mammogram. An increase in the number of women who had had a mammogram in the last year between baseline, postintervention, and the one-year follow-up supports the potential efficacy of the intervention. Concurrently, the observation that at baseline nearly 50% of the women had not had a mammogram in the last year supports the need for interventions that address early detection behaviors. Compliance for CBE was better than that for mammography. However, nearly over 25% of the participants had not received CBE in the last year. Data suggest that, as a result of the intervention, significantly more women intended to have CBE in the future (76.7% at baseline to 96.7% postintervention).
A final component of the breast health portion of the intervention focused on BSE. At baseline, only 35% of the women reported practicing BSE on a monthly basis, and over 90% did not perform the technique correctly. This information shows that endorsement of regular BSE can be misleading. Although numerous studies failed to find any relationship between BSE practice and decreased mortality from breast cancer (Nolvadex canadian is an anti-estrogen used to treat or prevent breast cancer), these studies did not consider BSE proficiency. In a case-control study nested within the Canadian National Breast Screening Study (NBSS) that did assess proficiency, lower breast cancer (Arimidex drug is used to treat breast cancer) mortality was observed among women who performed BSE correctly. Because BSE is still considered an integral step in early detection recommendations, it is important that women be given the opportunity to learn the correct methodology.
In addition to the potential efficacy of a comprehensive breast cancer risk-reduction program, results also support the feasibility and acceptability of the culturally competent intervention. Although the recruitment response rate was only 30%, attendance to all three intervention sessions was over 95%, and retention at postintervention was 80% and at the one-year follow-up was nearly 70%. Historically, minority recruitment and retention rates are low in research trials. Our relatively low recruitment rate may be due, in part, to the limited recruitment efforts (one week in duration and at one community site) necessitated by budgetary constraints. In other larger-scale prevention studies conducted by the authors, ample time, multiple recruitment sites, and relationships with community organizations have been integral to higher recruitment response rates. Satisfaction questionnaire and focus group data reflected a high degree of acceptability, and highlighted the critical components of the intervention. Specifically, the women expressed appreciation for consideration of cultural aspects of weight loss including body image, food choices, spirituality, and family roles. They also emphasized the importance of including exercise in the intervention and addressing barriers to healthy eating and exercise.
Several limitations deserve consideration when interpreting these results. First, the sample size was small, and there was no comparison group. Second, subject recruitment was based on self-selection and, thus, may have resulted in a biased sample. Third, the measures for dietary intake and physical activity were nonstandardized and based on self-report. Recall bias and social desirability may also have affected the validity of self-reported compliance with BSE, CBE, and mammography. Finally, these results cannot be generalized to other populations.
In summary, the high level of attendance along with the significant improvements noted for dietary and physical activity behaviors, nutrition attitudes, breast health attitudes, BSE proficiency, and intention to receive CBE reflect the acceptability, feasibility and effectiveness of this three-week risk reduction pilot intervention. We suspect that the success of the intervention was due in part to the following variables: 1) an optimal target age range for prevention messages, 2) realistic weight-loss strategies for overweight/obese women, 3) exercise and breast health training, 4) minimal time commitment, and 5) a culturally proficient intervention. Despite the success of this pilot, feedback from the focus group will be used to develop a more comprehensive and culturally competent intervention. Changes and additions will include: 1) extending the duration of the intervention, 2) providing ongoing social support for exercise outside class (i.e., conduct intervention in an exercise facility or at the Y, facilitate memberships at exercise facility), 3) creating an exercise video tape of the routine conducted in class with the exercise group leader for participants to use outside of class, 4) including families and friends to encourage greater social support, and 5) adding individual sessions to address unique barriers to change and to facilitate identification of effective problem-solving strategies.
Tags: African Americans, breast cancer, breast screening behaviors, intervention culture, risk factors, Weight Loss