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Breast Cancer Delays

PI Name: Karliner L
Title: Breast Cancer Delays
Institute: American Cancer Society

Background: Delays in diagnosis and treatment for breast cancer are both common and concerning. There is a strong association between longer delays and decreased 5-year survival; as well as between diagnostic delay and later stage at diagnosis. African American, Asian, and Latina women all are more likely than White women to have delays in diagnosis of breast cancer; they are also more likely to have significantly larger tumor size at the time of diagnosis. Among Asian and Latina women, this is particularly true for those born outside the United States, perhaps because of language differences. Diagnosis and initiation of treatment for breast cancer requires multiple interactions between clinicians and patients, and often transition of care from one clinician to another, creating frequent opportunities for miscommunication, which in turn can lead to delays. This potential for miscommunication is of particular concern for the more than 9 million U.S. women with language barriers.

Objective/Hypothesis: The investigators hypothesize that language barriers are an important contributor to delays to diagnosis and to treatment of breast cancer for immigrant women. The goal of this proposal's three studies is to obtain the information necessary to design an intervention to decrease delays in diagnosis and treatment for limited English proficiency Latinas with breast cancer.

Specific Aims: (1) To assess delays to pathologic diagnosis and to initiation of treatment for women in the San Francisco Mammography Registry (SFMR) and to examine language barriers as a mediator of those delays. (2) To identify system and communication factors contributing to clinical delays in breast cancer diagnosis for Latinas. (3) To conduct formative qualitative research necessary to the future design of a communication intervention to decrease breast cancer clinical delays for limited English proficiency Latinas.

Study Design: The overall research design of this proposal is a stepwise sequence of three studies that build upon each other. The first study (Aim 1) is a retrospective cohort analysis of data from the San SFMR merged with primary language data from UCSF, designed both to assess delays for women either diagnosed with cancer or with very abnormal (BI-RADS 4 or 5) mammograms requiring rapid diagnosis, and to examine the influence of language barriers on those delays. The second study (Aim 2) has two components: (1) a telephone survey of Latinas from the Aim 1 cohort as well as similar Latinas in the SFMR who received their care at a county hospital serving a large poor and uninsured immigrant population; and (2) a chart review of those women's medical records. The third study (Aim 3) is a qualitative study utilizing focus groups of Spanish-speaking Latinas with the following two goals: (a) to test potential key messages about abnormal breast signs, symptoms, and radiology results for use in a future intervention trial, and (b) to assess the acceptability of possible modalities of delivery of those messages to this target audience.

Cancer Relevance: The proposed research addresses an important public health problem because there are more than 9 million limited English proficiency women in the United States -- many of whom live in poverty and thus are subject to disparities in breast cancer care. Language barriers likely affect these women's ability to obtain a breast cancer diagnosis and initiate treatment in a timely manner, and thus negatively impact on their stage of diagnosis and possibly survival. Although this proposal focuses on Latinas, the intent is to develop methods while studying this population that can then be utilized in the future with other populations, such as LEP women from other language groups or even men and women with other cancers.