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Master’s and Doctoral Projects
2004
The utilization of breast self exam reminder systems
in females living in rural southeastern Michigan
Janine Ann Filipek
Medical College of Ohio
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Master’s and Doctoral Projects. Paper 312.
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The Utilization of Breast Self Exam Reminder Systems
in Females Living in Rural Southeastern Michigan
Janine Ann Filipek
Medical College of Ohio
2004
ii
Dedications
This project is dedicated to my family and loved ones, thank you for helping me
carry my rock. I know with your love and support any task I choose to conquer will be
accomplished. I cannot say it enough, thank you, you are my strength.
iii
Acknowledgements
To my major advisor, Prof. Susan Batten, thank you for your guidance,
encouragement and vision throughout this endeavor. It was your help and leadership
that got us to this day.
To the Medical College of Ohio, thank you for the financial support that helped
bring this project together. Thank you also for instilling a sense of accomplishment in
the completion of this project.
.
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TABLE OF CONTENTS
TITLE PAGE
DEDICATION ........................................................................................................ ii
ACKNOWLEDGEMENTS .................................................................................... iii
TABLE OF CONTENTS ....................................................................................... iv
CHAPTER I: Introduction ......................................................................................1
Statement of problem .................................................................................2
Statement of purpose .................................................................................2
CHAPTER II: Literature .........................................................................................3
Review of Literature ...................................................................................3
Summary ..................................................................................................31
CHAPTER III: Method ........................................................................................32
Design ......................................................................................................32
Research Questions.................................................................................32
Subjects ...................................................................................................34
Instrument ................................................................................................35
Method .....................................................................................................36
Validity......................................................................................................36
Reliability ..................................................................................................37
Protection of Subjects ..............................................................................37
Procedure.................................................................................................38
Data Analysis ...........................................................................................38
Summary ..................................................................................................39
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CHAPTER IV: Results
Findings....................................................................................................40
Summary ..................................................................................................58
CHAPTER V: Discussion
Findings....................................................................................................60
Implication for healthcare ........................................................................69
Limitations ...............................................................................................70
Recommendations for Future Research..................................................70
Conclusion...............................................................................................71
REFERENCES....................................................................................................73
APPENDICES .....................................................................................................78
ABSTRACT .........................................................................................................84
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TABLE OF FIGURES
Figure 1. Histogram of subjects age...................................................................40
Figure 2. Pie graph of age group clusters of subjects ........................................41
Figure 3. Bar graph of education level of subjects .............................................42
Figure 4. Boxplot of subject age and level of education .....................................43
Figure 5. Bar graph of family history of breast cancer ........................................44
Figure 6. Bar graph of friends with breast cancer history ...................................45
Figure 7. Bar graph of receiving BSE instruction................................................46
Figure 8. Pie chart of breast self exam instructors .............................................47
Figure 9. Bar graph of personal performance of BSE.........................................48
Figure 10. Bar graph of frequency of non-monthly BSE performance ................49
Figure 11. Bar graph of BSE aiding in breast lump detection.............................50
Figure 12. Bar graph of knowledge of someone who located breast cancer by BSE
............................................................................................................................51
Figure 13. Bar graph of the number of reminder systems heard of ....................52
Figure 14. Bar graph of the number of reminder systems used in the past ........53
Figure 15. Bar graph of the number of reminder systems currently used...........54
Figure 16. Histogram of percent importance of reminder systems for others .....55
Figure 17. Histogram of percent importance of reminder systems for self .........56
1
CHAPTER I
Introduction
Recent news reports have highlighted the controversy surrounding the
importance of performing a monthly breast self exam (BSE). Literature indicates
patients detect 75-90% of breast lumps themselves, either via performing a BSE
or by accident (Jankovsky, 2000). Past studies reported that physicians rate
BSE as a more effective breast cancer screening tool than clinical examination
(Warner et al., 1989). Since the 1950’s the American Cancer Society has
supported and promoted monthly BSE for women on a monthly basis (Leight &
Leslie, 1998).
A women’s lifetime risk of breast cancer is 1 in 8 (Wei et al., 2000);
therefore, any means of early detection is important and a key to decreasing the
mortality of breast cancer victims. Ku (2001) reported the survival rate for stage
1 breast cancer at diagnosis to be 98%, where stage 4 breast cancer was at
16%. The American Cancer Society suggests that 97% of breast cancers may
be treated successfully when detected early (Jankovsky, 2000).
Past research findings emphasize the importance of performing a
monthly BSE as a means to help women understand the normal texture, size,
shape and appearance of each breast. Knowing each breast characteristics
takes time and attention to detail. As reported in Harvard Women’s Health
Watch (Menonna-Quinn, 1999), a woman who has examined her breasts for
many years has a better idea of what abnormal is in her own breast. Knowledge
of "normal" on an individual level is important, especially when considering over
2
70% of women diagnosed with breast cancer had no prior risk factors (Wood et
al., 2002).
It is not always easy to remember to do a BSE every month. Various
reminder systems have been used over the years, such as calendar stickers,
date of birth, or phoning a friend on a pre-established day of the month (Ferris et
al. 1996).
Breast self examination is an inexpensive and non-invasive manner to
screen for breast cancer. Regardless of current controversy over the
significance of performing BSE, self exam remains a means to help women
recognize the normal and abnormal condition of their breasts. BSE is one way
motivated women take an active role in personal healthcare; establishing a
monthly reminder system for woman over 20 will facilitate action.
It is unclear whether women in Lenawee and Monroe Counties in
Michigan know to do a breast self exam (BSE) on a monthly basis and what
reminder systems they use. Therefore, this study helped to determine BSE
reminder systems used by women in Southeastern Michigan; the percent of
women using a monthly reminder system; and the percent of women who
perform a monthly BSE. Self reports of age, education and previous experience
with breast cancer allowed for exploration of relationships between the above
variables, and determination of the performance of monthly BSE.
3
CHAPTER II
Review of Literature
Breast Cancer Statistics
Breast cancer is one of the most prominent cancers plaguing society
today. Literature reports that 1 in every 8 women will develop breast cancer (Wei
et al., 2000). Leight and Leslie (1998) estimated there would be 178,700 new
cases of breast cancer diagnosed in American females, which calculated out as
one new diagnosis every three minutes. This figure incorporated all forms and
types of breast cancer, and predicted that of 178,700 newly diagnosed patients,
43,900 women would die of the disease (Leight & Leslie, 1998). Coleman et al.
(2003) estimated 211,300 breast cancer diagnoses would be made, with a death
rate nearing 39,800 women. Estimations increased by nearly 40,000 newly
diagnosed women in a matter of only 5 years.
In 2003, the Journal of the National Cancer Institute reported that female
breast cancer rates continue to be on the incline at a rate of 0.6% per year. That
statistic helps describe why 1 in 10 women have a first-degree relative diagnosed
with or having had breast cancer (Mulley & Sepucha, 2002). The 1 in 10 figure
takes into account only first-degree relatives meaning mother, sister and/or
daughters; friends and more distant family members are not considered firstdegree relatives.
In 2003 it was reported that late-stage breast cancer diagnosis and
mortality rose in two separate classes of women: African American and
Caucasian of low socioeconomic status (Coleman et al., 2003). Last year
4
invasive breast cancer was reported as the leading cause of cancer deaths
among women ages 40-59 (Coleman et al., 2003). This represents a startling
increase from the previous years claim that breast cancer was the second
leading cause of cancer-related deaths in American women (Wood, McGrath,
Narcisco, 2002).
Survival Rates
Although risk of developing breast cancer is on the rise, it is important to
realize that the 5-year survival rate of women with localized breast cancer has
significantly increased. Jankovsky (2000) points out that in the 1940’s the 5-year
survival rate for localized breast cancer was 72%, whereas in 2000 the 5-year
survival rate was reported at 97%.
Risk Factors for Breast Cancer
Age is a major risk factor for breast cancer. Breast cancer may occur at
any age, although it is rare before the age of 30 (Baxter, 2001). A woman at 40years-old has nearly a 1 in 217 chance of being diagnosed with breast cancer;
for women age 50 and older the risk increases to 1 in 50 (Jankovsky, 2000).
One report from the early 1990's noted that 85% of breast cancer cases are
found in women over the age of 45 (Hall, 1992). Postmenopausal women,
women with a positive family history, women who had a first child after the age of
thirty, and women that had either early menarche, or late menopause are also at
higher risk for breast cancer (Hall, 1992). Researchers have also included
personal history of endometrial cancer, never having had a child (nulliparous),
benign breast disease, obesity, diet high in animal fat or protein, use of estrogen
5
replacement therapy (HRT), or hypothyroidism as risk factors for development of
breast cancer (Prescott, 1999). Women that carry the genes BRCA1 and/or
BRCA2 are at increased risk of developing breast cancer (Jankovsky, 2000). As
cited by Jankovsky (2000), women with either of the two genes have a 80% to
90% risk of being diagnosed with breast cancer.
Risk Assessment
The risk of being diagnosed with and/or dying from breast cancer is known
to increase with age, with the most risk concentrated around age 65 (Wood et al.,
2002). Therefore it is important to assess risk at an earlier age in order to
enhance screening and breast cancer protection. There are a variety of risk
determination models currently in use to help assess an individual women’s risk
of receiving a breast cancer diagnosis.
One such model is the Gail Model that was developed by the Breast
Cancer Detection Demonstration Project (BCDDP) and modified by the National
Surgical Adjuvant Breast and Bowel Project (NSABP). This interactive computer
program will determine a woman’s risk of invasive breast cancer; the software is
distributed by the National Cancer Institute (Euhus, Leitch, Huth and Peters,
2002).
Investigators from the NSABP used the Gail Model to assess individual
females risk of being diagnosed with breast cancer in her lifetime; the research
predicted 159 women would be diagnosed with breast cancer in the future. Of
the 159 cases predicted, 155 breast cancers were diagnosed (Euhus et al.,
2002).
6
The Gail Model assesses six variables: current age, age at menarche, age
at first live birth/nulliparous, number of previous biopsies, number of first-degree
relatives with breast cancer, and previous diagnosis of atypical hyperplasia
(Euhus et al., 2002). The answers allow for prediction of percent risk for that
individual female at different ages within her lifespan. Currently, the Gail Model
is the only validated model for assessment of breast cancer risk.
Screening Tools
Research addressing tools for preventing breast cancer always
emphasize the three screening methods currently available; mammography,
clinical breast exam (CBE), and breast self exam (BSE), (Ku, 2001).
Mammography
Mammography is a well-known and widely used tool to assess the
breast (Jankovsky, 2000). Mammography is an imaging system that uses lowdose x-ray to view breast tissue; images are then read and interpreted by a
radiologist (“Radiological Society of North America, Inc,” 2004). A major benefit
of mammography is that it can detect a change in breast tissue up to two years
before the change may be palpable or easily located with touch (“Radiological
Society of North America, Inc,” 2004). Mammography is reported to be the most
effective method for breast cancer detection in early stages (Wood et al., 2002).
It has also been reported that mammography can locate a lump as small as 1cm
in diameter (Jankovsky, 2000). Mammography alone may leave 15% to 20% of
cancers undetected, however when combined with regular clinical breast exams
7
(CBE) the risk of cancer going undetected is then less than five percent (“Susan
Komen Foundation,” 2004).
The U.S. Department of Health and Human Services (HHS), American
Cancer Society (ACS), American Medical Association (AMA), and the American
College of Radiology (ACR) all recommend women age 40 and older receive one
screening mammogram yearly (“Radiological Society of North America, Inc,”
2004).
The Susan G. Komen Foundation (2004) and the American Cancer
Society (2004), both well-known foundations that support breast cancer research
suggests mammography be performed on women age 40 and higher every year.
The National Cancer Institute recommends those 40 and above receive
mammography every 1-2 years (“Susan Komen Foundation,” 2004).
The Komen Foundation (2004) notes that women age 40-49 can lower
breast cancer risk by 15-20 percent by receiving a yearly mammogram; the
Foundation also states that women age 50-69 can lower cancer risk by 25-30
percent with a yearly mammogram. Wood et al. (2002) portrayed mammography
as being the most effective method of detecting breast cancer in early stages
Clinical Breast Exams (CBE)
Lawrence (1994) specified what a Clinical Breast Examination entails;
these exams are primarily performed during yearly obstetrics/gynecologic exams.
Lawrence noted that women should anticipate the examiner to inspect and
palpate for change in breast size, color, contour or skin texture. Nipple changes
are also examined during the CBE to assess for change in color or noticeable
8
discharge. In order to complete the exam, the examiner will clarify the
chronology of any breast symptoms the woman may express. Lawrence
illustrates that questioning should accompany the exam if any abnormalities are
noticed at that time, for example; “when did this first appear?” and “has this
mass, discharge, or discomfort increased or decreased?” Lawrence also
discusses the need for physicians to be aware of any risk factors that may place
individual patients at risk. Lawrence points out that the yearly CBE is an
appropriate time to review patient history, identify and discuss possible risk
factors and note any changes or breast-related symptoms.
The Susan G. Komen Foundation (2004) recommends a Clinical Breast
Exam at least every 3 years between age 20-39, and yearly beginning at age 40.
The American Cancer Society (2004) issued the same recommendation;
however, the National Cancer Institute (2004) offers different recommendations
regarding CBE. The National Cancer Institute (2004) recommends that CBE be
performed yearly beginning at the age of 30; ten years earlier than current
American Cancer Society recommendations.
Jankovsky (2000) reported that using CBE is an essential additive to
performing a complete breast cancer prevention and surveillance. Jankovsky
noted that experienced clinicians are able to locate a lump as small as 8mm in
diameter due to technique and experience.
Breast Self Exams (BSE)
The practice of BSE is one of habit and good health-promotion behavior
similar to proper nutrition, diet and exercise (Gasalberti, 2002). Jankovsky
9
(2000) reported that the vast majority of lumps, approximately 75-90%, are
detected by women practicing a BSE or by accident.
Currently, there are a multitude of articles available in both professional
journals and popular press to help explain and teach proper BSE technique.
Breast Self Examination is a systematic method of self-inspection and palpation
focusing on the axillary region and breast bilaterally (Baxter, 2001). When
teaching BSE technique, Becker (1998) recommends examination of the breasts
when they are least tender, approximately 2-3 days after menstruation begins.
Becker suggests examining the breasts in the supine position placing a pillow
under one arm that is raised above the head, and using three different patterns of
self-palpation; circle, up and down, and wedge methods. BSE helps detect
lumps that may only be found by palpation, and helps identify any visible
abnormality in the breast and surrounding skin. Women who perform BSE are
taught to recognize areas of diffuse redness, dimpling, and any nipple discharge
(Becker, 1998).
Not only does BSE allow women to take an active part in their own
healthcare, it has been reported that women who choose to perform BSE on a
regular basis are eleven times more familiar with their breasts than women who
are only examined yearly by a physician (Pool & Judkins, 1990).
When comparing survival rates for breast cancer patients, individuals who
practice monthly exams were observed to have a better five-year survival rate
than those that did not practice (Behan & Reynolds, 1997). Five-year survival
10
rates were 76.7% for BSE participants compared to 61.0% for non-BSE
practicing patients (Behan & Reynolds, 1997).
The reasoning behind the predictably better five-year survival rate for
women who practice monthly BSE is that BSE is allowing women to find the
lumps sooner; therefore, lumps are more likely to be smaller, have less lymph
node involvement, and have higher likelihood of remaining localized without
metastasis or further spread throughout the body (Menonna-Quinn, 1999). Ku
(2001) reported that survival rates for localized breast cancer (stage 1) was close
to 98%, whereas, metastatic disease (stage 4) only had a 16% survival rate.
Current recommendations for the practice of BSE differ depending on the
association providing the guidance. Currently, the Susan G. Komen Foundation
(2004) recommends Breast Self Exams be performed on a monthly basis
beginning at the age of 20 years old. A popular press article highlighted a quote
from a Susan G. Komen foundation representative in the March of 2004 edition.
Matthews’ (2004) stated how valuable it is for women to learn what normal feels
like within their own breasts. The commentary also goes on to stress the
importance of being thorough while inspecting and or suspecting a lump within
the breast tissue.
The American Cancer Society (ACS) is of a slightly different opinion, that
by age 20 benefits and limitations of BSE performance should be discussed
between the woman and her health-care provider (“Susan Komen Foundation,”
2004). The ACS believes the decision to practice BSE should be left up to the
individual female (“Susan Komen Foundation,” 2004). The National Cancer
11
Institute currently has no recommendation on the matter of Breast Self Exam
performance, and the U.S. Preventative Services Task Force notes there is not
enough evidence to recommend either for or against (“Susan Komen
Foundation,” 2004).
Breast Self Exam Reminder Systems
Once women know what a BSE is and understand how to perform an
exam comfortably, the next concern is will they remember to perform a BSE on a
monthly basis? Hall (1992) discussed how women neglect this simple method of
self-care for a variety of reasons, one of which is forgetfulness. In a study done
by Grady (1988), it was found that because BSE is a conscious, infrequent
behavior, it is not likely to become a habit. Hall (1992) attempted to determine
effective use of a specially designed visual reminder to increase knowledge and
awareness of the need for regular BSE practice. The results indicated significant
improvement in both variables, leading to a conclusion that visual reminders are
useful in BSE practice.
Breast Self Exam reminder systems have been used for years to help
women remember a day each month to perform BSE. Many different types of
reminder systems have been practiced, some more successfully than others.
Examples of reminder systems include memos placed on oral contraceptive pill
(OCP) packages (Ferris et al.,1996), use of a special day, or date of birth
(Pilgrim, 2002), and the "BuddyCheck 2,” established in New York as a means to
allow women to communicate the need for monthly BSE to one another
(Johnson, 1999). Education on BSE has also been provided at the workplace to
12
increase awareness of BSE as a screening tool (Thomas, Leeseberg-Stamler,
Lafteniere and Delahunt, 2002). Multiple studies indicate that health education
programs within the workplace enhance distribution of health information
because many participants begin to engage in healthful decision-making
following program participation (Thomas et al. 2002). Local broadcast stations
have also been known to provide a monthly reminder to encourage the practice
of BSE by the viewing audience.
Numerous strategies have been tried over the years in an attempt to
promote the practice of BSE. Effective measures include information/pamphlet
distribution, individual training, monitored feedback from providers, as well as
monthly reminders (Baxter, 2001).
Increasing Breast Cancer Screening
Old age, low socioeconomic status, and decreased education characterize
women with the lowest breast cancer screening rates (Coleman, 2003).
Coleman states older women are less likely to have mammography due to the
lack of physician guidance, and that there is an insurance barrier especially for
the elderly on Medicare. Wood et al. (2002) noted that a number of women
couldn’t afford costly screening; only 15 to 40% of Medicare beneficiaries receive
mammography screening.
In one study involving 334 women, age 60 years and older, in communitybased urban settings throughout the United States, Wood et al. (2002) reported a
correlation between factors impacting the success of breast cancer lump
detection in older women. The study involved a 1-hour interview with subjects to
13
determine demographics, health, functional and cognitive abilities, as well as
breast health screening practices (Wood et al., 2002). The interview was
followed by a lump detection screening exercise using a Breast Self Examination
Proficiency Rating Instrument (BSEPRI). The instrument consisted of a vested
silicone breast model containing lumps in various quadrants of the breast. The
authors found that women, who were younger, more educated, and higher
income had a higher frequency of lump detection. A significant difference was
observed between the younger group and the older, less educated, lower
socioeconomic group in lump detection.
Adderley-Kelly & Green (1996) stress that lower education and income
level correlate to late breast cancer diagnosis and decreased survival rate after
diagnosis. The researchers also reported that the difference in survival for those
of lower socioeconomic status is due to late diagnosis and lack of “secondary
prevention.” Secondary prevention refers to mammography, clinical breast
examinations, and self breast examinations.
Prior breast self exam education enhanced performance; women
previously taught how to perform BSE were able to find a higher number of
lumps. However, older women previously given BSE education still had difficulty
detecting a high numbers of lumps (Wood et al., 2002).
Coleman et al. (2003) suggested the way to help increase breast cancer
screening was for nurses to become involved with preventative screening
methods. Coleman et al. emphasized need for outreach within rural communities
14
in the United States, based on knowledge that rural clinics serve more people
less likely to have transportation and telephones than urban residents.
For and Against BSE
The frequency of breast cancer cases, is one reason why it is necessary
to have proper screening as prevention for women who have never had breast
cancer and also for breast cancer survivors. Until recently, the American Cancer
Society (ACS) has recommended use of BSE as a monthly practice since the
1950's (Leight & Leslie, 1998). Controversy developed and led the ACS to
change the original recommendations. Since 1997 the ACS has recommended
women age 20 and older perform monthly BSE; however, the ACS revised the
recommended guidelines on May 1, 2003. New guidelines state BSE is to be
discussed with women in there 20's regarding benefits and limitations and the
choice to participate in BSE is for each individual (Champion, 2003). Therefore,
the new recommendations are designed only to inform patients that BSE is a
possible screening tool, and not coerce women one direction or another.
This recent change has caused further questioning as to whether BSE is
providing benefit to both the patient and the practitioner. Many articles are
currently available addressing the controversy.
The For Argument
Most women have no prior identifiable risk factor for breast cancer
(Baxter, 2001); therefore, screening tools help focus in on potential areas of
concern. A report by Erblich, Bovbjerg and Valdimarsdottir (2000) stated only
breast self-examination (BSE) allows women to perform a surveillance behavior
15
independently and may often be the only screening method available for women
without access to professional health care services (Erblich et al.). Nekhlyudov &
Fletcher (2001) found that one third of North American women perform regular
BSE and family physicians consider BSE as a more effective screening tool than
Clinical Breast Exam (CBE). Nekhlyudov and Fletcher (2001) state that
physicians desire more training on how to properly teach BSE to women, stating
that, “a survey of family physicians found that physicians rated BSE as a more
effective screening tool than clinical breast examination.” Breast selfexamination was thought of as a patient-centered, inexpensive and noninvasive
method for breast cancer screening and awareness. Most women in North
America are currently aware of BSE; approximately one-third performs the
examination regularly.
A Canadian National Breast Screening Study reported an association
between BSE proficiency and reduced breast cancer risk (Harvey, Miller, Baines
& Corey, 1997). Wood et al. (2002) showed that factors such as depth of
palpation and duration of search time invested influenced the risk reduction; any
training in BSE improves confidence, proficiency, and compliance.
Ku (2001) found BSE as being the basic screening device for women for
whom mammography screening might not be optional (e.g., younger women,
women having very dense breast tissue). This same finding appears from
research by Wood et al. (2002) and Adderley-Kelly & Green (1996).
16
The Against Argument
The sensitivity of BSE alone is estimated to be approximately 26% though
varying with age, 41% with women 35-39 years old and 21% among women 6074 years old (Baxter, 2001). Random control trials by Baxter and The Canadian
Task Force on Preventive Health Care (2001) report that there was no difference
in breast cancer mortality, diagnosis, or staging between women who had
previously used BSE as a preventive method and those that did not. Although
some of the trials sponsored by the Canadian Task Force on Preventive Health
Care were in progress at the time the article was published, a pattern was
apparent for women 40 and older of either no benefit, or inconclusive results as
to recommendations for BSE participation (Baxter, 2001).
Nekhlyudov and Fletcher (2001) described questions brought forward on
the effectiveness of BSE. The authors state that in 1996, the US task force gave
BSE a “grade C recommendation” for practice meaning that there is insufficient
evidence to recommend for or against screening. Based on randomized control
trials from Russia and China on effectiveness of BSE, groups including the NCI
and the ACS began to question true utility of BSE. This questioning went so far
as to suggest BSE provides no benefit, and is perhaps promoting good evidence
of harm. The authors concluded there remains a lack in evidence needed to
make firm conclusions for or against the practice of monthly BSE.
In a meta-analysis, Ku (2001) reviewed 20 studies addressing the value of
performing regular BSE. Ku found that the relationship between breast cancer
17
staging, survival, and BSE education and behavior was unclear. Ku suggests
further study to determine if correlation exists.
Limitations Women Associate with BSE
Knowing that BSE is most effective in educated and experienced
examiners, what would keep women from performing the screening test on a
monthly basis? Persson, Ek and Svensson (1997) explored what factors affect
women in practice of BSE. Based on the framework of the Health Belief Model
(HBM), the study encompasses what it is that may prevent a person from
practicing a preventative screening exam such as breast self exams such as
perceived susceptibility, seriousness, benefits, and barriers as four main
obstacles for practice of BSE. A study by Champion (1985) found a positive
correlation between health motivation and practice of BSE. The study evaluated
the relation of fear and anxiety women may experience at the thought of
searching for and potentially finding a lump within the breast that may yield a
negative outcome. BSE participation is portrayed as a complex decision with
potential serious outcomes (Champion, 1985). Women decide the benefits
received from BSE performance, adequacy of personal assessment, and comfort
level with BSE education and technique (Persson et al.).
BSE effectiveness does depend largely on ability of the examiner to
understand what it is they are looking and feeling for, as well as what is normal
from abnormal. Training programs for women to help increase efficacy level with
BSE have demonstrated improvement in lump detection (Wood et. al., 2002).
18
Studies show that a woman’s ability to detect lumps within silicone breast
is determined by four elements: number of steps used in the examination;
completeness of palpation; length of search and palpation; and how well the
finger pads are used for detection (Baxter, 2001).
Women who understand that BSE performance is a recommendation to
complement other forms of breast surveillance are then ready to become
comfortable and confident performing BSE. Past research has identified
women’s attitudes and influences related to breast health. Women tend to use
family and friends as a source of influence and encouragement for performing
BSE (Leeseberg-Stamler, Thomas and Lafreniere, 2000). Reinforcement helps
women face obstacles such as forgetfulness, fear of what may be found, lack of
skill, modesty and lack of comfort in performing BSE (Leight & Leslie, 1997).
When women and men are compared, women appear to be more influenced to
perform positive health behaviors when adequate supportive relationships are
available to them (Katapodi, Facione, Miaskowski, Dodd and Waters, 2002).
Using the Health Belief Model Erblich et al. (2000) theorized why women
may have difficulty with BSE: perceived seriousness of the disease, susceptibility
to disease, benefits of engaging in surveillance behavior, barriers to engaging in
the behavior, and confidence in correctly performing surveillance. Cohen (2000)
states that anxiety is the most examined emotion when studying BSE
performance. One way this emotion can be calmed is through positive support.
19
Summary
Breast cancer is an obvious challenge for women and health care
providers today. The need for the practice of BSE is unclear; however,
suggestions that BSE is the only method of breast cancer screening for certain
populations is compelling. Studies suggest that many nations where lower
socioeconomic populations live in or around a rural community may be practicing
only BSE if using any screening tools at all. Currently, it is unknown as to
whether women in Southeastern Michigan know to do a Breast Self Exam on a
monthly basis and what reminder systems are used.
The purpose of this study is to determine BSE reminder systems utilizedby
women in Southeastern Michigan. The research will identify the percent of
women who perform a monthly BSE. Demographic information on age,
education and previous experience with breast cancer will permit exploration of
relationships between the above variables and performance of monthly BSE.
20
CHAPTER III
Methodology
The purpose of this exploratory study was to assess the utilization of
breast self exam reminder systems in women living in rural Southeastern
Michigan. The study included assessment of age, level of education achieved,
personal and family history of breast cancer, use and importance of breast self
exams, and reminder systems participants have heard of, used, and currently
practice, as well as known breast cancer risk factors. This chapter will discuss
the design, study participants, tools used for data collection, plan for obtaining
data and analysis of the data.
Design
This exploratory and non-randomized study was conducted to determine
the utilization of breast self exam reminders by women as a breast cancer
screening tool in an attempt to contribute data to this research gap. The nonrandomized convenience sample for this study was solicited at sites in a primarily
agricultural area of the upper mid-west.
Research Questions
1. What are the age demographics of the study population?
2. What is the level of education demographics of the study population?
3. How many women in southeastern Michigan have had breast cancer?
4. How many women in southeastern Michigan have a positive family history
for breast cancer? What relative is most reported to have breast cancer?
5. Has a friend had breast cancer?
21
6. How many women in southeastern Michigan have been taught to perform
BSE?
7. Who are the most common teachers of breast self examinations?
8. How many women in southeastern Michigan report practicing BSE?
9. Do women in southeastern Michigan believe BSE can detect breast
lumps?
10. How many women in southeastern Michigan know someone that has
found a breast lump using BSE?
11. How many women in southeastern Michigan have heard of BSE
reminders? Which BSE reminders have been heard of most?
12. How many women in southeastern Michigan have used BSE reminders?
Which BSE reminders have been used most?
13. How many women in southeastern Michigan currently use BSE reminder
systems? Which BSE reminders are being used most?
14. How important do women in southeastern Michigan feel reminder
systems for BSE practice are for others?
15. How important do women in southeastern Michigan feel reminder
systems for BSE practice are for themselves?
16. What do women in southeastern Michigan consider risk factors for breast
cancer?
17. Is there a correlation between level of education and breast self exam
performance?
22
18. Is there a correlation between belief that BSE can detect a breast lump
and performance of BSE?
19. Is there a correlation between knowledge of BSE reminder systems and
performance of BSE?
20. Is there a correlation between the number of reminder systems used and
knowing someone who found a breast lump with BSE?
21. Is there a correlation between age and BSE performance?
Subjects
The target population for this study was women aged 18 years old and
older. The population sample totaled 275 women ranging between age 18 years
old and 88 years old. The sample was obtained in two separate counties within
rural Southeastern Michigan.
In order to participate in the study subjects must be: 1) female 2) age 18
years and older 3) able to read, write, and understand the English language 4)
willing to participate in the study 5) at the data collection site on the day of survey
distribution. Data collection sites included three colleges, one pharmacy and one
bank. Women attending college, and women residing in the surrounding rural
communities were asked to be subjects. Males and women less than 18 years of
age were excluded from participation in this study. Participation was fully
voluntary, and limited to the five locations of survey distribution.
23
Instrument
Data collection was performed via a researcher developed questionnaire
(Appendix B). Consultation with three health care practioners was utilized to
refine items contained within the tool.
The questionnaire consists of open and closed ended questions to
determine reminder systems in use (independent variable) and practice of
monthly BSE (dependent variable.) Age of the subjects was assessed via a fill in
question. Level of education of the subjects was assessed second on the
questionnaire as a multiple choice question. Subjects were able to circle either:
junior high, high school, technical, associate, bachelors, masters, doctorate and
other. Following the first two questions was seven yes/no questions regarding
experience with breast cancer, as well as knowledge and performance of BSE.
One multiple choice question addressed who taught each subject to perform
BSE. Subjects were able to circle: doctor, nurse, physician assistant, mother,
friend and other. Three multiple choice questions then addressed what reminder
systems subjects had heard of, used, and were currently using. The answers
provided include: a special number (birthday), day period starts, day period ends,
hanging reminder in bath, call or email from someone, none of the above, no
reminder needed and other. Two analog scale questions asked subjects to mark
an “X” on a line ranked not important to important. This method assessed the
importance of the performance of BSE for self and others according to subjects.
Lastly, one fill-in the blank (open-ended question) regarding risk factors each
woman knew of was assessed.
24
Method
A survey was used to aid in answering the research questions to
determine the utilization of breast self exam reminder systems used by women in
rural southeastern Michigan. Survey research is currently one of the most
commonly used observation studies performed. Surveys are useful for
exploratory and descriptive research, and are used primarily in studies that are
assessing certain populations of individuals (Babbie, 1989).
Exploratory studies are performed to satisfy curiosity, assess
understanding of a subject and develop further knowledge and understanding of
a topic. This type of research is useful when studying new information, or in
adding additional findings to current understanding (Babbie, 1989). Exploratory
research was conducted in this study.
Validity
Content validity of the survey tool was assessed prior to distribution;
three healthcare professionals reviewed the questions for appropriateness and
likelihood to solicit response. Healthcare professionals assisting with tool
refinement include: 1) Medical Doctor of Oncology with expertise in breast
cancer, 2) Nurse Practioner with expertise in women’s health and breast cancer
screening, 3) Physician Assistant with expertise in Family Medicine including
women’s health screening. Reliability was determined using data from
completed surveys.
25
Reliability
A total of 275 women were solicited from five sites within Southeastern
Michigan in two separate counties. A total of 82 subjects were obtained from
both private colleges solicited, 40 subjects were obtained from the community
college, 48 subjects solicited from the bank, and 23 subjects obtained from the
pharmacy.
Women were solicited in a variety of manners depending on specifications
from the site used. One private college and the community college allowed the
researcher to approach possible participants in the hallways, lunchroom, or on
campus grounds outdoors. One private college permitted the researcher to
distribute surveys in the lunchroom, and to any female faculty who would like to
participate. The bank and the pharmacy permitted a table set up for the
researcher for one day so survey distribution and collection could occur.
Protection of Subjects
Approval to do the research study was obtained from the Medical College
of Ohio Institutional Review Board; exempt status was received. Permission for
distribution of surveys was obtained from each of the five sites. Administration at
each facility reviewed the study protocol and was provided a copy of the Medical
College of Ohio Institutional Review Board approval and the study instrument
before participation was granted. A letter of consent attached to each survey
distributed explained the purpose of the research, risks to participants, and
anonymity.
26
Procedure
For all distribution sites, the researcher distributed and collected
completed surveys on the same day. An informed consent letter and
questionnaire was handed to each individual interested in the study. Subjects
choosing to participate in the study were asked to read the consent letter and
questionnaire directions before completing the questionnaire. Upon completion
of the questionnaire, participants placed completed surveys into a locked box.
Each woman received a complimentary pen for participation in the study.
Processing of surveys was initiated one or more weeks after data
collection at each site. Completed surveys are stored in a locked file, in no
particular order to assure the participants remain anonymous. Data collection
forms will be destroyed after six years.
Data Analysis
Statistical analysis was performed using SPSS 11.5 for Windows software
package. Descriptive statistics were used to clean data and prepare
demographic summaries. Chi-square testing was used to tabulate a goodnessof-fit model to compare observed and expected frequencies, for nominal or
ordinal level data of independent samples. ANOVA testing provided one-way
analysis for quantitative dependent variables by the independent variable;
ANOVA tests equality of several means as well as illustrating existing differences
between two means.
27
SPSS was used to generate charts and graphs displays to allow for easy
interpretation of data. Data was recoded as a “0” when subjects failed to provide
an answer.
Summary
This descriptive study assessed the utilization of breast self exam
reminder systems in women living in rural Southeastern Michigan. Target
populations for this study consisted of females ages 18 years old and older.
Content validity for the questionnaire was assessed and reliability testing
performed. Statistical analysis was performed; chi-square, correlations and
ANOVA outcomes were then used for interpretation of data.
28
CHAPTER IV
Results
In an attempt to achieve adequate sample size 300 surveys were
distributed at five locations. Out of the 300 surveys distributed, 275 were
returned for a response rate of 91.7%.
Findings
Research Question 1.
The mean age of women surveyed was 30.3; age distribution was 18 to 88
years old (see Figure 1).
200
Number of subjects
100
Std. Dev = 16.77
Mean = 30.3
N = 275.00
0
0.0
50.0
Age
Figure 1. Histogram of subjects age.
29
Subjects were grouped by age clusters; 18 to 30, 31 to 60, and 61 to 90
years old. Majority of subjects were within the 18 to 30 year old age group (see
Figure 2).
Age 61 to 90
6.7%
Age 31 to 60
28.1%
65.2%
Age 18 to 30
Figure 2. Pie graph of age group clusters of subjects.
Research Question 2.
Subjects answered a multiple-choice question regarding level of education
by circling one of the following: high school, technical, associate, bachelors,
masters, other (see Figure 3).
30
200
Number of subjects
100
0
r
te
r
he
ot
as
m
s
s
al
or
el
ch
ba
ic
hn
e
at
ci
so
as
c
te
se
on
ol
ho
sc
sp
re
gh
hi
no
Highest degree
Figure 3. Bar graph of education level of subjects.
The majority of participants were high school graduates, 173 (63%); the
age mean for this subset of subjects was 20. Subjects with a masters degree;
mean age was 40 years old (see Figure 4). Ninety-nine (36%) subjects reported
a level of education greater than high school.
31
100
57
51
64
43
80
69
2
1
4
16
6
55
71
20
54
25
269
46
266
21
24
60
66
27
17
18
67
65
42
35
34
271
32
109
11
22
56
275
244
241
62
247
60
40
20
Age
0
154
14
5
-20
N=
3
173
8
31
41
13
6
O
rs
te
as
s
or
e
at
ci
er
th
M
so
el
ch
Ba
As
e
ns
po
l
oo
ho
sc
s
re
h
ig
o
l
ca
ni
ch
Te
H
N
Level of education
Figure 4. Boxplot of subject age and level of education.
Research Question 3.
Only one (0.4%) subject reported a positive past medical history for breast
cancer. All participants responded to this question.
Research Question 4.
A total of 175 (63.6%) subjects reported no family history of breast cancer.
Subjects reporting a positive family history of breast cancer are illustrated in
Figure 5.
32
Number of subjects
200
100
0
e
on
an
th
e
e
or
tiv
m
la
re
e
al
m
in
us
co
r
r
nt
he
au
ot
dm
an
er
st
s
he
ot
gr
si
m
ye
se
no
on
sp
re
no
ti
la
re
Family history
Figure 5. Bar graph of family history of breast cancer.
Of the relatives listed, aunt was the most commonly listed response with
35 (12.7%) of total subjects; of those with a positive family history, aunt
compromises 36.1% of relatives with breast cancer.
The one subject with a positive personal history of breast cancer did not
report a positive family history of breast cancer.
Research Question 5.
Forty-one percent of subjects reported having a friend with breast cancer;
Figure 6.
33
200
Number of subjects
100
0
0
No
Yes
Breast cancer in a friend
Figure 6. Bar graph of friends with breast cancer history.
A report of positive family history of breast cancer and a friend with breast
cancer was made by 42 (15.3%) participants.
Research Question 6.
240 (87.2%) subjects reported having been taught how to perform a
breast self exam; 35 (12.8%) persons reported never having been taught BSE
(Figure 7).
34
300
Number of subjects
200
100
0
No
Yes
BSE instruction
Figure 7. Bar graph of receiving BSE instruction.
Subjects never having been taught how to perform a BSE were grouped
by age; 32 were under the age of 27. Out of the total number of subjects, 116
were age 20 and under, 23.3% never been taught how to perform a BSE.
Research Question 7.
Subjects were asked to identify who taught them to perform a breast self
exam; doctor, nurse, physician assistant, mother, friend, other. Figure 8
illustrates the responses; 132 (54.3%) of subjects reported that a doctor taught
them; only one subject reported being taught by a friend alone, and 29 (10.5%)
subjects reported being taught by more than one person.
35
more than one
10.5%
other
friend
no response
11.6%
9.5%
mother
P.A.
40.7%
18.9%
doctor
nurse
Figure 8. Pie chart of breast self exam instructors.
Research Question 8.
A total of 152 (55.3%) of subjects report practicing breast self
examination; 66 (24.0%) of them reported performing it on a monthly basis (see
Figure 9). A total of 121 (44.0%) subjects reported choosing not to practice
breast self examination.
36
140
120
100
80
Number of subjects
60
40
20
0
0
No
Yes (non-monthly)
Monthly
Performance of BSE
Figure 9. Bar graph of personal performance of BSE.
The remaining 86 (31.3%) subjects that admitted to practicing BSE,
anywhere from daily to a few times each year (Figure 10).
37
40
Number of subjects
30
20
10
0
to
2
ly
ar
ul
eg
tr
r
no
ea
ry
pe
s
2
th
to
on
1
m
ur
s
fo
th
y
er
on
m
ev
e
re
th
th
y
er
on
ev
rm
he
ot
y
er
th
ev
on
m
a
e
k
ic
tw
ee
rw
pe
1
ily
da
BSE performance
Figure 10. Bar graph of frequency of non-monthly BSE performance.
Research Question 9.
Belief that breast lumps may be detected using BSE was assessed. A
total of 242 (88.0%) subjects reported they believe performance of breast self
examination will help to detect a breast lump; 23 (8.4%) subjects did not believe
BSE useful in breast lump detection (see Figure 11).
38
300
Number of subjects
200
100
0
0
No
Yes
BSE in breast lump detection
Figure 11. Bar graph of BSE aiding in breast lump detection.
Research Question 10.
Subjects were asked if they were aware of anyone who had located a
breast lump by BSE (Figure 12).
Ninety-seven (35.5%) of responding subjects reported they knew
someone who had found a lump by BSE. The remaining 172 (62.5%) subjects
reported never knowing of anyone that found a breast lump by BSE.
39
180
160
Number of subjects
140
120
100
80
No
Yes
Detection with BSE
Figure 12. Bar graph of knowledge of someone who located breast cancer by
BSE.
Comparison of subjects knowing someone that found a lump using BSE to
age of those responding revealed a statistical significance. Pearson Chi-square
test illustrated, χ2 (2, N = 264) = 19.096, p=.000. Subjects in the 18 to 30 age
group knew the most individuals having found a lump with BSE. Subjects in the
61 to 90 age group knew the least number of individuals.
Research Question 11.
40
Multiple choice answers were provided for subjects to choose which BSE
reminder systems they had heard of. Figure 13 illustrates the number of
reminder systems.
120
100
80
Number of subjects
60
40
20
0
no response
0
1
2
3
4
5
Reminder systems
Figure 13. Bar graph of the number of reminder systems heard of.
Subjects’ response was also used to identify which reminder systems
were heard of most frequently. Of eight possible responses “hanging reminder in
bath,” was chosen by 93 (33.8%) subjects. The second most common answer
was “day period starts,” with 72 (26.2%) subjects responding, followed by “day
period ends;” 62 (22.5%), “none of the above,” 56 (20.4%), “a special number,”
50 (18.2%), “call or email from someone,” 35 (12.7%), “no reminder needed,” 30
(10.9%), and least chosen response, “other” by 18 (6.5%) subjects.
41
Research Question 12.
Subjects were asked which breast self exam reminder system they have
used in the past. Fewer than half, 112 (40.7%), reported using only one
reminder system (see Figure 14).
120
100
80
Number of subjects
60
40
20
0
no response
0
1
2
3
4
Reminder systems
Figure 14. Bar graph of the number of reminder systems used in the past.
The most frequent response was “hanging reminder in bath” with 43
(15.6%). Subjects answering “none of the above” comprised the highest percent,
105 (38.2%). “Calling or emailing someone” as a reminder had the lowest
response with only 3 responses.
Research Question 13.
42
Number of breast self exam reminder systems currently in use are
illustrated below; using four reminder systems compiled the largest group at 131
(47.6%) (Figure 15).
140
120
100
80
Number of subjects
60
40
20
0
no response
0
1
2
3
4
Reminder systems
Figure 15. Bar graph of the number of reminder systems currently used.
The highest number of women currently using a reminder use the “day
period starts” as their BSE reminder. All subjects responded highest overall to
“none of the above,” 135 (49.1%) women responding. “No reminder needed”
generated a response from 43 (15.6%) women.
Research Question 14.
An analog scale was used to assess how important subjects viewed BSE
reminder systems for others. The mean was 75.1% (SD=26.9). Results were
43
highly skewed to the right, as most women perceived BSE as important (Figure
16).
70
60
50
40
Number of subjects
30
20
Std. Dev = 26.90
10
Mean = 75
N = 275.00
0
0
25
50
75
100
Importance of reminder systems
Figure 16. Histogram of percent importance of reminder systems for others.
Research Question 15.
Subjects were asked about importance of a BSE reminder system for
personal BSE performance. The mean was 64.6 (SD=32.9). Results are
skewed to the right, indicating personal value regarding BSE performance (see
Figure 17).
44
50
40
Number of subjects
30
20
10
Std. Dev = 32.98
Mean = 65
N = 275.00
0
0
25
50
75
100
Importance of reminder system
Figure 17. Histogram of percent importance of reminder systems for self.
Research Question 16.
Subjects were asked an open-ended question about what they consider to
be risk factors for breast cancer. Correct answers consisted of: family history,
obesity, age (>40), sedentary lifestyle, smoking, post-menopausal, late/no
childbearing, early menarche, late menopause, benign breast disease, diet high
in animal fat, hormone replacement therapy, and hypothyroidism. Of the 275
subjects, 64 (23.3%) did not respond to this question. Of those responding, 89
(32.4%) wrote one correct response, 38 (13.8%) wrote two correct responses, 18
(6.5%) wrote three correct responses, 8 (2.9%) wrote four correct responses and
1 (0.4%) subject was able to list more than four correct responses.
45
Research Question 17.
A Pearson’s chi square test for a relationship between level of education and
personal performance of BSE indicates a statistically significant difference;
χ2(10, N = 270) = 18.603, p=.046. Kendall’s correlation illustrates r = .163, p =
.003. 15.4% of subjects with a masters degree reported not performing BSE,
61.5% of masters degree perform BSE monthly. 23.1% perform BSE at a
frequency other than monthly; Associate, bachelor and technical degree holders
all had a performance rate greater than 58%; subjects with high school degrees
had performance rates of 50.3%.
Research Question 18.
Pearson’s chi square test for a relationship between belief that breast self
examination aides in breast lump detection and performance of BSE was
significant, χ2 (2, N = 264) = 10.821, p=.004. Kendall’s correlation illustrates
r=.189, p = .001. 58.2% of subjects believing BSE can detect a breast lump said
they perform BSE with some regularity.
Research Question 19.
Pearson’s chi square test was used to detect a relationship between the
number of breast self exam reminder systems subjects had heard of and BSE
performance was statistically significant, χ2 (8, N = 261) = 34.272, p=.000.
Correlation between the two variables was not significant at, r=-.088, p = .109.
Research Question 20.
Pearson chi square test was used to detect a relationship between
knowing someone who found a cancer by BSE and current personal use of a
46
BSE reminder system, χ2 ( 3, N = 227) = 1.374, p=.712. No relationship was
noted.
Research Question 21.
Pearson chi square test was used to test for a relationship between age
(by groups of 18 to 30, 31 to 60, and 61-88) and BSE performance,
χ2 (4, N = 268) = 30.920, p =.000. Subjects in the age range of 31 to 60 years
old were more likely to perform BSE.
Summary
A researcher designed survey was used to assess twenty-one research
questions. Data was analyzed using descriptive, correlational, ANOVA and chi
square tests for statistical significance.
Approximately 55% of women in this study report practicing BSE; 24% of
them report performing on a monthly basis. Majority of subjects reported that
they had heard of one BSE reminder system, approximately 40% report they
have used a reminder system in the past, and approximately 7% currently use a
reminder system.
The most popular reminder system heard of by subjects and used in the
past was “hanging reminder in bath,” whereas the most popular reminder
currently in use is the “day period starts.”
There was a statistically significant correlation between the level of
education and performance of breast self exams. The correlation illustrated that
with advanced education a higher rate of BSE performance was noted.
Performance of BSE and belief that BSE can help detect a lump also illustrated a
47
significant correlation. Age and BSE performance also illustrated a statistical
significance, although a weak correlation was made.
48
CHAPTER V
Discussion
This chapter presents a summary of the findings of this research,
discussion of the findings and conclusions that may be drawn from this research;
limitations as well as implications and recommendation for future research in this
area of study are discussed.
Findings
Research Question 1.
With the mean age of subjects in this study at 30.3 years of age, most
were 18 - 30 years old, which is younger than the age range affected most by
breast cancer. Breast cancer is the leading cause of death in women among the
ages of 40 - 59 years old (Coleman et al., 2003). Harras, Edwards, Blot and Reis
(1996) state that breast cancer risk increases as age increases, magnifying the
impact of breast cancer in women above age 65. Most study participants would
be regarded as having low risk at the present time.
Research Question 2.
The majority of subjects hold a high school degree as the highest level of
education; an expected finding since the average age of high school degree
holders was 20. This outcome is not surprising given the locations of survey
distribution; of the five survey sites, three were colleges. There were also a
number of older subjects who listed high school as there highest degree.
49
Ninety-nine participants hold degrees greater than high school; mean age
for bachelors degree attainment was 22, subjects holding a masters degree
average age was 42.
Research Question 3.
Women have a lifetime risk of breast cancer equal to 12.5% or 1 out of 8
women (Wei et al., 2000). Of 275 women in this sample, only one person had a
personal history of breast cancer. This is not an unexpected finding in examining
the age distribution of the study group, especially when considering that
approximately 85% of breast cancer cases occur at age 45 or older and are rare
before age 20 (Hall, 1992).
Research Question 4.
A majority of participants did not have a family history of breast cancer.
However, of the 36.4% reporting a family history of breast cancer, 4.4% had
more than one relative affected. Interestingly, the family member most reported
with a positive history of breast cancer was an aunt; second was a grandmother.
Only 15 subjects listed a first-degree relative as having breast cancer, none of
which were daughters.
Although a correlation between a positive family history of breast cancer
and personal performance of BSE would seem logical, subjects participating in
this study did not show more compliance with increased risk.
Hall (1992) summarized that subjects with a positive personal history of
breast cancer and a family history of breast cancer would have increased rates of
BSE performance themselves; no correlation was made by Hall (1992) or this
50
researcher. This study revealed only one subject with a personal history of
breast cancer; and there was no positive family history for that individual.
Research Question 5.
The number of subjects knowing a friend with breast cancer was greater
than those with a family history. Most subjects reporting a friend with breast
cancer were within the 18 - 30 age group; women in the 31 - 60 age group were
the second highest to know a friend with breast cancer. Gasalberti (2002) found
that older women have more friends and family members with breast cancer
history; what Gasalberti found seems more logical. The findings of this study
demonstrate that subjects in the younger age group knew more individuals with
breast cancer histories, this is likely influenced by the age distribution of subjects
as well as by the age of the friend, which was not assessed in this study.
Research Question 6.
More than 85% of subjects reported having been taught how to perform a
breast self exam. More 18 - 30 year old women reported not being taught BSE;
over 95% of women older than 30 had been taught. This population differs from
a study by Ludwick & Gaczkowski (2001) where only 25% of women in the 18 39 age group indicated learning cancer screening techniques.
Interestingly, one subject within the 61 - 90 category had never been
taught how to perform a BSE, and two subjects within the 31 - 60 age group had
never been taught. The number of subjects that had never been taught to
perform a BSE may relate to the level of healthcare they obtained or may be
51
based on the age of the individual subject; as younger women may not always be
exposed to BSE at an early age.
Research Question 7.
A large proportion of the study population reported being taught how to
perform a breast self examination; over 50% were instructed by a doctor. This is
similar to the study by Hall (1992), who reported that between 45 - 76% of
subjects had been taught by a physician. Hall (1992) noted a nurse taught only
5% of subjects. This study showed 18.9% being taught by a nurse, an obvious
increase. Hall (1992) also assessed the number of subjects being taught via an
educational pamphlet as 35 - 48%. This research did not specifically address
that option. Although, 9.5% of subjects answered the “other” category to specify
how they were taught exactly which strategy is unknown.
In a study by Leeseberg-Stamler, Thomas and Lafreniere (2000), the
majority of women less than fifty years old reported learning BSE from a
physician or an educational pamphlet. In this study, 90% of subjects were sixty
or younger; majority of which were taught BSE by a physician, which could be
compared proportionally to the study by Leeseberg-Stamler et al. (2000).
Research Question 8.
Evaluation of the rate of BSE performance in this study showed a
consistent comparison with rates found by Wei & Borum (2000). Wei & Borum
found subjects perform BSE on a monthly, every 2-4 months, once a year and
almost never basis. This finding closely outlines results illustrated in this
researchers study.
52
Lesseberg-Stamler, Thomas and Lafreniere (2000) also studied
performance of BSE and found that more than one time per month, monthly,
yearly, and occasionally were commonly reported frequencies. This study found
that 5% of subjects perform BSE more than one time per month, 24% perform
monthly, 5.5% perform yearly, and 28% of subjects stated they perform
occasionally closely outlining those gathered by Lesseberg-Stamler et al. (2000).
This study found a much lower incidence of occasional practice; this may be a
result of practice at different frequencies such as every other month, every third
and every forth month which were not addressed by Lesseberg-Stamler et al.
(2000).
Research Question 9.
A majority of subjects believed BSE will help in breast lump detection,
although, no statistically significant difference by age group was found. This
study duplicates a study by Ferris et al. (1996) when researchers found that
87.3% of their subjects thought of BSE as being either important or very
important. This finding was somewhat anticipated based on the study population
consisting of primarily well-educated subjects, with majority of subjects sampled
at colleges.
Research Question 10.
Approximately 35% of subjects knew someone who had located a breast
lump via breast self examination. Although there is a statistically significant
difference between younger (18-30 year old) and older (31-60 year old) women,
it would seem that the latter age group would have known more individuals with
53
breast cancer. The outcome may be influenced by the skewed age distribution of
the study population.
This researcher was unable to find published research addressing this
topic, therefore, no comparison is made.
Research Question 11.
This researcher found 95% of participants had heard of at least one of the
BSE prompts listed on the survey, or were able to think of one not listed that they
had heard of.
Ferris et al. (1996) states the main reason women do not perform BSE is
because of forgetfulness and that an increase in the frequency of BSE
performance was noted when a prompt was available to subjects. This study
found that majority of participants had heard of BSE reminders; an expected
finding due to the education level of the sample population.
Research Question 12.
More than 60% of subjects reported they had used at least one BSE
prompt in the past; a 35% decrease from the total number of subjects that know
of BSE reminder systems. This may be due to the age distribution of subjects
with majority of subjects in the 18 - 30 age group. This researcher did not find
published data that provided a comparison to the data in this study.
Research Question 13.
Twenty-one percent of subjects reported they use some form of a
reminder currently. Research by Hall (1992) concluded that effective education
of breast cancer and breast cancer prevention with BSE using a BSE reminder
54
will provide the stimulus needed for regular BSE performance. Influences of BSE
performance have been found to be family/medical history of breast cancer,
knowledge of breast cancer and screening behaviors (Rutledge, Barsevick,
Knobf and Bookbinder, 2001).
In this study, 55% of subjects reported performing BSE; therefore 38% of
subjects performing BSE use a reminder system.
Research Question 14.
Subjects reported they believe reminder systems are very important for
women to use. The mean percent was over 75%, therefore, this expresses that
women feel reminder systems are a necessary additive in the regular practice of
BSE. This supports the finding by Ferris et al. (1996) who found that women feel
BSE and BSE reminder systems are important or very important in performing
regular health maintenance.
Findings in this study were expected due to the education level of the
study population.
Research Question 15.
Subjects reported less need for BSE reminder systems for personal use
than the need of reminders for other women. The mean of 64.6% supports Hall
(1992) who concluded that all women need a reminder system in order to
regularly perform BSE. The age of subjects in this study may influence why
subjects felt BSE reminder systems are more necessary for others than
themselves; considering a large number of study participants were in the 18 - 30
age group.
55
Research Question 16.
A majority of subjects were able to list at least one risk factor for breast
cancer. Common answers provided include smoking, heredity, hormone
replacement therapies, obesity and age. A study by Hall (1992) nicely outlines
the risk factors for breast cancer. Various answers not considered risk factors
for breast cancer were also provided; such as alcohol consumption, tanning
beds, chemotherapy, red meat and UV light. Subjects may have provided these
answers out of association with various other cancers, although having no
relation to breast cancer risk.
Research Question 17.
Statistical significance was shown between education level of subjects
and performance of BSE. Subjects with an advanced education level showed an
increased BSE performance rate when compared to subjects reporting a high
school degree. It is possible that subjects with a higher education level have also
been educated more on preventive health measures. Strickland et al. (1997)
found that women who received more education on BSE screening and
prevention had a higher rate of frequency and compliance with breast self
examination; this same finding was also demonstrated by Gasalberti (2002).
Research Question 18.
Statistical significance was noted for subjects who believe BSE can help
detect a breast lump and personal performance of BSE. Subjects reporting they
do not believe BSE can help in breast lump detection were found to not perform
BSE. This was an expected finding and supports that belief and confidence in
56
this belief influences the practice of BSE as stated by the Health Belief Model
(Agars & McMurray, 1993).
Research Question 19.
A relationship exists between the practice of BSE and the number of
reminder systems subjects had heard of, however, a negative correlation.
Subjects reporting knowledge of three reminder systems had the highest BSE
performance rate; interestingly, subjects who knew four or five reminder systems
reported considerably lower BSE performance rates. This researcher expected
to see a relationship between an increasing number of BSE reminder systems
known and increased BSE performance; however, that relationship was not
found.
Research Question 20.
No relationship was observed for current use of breast self exam
reminders and familiarity with someone who has found a lump by breast selfexamination. Subjects reporting knowing someone who found a lump using BSE
reported using one, two or four BSE reminder systems. Interestingly, 100% of
subjects using three reminder systems reported not knowing anyone who found a
lump with BSE. This researcher expected to see a relationship between these
two variables; it would seem that knowing someone for whom BSE was
successful would prompt use of BSE and BSE reminder systems, however no
relationship was found to exist.
Research Question 21.
57
Age groups of subjects and performance of BSE was found to be highly
related. Subjects in the 31 - 60 year old group reported the highest BSE
performance rate; BSE practice declined with age somewhat. The younger
participants, 18 - 30 years old, reported the lowest frequency of BSE
performance, this was anticipated since BSE performance is not pushed as
essential for young women due to breast cancer risk being lower in younger age
groups.
A study by Hall (1992) addressed the practice of BSE as it correlated to
age. Although Hall states it was expected to see an increase in BSE
performance with age, only a weak correlation could be proven. In this study,
the skewed age distribution of the sample population may have influenced
results.
Implications for Healthcare
Even though healthcare professionals are currently in limbo about the
necessity of breast self examination, women need the opportunity to make their
own decision to perform or not perform BSE. Women need to understand the
current recommendations, what prompted the association to recommend a
particular screening regimen and the scientific basis for the change. It has been
suggested that self performance of BSE may be the only screening tool certain
patients are using or can afford. Concern that frequency of mammography will
increase with worry about breast lump discovery would not apply to this particular
population.
58
Reminder systems to perform breast self examination on a regular basis
may prove helpful for women. The most reported reminder system in this study
was a hanging shower reminder; however, women will use a reminder system
that best suits their needs. Breast self examination is known to increase a
woman’s knowledge about her breast, especially if performed on a regular basis.
When BSE is effective, it can create awareness to an area of future concern.
All healthcare practitioners should know what current recommendations
exist and, from what association; healthcare providers need to have adequate
information to answer women’s questions about need, benefits and drawbacks of
BSE practice. Practitioners should present a variety of BSE reminder systems to
the patient and encourage women to decide which BSE screening tool they to
perform.
Limitations
Subjects were solicited from five different locations, but overall distribution
was restricted. Specific outcomes are limited to female citizens of the
Southeastern Michigan area; however, findings may be generalized to other
femalepopulations as well. The majority of participants came from educational
settings; therefore, the age of participants was skewed.
Recommendations for Future Research
Breast self examination is controversial at the present time, with different
recommendations from various institutions. Nekhlyudov & Fletcher (2001)
stated, “For over 30 years many women have grown to accept BSE as a
screening tool for breast cancer. They have become comfortable with examining
59
their breasts and have gained a sense of control over their health care.”
Nekhlyudov & Fletcher (2001) suggested the need for additional research and
less aggressive change regarding dismissal of BSE.
This researcher believes there is still more work to be done before
deciding if BSE should be continued to be recommended, or if in time the
screening tool should no longer be encouraged. With the inconclusiveness of
findings related to practice of BSE looming over heads of all women, one more
element toward not engaging in self care is added. The problem with the latest
strategy is that BSE may be the only breast cancer screening tool used by or
available to certain populations. For these women and any woman who
expresses interest in an active roll in personal health maintenance, education,
experience and prompts on a monthly basis may be helpful in determining
normal from abnormal breast tissue.
Conclusions
This exploratory study collected data from 275 female subjects living in
rural southeastern Michigan. Strengths of this study are the age distribution of
the subjects (age range of 18 to 88 years old), number of subjects with a form of
personal experience with breast cancer (through a friend, family member or
personal), as well as the illustrated knowledge of BSE reminders and breast
cancer risk factors. Findings for subjects in this study corresponded well to that
of previous research, indicating women in rural southeastern Michigan are
comparable to other populations.
60
Conclusions drawn from this study include a statistically significant
correlation between the education level of subjects and the performance of
breast self examination. Other areas of statistical significance include belief in
and performance of breast self examinations, as well as age and BSE
performance.
61
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66
Appendix A
Name
Address
Nov. 20, 2003
Dear Mr./Ms. ________,
I am writing to thank you for discussing my current research project
entitled, “The Utilization of Breast Self Exam Reminder Systems in
Females Living in Rural Southeastern Michigan”. I would like you to know
that I am excited at the ability to be able to distribute my survey at Monroe
County Community College.
I would also like you to know that I am in the process of submitting
my proposal for my research to the Internal Review Board (IRB) at the
Medical College of Ohio. As part of the IRB process it is my responsibility
to obtain a signature from my contact at each location. This signature will
state to the IRB that I have discussed my project with you and that you
have agreed to allow me to distribute my survey at your institution.
Please understand, this signature merely allows me to submit my
project to the IRB. Once my project has been approved, detailed copies
of the project will be provided to you for review. If at this time you are no
longer interested in participating in my project please feel free to withdraw.
Please sign the blank at the bottom of this page to state your agreement
with my project. Thank you in advance for your participation.
Respectfully yours,
Janine Filipek
Physician Assistant Student
Medical College of Ohio
517-486-4183
Susan Batten, PhD, RN
Principle Investigator
Associate Professor
419-383-5859
I, __________________________, am in agreement with Janine Filipeks’
research project and consent to survey distribution at Monroe County
Community College.
Signed_________________________________
67
Appendix B
Bob Lips
204 E. Jefferson St.
Blissfield, MI 49228
January 15, 2003
Dear Mr. Lips,
Enclosed you will find a copy of the Institutional Review Board (IRB) approval for
my current research project that I previously discussed with you entitled, "The
Utilization of Breast Self Exam Reminder Systems in Females Living in Rural
Southeastern Michigan". Included you will also find a copy of the Medical
College of Ohio IRB approval sheet, as well as a copy of the participant letter and
survey which will be given to each willing participant.
Currently, I am planning on surveying participants at your site in the months of
February and March. I will be in contact with you to set up a formal date and
time for the research.
If you should have any further questions please feel free to contact me.
Thank you again for your participation,
Janine Filipek
Physician Assistant Student
Medical College of Ohio
517-486-4183
Susan Batten
Principle Investigator
Associate Professor
419-383-5859
68
Appendix C
The Utilization of Breast Self Exam Reminder Systems
in Females Living in Rural Southeastern Michigan.
IRB # 104560
Dear Participant,
November 16, 2003
We are asking you to take part in a study because you live or attend school in
Monroe and Lenawee County, Michigan. The study looks at ways women
remember to do breast self-exam, and will help healthcare providers learn if
reminders are helpful.
It will take you less than five minutes to answer the questions. After filling out the
survey, return it in the envelope. Please keep the pen as a "Thank you" for doing
the survey.
Taking part in this study is voluntary; you agree to participate by writing and
returning the survey. If you do not want to answer a question, leave it blank.
The information we receive from you is confidential. Other people will not know
how you responded because answers will be coded and entered into a computer
program. Completed surveys will be stored in a locked file for six years and then
destroyed. Reports of this study will not use information that identifies any
person.
If you have questions about the study, please call us. The study is "exempt
research" under the Medical College of Ohio Research and Grants
Administration guidelines for protecting people who take part in research.
Thank you for taking time to contribute to this project.
Janine Filipek
Physician Assistant Student
School of Allied Health
517-605-6725
517-486-4183
Susan Batten RN PhD
Associate Professor
School of Nursing
School of Allied Health
419-383-5859
69
Appendix D
70
Appendix E
71
Appendix F
72
Abstract
Objective: This exploratory study assessed breast self exam (BSE)
reminder systems utilized by women living in rural Southeastern Michigan. Age,
education, breast cancer experience, BSE performance, reminder systems, and
breast cancer risk was assessed.
Method: Permission was obtained from administration at all sites; prior
IRB approval was obtained. Surveys were distributed at five community-based
sites; a cover letter explained implied consent. Data was entered into SPSS and
recoded for analysis; exploratory and comparative statistics were obtained.
Results: Statistically significant relationships exist between education
level and BSE performance, as well as belief in BSE and BSE performance, and
age and BSE performance. Statistical significance exists for the number of
reminder systems subjects knew of and BSE performance, but no correlation
was noted.
Conclusion: Most women know of breast self exam reminder systems.
Although familiar with reminder systems, 85% of women reported being taught
BSE performance, but only 50% reported performing BSE.
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76
Appendix E
MedicalCollegeof Ohio
INSTITUTIONAL REVIEW BOARD
MEMORANDUM
)
Susan Batten, Ph.D.,RN.
Departmentof Schoolof Nursing
MCO
EricA.Schaub,
M.D.~~~
$~~""-~J-
0
Chair,InstitutionalReviewBoard
Researchand GrantsAdministration
DATE:
January2,2004
SUBJECT: IRB # 104560-The Utilization of BreastSelfExam Reminder SyStemsin Females
Living in Rural Southeastern
Michigan
~
~
---
It was detennined by tlie Ciiainnan ofllie ~titlitiol1al ReView Board ~at .this p~ject can be
desi~ated as exempted research (category # 2b). This review ~d~ppr?~~fuc1~~5s~e ~ey tool
submitted with the IRE applicatiQiI. The fequir~ent to 9otain
a sigried.co~~t!~ut!t~tiorifor
use
,
,
" ",
"
.
and disclosure ofpr9tected h~lth,info~~OI!
foI'Dl~
be~ waived ~ ~~re~~;~c~ !~de~ed
~ ~e
minimal ri~k and a signed .co~e:nt/auth<:>tii.ation document woul9 be ~~~y
iecoi;dJ~g
the subjeCt to
-""',
".
"'-'cr"",",
the data., It was deternrinedthat
this waiver for signed C9nsent/auth~1;iQn
fQt~'"~caija
disclosure, of
'
.,
c ,,",
, .' .'of"
,. '-'.'"'""',
.protectedhealth infoi1i1ition foI'Dlwill riot adverSelyaffec~ij1erigptS~d w~l,(~ 'Oftq~:p~cip~ts. The
Principal Investiga~Ot must pf9Vide ~ copy of the.'cov~ ie#er Wi~ th~~~tit
fiiPi tg ~)p#,ci'p~ts
prior
to pamcipation. Th~ full boar~ Will be notified i>fthis action at its ~eefu1g'on f)W51?9M:'~',\,
,', co';
,
,,:'
DESIGNATED as EXEMPTED RE;SEARCH on:
,
--
, .,
12/29/2003
";,,'~ !:"'~{:;:~'
:!
I
77
Ap~lendix F
PRINCIPAL
INVESnGATOR'S
ASSURANCE STATEMENT:
~-
Note:YouWIllnot beable10~
in ibisformfiumthispointfOfl'"ard.
-
I certify that the information pro\ided in this applicationis completeand correct.
I
I understandthat asPrincipal Investigator,I havethe ullin13teresponsipilityfor the conductof the research.the ethicalperfonnanceof the project,the
protec~onof the rigirtS andwelfare of humansubjects,theprjvacyof their protectedhealfuinformation, and smct adherenceto any stipulationsimposed
by theMCO-IRB.
I agreeto comply with all MCO IRB and Institutionalpoliciesandprocedures,aswell aswifu all applicableFederal,State,andlocal lawsregardingthe
protectionof human subjectsin researchandtheprotectionof the prjvacy oflbeir individually identifiable healthinfOlIl1ation.
I un4ersbn41hatthe approvalof dtis requestfor waiver of authorizationfor 1JSe
anddisclosureof Pill is contingentuponmy agreementto the following:
1) this wa,iyerof aufuorizationfor useor disclosureofl'Hr is soughtsolely for thepwposeof this particular researchproject and includes2JJ!ythePIn
as descn"bed
in the researchprot!)bOlapprovedby !heMOO IRB;
..
i 2) the pJQ~ed health infOmJationfor which waiver of authorizationCoruseor accessis being soughtis necessaryfor the researchpmposestatedm
the researcliprotocol;
3) a copyofMCO IRB apprQ~'31
of waiver of autborization"ill be ~ted
to theappropriatepersonnelrCSponSlole
for the source(s)from
I
which ~m is soughtprior to informationbeing used~m that so=e;
..,
4) asPrincipal fuvestigator I am re5DODSI"ble
fpr maintlliningall researchrelatedWolIl1ationassociatedwith this waiver, along WItha COPY
of
this
~iLosc
data
1.5)
q: \common \shared\forms\regcomp\irb
\rga3 23.doc
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