2015 Komen Central Valley COMMUNITY PROFILE

Transcription

SUSAN G. KOMEN®
CENTRAL VALLEY
Table of Contents
Table of Contents ........................................................................................................................ 2
Acknowledgments ...................................................................................................................... 3
Executive Summary .................................................................................................................... 4
Introduction to the Community Profile Report ........................................................................... 4
Quantitative Data: Measuring Breast Cancer Impact in Local Communities ............................. 5
Health System and Public Policy Analysis ................................................................................ 6
Qualitative Data: Ensuring Community Input ............................................................................ 6
Mission Action Plan ................................................................................................................... 7
Introduction ................................................................................................................................. 9
Affiliate History ......................................................................................................................... 9
Affiliate Organizational Structure ............................................................................................... 9
Affiliate Service Area ............................................................................................................... 10
Purpose of the Community Profile Report ............................................................................... 12
Quantitative Data: Measuring Breast Cancer Impact in Local Communities ...................... 13
Quantitative Data Report ......................................................................................................... 13
Additional Quantitative Data Exploration ................................................................................. 27
Selection of Target Communities ............................................................................................ 30
Health Systems and Public Policy Analysis ........................................................................... 32
Health Systems Analysis Data Sources .................................................................................. 32
Health Systems Overview ....................................................................................................... 32
Public Policy Overview ............................................................................................................ 41
Health Systems and Public Policy Analysis Findings .............................................................. 44
Qualitative Data: Ensuring Community Input ........................................................................ 45
Qualitative Data Sources and Methodology Overview ............................................................ 45
Qualitative Data Overview ....................................................................................................... 45
Qualitative Data Findings ........................................................................................................ 55
Mission Action Plan .................................................................................................................. 57
Breast Health and Breast Cancer Findings of the Target Communities .................................. 57
Mission Action Plan ................................................................................................................. 59
References................................................................................................................................. 61
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Susan G. Komen® Central Valley
Acknowledgments
Susan G. Komen® Central Valley dedicates this Community Profile Report to the memory
of Carolyn Montez Jorgensen.
The Community Profile Report could not have been accomplished without the exceptional work,
effort, time and commitment from many people involved in the process.
Susan G. Komen Central Valley would like to extend its deepest gratitude to the Board of
Directors and the following individuals who participated on the 2015 Community Profile
Team:
Rowena Chu, MS
Research Bioengineer
SRI International
Affiliate Grants Chair
Sharon Johnson AS, OT
Executive Director
Debbie Garrett, BS, MHA
Project Director; Every Woman Counts, Patient Navigation and Support Project
Clinical Education Coordination/Nurse Navigation
California Health Collaborative
Sothida Tan, MSW, MPH candidate
Intern, Master of Public Health Student
California State University, Fullerton
A special thank you to the following entities for their assistance with data collection and
analyses, as well as providing information included in this report:
 Centro La Familia
 West Fresno Family Resource Center
Community Profile Consultation services provided by:
Erin M. Kelly, MPH - 2014
Carol Kim, MPH - 2015
Report Prepared by:
Susan G Komen® Central Valley
PMB 551 5730 N. First Street, Suite 105
Fresno, CA 93710
(559) 229-4255
www.komencentralvalley.org
Contact: Sharon Johnson, Executive Director
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Executive Summary
Introduction to the Community Profile Report
The purpose of the 2015 Community Profile (CP) report is to provide information about the
current status of breast health/cancer in Central Valley. This report serves to inform Susan G.
Komen® Central Valley on breast health issues in the community through an informed process
that includes stakeholder input and community members’ participation. The data and
information collected in this report will guide the Affiliate on: inclusion efforts in the breast cancer
community; grant priorities; public policy efforts; outreach and education needs; and fundraising
and marketing goals. This final report outlines the status of breast health and services in
Central Valley and will serve as a road map for the Affiliate on future strategic and program
planning.
Since its incorporation in 1999, Komen Central Valley has seen a presence of dedicated women
and men in pursuit of Komen’s promise to save lives and end breast cancer forever. Carolyn
Montez Jorgensen, a breast cancer survivor, brought the first Susan G. Komen Race for the
Cure® to the greater Fresno community in 1999. Carolyn continued to serve as a dedicated and
selfless volunteer for Komen Central Valley until she lost her battle to a breast cancer in 2007.
Through events like the Race for the Cure®, Komen Central Valley has invested over $3.4
million dollars in local breast health and breast cancer awareness projects in Fresno County.
Up to 75 percent of net funds raised by the Affiliate stay in Fresno County while the remaining
income goes to the Susan G. Komen Research Programs supporting research; as the global
leader in the fight against breast cancer, Komen strives to identify and support the best science
around the world.
As well, through special outreach and education initiatives targeting populations at greatest risk;
the Affiliate has been the constant presence for the Central Valley service area regarding the
dialogue on reducing breast cancer disparities with key community leaders. The Affiliate has
joined the six California Komen Affiliates in the Susan G. Komen® Circle of Promise AfricanAmerican Initiative, the first initiative of its kind in Susan G. Komen history. With the assistance
of bilingual volunteers, Komen Central Valley provides educational outreach to Hispanic/Latino,
Punjab and Hmong communities. Additionally, the Affiliate is one of seven Affiliates that
comprise the California Public Policy Collaborative that advocates on behalf of federal and state
key legislative issues that impact breast health care services and access to care.
Through a rigorous review process, breast health projects are selected by an independent Grant
Review Panel that demonstrate great potential in making a substantial impact on the breast
health needs of the Central Valley service area, specifically for the medically underserved and
uninsured. And through this grant process, the Komen Central Valley is the only nonprofit in
Fresno County to fund life-saving projects addressing breast education, screening and
treatment.
The Affiliate Board of Directors is committed to enhancing the public standing of the Affiliate by
serving as ambassadors and advocates in the community; ensuring a healthy and accurate
public image; designating spokespersons and sending them to Affiliate Media Training; and,
taking every opportunity to inform the public about the Komen organization.
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The Affiliate Board of Directors consists of volunteer board members with delegated and
specific job descriptions outlining general responsibilities of the position, as well as duties as an
officer and/or committee member. The Affiliate is staffed with an Executive Director and a part
time Administrative Assistant. The organization also relies on the generosity of more than 200
registered volunteers who provide nearly 1,400 hours, and an estimated $28,000 of volunteer
work every year.
Fresno County is in the center of the expansive San Joaquin Valley in the Central Valley of
California. The city is the cultural and economic center of the Fresno-Clovis metropolitan area.
The county seat is Fresno. The Komen Central Valley service area has a slightly larger White
female population than the US as a whole, a substantially smaller Black/African-American
female population, a substantially larger Asian and Pacific Islander (API) female population, a
slightly larger American Indian and Alaska Native (AIAN) female population, and a substantially
larger Hispanic/Latina female population.
Quantitative Data: Measuring Breast Cancer Impact in Local Communities
The quantitative data collected in this report were derived from several statistical sources
including the California Cancer Registry (CCR); California Health Interview Survey (CHIS);
Centers for Disease Control and Prevention (CDC); Health Resources and Services
Administration (HRSA); North American Association of Central Cancer Registries (NAACCR);
and the U.S. Census Bureau. The combined data presents evidence on breast cancer
incidences, late-stage diagnosis, death rates, mammography screening behavior,
demographics, and socioeconomic indicators within the region of Central Valley, California.
Thorough review of the data were conducted to analyze breast health disparities and to
determine the target populations and priorities for Komen Central Valley’s programmatic efforts.
Based upon complete analysis of the statistics, the Affiliate selected four Medical Service Study
Areas (MSSA) or medically underserved areas, as classified by the California Office of
Statewide Planning and Development for further exploration (OSPD, 2014). These areas
include: Hispanic/Latina women in MSSA 25, Firebaugh, Mendota, and MSSA 26, Cantua
Creek, San Joaquin, Tranquility; all women in MSSA 32, Orange Cove, Parlier, Reedley, Squaw
Valley, Tivy Valley, Wonder Valley; Black/African-American women in MSSA 35e, Fresno
South, West, and 35c, Fresno West Central.
In MSSA 25, over 90 percent of the population is Hispanic/Latino and 40.0 percent of the
community is linguistically isolated. Similarly in MSSA 26, 91.3 percent of the population is
Hispanic/Latino. In MSSA 25 and 26, 31.8 percent and 33.0 percent of the residents are also
without health insurance. Both MSSA 25 and 26 have poorer socioeconomic indicators
compared to other areas in Fresno County, which are associated with health disparities and
reduced access to care.
In MSSA 32, 75.0 percent of the population is Hispanic/Latino in a predominantly rural area,
with 24.2 percent of residents who are without health insurance. Additionally, 40.5 percent of
breast cancer cases in this area were advanced stage diagnoses.
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In MSSA 35e and 35c, 12.6 percent and 8.9 percent are Black/African-American with
approximately 25 percent who are uninsured. Black/African-American women in Fresno County
have the highest death and late-stage breast cancer rates of all ethnicities, with an increasing
trend for late-stage breast cancer while the trend is reversing for all other ethnicities. Further,
this area has also been identified as having an elevated percentage of advanced breast cancer
cases. As such, these target groups will be the focus of the Affiliate’s efforts over the next four
years.
Health System and Public Policy Analysis
The Affiliate utilizes the breast continuum of care model as a framework to identify the gaps and
barriers women encounter as they navigate through screenings, diagnostic testing, treatment,
and follow up care. A comprehensive inventory of health care services in the four target
communities highlights the needs. Fresno County is an area that is designated as a medically
underserved area and a primary care shortage area (OSPD, 2014). The majority of breast
health services are centralized in Fresno but services are lacking in rural areas of the county.
MSSA 25 and 26 have the most limited services with only three community health centers and a
few Every Woman Counts (EWC) providers. The distance to the nearest breast diagnostic and
treatment center is over 45 miles away. However, the area is also less densely populated
compared to other regions in the county.
MSSA 32 also has limited breast health services with four community health centers, nine EWC
providers, and one breast diagnostic center. There is a hospital for breast treatment services
but it is located 30 to 40 minutes away. MSSA 35c and 35e have the most available services
including three Affiliate grantees, one free clinic, 12 community health centers, 17 EWC
providers, and one breast diagnostic center. There is no breast cancer treatment center in the
area. While there are more breast health services available in MSSA 35, the qualitative data
will provide more information about access to care. The Affiliate will need to explore
opportunities with existing and new partnerships to bring services to the community and to
ensure residents have access to available services in the target communities.
In terms of health policy, California has made great strides under the Affordable Care Act and
the expansion of coverage through Medi-Cal and Covered California. Yet many populations
remain uninsured and are lagging behind other ethnic groups. Additionally, there will be women
who will be without health coverage due to residential and/or financial status. The Affiliate will
need to ensure that programs for no and low-cost breast health services are available and will
need to work closely with its partners to ensure women are aware and have access to EWC
providers in the region.
Qualitative Data: Ensuring Community Input
The qualitative data collection methods for Komen Central Valley’s four target communities
include using key informant interviews, focus groups and a document review to explore
important gaps; challenges or barriers to breast health information and care; access to and
utilization of breast health services; and attitudes, beliefs and behaviors around breast cancer
and breast health services. Questions for the key informant interview guide and focus group
guide were based on questions that came out of a careful review of the quantitative data and
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health systems and public policy analysis The data collection tools also included questions
about opportunities for Komen to develop and strengthen outreach efforts, as well as
partnership development and education/health promotion.
Additionally, a document review of the Central Valley service area, specifically focusing on
MSSA 25 and 26 in the Hispanic/Latino community, provided additional information to aid in
supporting other methods conducted to better understand the needs and barriers of this
community that could not otherwise be observed and/or gathered. The following overview
provides the rationale and details of each qualitative data collection methods and ethics applied
for each of the target communities: 1) MSSA 25, Hispanic/Latina women; 2) MSSA 26,
Hispanic/Latina women; 3) MSSA 32, all women; and 4) MSSA 35, Black/African-American
women.
Having gathered information from the community through key informant interviews, focus
groups and reviewing documents, the Affiliate found some common themes across all target
communities and data sources. Most particularly that there is/are:
 A need for ongoing education – general breast health, screening, and treatment
information;
 An additional burden of cancer – financial costs, need for social support
 Breast health resources are available, but not accessible to all
 Continued need for early detection services
 Opportunities for working with faith based organizations, community leaders, and
community centers
 A disconnect between education and behavior – especially in regard to pain and fear as
a barrier to screening
 Opportunities for partnership in outreach and education and bridging relationships with
key leaders and organizations in all communities
Mission Action Plan
The Mission Committee engaged in a strategic process to develop an action plan covering April
1, 2015 to March 31, 2019. Key findings from the quantitative, qualitative, health systems and
policy analysis were all considered in the development of the following Mission Action Plan for
Komen Central Valley to address by March 31, 2019:
HISPANIC/LATINA WOMEN IN MSSA 25 AND 26
Priority Need/Problem: From health system analysis and qualitative data there is a lack of
breast health services and information across the continuum of care.
Priority Statement: Increase knowledge and awareness of available breast cancer screening
services that is culturally and linguistically appropriate for Hispanic/Latina women in MSSA 25
and 26.
Objective 1: From FY16- FY19, Komen Central Valley will attend at least four
cultural/community events in MSSA 25 and 26 reaching 500 Hispanic/Latina women with
information about available breast cancer screening services.
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Objective 2: In the FY18, Community Grant Request for Application, programs that link
and/or provide screening services for Hispanic/Latina women in MSSA25 and 26 will be
a funding priority.
Objective 3: By 2019, Komen Central Valley will recruit and train six to eight breast
health advocates who are bilingual, bicultural, and/or age-appropriate in Spanish to
provide breast cancer and breast health education and information on available
programs/services to Hispanic/Latina women in MSSA 25 and 26.
ALL WOMEN IN MSSA 32
Priority Need/Problem: From the health system analysis and qualitative data, there is a
substantial gap in breast services within the continuum of care, specifically in breast health
diagnostics and treatment.
Priority Statement: Build relationships with organizations/agencies to better understand the
gaps in service and how to address them appropriately.
Objective 1: By 2017, Komen Central Valley will develop three new collaborative
relationships with organizations that serve women residing MSSA 32 to understand and
learn more about how to address their breast health needs and barriers to access.
Objective 2: In the FY17, Komen Central Valley will give priority (or add weighted value
during review process) to grant applications that propose to provide breast health and
breast cancer-specific patient navigation and/or aims to reduce access barriers, such as
transportation barriers for their breast cancer diagnostic and treatment needs.
BLACK/AFRICAN-AMERICAN WOMEN IN MSSA 35
Priority Need/Problem: From the qualitative data, there is a lack of awareness of available
programs and services to help reduce barriers to accessing breast health care services.
Priority Statement: Partner with organizations, agencies, and/or professional associations to
help address the diverse needs and barriers to motivate for Black/African-American women in
Central Valley to obtain breast health care services.
Objective 1: By 2017, Komen Central Valley will build three to five strong local
Black/African-American partnerships that are effective, sustainable, and visible in the
community to ensure engagement in activities such as breast health outreach and
education, access to care, and advocacy efforts.
cultural/community events in MSSA 35 reaching 1,000 Black/African-American women
with information about available breast cancer screening services.
Objective 3: In the FY17 Community Grant Request for Application, programs that
address health-care decision-making to improve access to screening services for
Black/African-American women in MSSA35 will be a funding priority.
Disclaimer: Comprehensive data for the Executive Summary can be found in the 2015 Susan
G. Komen® Central Valley Community Profile Report.
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Introduction
Affiliate History
Since its incorporation in 1999, Susan G. Komen® Central Valley has seen a presence of
dedicated women and men in pursuit of Komen’s promise to save lives and end breast cancer
forever. Carolyn Montez Jorgensen, a breast cancer survivor, brought the first Susan G. Komen
Race for the Cure® to the greater Fresno community in 1999. Carolyn continued to serve as a
dedicated and selfless volunteer for Komen Central Valley until she lost her battle to a breast
cancer in 2007.
Through events like the Susan G. Komen Central Valley Race for the Cure®, the Affiliate has
invested over $3.4 million dollars in local breast health and breast cancer awareness projects in
Fresno County. Up to 75 percent of funds raised by the Affiliate stay in Fresno County while the
remaining income goes to the Susan G. Komen Research Programs supporting research; as
the global leader in the fight against breast cancer, Komen strives to identify and support the
best science around the world.
Through special outreach and education initiatives targeting populations at greatest risk; the
Affiliate has been the constant presence for the Central Valley service area regarding the
dialogue on reducing breast cancer disparities with key community leaders. The Affiliate has
joined the six California Komen Affiliates in the Susan G. Komen® Circle of Promise AfricanAmerican Initiative, the first initiative of its kind in Susan G. Komen history. With the assistance
of bilingual volunteers, Komen Central Valley provides educational outreach to the Hispanic,
Punjab and Hmong communities.
Through a rigorous review process, these breast health projects are selected by an independent
Grant Review Panel that demonstrate great potential in making an impact on the breast health
needs of the Central Valley service area, specifically for the medically underserved and
uninsured. And through this grant process, Komen Central Valley is the only nonprofit in Fresno
County to fund life-saving projects addressing breast education, screening and treatment.
Komen Central Valley also addresses communication disparity within the deaf and hard of
hearing community.
The Affiliate is one of seven Affiliates that comprise the California Public Policy Collaborative
that advocates on behalf of federal and state key legislative issues that impact breast health
care services and access to care. For information about the Affiliate’s programs and services
please contact the office at (559) 229-4255 or visit www.komencentralvalley.org.
Affiliate Organizational Structure
The Affiliate Board of Directors is committed to enhancing the public standing of the Affiliate by:
 Serving as ambassadors and advocates in the community;
 Ensuring a healthy and accurate public image;
 Designating spokespersons and sending them to Affiliate Media Training; and,
 Taking every opportunity to inform the public about the Komen organization.
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The Affiliate Board of Directors (Figure 1.1) consists of volunteer board members and advisors
with delegated and specific job descriptions outlining general responsibilities of the position, as
well as duties as an officer and/or committee member. The Affiliate is staffed with an Executive
Director and a part time Administrative Assistant. The organization also relies on the generosity
of more than 200 registered volunteers who provide nearly 1,400 hours, and an estimated
$28,000 of volunteer work every year.
Figure 1.1. Susan G. Komen Central Valley organizational chart
Affiliate Service Area
Komen Affiliates are charged with furthering the promise of Susan G. Komen in a specific
service area (Figure 1.2). A service area is the specific geographic region, as defined in the
Affiliation Agreement, where the Affiliate conducts its programs, activities, fundraising, grants
and operations. Affiliates are required to conduct these activities exclusively within the
boundaries of the service area, taking care to cover the entire service area.
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Figure 1.2. Susan G. Komen® Central Valley service area
Fresno County is in the center of the expansive San Joaquin Valley in the Central Valley of
California. The city is the cultural and economic center of the Fresno-Clovis metropolitan area.
The county seat is Fresno. The Komen Central Valley service area has a slightly larger White
female population than the US as a whole, a substantially smaller Black/African-American
female population, a substantially larger Asian and Pacific Islander (API) female population, a
slightly larger American Indian and Alaska Native (AIAN) female population, and a substantially
larger Hispanic/Latina female population.
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The Affiliate’s female population is slightly younger than that of the US as a whole. The
Affiliate’s education and income levels are also lower than those of the US as a whole. The
percentage of unemployed is substantially larger in the Affiliate service area. The Affiliate
service area has a substantially larger percentage of people who are foreign born and a
substantially larger percentage of people who are linguistically isolated. There is a substantially
smaller percentage of people living in rural areas, a substantially larger percentage of people
without health insurance, and a slightly smaller percentage of people living in medically
underserved areas.
Fresno County is the tenth most populous county in California with an estimated population of
954,700, and the sixth largest in size with an area of 6,017.4 square miles. Fresno is the
second largest inland city in the state, after San Jose. Fresno city has an estimated population
of 505,479 as of January 2010, making it the fifth-largest city in California.
Purpose of the Community Profile Report
The purpose of the Community Profile is to identify the areas of greatest needs and gaps in
breast health services and strategically guide the Affiliate’s programs and initiatives to be
focused and impactful. This thorough needs assessment process enables the Affiliate to
understand the populations to be served, the access, the location and the barriers to services
and any other gaps that might be evident.
The identified gaps and program priorities derived from the Community Profile will be used as
part of the Affiliate’s Strategic Plan to determine funding priorities of Komen programs through
education and outreach strategies, guidance on granting priorities, and many other events and
projects during the next several years.
This information can also be used by other community organizations for the following purposes:
 Program planning and service delivery
 Grant writing
 Opportunities for expanded referrals and inter-agency collaborations
In summary, the Community Profile not only serves to inform the Affiliate, but the entire breast
health/cancer community in Central Valley. The final report provides a snapshot of breast
health/cancer in the Affiliate’s service area, and serves as a road map for future strategic and
program planning. It will be shared with all community partners and health care systems and
made available online through the Affiliate website.
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Quantitative Data: Measuring Breast Cancer Impact in
Local Communities
Quantitative Data Report
Introduction
The purpose of the quantitative data report for Susan G. Komen® Central Valley is to combine
evidence from many credible sources and use the data to identify the highest priority areas for
evidence-based breast cancer programs.
The data provided in the report are used to identify priorities within the Affiliate’s service area
based on estimates of how long it would take an area to achieve Healthy People 2020
objectives for breast cancer late-stage diagnosis and death rates
(http://www.healthypeople.gov/2020/default.aspx).
The following is a summary of Komen® Central Valley’s Quantitative Data Report. For a full
report please contact the Affiliate.
Breast Cancer Statistics
Incidence rates
The breast cancer incidence rate shows the frequency of new cases of breast cancer among
women living in an area during a certain time period (Table 2.1). Incidence rates may be
calculated for all women or for specific groups of women (e.g. for Asian/Pacific Islander women
living in the area).
The female breast cancer incidence rate is calculated as the number of females in an area who
were diagnosed with breast cancer divided by the total number of females living in that area.
Incidence rates are usually expressed in terms of 100,000 people. For example, suppose there
are 50,000 females living in an area and 60 of them are diagnosed with breast cancer during a
certain time period. Sixty out of 50,000 is the same as 120 out of 100,000. So the female breast
cancer incidence rate would be reported as 120 per 100,000 for that time period.
When comparing breast cancer rates for an area where many older people live to rates for an
area where younger people live, it’s hard to know whether the differences are due to age or
whether other factors might also be involved. To account for age, breast cancer rates are
usually adjusted to a common standard age distribution. Using age-adjusted rates makes it
possible to spot differences in breast cancer rates caused by factors other than differences in
age between groups of women.
To show trends (changes over time) in cancer incidence, data for the annual percent change in
the incidence rate over a five-year period were included in the report. The annual percent
change is the average year-to-year change of the incidence rate. It may be either a positive or
negative number.
 A negative value means that the rates are getting lower.
 A positive value means that the rates are getting higher.
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
A positive value (rates getting higher) may seem undesirable—and it generally is.
However, it’s important to remember that an increase in breast cancer incidence could
also mean that more breast cancers are being found because more women are getting
mammograms. So higher rates don’t necessarily mean that there has been an increase
in the occurrence of breast cancer.
Death rates
The breast cancer death rate shows the frequency of death from breast cancer among women
living in a given area during a certain time period (Table 2.1). Like incidence rates, death rates
may be calculated for all women or for specific groups of women (e.g. Black/African-American
women).
The death rate is calculated as the number of women from a particular geographic area who
died from breast cancer divided by the total number of women living in that area. Death rates
are shown in terms of 100,000 women and adjusted for age.
Data are included for the annual percent change in the death rate over a five-year period.
The meanings of these data are the same as for incidence rates, with one exception. Changes
in screening don’t affect death rates in the way that they affect incidence rates. So a negative
value, which means that death rates are getting lower, is always desirable. A positive value,
which means that death rates are getting higher, is always undesirable.
Late-stage incidence rates
For this report, late-stage breast cancer is defined as regional or distant stage using the
Surveillance, Epidemiology and End Results (SEER) Summary Stage definitions
(http://seer.cancer.gov/tools/ssm/). State and national reporting usually uses the SEER
Summary Stage. It provides a consistent set of definitions of stages for historical comparisons.
The late-stage breast cancer incidence rate is calculated as the number of women with regional
or distant breast cancer in a particular geographic area divided by the number of women living
in that area (Table 2.1). Late-stage incidence rates are shown in terms of 100,000 women and
adjusted for age.
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Table 2.1. Female breast cancer incidence rates and trends,
death rates and trends, and late-stage rates and trends
Incidence Rates and Trends
Female
Population
(Annual
Average)
# of
New
Cases
(Annual
Average)
Ageadjusted
Rate/
100,000
154,540,194
198,602
122.1
.
-
18,413,837
Death Rates and Trends
Late-stage Rates and Trends
# of
New
Cases
(Annual
Average)
Ageadjusted
Rate/
100,000
-1.9%
70,218
43.7
-1.2%
20.6*
-
-
41.0*
-
4,251
21.9
-2.1%
8,287
43.5
-1.7%
1.8%
86
20.0
-1.8%
169
40.6
-1.3%
116.8
1.9%
78
21.5
NA
147
42.1
-1.5%
22
104.4
-1.3%
5
21.9
NA
9
44.3
6.0%
14,142
4
52.3
3.4%
SN
SN
SN
SN
SN
SN
48,846
27
71.2
1.4%
4
9.5
NA
10
25.4
-0.7%
Non-Hispanic/ Latina
235,903
346
122.5
2.3%
67
21.6
NA
118
42.8
-1.0%
Hispanic/ Latina
218,797
120
88.0
3.7%
19
14.9
NA
51
35.9
0.9%
# of
Deaths
(Annual
Average)
Ageadjusted
Rate/
100,000
-0.2%
40,736
22.6
-
-
-
23,266
122.0
-0.6%
454,700
466
111.8
362,683
408
Black/African-American
29,029
American Indian/Alaska
Population Group
US
HP2020
California
Komen Central Valley
Service Area (Fresno
County – CA)
White
Trend
(Annual
Percent
Change)
Trend
(Annual
Percent
Change)
Trend
(Annual
Percent
Change)
Native (AIAN)
Asian Pacific Islander
(API)
*Target as of the writing of this report.
NA – data not available
SN – data suppressed due to small numbers (15 cases or fewer for the 5-year data period).
Data are for years 2006-2010.
Rates are in cases or deaths per 100,000.
Age-adjusted rates are adjusted to the 2000 US standard population.
Source of incidence and late-stage data: North American Association of Central Cancer Registries (NAACCR) –
Cancer in North America (CINA) Deluxe Analytic File.
Source of death rate data: Centers for Disease Control and Prevention (CDC) – National Center for Health Statistics
(NCHS) mortality data in SEER*Stat.
Source of death trend data: National Cancer Institute (NCI)/CDC State Cancer Profiles.
Incidence rates and trends summary
Overall, the breast cancer incidence rate in the Komen Central Valley service area was lower
than that observed in the US as a whole and the incidence trend was higher than the US as a
whole. The incidence rate of the Affiliate service area was significantly lower than that observed
for the State of California and the incidence trend was not significantly different than the State of
California.
For the United States, breast cancer incidence in Blacks/African-Americans is lower than in
Whites overall. The most recent estimated breast cancer incidence rates for APIs and AIANs
were lower than for Non-Hispanic Whites and Blacks/African-Americans. The most recent
estimated incidence rates for Hispanics/Latinas were lower than for Non-Hispanic Whites and
Blacks/African-Americans. For the Affiliate service area as a whole, the incidence rate was
lower among Blacks/African-Americans than Whites, lower among APIs than Whites, and lower
among AIANs than Whites. The incidence rate among Hispanics/Latinas was lower than among
Non-Hispanics/Latinas.
15 | P a g e
It’s important to remember that an increase in breast cancer incidence could also mean that
more breast cancers are being found because more women are getting mammograms.
Death rates and trends
Overall, the breast cancer death rate in the Komen Central Valley service area was slightly
lower than that observed in the US as a whole and the death rate trend was higher than the US
as a whole. The death rate of the Affiliate service area was not significantly different than that
observed for the State of California.
For the United States, breast cancer death rates in Blacks/African-Americans are substantially
higher than in Whites overall. The most recent estimated breast cancer death rates for APIs
and AIANs were lower than for Non-Hispanic Whites and Blacks/African-Americans. The most
recent estimated death rates for Hispanics/Latinas were lower than for Non-Hispanic Whites
and Blacks/African-Americans. For the Affiliate service area as a whole, the death rate was
about the same among Blacks/African-Americans and Whites and lower among APIs than
Whites. There were not enough data available within the Affiliate service area to report on
AIANs so comparisons cannot be made for this racial group. The death rate among
Hispanics/Latinas was lower than among Non-Hispanics/Latinas.
Late-stage incidence rates and trends
Overall, the breast cancer late-stage incidence rate and trend in the Komen Central Valley
service area were slightly lower than that observed in the US as a whole. The late-stage
incidence rate and trend of the Affiliate service area were not significantly different than that
observed for the State of California.
For the United States, late-stage incidence rates in Blacks/African-Americans are higher than
among Whites. Hispanics/Latinas tend to be diagnosed with late-stage breast cancers more
often than Whites. For the Affiliate service area as a whole, the late-stage incidence rate was
slightly higher among Blacks/African-Americans than Whites and lower among APIs than
Whites. There were not enough data available within the Affiliate service area to report on
AIANs so comparisons cannot be made for this racial group. The late-stage incidence rate
among Hispanics/Latinas was lower than among Non-Hispanics/Latinas.
Mammography Screening
Getting regular screening mammograms (and treatment if diagnosed) lowers the risk of dying
from breast cancer. Screening mammography can find breast cancer early, when the chances
of survival are highest. Table 2.2 shows some screening recommendations among major
organizations for women at average risk.
16 | P a g e
Table 2.2. Breast cancer screening recommendations
for women at average risk
American Cancer
Society
Mammography every
year starting
at age 40
National Cancer
Institute
Mammography every 12 years starting
at age 40
National
Comprehensive
Cancer Network
Mammography every
year starting
at age 40
US Preventive
Services
Task Force
Informed decisionmaking
with a health care
provider
ages 40-49
Mammography every
two years
ages 50-74
Because having mammograms lowers the chances of dying from breast cancer, it’s important to
know whether women are having mammograms when they should. This information can be
used to identify groups of women who should be screened who need help in meeting the current
recommendations for screening mammography. The Centers for Disease Control and
Prevention’s (CDC) Behavioral Risk Factors Surveillance System (BRFSS) collected the data
on mammograms that are used in this report. The data come from interviews with women age
50 to 74 from across the United States. During the interviews, each woman was asked how
long it has been since she has had a mammogram. BRFSS is the best and most widely used
source available for information on mammography usage among women in the United States,
although it does not collect data in alignment with Komen breast self-awareness messaging (i.e.
from women age 40 and older). The proportions in Table 2.3 are based on the number of
women age 50 to 74 who reported in 2012 having had a mammogram in the last two years.
The data have been weighted to account for differences between the women who were
interviewed and all the women in the area. For example, if 20.0 percent of the women
interviewed are Latina, but only 10.0 percent of the total women in the area are Latina,
weighting is used to account for this difference.
The report uses the mammography screening proportion to show whether the women in an area
are getting screening mammograms when they should. Mammography screening proportion is
calculated from two pieces of information:
 The number of women living in an area whom the BRFSS determines should have
mammograms (i.e. women age 50 to 74).
 The number of these women who actually had a mammogram during the past two years.
The number of women who had a mammogram is divided by the number who should have had
one. For example, if there are 500 women in an area who should have had mammograms and
250 of those women actually had a mammogram in the past two years, the mammography
screening proportion is 50.0 percent.
Because the screening proportions come from samples of women in an area and are not exact,
Table 2.3 includes confidence intervals. A confidence interval is a range of values that gives an
17 | P a g e
idea of how uncertain a value may be. It’s shown as two numbers—a lower value and a higher
one. It is very unlikely that the true rate is less than the lower value or more than the higher
value.
For example, if screening proportion was reported as 50.0 percent, with a confidence interval of
35.0 to 65.0 percent, the real rate might not be exactly 50.0 percent, but it’s very unlikely that it’s
less than 35.0 or more than 65.0 percent.
In general, screening proportions at the county level have fairly wide confidence intervals. The
confidence interval should always be considered before concluding that the screening
proportion in one county is higher or lower than that in another county.
Table 2.3. Proportion of women ages 50-74 with screening mammography
in the last two years, self-report
Population Group
US
# of Women
Interviewed
(Sample Size)
# w/ SelfReported
Mammogram
Proportion
Screened
(Weighted
Average)
Confidence
Interval of
Proportion
Screened
174,796
133,399
77.5%
77.2%-77.7%
4,347
3,512
81.8%
80.3%-83.2%
93
73
84.6%
72.1%-92.1%
White
78
60
80.4%
65.2%-90.0%
Black/African-American
SN
SN
SN
SN
AIAN
SN
SN
SN
SN
API
SN
SN
SN
SN
Hispanic/ Latina
18
14
84.5%
49.5%-96.8%
Non-Hispanic/ Latina
74
58
84.6%
72.0%-92.2%
California
Komen Central Valley Service Area (Fresno
County – CA)
SN – data suppressed due to small numbers (fewer than 10 samples).
Data are for 2012.
Source: CDC – Behavioral Risk Factor Surveillance System (BRFSS).
Breast cancer screening proportions summary
The breast cancer screening proportion in the Komen Central Valley service area was not
significantly different than that observed in the US as a whole. The screening proportion of the
Affiliate service area was not significantly different than the State of California.
For the United States, breast cancer screening proportions among Blacks/African-Americans
are similar to those among Whites overall. APIs have somewhat lower screening proportions
than Whites and Blacks/African-Americans. Although data are limited, screening proportions
among AIANs are similar to those among Whites. Screening proportions among
Hispanics/Latinas are similar to those among Non-Hispanic Whites and Blacks/AfricanAmericans. There were not enough data available within the Affiliate service area to report on
Blacks/African-Americans, APIs, and AIANs so comparisons cannot be made for these racial
groups. The screening proportion among Hispanics/Latinas was not significantly different than
among Non-Hispanics/Latinas.
18 | P a g e
Population Characteristics
The report includes basic information about the women in each area (demographic measures)
and about factors like education, income, and unemployment (socioeconomic measures) in the
areas where they live (Tables 2.4 and 2.5). Demographic and socioeconomic data can be used
to identify which groups of women are most in need of help and to figure out the best ways to
help them.
It is important to note that the report uses the race and ethnicity categories used by the US
Census Bureau, and that race and ethnicity are separate and independent categories. This
means that everyone is classified as both a member of one of the four race groups as well as
either Hispanic/Latina or Non-Hispanic/Latina.
The demographic and socioeconomic data in this report are the most recent data available for
US counties. All the data are shown as percentages. However, the percentages weren’t all
calculated in the same way.
 The race, ethnicity, and age data are based on the total female population in the area
(e.g. the percent of females over the age of 40).
 The socioeconomic data are based on all the people in the area, not just women.
 Income, education and unemployment data don’t include children. They’re based on
people age 15 and older for income and unemployment and age 25 and older for
education.
 The data on the use of English, called “linguistic isolation”, are based on the total
number of households in the area. The Census Bureau defines a linguistically isolated
household as one in which all the adults have difficulty with English.
19 | P a g e
Table 2.4. Population characteristics – demographics
Population Group
White
Black
/AfricanAmerican
AIAN
API
NonHispanic
/Latina
Hispanic
/Latina
Female
Age
40 Plus
Female
Age
50 Plus
Female
Age
65 Plus
US
78.8 %
14.1 %
1.4 %
5.8 %
83.8 %
16.2 %
48.3 %
34.5 %
14.8 %
California
75.1 %
7.3 %
2.0 %
15.6 %
62.5 %
37.5 %
45.5 %
31.5 %
13.1 %
Komen Central Valley Service
Area (Fresno County –CA)
79.0 %
6.4 %
3.4 %
11.1 %
50.1 %
49.9 %
39.9 %
27.7 %
11.5 %
25 - Firebaugh/ Mendota
56.2%
1.2%
1.8%
1.0%
7.4%
92.6%
30.8%
18.5%
6.3%
26 - Cantua Creek/ San Joaquin/
Tranquility
52.4%
1.0%
1.6%
1.2%
8.7%
91.3%
29.5%
18.5%
5.7%
27 - Coalinga
57.2%
10.0%
1.8%
3.3%
48.4%
51.6%
37.6%
24.4%
8.7%
28 - Huron
33.3%
1.1%
1.5%
1.4%
3.7%
96.3%
27.3%
16.6%
5.4%
29 - Biola/ Herndon/ Highway
City/ Kerman
49.6%
3.8%
2.7%
13.6%
41.0%
59.0%
35.0%
23.0%
8.9%
30 - Bowles/ Caruthers/ Easton/
Kingsburg/ Lanare/ Laton/ Raisin
City/ Riverdale/ Selma
52.1%
6.0%
3.0%
8.1%
36.8%
63.2%
37.9%
25.7%
11.3%
31 - Auberry/ Calwa/ Centerville/
Clovis East/ Del Rey/ Fowler/
Friant/ Sanger/ Shaver Lake
68.0%
1.8%
2.7%
10.1%
58.8%
41.2%
44.0%
30.1%
11.9%
32 - Orange Cove/ Parlier/
Reedley/ Squaw Valley/ Tivy
Valley/ Wonder Valley
57.3%
1.0%
2.1%
3.3%
24.7%
75.3%
36.5%
24.4%
10.0%
35a - Fresno Northwest
69.5%
5.7%
1.8%
13.6%
77.0%
23.0%
48.4%
34.2%
14.2%
35b - Clovis West/ Fresno East
60.0%
4.7%
2.9%
17.0%
66.7%
33.3%
41.4%
29.1%
11.8%
35c - Fresno West Central
49.1%
8.9%
3.6%
8.5%
42.6%
57.4%
37.5%
25.3%
10.2%
35d - Fresno East Central
39.0%
7.9%
3.3%
16.4%
39.1%
60.9%
34.0%
23.0%
10.0%
35e - Fresno South and West
40.0%
12.6%
3.1%
12.6%
39.4%
60.6%
34.1%
22.2%
8.5%
35f - Fresno North Central
60.1%
8.3%
2.9%
11.1%
64.6%
35.4%
42.2%
31.6%
16.0%
US, state, and county data are for 2011; MSSA data are for 2010.
Data are in the percentage of women in the population.
Source: US Census Bureau – Population Estimates and Census 2010.
20 | P a g e
Table 2.5. Population characteristics – socioeconomics
Population Group
Less than
HS
Education
Income
Below
100%
Poverty
Income
Below
250%
Poverty
(Age:
40-64)
Unemployed
Foreign
Born
Linguistically
Isolated
In Rural
Areas
In
Medically
Underserved
Areas
No Health
Insurance
(Age:
40-64)*
US
14.6 %
14.3 %
33.3 %
8.7 %
12.8 %
4.7 %
19.3 %
23.3 %
16.6 %
California
19.2 %
14.4 %
35.6 %
10.1 %
27.2 %
10.3 %
5.0 %
16.7 %
20.2 %
Komen Central Valley
Service Area (Fresno
County – CA)
27.2 %
23.4 %
46.7 %
12.7 %
22.1 %
10.2 %
10.8 %
18.8 %
23.1 %
64.2%
40.1%
NA
20.7%
49.0%
40.0%
14.8%
72.4%
31.8%
26 - Cantua Creek/ San
Joaquin/ Tranquility
63.7%
46.3%
NA
11.8%
42.3%
30.0%
42.9%
100.0%
28.5%
27 - Coalinga
34.8%
27.2%
NA
6.7%
20.0%
11.9%
34.4%
100.0%
17.3%
28 - Huron
72.7%
44.6%
NA
15.2%
51.3%
44.4%
15.5%
100.0%
33.8%
29 - Biola/ Herndon/
Highway City/ Kerman
31.6%
22.3%
NA
11.8%
25.7%
11.4%
29.7%
100.0%
21.2%
30 - Bowles/ Caruthers/
Easton/ Kingsburg/
Lanare/ Laton/ Raisin City/
Riverdale/ Selma
38.8%
27.9%
NA
15.0%
27.4%
15.0%
33.4%
32.8%
22.6%
31 - Auberry/ Calwa/
Centerville/ Clovis East/
Del Rey/ Fowler/ Friant/
Sanger/ Shaver Lake
19.4%
13.7%
NA
9.6%
17.3%
6.6%
31.0%
2.3%
14.4%
Reedley/ Squaw Valley/
Tivy Valley/ Wonder Valley
42.5%
28.2%
NA
16.1%
32.4%
17.5%
22.4%
26.3%
24.2%
6.7%
7.5%
NA
9.3%
13.5%
4.0%
0.1%
0.0%
10.4%
35b - Clovis West/ Fresno
East
16.1%
17.0%
NA
12.6%
15.4%
4.4%
0.4%
0.0%
16.2%
32.9%
37.1%
NA
17.9%
21.4%
11.2%
0.0%
22.2%
23.9%
39.3%
37.5%
NA
19.3%
26.5%
12.9%
0.0%
0.0%
24.9%
35e - Fresno South and
West
38.2%
34.3%
NA
16.0%
26.3%
15.0%
0.1%
18.5%
24.5%
14.3%
24.0%
NA
16.3%
13.2%
5.2%
0.0%
0.0%
19.0%
35a - Fresno Northwest
* Health Insurance coverage data for MSSAs are for all ages.
Data are in the percentage of people (men and women) in the population.
Source of health insurance data: US Census Bureau – Small Area Health Insurance Estimates (SAHIE) for 2011 and American
Community Survey (ACS) for 2008-2012.
Source of rural population data: US Census Bureau – Census 2010.
Source of medically underserved data: Health Resources and Services Administration (HRSA) for 2013.
Source of other data: US Census Bureau – American Community Survey (ACS) for 2007-2011 and 2008-2012.
21 | P a g e
Population characteristics summary
Proportionately, the Komen Central Valley service area has a slightly larger White female
population than the US as a whole, a substantially smaller Black/African-American female
population, a substantially larger Asian and Pacific Islander (API) female population, a slightly
larger American Indian and Alaska Native (AIAN) female population, and a substantially larger
Hispanic/Latina female population. The Affiliate’s female population is slightly younger than that
of the US as a whole. The Affiliate’s education level is substantially lower than and income level
is substantially lower than those of the US as a whole. There are a substantially larger
percentage of people who are unemployed in the Affiliate service area. The Affiliate service area
has a substantially larger percentage of people who are foreign born and a substantially larger
percentage of people who are linguistically isolated. There are a substantially smaller
percentage of people living in rural areas, a substantially larger percentage of people without
health insurance, and a slightly smaller percentage of people living in medically underserved
areas.
The following MSSA has substantially larger Black/African-American female population
percentages than that of the Affiliate service area as a whole:
• 35e - Fresno South and West
The following MSSAs have substantially larger API female population percentages than that of
the Affiliate service area as a whole:
• 35b - Clovis West/ Fresno East
• 35d - Fresno East Central
The following MSSAs have substantially larger Hispanic/Latina female population percentages
than that of the Affiliate service area as a whole:
• 25 - Firebaugh/ Mendota
• 26 - Cantua Creek/ San Joaquin/ Tranquility
• 28 - Huron
• 29 - Biola/ Herndon/ Highway City/ Kerman
• 30 - Bowles/ Caruthers/ Easton/ Kingsburg/ Lanare/ Laton/ Raisin City/ Riverdale/ Selma
• 32 - Orange Cove/ Parlier/ Reedley/ Squaw Valley/ Tivy Valley/ Wonder Valley
• 35c - Fresno West Central
The following MSSAs have substantially lower education levels than that of the Affiliate service
area as a whole:
• 27 - Coalinga
• 28 - Huron
22 | P a g e
The following MSSAs have substantially lower income levels than that of the Affiliate service
area as a whole:
• 28 - Huron
The following MSSAs have substantially lower employment levels than that of the Affiliate
service area as a whole:
• 35f - Fresno North Central
The MSSAs with substantial foreign born and linguistically isolated populations are:
• 28 - Huron
The following MSSAs have substantially larger percentage of adults without health insurance
than does the Affiliate service area as a whole:
• 28 - Huron
Priority Areas
Healthy People 2020 forecasts
Healthy People 2020 (HP2020) is a major federal government initiative that provides specific
health objectives for communities and for the country as a whole. Many national health
organizations use HP2020 targets to monitor progress in reducing the burden of disease and
improve the health of the nation. Likewise, Komen believes it is important to refer to HP2020 to
see how areas across the country are progressing towards reducing the burden of breast
cancer.
HP2020 has several cancer-related objectives, including:
 Reducing women’s death rate from breast cancer (Target as of the writing of this report:
41.0 cases per 100,000 women).
 Reducing the number of breast cancers that are found at a late-stage (Target as of the
writing of this report: 41.0 cases per 100,000 women).
23 | P a g e
To see how well counties in the Komen Central Valley service area are progressing toward
these targets, the report uses the following information:
 County breast cancer death rate and late-stage diagnosis data for years 2006 to 2010.
 Estimates for the trend (annual percent change) in county breast cancer death rates and
late-stage diagnoses for years 2006 to 2010.
 Both the data and the HP2020 target are age-adjusted.
These data are used to estimate how many years it will take for each county to meet the
HP2020 objectives. Because the target date for meeting the objective is 2020, and 2008 (the
middle of the 2006-2010 period) was used as a starting point, a county has 12 years to meet the
target.
Death rate and late-stage diagnosis data and trends are used to calculate whether an area will
meet the HP2020 target, assuming that the trend seen in years 2006 to 2010 continues for 2011
and beyond.
Identification of priority areas
The purpose of this report is to combine evidence from many credible sources and use the data
to identify the highest priority areas for breast cancer programs (i.e. the areas of greatest need).
Classification of priority areas are based on the time needed to achieve HP2020 targets in each
area. These time projections depend on both the starting point and the trends in death rates
and late-stage incidence.
Late-stage incidence reflects both the overall breast cancer incidence rate in the population and
the mammography screening coverage. The breast cancer death rate reflects the access to
care and the quality of care in the health care delivery area, as well as cancer stage at
diagnosis.
There has not been any indication that either one of the two HP2020 targets is more important
than the other. Therefore, the report considers them equally important.
Counties are classified as follows (Table 2.6):
 Counties that are not likely to achieve either of the HP2020 targets are considered to
have the highest needs.
 Counties that have already achieved both targets are considered to have the lowest
needs.
 Other counties are classified based on the number of years needed to achieve the two
targets.
24 | P a g e
Table 2.6. Needs/priority classification based on the projected time to achieve
HP2020 breast cancer targets
Time to Achieve
Death Rate
Reduction Target
13 years or
longer
7-12 yrs.
0 – six yrs.
Currently
meets target
Unknown
Time to Achieve Late-stage Incidence Reduction Target
13 years or 7-12 yrs.
0 – six
Currently
Unknown
longer
yrs.
meets target
Medium
Highest
Highest
High
Medium
High
Medium
Medium
Medium
High
Medium
High
Low
High
Medium
Medium
Medium
Medium
Low
High
Low
Low
Medium
Lowest
Lowest
Medium
Low
Low
Medium
Medium
Highest
Lowest
Unknown
High
Low
If the time to achieve a target cannot be calculated for one of the HP2020 indicators, then the
county is classified based on the other indicator. If both indicators are missing, then the county
is not classified. This doesn’t mean that the county may not have high needs; it only means that
sufficient data are not available to classify the county.
Affiliate Service Area Healthy People 2020 Forecasts and Priority Areas
The results presented in Table 2.7 help identify which counties have the greatest needs when it
comes to meeting the HP2020 breast cancer targets.
 For counties in the “13 years or longer” category, current trends would need to change to
achieve the target.
 Some counties may currently meet the target but their rates are increasing and they
could fail to meet the target if the trend is not reversed.
Trends can change for a number of reasons, including:
 Improved screening programs could lead to breast cancers being diagnosed earlier,
resulting in a decrease in both late-stage incidence rates and death rates.
 Improved socioeconomic conditions, such as reductions in poverty and linguistic
isolation could lead to more timely treatment of breast cancer, causing a decrease in
death rates.
The data in this table should be considered together with other information on factors that affect
breast cancer death rates such as screening percentages and key breast cancer death
determinants such as poverty and linguistic isolation.
25 | P a g e
Table 2.7. Intervention priorities for Komen Central Valley service area with predicted time to
achieve the HP2020 breast cancer targets and key population characteristics
Population Group
Fresno County - CA
Priority
Predicted Time to
Achieve Death Rate
Target
Predicted Time to
Achieve Late-stage
Incidence Target
Lowest
Currently meets target Currently meets target
Key Population
Characteristics
NA
NA
NA
%Hispanic/Latina, education,
poverty, employment, foreign,
language, insurance, medically
underserved
26 - Cantua Creek/ San
Joaquin/ Tranquility
NA
NA
NA
poverty, foreign, language, rural,
insurance, medically
underserved
27 - Coalinga
NA
NA
NA
Education, rural, medically
underserved
28 - Huron
NA
NA
NA
poverty, foreign, language,
insurance, medically
underserved
29 - Biola/ Herndon/ Highway
City/ Kerman
NA
NA
NA
%Hispanic/Latina, rural,
medically underserved
30 - Bowles/ Caruthers/
Easton/ Kingsburg/ Lanare/
Laton/ Raisin City/ Riverdale/
Selma
NA
NA
NA
foreign, language, rural,
medically underserved
31 - Auberry/ Calwa/
Centerville/ Clovis East/ Del
Rey/ Fowler/ Friant/ Sanger/
Shaver Lake
NA
NA
NA
Rural
Reedley/ Squaw Valley/ Tivy
Valley/ Wonder Valley
NA
NA
NA
employment, foreign, language,
rural, medically underserved
35b - Clovis West/ Fresno
East
NA
NA
NA
%API
NA
NA
NA
poverty, employment
NA
NA
NA
%API, %Hispanic/Latina,
education, poverty, employment
35e - Fresno South and West
NA
NA
NA
%Black/African-American,
poverty, employment, language
NA
NA
NA
Employment
NA – data not available.
SN – data suppressed due to small numbers (15 cases or fewer for the 5-year data period).
26 | P a g e
Data Limitations
The following data limitations need to be considered when utilizing the data of the Quantitative
Data Report:
 The most recent data available were used but, for cancer incidence and deaths, these
data are still several years behind.
 For some areas, data might not be available or might be of varying quality.
 Areas with small populations might not have enough breast cancer cases or breast
cancer deaths each year to support the generation of reliable statistics.
 There are often several sources of cancer statistics for a given population and
geographic area; therefore, other sources of cancer data may result in minor differences
in the values even in the same time period.
 Data on cancer rates for specific racial and ethnic subgroups such as Somali, Hmong, or
Ethiopian are not generally available.
 The various types of breast cancer data in this report are inter-dependent.
 There are many factors that impact breast cancer risk and survival for which quantitative
data are not available. Some examples include family history, genetic markers like
HER2 and BRCA, other medical conditions that can complicate treatment, and the level
of family and community support available to the patient.
 The calculation of the years needed to meet the HP2020 objectives assume that the
current trends will continue until 2020. However, the trends can change for a number of
reasons.
 Not all breast cancer cases have a stage indication.
Quantitative Data Report Conclusions
Lowest priority areas
The Komen Central Valley (Fresno County) service area is in the lowest priority category.
Fresno County currently meets the HP2020 breast cancer death and late-stage targets.
Additional Quantitative Data Exploration
As evidenced in the Komen Central Valley Quantitative Data Report (QDR), the Affiliate is
currently meeting the targets for Healthy People 2020 for reducing women’s death rate from
breast cancer and reducing the number of breast cancers that are found late-stage. Although
these are positive indicators for the Affiliate, there are still pervasive breast cancer disparities
among specific ethnic populations and geographic areas in the region.
The Community Profile Team identified relevant data from the California Health Interview
Survey (CHIS) and the California Cancer Registry (CCR) that further illuminates these
disparities.
California Health Interview Survey
The California Health Interview Survey (CHIS) is the largest state health survey in the nation. It
consists of a random-dial telephone survey that asks questions on a variety of health topics,
including mammography screening behavior. While Table 2.3 references that 84.6 percent of
women in Fresno County, between the ages of 50-74 have had a mammogram within the last
two years, the percentiles for specific ethnicities were statistically unstable due to small sample
sizes. Additionally, screening behavior was not evaluated based on insurance status and
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poverty level. Therefore, the Community Profile Team expanded the sample pool to encompass
the entire San Joaquin Valley, which includes Fresno, Kern, Kings, Madera, Merced, San
Joaquin, Stanislaus, and Tulare counties. Race/ethnicity, insurance status, and poverty level
were assessed as it relates to screening behavior (Tables 2.8, 2.9 and 2.10).
Table 2.8. Mammography screening behavior by ethnicity
African-American is the same as black
Table 2.9. Mammography screening behavior by insurance status
Table 2.10. Mammography screening behavior by federal poverty level
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The data from these tables suggests that Asian women (63.3 percent), women without health
insurance (64.2 percent) and low income women below 200 percent of the federal poverty level
(FPL) (70.9 percent and 66.9 percent), are less likely to be screened regularly.
California Cancer Registry
The Community Profile Team also reviewed a study conducted by the California Cancer
Registry that identified and mapped communities with a higher percentage of breast cancer
cases detected at an advanced stage compared to the state overall. The cases studied were
from January 1, 2007 and December 31, 2011 and only included women 40 years and older.
The geographic areas were classified as Medical Service Study Areas (MSSA), which are
aggregations of census tracts that make up “service areas” for primary health care and are used
to identify medically underserved areas.
The Community Profile Team felt the information was relevant, given that the Quantitative Data
Report (QDR) did not include sub-county level breast cancer data. The findings demonstrated
that there are specific regions within Fresno County that have a higher percentage of advanced
breast cancer as demonstrated in Figure 2.1.
Source: California Cancer Registry, California Department of Public Health (2014)
Figure 2.1. Fresno MSSAs map
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The data for the MSSA areas with elevated number of advance breast cancer cases are
referenced in Table 2.11.
Table 2.11. MSSAs with elevated number of advanced breast cancer cases
MSSA Description
Orange Cove/
Parlier/Reedley/Squaw, Tivy
and Wonder Valley
MSSA ID
% Advanced Stage
Total
Cases
Advanced
Observed
32
40.0%
126
50
Fresno South and West
35e
36.0%
163
58
Fresno West Central
35c
33.0%
202
67
Clovis West/ Fresno East
35b
31.0%
312
97
Selection of Target Communities
After careful review of the data provided in the Quantitative Data Report and the additional
supplemental data, the Community Profile Team selected four target communities for further
exploration in the Health Systems Analysis and Qualitative Data Sections of the Community
Profile Report. These target communities are either disproportionately affected by breast
cancer, and/or have other determining factors that have been associated with poorer health
outcomes that could increase risk for late-stage diagnosis and deaths.
The indicators that the Affiliate reviewed when selecting target communities included, but were
not limited to:
 Incidence rates and trends
 Death rates and trends
 Late-stage rates and trends
 Screening behavior rates
 Socioeconomic indicators such as: poverty level, unemployment, insurance status
Hispanic/ Latina Women in MSSA 25; Firebaugh and Mendota, and MSSA 26; Cantua
Creek, San Joaquin, Tranquility: This region has poorer socioeconomic indicators than other
MSSAs in Fresno County. In MSSA 25, over 90 percent of the population is Hispanic/Latino and
40 percent of the community is linguistically isolated. An alarming 31.8 percent of the residents
are without health insurance and 40.0 percent of the population is below 100 percent of the
federal poverty level. One in five residents are also unemployed at any given time. MSSA 26
borders Firebaugh and Mendota, and has comparable socioeconomic indicators to that of
Firebaugh and Mendota. The population is predominantly Hispanic/Latino (91.3 percent), with
63.7 percent of the population having less than a high school degree. Additionally, one in three
residents are without health insurance and 100 percent of the population is in an underserved
medical area. These socioeconomic factors have been associated to health disparities and
reduced access to care that can increase a woman’s risk for late-stage diagnosis and breast
cancer deaths.
MSSA 32; Orange Cove, Parlier, Reedley, Squaw Valley, Tivy Valley and Wonder Valley:
This MSSA is predominantly rural with over 75.0 percent of the population identifying as
Hispanic/Latino (Table 2.4). Approximately, 43.0 percent of the population has less than a high
school education and 24.2 percent are not insured (Table 2.5). Additionally, 40.5 percent of the
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111 breast cancer cases were diagnosed at an advanced stage making it a priority community
of interest (Table 2.11).
Black/African-American Women in MSSA 35e; Fresno South and West and MSSA 35c;
Fresno West Central: Black/African-American women in Fresno County have the highest death
and late-stage breast cancer rates of all ethnicities in Fresno County. The trend for late-stage
breast cancer is steadily increasing among Black/African-American women, where the trend has
been decreasing for all other ethnicities. The MSSAs with the largest Black/African-American
population is Fresno South and West at 12.6 percent and Fresno West Central at 8.9 percent
respectively. Approximately one in four residents in this area do not have health insurance and
close to 40 percent have less than a high school education. These MSSAs, (35e) and (35c),
have also been identified as having an elevated percentage of advanced breast cancer cases
as evidenced in the Figure 2.1.
The health systems and public policy analysis component of this report will take a more in-depth
look at the continuum of care and the delivery of breast health care among these four target
communities. Potential assets, as well as gaps in the health care delivery system and
community based services will be further illuminated, which will help to inform the Affiliate of its
strategic priorities over the next several years.
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Health Systems and Public Policy Analysis
Health Systems Analysis Data Sources
Komen Central Valley conducted an extensive inventory of breast health services within the four
target communities. The Community Profile Advisory Team (Team) started the process with
making a formal request to the California Health Collaborative, the regional provider for the
Every Woman Counts (EWC) program, to get a populated list of (EWC) primary care providers
and diagnostic centers within the target regions.
Additionally, the Team used online search portals to gather detailed information on the following
facilities in the target regions:
 Community health centers, including Federally Qualified Health Centers (FQHCs) and
FQHC look-alikes
 Free clinics
 Hospitals
 Local health departments.
 American College of Radiology Centers of Excellence
 American College of Surgeons National Accreditation Program for Breast Centers
(NAPBC)
 National Cancer Institute Designated Cancer Centers
The websites for these search portals are included in the reference section of this report. The
findings from this exhaustive search were compiled in an excel spreadsheet, and organized
according by each target community. Using the breast continuum of care framework (CoC), the
Team reviewed the findings for each community in terms of potential gaps in services,
specifically geography and others barriers to access.
Health Systems Overview
Komen Central Valley uses the CoC model
(Figure 3.1) as an important guide to identify
the gaps, barriers and issues present when
assessing why some women do not receive
regular screening, and why others who are
screened may not receive timely diagnostic
tests, treatment, or follow-up care. The CoC
shows how a woman typically moves through
the health care system for breast care. A
woman would ideally move through the CoC
quickly and seamlessly, receiving timely, quality
care in order to have the best outcomes.
Education can play an important role
throughout the entire CoC.
Figure 3.1. Breast Cancer Continuum of Care (CoC)
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While a woman may enter the continuum at any point, ideally, a woman would enter the CoC by
getting screened for breast cancer – with a clinical breast exam or a screening mammogram. If
the screening test results are normal, she would loop back into follow-up care, where she would
receive annual or provider recommended interval screenings. Education plays a role in both
providing education to encourage women to get screened and reinforcing the need to continue
screenings thereafter.
If a screening exam resulted in abnormal results, diagnostic tests would be needed, possibly
several, to determine if the abnormal finding is in fact breast cancer. These tests might include
a diagnostic mammogram, breast ultrasound or biopsy. If the tests were negative (or benign)
and breast cancer was not found, she would go into the follow-up loop, and return for screening
at the recommended interval. The recommended intervals may range from three to six months
for some women to 12 months for most women. Education plays a role in communicating the
importance of proactively getting test results, keeping follow-up appointments and
understanding what it all means. Education can empower a woman and help manage anxiety
and fear.
If breast cancer is diagnosed, she would proceed to treatment. Education can cover such topics
as treatment options, how a pathology reports determines the best options for treatment,
understanding side effects and how to manage them, and helping to formulate questions a
woman may have for her providers.
For some breast cancer patients, treatment may last a few months and for others, it may last
years. While the CoC model shows that follow up and survivorship come after treatment ends,
they actually may occur at the same time. Follow up and survivorship may include things like
navigating insurance issues, locating financial assistance, symptom management, such as pain,
fatigue, sexual issues, bone health, etc. Education may address topics such as making healthy
lifestyle choices, long term effects of treatment, managing side effects, the importance of followup appointments and communication with their providers. Most women will return to screening
at a recommended interval after treatment ends, or for some, during treatment (such as those
taking long term hormone therapy).
There are often delays in moving from one point of the continuum to another – at the point of
follow-up of abnormal screening exam results, starting treatment, and completing treatment –
that can all contribute to poorer outcomes. There are also many reasons why a woman does
not enter or continue in the breast cancer CoC. These barriers can include things such as lack
of transportation, system issues including long waits for appointments and inconvenient clinic
hours, language barriers, fear, and lack of information - or the wrong information (myths and
misconceptions). Education can address some of these barriers and help a woman progress
through the CoC more quickly.
It has been well documented that Fresno County is an area of immense need with fewer health
care resources than the rest of the state. Fresno County is a region that is designated as a
medically underserved area by the California Office of Statewide Planning and Development
(OSPD), and also a primary care shortage area (OSPD, 2014). In general, there is an
inequitable distribution of resources across the county region, with the majority of breast health
care services falling within the city of Fresno. The entire west region of the county only has one
hospital, which does not provide breast cancer diagnostic or treatment services. The east
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county region has a greater number of primary care breast health services than the west, but
still lacks diagnostic and treatment centers within its region. FQHCs and FQHC look-alikes
provide a high volume of care for the county’s most needy residents. Federally Qualified Health
Centers include all organizations receiving grants under Section 330 of the Public Health
Service Act (PHS). FQHCs qualify for enhanced reimbursement from Medicare and Medicaid,
as well as other benefits. FQHCs must also serve an underserved area or population, offer a
sliding fee scale, provide comprehensive services, have an ongoing quality assurance program,
and have a governing board of directors. FQHC look-alikes are organizations that meet PHS
Section 330 eligibility requirements and also receive special Medicare and Medicaid
reimbursement, but do not receive grant funding.
The local Affiliate conducted a comprehensive inventory and analysis of health care services in
the four target communities and a summary of the key findings, as well as current and potential
new partnerships, are outlined below in alphabetical order.
Black/African-American Women in MSSA 35e; Fresno South and West and MSSA 35c;
Fresno West Central
Medical Service Study Areas (MSSAs) 35c and 35e are adjacent to one another and are within
the city limits of Fresno with a total estimated population of 175,397 (OSPD, 2014). The
Black/African-American population within MSSA 35c is 8.9 percent and for MSSA 35e is 12.6
percent, respectively as referenced in Table 2.4 of the quantitative data section. The physician
ratio for 35c is 561 civilians per primary care physician and for 35e, the ratio is 89,070 civilians
per primary care physician (OSPD, 2014). As noted, there is a difference in the ratios for each
of these MSSA areas, and is a finding that should be explored further in the qualitative section.
The health systems inventory for these areas revealed the following services within these MSSA
regions (Figure 3.2):
 Three Susan G. Komen Central Valley Grantees
 One free clinic
 One breast diagnostic center
 12 Community Health Centers that are FQHC or FQHC look-alikes; nine of which are
EWC contracted providers
 Eight EWC contract private practice primary care providers
 Zero breast cancer treatment centers
The Komen Central Valley grant funded organizations in this region provide services throughout
Fresno County, but its offices are located within this region. California Health Collaborative
(CHC) provides breast health education, patient navigation and financial assistance to cover the
cost of diagnostic procedures for women who do not qualify for government funded programs.
Central California Legal Services, Inc. provides education and legal support services; and Hinds
Hospice provides end of life psychosocial support for families facing a terminal breast cancer
diagnoses.
Based on population size and proximity to other breast services in the city of Fresno, the Team
felt that the number of available breast health care services seemed adequate to meet the
needs of the population. Additional information needs to be gathered in terms of health center
appointment availability, hours of operation, referrals for mammography, diagnostic care and
treatment as it relates to breast care. There is one diagnostic breast cancer center located
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within the region, but there are at least two more EWC approved and American College of
Radiology Center (ACR) accredited diagnostic centers located within Fresno city limits, just a
few miles outside of the target region. There are three breast cancer treatment centers located
within the city of Fresno, and is a short driving distance away and accessible by public transit.
The local Affiliate is in the process of strengthening relationships with local organizations and
churches that serve Black/African-American women. The seven California Affiliates, including
Komen Central Valley, recently embarked on a statewide initiative to increase rates of early
detection among Black/African-American women through community partnerships, outreach and
education, and linkage to screening services. The local Affiliate established Susan G. Komen®
Circle of Promise® California Initiative Advisory Council, a community advisory council
comprised of stakeholders and community members that have strong ties to the Black/AfricanAmerican community in Fresno County. The advisory council will be assisting the local Affiliate
with recommendations for new partnerships, and the creation of an action plan to conduct
outreach and education, in order to motivate women to get screened regularly and link them to
screening services.
The organizations represented on this advisory council are West Family Resource Center,
which was formerly a grantee and serves the Black/African-American community, and California
Health Collaborative, which provides services to all low income women. Also on the Council are
a Black/African-American physician, dentist and two breast cancer survivors under the age of
40.
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Figure 3.2. Breast cancer services available for Black/African-American women
in MSSA 35c and 35e
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Hispanic/Latina Women in MSSA 25; Firebaugh and Mendota, and MSSA 26; Cantua
Creek, San Joaquin, Tranquility
MSSA 25 and 26 border one another, and are located in the northwest region of the county.
This region is predominantly rural with a small population of 30,743 (OSPD, 2014). The
residents in the region are predominantly Hispanic/Latino (92.0 percent) with a considerable
number of migrant farm workers (OSPD, 2014).The physician ratio for MSSA 25 is 3,196
civilians per primary care physician. For MSSA 26, the physician ratio is 4,184 per primary care
physician, which is considered a health professional shortage area (OSPD, 2014). The health
systems inventory revealed that there are limited breast cancer screening services available in
this region, and virtually no diagnostic or cancer treatment centers within or proximal to this
region.
The following services were identified (Figure 3.3):
 Three FQHC or FQHC look-alike community health centers, one of which is an EWC
contracted provider
 Two EWC contracted private practice primary care providers
Given the extreme poverty and lack of insurance for this region, the number of approved EWC
providers appears to be somewhat limited. Additional information needs to be gathered in terms
of EWC private providers and health center appointment availability, hours of operation,
referrals for diagnostics and treatment, as it relates to breast care. The closest breast
diagnostic center and treatment center are located over 45 miles away, which creates a
potential barrier for low income women to receive necessary and timely breast care
The local Affiliate has limited partnerships in the region, and will work diligently to cultivate new
partners in light of the Community Profile findings. Centro la Familia was a former grantee of the
Affiliate, and provides services in the rural areas of Fresno. The local Affiliate will reevaluate its
relationship with this organization and ensure it receives the next Komen Central Valley request
for applications (RFA) to explore opportunities for collaboration. The Team also thought it is
imperative to establish a stronger relationship with the EWC contracted community health
center, United Health Centers of San Joaquin Valley, located in the city of Mendota. The
possibility of partnering with a mobile mammography provider to come to the clinic site, could
increase access to services. Additionally, the local Affiliate can explore the possibility of
partnering with United Health Centers to conduct breast health education initiatives.
In the qualitative data section of the Community Profile, the Team will conduct a key informant
interview with one of the clinic staff members to further understand its scope of services and
explore opportunities for partnerships. Additionally, it will be prudent to identify a community
leader or stakeholder from the region to interview as part of the qualitative data gathering
process to inform the Team on new partnerships with trusted organizations within the region,
that serve the Hispanic/Latino community.
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Figure 3.3. Breast cancer services available for Hispanic/Latina women in MSSA 25 and 26
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MSSA 32; Orange Cove, Parlier, Reedley, Squaw Valley, Tivy Valley and Wonder Valley
This MSSA is located in the eastern region of the county and is also predominantly rural, with a
large population of transient farm workers. The total population for this area is 61,928 (OSPD,
2014). The physician ratio is 2,693 civilians per primary care physician (OSPD, 2014). There is
not a hospital with breast care treatment services, and only one breast diagnostic center within
the region located at Adventist Medical Center in Reedley (Figure 3.4). There are a total of four
FQHC or FQHC look-alike community health centers, three of which are also contracted EWC
providers. Additionally, there are three private EWC providers also in the region and a total of
three Adventist Health Community Care Clinics that are contracted as EWC providers. The
closest hospital for breast treatment services is approximately 30 to 40 minutes away in Hanford
and city of Fresno.
The Team raised similar concerns as they did for MSSA 25 and 26, regarding the lengthy travel
distance for treatment services. Additionally, Adventist Medical Center in Reedley, is the only
diagnostic center, and therefore cannot serve all women in need for this region. Traveling into
the city of Fresno for services, can be a considerable barrier to care for low income women.
The Team will conduct key informant interviews at EWC contracted clinic sites and Adventist
Medical Center to get a better understanding of locations for breast care referrals, hours of
operation, and appointment times. Mobile mammography at one or more clinic sites or another
trusted community location would increase access to screening services, and should be
explored. Among county residents, the city of Reedley is commonly known as the world’s fruit
basket, given that it holds a number of festivals year around and is known for its plethora of fruit.
These festivals could be an opportunity for the local Affiliate to distribute breast health
information to the community residents. Given that the region is primarily agricultural, it will be
important to establish partnerships with local economic or community agencies that serve rural
farm workers.
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Figure 3.4. Breast cancer services available in MSSA 32
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Public Policy Overview
The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) supports, the
provision of clinical breast exams, mammograms, Pap tests, pelvic exams, diagnostic testing,
and referrals to treatment for low income and uninsured women. The program is supported by
the Centers for Disease Control and Prevention, which provides a federal grant to each state
(CDC, 2014).
In California, the program is referred to as Every Woman Counts (EWC), and receives funding
support from general state funds and through state tobacco tax revenue. EWC is part of the
Department of Health Care Service's Cancer Detection and Treatment Branch (CDTB) and is
separate from Medi-Cal (California’s Medicaid Program). The mission of the EWC is to save
lives by preventing and reducing the devastating effects of cancer for Californians through
education, early detection, diagnosis and treatment, and integrated preventive services, with
special emphasis on the underserved. (DHCS: EWC, 2014)
The eligibility requirements for EWC are the following:
 Uninsured or underinsured
 Income at or below 200 percent FPL
 Must between the ages of 40-64 for breast care services
 Proof of California residency
 Not eligible for any other state or federally funded programs, such as Medi-Cal
In California, oversight for EWC services is provided through regional contractors throughout the
state. A statewide 1-800 number is available for inquiries regarding eligibility and referrals for
services. The phone line is available Monday through Friday from 8:30am to 5:00pm and
provides language assistance in English, Spanish, Mandarin, Cantonese, Korean and
Vietnamese. Additionally, the EWC website provides a search portal for women and providers to
identify local EWC services in their area. Individuals can enroll on-site at local EWC provider
offices and health centers (DHCS; EWC, 2014).
If breast cancer is found, treatment is provided to eligible individuals through the Breast and
Cervical Cancer Treatment Program (BCCTP). BCCTP provides full-scope Medi-Cal to low
income and uninsured women who meet the federal eligibility criteria. The state-funded BCCTP
only provides cancer treatment and related services to individuals, including men, who do not
meet the federal criteria. The State BCCTP program provides no cost breast cancer treatment
services for up to 18 continuous months. The application and required documents for the
BCCTP program are available in 11 languages, including English, Spanish, Vietnamese,
Cambodian, Hmong, Armenian, Cantonese, Korean, Russian, Farsi and Laotian. Individuals
can request an application for enrollment through the state BCCTP phone number, or enroll
through certified application assistants at health centers and hospitals (CDPH; BCCTP, 2014).
Komen Central Valley provides grant funding to California Health Collaborative, the regional
contractor for EWC in Fresno County, to support the provision of breast health education, health
services and patient navigation for women who do not qualify for other government program,
such as EWC. The California Health Collaborative deploys health educators to conduct breast
health education to priority populations, and also has staff to support the enrollment and
retention of clinical providers for the EWC program.
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Komen Central Valley is also an active member of the Komen California Collaborative Public
Policy Committee (KCCPPC), which is comprised of representatives from all seven California
Affiliates. The KCCPPC has relationships with the Department of Health Care Services and
EWC Administration, and closely monitors the program in terms of potential budgetary impacts,
changes to eligibility, and screening recommendations. The local Affiliate, along with other
members of the KCCPPC, will continue to strengthen relationships with legislators, DHCS staff
and EWC Administration.
The California Dialogue on Cancer (CDOC) is a statewide cancer coalition, established by the
California’s Comprehensive Cancer Control Program in 2002. It is comprised of stakeholders
and representatives from community organizations working together to reduce the burden of
cancer in the state of California. CDOC was created to develop and implement California’s
Comprehensive Cancer Control Plan (CCCP).
The California Cancer Control Plan for 2011-2015 addresses the cancer continuum and
includes primary prevention, early detection and screening, treatment, quality of life and end-oflife care. It also addresses cross-cutting issues such as advocacy, eliminating disparities,
research, and surveillance.
The two breast cancer objectives for the plan are:
1. By 2015, increase the prevalence of women 40 years and older who report having both
a mammogram and a clinical breast exam (CBE) within the prior two years by 7.5
percent, from a baseline prevalence of 79.1 percent to 85.0 percent (CDOC, 2014).
2. By 2015, increase the proportion of early-stage diagnoses of breast cancer among all
women by 29.0 percent, from the baseline proportion of 69.0 percent to 89.0 percent
(CDOC, 2011).
The KCCPPC participates in the CDOC stakeholder meetings and is part of the email
distribution network to receive information related to training opportunities and other pertinent
updates. CDOC is in the process of developing a new strategic plan for 2015 and the KCCPPC
will be involved in the planning sessions to inform objectives and activities for breast cancer.
In 2010, California was the first state in the nation to enact legislation to implement the
provisions of the federal Affordable Care Act (ACA), creating Covered California (Covered
California, 2014). This health care marketplace was established to increase access to
affordable and quality health care. California also decided to expand its Medi-Cal Program to
cover individuals at or below 138 percent of the federal poverty level. California has the
greatest number of uninsured of all the states with over seven million uninsured (CFHC, 2014).
By 2014, 2.6 million Californians were eligible to access financial assistance through Covered
California to pay for their health insurance, and 1.4 million were newly eligible for Medi-Cal
(Covered California, 2014). However, a large number of individuals (nearly three million) will
remain uninsured in California (CHFC, 2014). Approximately 703,000 will be eligible to MediCal and not enroll; 959,000 will be undocumented and ineligible for insurance coverage; and 1.4
million will be eligible for coverage through Covered California and not enroll (CHFC, 2014). Of
this 1.4 million, 577,000 will be eligible for subsidy but will not take it and 832,000 are not
eligible for the subsidy (CFHC, 2014).
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As of March 31, 2014, a total of 1,395,929 consumers enrolled in plans statewide and a total of
1.9 million California residents enrolled in Medi-Cal. A report by the Commonwealth Fund
estimates that roughly one in four people who were uninsured last in 2013, now have received
coverage, with the state of California having the highest expansion in coverage. The
percentage of Californians without health insurance was cut in half, from 22.0 percent a year
ago to 11.0 percent by the end of June, 2014 (Collins, Rasmussen and Doty, 2014).
The ACA through its marketplace health plans cover the following preventive health services for
women, specific to breast health, without charging the patient a co-payment or co-insurance:
1. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast
cancer,
2. Breast cancer mammography screenings every one to two years for women over 40,
and
3. Breast cancer chemoprevention counseling for women at higher risk (Healthcare.gov,
2014).
However, individuals who remain uninsured due to ineligibility or opting not to purchase
coverage, will not have access to these preventive health services for women. As a result, the
NBCCEDP/EWC program will still be needed to provide clinical breast exams, mammograms,
diagnostic testing for women and referrals to treatment for women (Levy, Bruen and Ku, 2014).
While the overall number of women eligible to services through NBCCEDP will likely reduce due
to ACA and Medicaid expansion, a large number of women will remain uninsured and will still
rely on EWC and BCCTP services for breast cancer screening and treatment. Additionally, while
mammography is a covered benefit under ACA, there will still be women that purchased a
higher deductible health plan and have higher out of pocket costs as it relates to breast cancer
diagnostic care and treatment.
While much excitement has surrounded the ACA and the roll out of the health care marketplace,
much remains undetermined in terms of access and utilization. Some have expressed concerns
about the availability of health care providers to respond to an increase of 30 million insured
Americans across the country (Anderson, 2014). Some studies report not only a shortfall in
health care providers, but also in the health care workforce as a whole, in responding to the
ACA changes (Anderson, 2014). While these concerns may be warranted, other efforts are
taking place at all levels to ensure collaboration and partnership across providers (safety net
providers, private providers, Medi-Cal providers, hospitals, and health systems) to ensure
strategies to meet the changing needs of health care delivery (HRSA, 2014).
For the local Affiliate, there will remain a number of uninsured individuals who are in need of
breast health services and may need access to NBCCEDP/EWC or Affiliate resources to ensure
timely and quality access to breast health services. The Affiliate will continue to work closely
with its partners in health and health policy to stay abreast of the breast health needs in the
Affiliate service area and respond accordingly in providing support for access to care.
The local Affiliate is actively involved in public policy activities at the state and local level and
stays apprised of key public policy issues in the service area. The Affiliate participates on the
KCCPPC monthly calls, attends both state and national lobby days, and meets with local
legislators regularly to educate on pertinent breast health issues and maintain relationships.
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Health Systems and Public Policy Analysis Findings
In summary, Fresno County is an area with unequal distribution of health care services for its
residents. The majority of breast health care services is located in the heart of the city of
Fresno, and get sparser in more rural areas of the county. MSSA 25 and MSSA 26 are the
most limited in terms of breast health care services, but it is also the most rural with the smallest
population. Additionally, MSSA 32 has limited breast health care resources when it comes to
breast cancer mammography, diagnostic and treatment services. The local Affiliate will need to
explore opportunities to bring services to these communities through mobile mammography,
and/or offer patient navigation support to ensure women have access to available services
within the city of Fresno. Additionally, new partnerships and opportunities for the local Affiliate to
conduct breast health outreach and education in these communities will be imperative.
For Black/African-American women, the access and number of services appear to be sufficient
for the MSSA regions, but more information needs to be gathered regarding cultural
competency, hours of operation, and appointment time availability. The formation of the Susan
G. Komen® Circle of Promise® California Initiative Advisory Council is a great start to
identifying new partnerships and opportunities for the local Affiliate to provide education to
Black/African-American women. Strong partnerships and the identification of key community
leaders within the Black/African-American faith-based organizations, civic associations, and
sororities will increase effectiveness in reaching these priority populations.
While great strides have been made in California, as it relates to more individuals getting
coverage through Medi-Cal and Covered California, there are still populations that are lagging
behind other racial/ethnic groups in terms of enrollment. Covered California will focus its media
and outreach efforts on these two populations during the next phase of open enrollment in fall of
2014 (Covered California, 2014). The local Affiliate and its grantees need to inform its
constituents on the available coverage options to increase enrollment of Fresno County
residents into more comprehensive health coverage. Additionally, there will be left behind
women without coverage, and the local Affiliate in collaboration with the KCCPPC, will need to
ensure that EWC and BCCTP remain viable and well-funded. Additionally, the local Affiliate will
need to work closely with the California Health Collaborative to ensure that women know about,
and have access to local EWC providers in the county region.
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Qualitative Data: Ensuring Community Input
Qualitative Data Sources and Methodology Overview
The qualitative data collection methods for Komen Central Valley’s four target communities
include using key informant interviews, focus groups and a document review to explore
important gaps; challenges or barriers to breast health information and care; access to and
utilization of breast health services; and attitudes, beliefs and behaviors around breast cancer
and breast health services. Questions for the key informant interview guide and focus group
guide were based on questions that came out of a careful review of the quantitative data and
health systems and public policy analysis The data collection tools also included questions
about opportunities for Komen to develop and strengthen outreach efforts, as well as
partnership development and education/health promotion. Additionally, a document review of
the Central Valley service area, specifically focusing on MSSA 25 and 26 in the Hispanic/Latino
community, provided additional information to aid in supporting other methods conducted to
better understand the needs and barriers of this community that could not otherwise be
observed and/or gathered. The following overview provides the rationale and details of each
qualitative data collection methods and ethics applied for each of the target communities: 1)
MSSA 25, Hispanic/Latina women; 2) MSSA 26, Hispanic/Latina women; 3) MSSA 32, all
women; and 4) MSSA 35, Black/African-American women.
Qualitative Data Overview
Key Informant Interviews
Key informant interviews were the first method of data collection for all target communities
selected. Key informant interviews were selected for this group to aid in gathering diverse
perspectives of the needs of these target communities. Particularly for the Hispanic/Latino
community, this method allowed for meeting with key members of the community of community
health centers to address and identify their perception of health needs, as well as observed
utilization of and availability of breast health services. For women in MSSA 35, this method
allowed for meeting with individuals with different roles serving women of all racial/ethnic and
other socioeconomic backgrounds such as various income levels to hear the different
perspectives they had in serving this community – such as those who are providing education
and risk reduction, screening, and those working with diagnosed clients through survivorship. In
MSSA 35, specifically Black/African-American women in this area, the same rationale was
applied.
Komen Central Valley used a convenience sampling from the Health System Analysis to recruit
potential interviewees; referrals from interviewees for other resources for interviews were also
requested. The Affiliate was able to identify key community health centers serving those
specific communities, however it became apparent that while there were health centers and
organizations that work with these target communities in Central Valley, there were only a
handful of individuals that specifically had knowledge and/or comfort in sharing their thoughts
regarding the breast health needs of these target communities. The Affiliate’s goal was to follow
best practice standards of conducting interviews of those who identified themselves as experts
in serving these target communities in each respective geographic area.
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Eight interviews were completed from November 2014 to February 2015. Interviews were
conducted in English with a note taker present; most of the sessions were conducted via
telephone. All notes were evaluated and made sure no key elements were missing. The notes
were separately reviewed and coded to identify key categories and themes. Data analysis was
performed with hand coding and checked for accuracy using inter-rater reliability. Common
findings were then evaluated between the interviews and focus groups. Verbal consent was
collected from all participants. Consent forms and notes taken are stored a DropBox that is
protected by user log in and password.
MSSA 25 and 26 – Hispanic/Latina Women
Two interviews were conducted in MSSA 25 and 26 addressing the needs and access to health
services among Hispanic/Latina women. The first informant shared her knowledge as the
executive director of the local community organization that provides services to the
Hispanic/Latino community in rural Fresno. During this interview, questions from the focus group
guide were used because the questions in the key informant interview guide were tailored
towards clinical providers, whereas the focus group question guide was more appropriate for
community health workers and/or lay community members. The second interview was
conducted with a family practice physician and he shared that he has worked for 20 years in his
practice, and most of his patient demographic include Hispanic/Latino farmworkers.
While this was one of the four target communities, identifying key informants that served this
community and had knowledge and expertise around breast health and breast cancer issues
was extremely challenging. Despite the difficulties, the Affiliate was able to identify the following:
The most important breast health needs for women in MSSA 25 & 26
Interviewees shared that there is little awareness regarding breast health in rural communities;
breast health education should be very simple, culturally relevant and friendly. One of the
informants shared that there is great fear when it comes to a diagnosis of cancer; many do not
want to be burdened with the potential costs. Moreover, there is little awareness about available
programs and services for women in the community.
Challenges or barriers to breast health
As mentioned, the challenges and barriers to breast health were mainly based on fear of the
unknown and fear of unanticipated costs of a cancer diagnosis. Additionally, other barriers such
as lack of transportation and lack of health insurance were other challenges that prevented
women in this community to seek and follow through with their breast health care referrals.
Utilization / Attitudes towards accessing health care
The informant shared a high utilization rate of 86.0 percent of screening mammograms and was
aware of the guidelines on when to begin and how often to screen for women at average risk, as
well as at high risk.
One interesting note that was shared was the privacy concerns in going to the local clinic; many
are worried to go to the local clinics out of fear that their privacy might be compromised, which
can explain the community’s attitude towards seeking health care because there is a lack of
trust towards community clinics and many may forego seeking medical services out of fear that
their medical history might get revealed.
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Gaps in Breast Services
When asked about the types of programs and/or services that are missing, it was shared that
there are gaps in providing transportation assistance, language services particularly for
specialty care needs, and patient education about their insurance options through Covered CA’s
health insurance exchange.
Breast Health Education / Understanding Breast Cancer Awareness and Attitudes
During this part of the interview, it was shared that breast health education is provided via
brochures in the waiting room, Komen’s Breast Self-Awareness cards and through the state’s
BCEDP or from the internet. One of the informants shared that women often perceive
themselves as not being at risk for breast cancer and will say that no one in their family has
breast cancer, therefore they are not at risk.
Screening Guidelines and Breast Health Knowledge
One of the interviewees shared that there was no confusion regarding the screening guidelines;
for women at average risk it was recommended that they should be screened every year, and
for those at higher risk, they would coordinate with a breast surgeon. Respectively, in the
community, it was shared that there is very little awareness about breast health given their
language and education of these women in the rural areas of Fresno.
Future Opportunities / How participants perceived Susan G. Komen
For these communities, there is little awareness about Susan G. Komen; however there was
expressed interest in partnering and collaborating with the Affiliate using evidence-based
approaches like the promotora model to build trust and credibility, as well as increase
awareness of programs and services for the medically underserved and uninsured. For future
opportunities, it was shared that partnering with churches in providing breast health education
and information to the community would also be an effective way to raise awareness.
MSSA 32 – All Women
Three interviews were conducted around the needs of women in MSSA 32, specifically of
Orange Cove, Parlier, and Reedley areas in Central Valley. Individuals were clinical providers
in the community. All three interviewees were women, all identified as Latino, and the number
of years as a provider spanned from two to thirteen years.
Much like the challenges faced with identifying key informants in MSSA 25 and 26, similar
challenges were realized for MSSA 32. The Affiliate identified multiple organizations that serve
individuals in MSSA 32, however a few of them declined participation because they did not feel
that they could speak about breast health or breast cancer needs of their communities.
While the Affiliate faced this challenge, the Affiliate was also able to conduct three rich
interviews that revealed the following information in the community. Please note that because
of the small sample size this information may not be generalizable for all women throughout
MSSA 32 in Central Valley. However, among this small group there was much similarity about
clinical practice, breast health education, screening procedures/recommendations, as well as
their perspective regarding the needs of women in Orange Cove, Parlier, and Reedley.
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The most important breast health needs for women in MSSA 32
Interviewees shared that education continues to be one of the most important health needs for
women. Specifically, information about available resources and programs, participants shared
that many women often are hesitant to seek breast health care because of the fear of that they
will incur additional costs that they can’t afford. All three shared that there needs to be more
information about the availability of programs that provide free mammograms. Interestingly, all
of the informants believed that breast health/cancer education should begin in high school.
In discussing challenges or barriers to breast health, interviewees shared that for some women
transportation issues; fear of the unknown; fear of the outcome; and cost were the most
common factors that prevent women from seeking and following through on their breast health
care referrals.
Utilization
Overall interviewees felt that breast health utilization was high in the community, especially
among those with MediCal and Medicare or a part of the BCEDP/EWC. Informants shared that
the insured or EWC patients that has received education on breast health are compliant about
accessing and utilizing breast cancer screenings.
Informants were asked to share what they felt were key gaps in breast health services in Central
Valley, and all of them shared that the lack of awareness of available resources. Additional gaps
in services were transportation assistance and diagnostic breast health care services for
uninsured women younger than 40. In particular, there was mention of a need for low or no cost
alternatives for screening, and diagnostic breast health care to ensure even those uninsured
can access screening.
Breast Health Education
Through the interview process the Affiliate spoke to participants about the provision of breast
health education. Informants shared their process for providing breast health education, and
health education/information on other topics as well, is by using their electronic medical records
(EMR) system, that enables them to print out in various languages on any health topic that the
patient requests. There are pamphlets in the waiting room, but most of the information is
provided via EMR.
Since education was shared as an important need in the community, informants also discussed
whether or not there was confusion in the community around screening guidelines and the
knowledge level for breast health in the community. All noted that there was no confusion in the
community around breast health. The respondents shared that most of their patients are
compliant and one shared that if they are worried about it, then they emphasize to the patient to
get it checked out before it gets worse. When asked about their practices recommendations for
women at average risk, they shared that their patients would start at 40 years, and if it was a
normal screen, then the provider recommends that they come back in two years for their next
mammogram. For those at high risk, all providers shared that those patients are screened every
year.
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Future Opportunities
Informants were asked to share recommendations on strategies and opportunities for Komen to
strengthen relationships and partnerships in their communities. And all of them shared that they
would be interested in collaborating with community organizations to address the breast health
issues of the community and suggested that the Affiliate participate at their community events to
increase awareness and education on breast health, but most importantly, the availability of
programs and services that are low or no cost.
MSSA 35 –Black/African-American Women
Three interviews were conducted around the needs of Black/African-American women in MSSA
35, specifically in Central, South Central and West Fresno of Central Valley. Individuals were
clinical providers in the community. All three interviewees were women; two identified
themselves as Black/African-American and one identified as Latino; and the number of years as
a provider spanned from three to six years.
Recruitment challenges were similarly faced with identifying key informants in MSSA 35 that
were knowledgeable of the breast health needs in the Black/African-American community.
However, the Affiliate was also able to conduct three rich interviews that revealed the following
information in the community. Please note that because of the small sample size this
information may not be generalizable for all Black/African-American women throughout MSSA
35 in Central Valley. However, among this small group there was similarity about clinical
practice, breast health education, screening procedures/recommendations, as well as their
perspectives regarding the needs of Black/African-American women in this target area.
The most important breast health needs for Black/African-American women in MSSA 35
Informants shared that assistance to support services such as transportation and financial
assistance to help reduce costs were the needs for Black/African-American women. Education
was also shared as a need for the community.
In discussing challenges or barriers to breast health, interviewees shared that for some women
transportation issues; fear of the unknown; fear of the outcome; and cost were the most
common factors that prevent women from seeking and following through on their breast health
care referrals. Additionally, informants shared that other life priorities and mistrust of non-Fresno
natives are other barriers and factors that prevent Black/African-American women in the
community to seek and utilize breast cancer screening services and/or health benefits through
their insurance.
Utilization
Overall interviewees felt that breast health utilization was average (about 70 percent) in the
community.
Informants were asked to share what they felt were key gaps in breast health services in MSSA
35 of Central Valley, and all of them shared that the lack of awareness of available resources,
lack of patient navigation, and a lack of assistance to enroll in Covered California. Additional
gaps in services were transportation assistance and financial assistance to meet basic needs.
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Breast Health Education & Educational Messaging
Through the interview process the Affiliate spoke to participants about the provision of breast
health education. Two of the informants shared their process for providing breast health
education as well as other health education topics by using their electronic medical records
(EMR) system, which enables them to print out patient requested health topics in various
languages. In addition, one of the interviewees shared that there needs to be a stronger push
for education within the communities – getting the churches, community centers, libraries,
schools, local politicians more involved in the need for breast health education. And the needs
of the community are multi-factorial, so the education and support also needs to be
comprehensive in order to make an impact and motivate Black/African-American women into
action and get screened.
When asked about the screening guidelines and their perspective of the breast health
knowledge of Black/African-American women in the community, all informants were very similar
in response. They shared that women at average risk should be screened every year and for
those at higher risk, they shared that their practice recommends every six months. In terms of
breast health knowledge, Black/African-American women are not aware of their own individual
risk for breast cancer. And for cultural reasons/difference, many do not want to know as a result
of fear of the possible outcome.
Informants were asked to share recommendations on strategies and opportunities for Komen to
strengthen relationships and partnerships in their communities. And all of them shared that they
would be interested in collaborating with community organizations to address the breast health
issues of the community and suggested that Komen paves the way in providing or assisting to
provide Black/African-American women through peer to peer support efforts in going through
the breast cancer continuum of care to alleviate the potential for isolation, feelings of
helplessness and fear.
Focus Groups
Focus groups were the second method of data collection used for the target communities
selected. A total of five focus groups were conducted; one focus group session was conducted
with Hispanic/Latina women in MSSA 25 and 26; another focus group of all women in MSSA 32;
and three focus group sessions were conducted with Black/African-American women in MSSA
35. Three out of the five focus group sessions were conducted in English, with a note taker, and
facilitator. For MSSA 25, 26 and 32, the focus group session was conducted in Spanish. On
average, the sessions were approximately two hours long. Verbal consent was collected from all
participants. Consent forms and notes taken are stored a DropBox that is protected by user log
in and password.
One focus group session was held with the Hispanic/Latino community with eight participants.
All participants were female. Participants included general community members. All
participants identified as Hispanic/Latino; one reported being 19; two reported 30-39; five
reported being 40 and older; three reported not having health insurance; and all preferred
primarily speaking in Spanish. The session had a facilitator and a note taker. The session
lasted two hours. The focus group was conducted in Spanish; notes were taken in Spanish and
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then translated into English. The focus group was audio recorded. A different guide was used
to formulate a focus group discussion guide with three key areas – understanding breast cancer
awareness and attitudes, attitudes towards accessing health care, and how participants
perceived Susan G. Komen.
Understanding breast cancer awareness and attitudes
Focus group participants shared with us their thoughts and insights on key health issues that
are most concerning to them; and many shared diabetes, cancer, arthritis, and domestic
violence. They were aware that having a family history of cancer increases their risk for getting
cancer and all of them shared that they would see a doctor if they noticed any changes or felt a
lump in the breast; however, all but one participant shared that they see their primary care
physician every year for a general exam. And many believe that a woman can get breast cancer
due to an injury to the breast, poor nutrition, stress, and genetics. Others shared that wearing a
bra gives you breast cancer, and that breast cancer only happens to women and not men.
Additionally, many shared that fear of dying comes first and then the fear of suffering and
leaving their families behind as their greatest concerns about having breast cancer. Others
shared overcoming depression when diagnosed and feeling like an outcast in their community
are additional challenges they face when they think about having breast cancer.
Attitudes towards accessing health care
In regard to knowledge about screening, 100 percent of participants noted that they were aware
of a need for annual screening starting at age 40. While the majority of participants mentioned
a need for an annual screening or check up, they noted that if one has a family history or is
symptomatic they should be screened more frequently.
How participants perceived Susan G. Komen
In regard to perceptions about Susan G. Komen, all participants shared they heard of Susan G.
Komen because of television commercials and in Avon books. Susan G. Komen is a familiar
organization that has funds to help women and walks for breast cancer awareness. All women
expressed a need for group support during their illness and shared that information should be
provided to community members via the Internet, brochures and in clinics and via organizations
such as WIC, and schools, hospitals, and clinics.
Others shared suggestions on how Susan G. Komen can have a better educational presence in
their community, which includes providing community conferences in rural areas to be able to
share information to the community and support groups for those diagnosed with breast cancer.
Another suggestion was to provide educational materials in other languages such as Spanish
and Hmong.
MSSA 32 – All Women
One focus group session was held in MSSA 32, Orange Cove/Parlier community with eight
participants. All participants were female. Participants included general community members.
All participants identified as Hispanic/Latino; two reported being 30-39; six reported being 40
and older; two reported not having health insurance; and all preferred primarily speaking in
Spanish. The session had a facilitator and a note taker. The session lasted about two hours.
The focus group was conducted in Spanish; notes were taken in Spanish and then translated
into English. The focus group was audio recorded. A different guide was used to formulate a
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focus group discussion guide with three key areas – understanding breast cancer awareness
and attitudes, experiences with accessing health care, and how participants perceived Susan G.
Komen.
Focus group participants were asked to share their thoughts and insights on health issues that
were most concerning to them; and many shared feeling a lump in the breast, womb problems,
any disease in the body, cancer, diabetes, high blood pressure were some of the key health
issues mentioned.
When asked what first comes to mind when they think about having breast cancer, many shared
that death is the first thing, and then side effects of chemotherapy, and fear of pain and
suffering. Additionally, they also shared support from family, partner, community and the
importance of continuing to love (take care of) oneself.
In regard to knowledge about screening, 100 percent of participants noted that they were aware
of a need for annual screening starting at age 40. And all of the participants shared that they
would see their doctor if they found a lump or felt pain in their breast, however five out of the
eight participants shared that they see their primary care physician for their annual exams.
As for the group’s perception of Susan G. Komen, many of them were aware of the organization
because of a recent participation at community outreach event, but they also shared that
education needs to be more frequent in the community. They explained that Komen needs to
help members of the community to increase their awareness of breast cancer screening, and
available resources to guide people and how to navigate or enroll health insurance. It was also
noted that Komen needs to provide education to young women starting at high school on how to
do self-examinations and about their risk factors.
MSSA 35 –Black/African-American Women
Three focus groups were held for Black/African-American women in MSSA 35 with 21
participants. All participants were female. Participants included general community members.
All participants identified as Black; three reported being 20-39 and twelve reported being 40 and
older (the rest are unknown); all reported having health insurance; and all preferred primarily
speaking in English. Participants were predominantly community members without
organizational affiliations; three were associated with community based organizations; one with
a university and four with a county or government agency. Each session had a facilitator and a
note taker. The average session lasted about two hours. All groups were audio recorded. A
different guide was used to formulate a focus group discussion guide with three key areas –
understanding breast cancer awareness and attitudes, attitudes towards accessing health care,
and how participants perceived Susan G. Komen.
Focus group participants were asked to share their thoughts and insights on health issues that
were most concerning to them; and many shared that they are mainly concerned about their
weight, diabetes and heart trouble. In one of the focus groups that were comprised of all women
between the ages of 50-82 years old, it was shared that they don’t take their health seriously;
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one participant specifically said, “I know I should be eating better and develop better habits and
lifestyle [but I don’t].”
When asked what first comes to mind when they think about having breast cancer, many shared
the feeling of devastation and fear, and all agreed that it is a death sentence in one of the focus
groups. In another focus group, one noted, “what would happen to my kids if I don’t survive?”
That sentiment also resonated from the third focus group about their family and how they would
share the news with them if they were diagnosed with breast cancer, as well as financial
worries.
Moreover, when asked what they have heard that causes breast cancer, two of the focus
groups shared that poor nutrition; breast feeding; deodorant; laying on ones stomach; and
keeping cell phones close to the chest, as their beliefs about what causes breast cancer. The
third focus groups have heard about myths and misconceptions about underwire bras and
deodorant use but know that those do not cause breast cancer.
In regard to knowledge about screening, 100 percent of participants that were 40 years old or
older noted that they were aware of the need for annual screening to start at age 40. And most
of the participants shared that they would see their doctor if they found a lump or felt pain in
their breast, but others shared that they would tell their family member first. Overall, their
attitude towards access breast health care appears to be positive.
As for the group’s perception of Susan G. Komen, many of them were aware of the organization
through various ways such as participation at the Komen Central Valley’s Race for the Cure, but
some also shared that they were unaware of the Affiliate’s educational outreach and grant
program. They explained that Komen needs to increase their presence at community events
and increase their visibility to the community and provide realistic images of those touched by
breast cancer.
Document Review
The third qualitative data collection method, specifically for MSSA 25 and 26 of Hispanic/Latina
women was incorporated as a result of the challenges that were faced in the recruitment of key
informant interview and focus group participants. A document review was conducted to expand
on what was gathered from the two data collection methods and identify other potential areas of
need and/or barriers for the Hispanic/Latino communities in MSSA 25 and 26.
The main search engine was accessed through California State University’s Health Sciences
main database, which includes access to CINAHL Plus with Full-Text, PubMed, ScienceDirect,
PsycINFO, Academic Search Premier, SAGE Journals Online, Wiley Online, and more. Google
Scholar, and Google News were also used to search for documents, and/or articles. The search
criteria included key words, such as breast, cervical, cancer, screenings, barriers, services,
gaps, access, rural, California, Fresno, Central Valley, farm workers, migrant workers,
agricultural workers, Latino, Latina, and Hispanic, chronic diseases.
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The search also included a review of key search words, such as reference review; related
citations, cited articles, related articles of interest were examined to increase the potential for
possible articles. Articles were narrowed by year from 2009-2015. Older articles were reviewed
for any recent and relevant citations. A total of nine articles resulted from the search process,
and six articles were selected to be reviewed using the following criteria; challenges or barriers
to breast health; utilization/attitudes towards accessing health care; and future opportunities.
These criterions were based on what was used in the key informant interview and focus group
guides. The review process included completion of a document review form providing a
synopsis of each article completed by a public health graduate student intern of California State
University, Fullerton and evaluated by a member of the CP team.
Most of the articles selected shared a common element in terms of the identification of key
challenges and barriers among Hispanic/Latina farm or migrant workers to breast health, which
includes lack of transportation, lack understanding of the health care system and how to
navigate it; fear of deportation; lack of access to interpreters for indigenous language speakers;
lack physical access to mammography screening programs; and the health coverage enrollment
process is too onerous with stringent requirements (Fernandez, M., et. al, 2009; Capitman, J., et
al, 2009; Mills, P., et al., 2014).
Other barriers to note include providers not understanding the patients’ health issue; language;
services were needed but were not offered to patients; and the strongest barrier identified in all
data collection methods was costs (Hoerster, K., et al., 2010).
Utilization / Attitudes towards accessing health care
Three of the articles addressed utilization and attitudes towards accessing health care among
the Hispanic/Latina farm/migrant workers; one of the key findings from a study published in the
American Journal of Public Health, which tested lay community health workers’ effectiveness to
increase breast and cervical cancer screening percentages among low-income Hispanic/Latina
women, found that post intervention, the experimental group (with lay community health
workers) had statistically higher breast cancer screening percentages than the control group. In
addition, the study found that interventions were also effective among women who had lower
levels of acculturation; emphasizing the importance of community health workers that can
deliver culturally relevant services (Fernandez, M., et al., 2009).
Moreover, an article found that many undocumented Latinos are uninsured, and lack a medical
home; however many fear deportation among other barriers, and consequently refuse to seek
health care (Capitman, J., et al., 2009; and Hoerster, K., 2010).
Most of the articles suggested the use of promotoras or community health workers as an
effective approach to establishing trust and ensuring women in the community are getting
screened and understand their breast health, as well as how to navigate the health care system
(Fernandez, M., et. al, 2009; Livaudais, J., 2010; and Capitman, J., et al, 2009). Although the
articles did not explicitly address breast health education, the use of promotoras or community
health workers would be appropriate to utilize their strengths to serve as messengers of breast
health education; and efforts to partner and/or collaborate would also be appropriate in making
an impact in the Hispanic/Latino communities of the Affiliate’s service area.
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Qualitative Data Findings
In MSSA25 and 26, commonalities among the qualitative data collected include:
 Fear and costs as the key barriers to seek and access breast health care services
 Lack of transportation and lack of interpreters as gaps in services
 Effectiveness of community health workers especially in rural areas where language and
education are limited
In MSSA32, commonalities among the qualitative data collected include:
 A need to increase awareness of available resources and programs that provide low or
no cost breast cancer screenings and diagnostics
 Fear and costs were also identified as a commonality as major barrier in accessing
breast health care services
 A need to collaborate and participate in more community outreach events to increase
visibility of Susan G. Komen and increase awareness of breast health
In MSSA35, commonalities among the qualitative data collected include:
 Access barriers to health care services are cultural and multi-factorial
 Transportation, financial assistance and education were found to be of greatest need
 Lack of knowledge/awareness of their risk factors for breast cancer
 Lack of awareness of available programs/resources
Limitations
Challenges were faced in the implementation of all qualitative data collection methods. The
Affiliate faced challenges in recruitment for both focus groups and key informant interviews.
While resources and service providers existed for most of the target populations, it was
challenging to find a large number of focus group participants and key informant interviewees
that wanted and could participate in the data collection process to discuss breast health and
breast cancer.
For focus groups the Affiliate had a great challenge in reaching out to the Black/AfricanAmerican and Hispanic/Latino community and securing focus group participation. While the
Affiliate recognizes this is a small population in Central Valley, it leveraged relationships with
key leaders and organizations and still struggled to identify interested participants. Low
participation may be associated with the lack of public dialogue about breast health in this
community.
For key informant interviews, the Affiliate faced the greatest struggle in identifying informants
that could speak about breast health and breast cancer specifically for MSSA 25 and 26. Lastly,
as for the document review, the Affiliate struggled in identifying articles that would help expand
on the information gathered in MSSA 25 and 26; three of the articles selected focused on the
Central Valley area as a whole; two of the articles were focused in California on low-income
Hispanic/Latino farm/migrant workers; and the last article is from Yakima, Washington but
focused on using promotoras for low-income Latinas in addressing breast cancer screening
practices. Although it is not specific to the MSSA 25 and 26 Hispanic/Latina women, these
articles were included for review because of the similarities in the population’s sociodemographics.
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The challenges noted above place limitations on the generalizability of the data to all target
communities in Central Valley. The time frame in which the Affiliate had to identify and recruit
participants also limited the ability to more robustly recruit and gather qualitative data however,
even with these challenges the Affiliate believes that it has gathered a representative and
convenient sample of perspectives to more deeply understand the concerns, issues and needs
of the four target communities. The data combined from the quantitative data analysis, health
systems and policy analysis, and qualitative data collection has provided rich information on the
local communities and allowed the Affiliate to look deeper into the areas of greatest needs in
these communities regarding breast health and cancer.
Having gathered information from the community through key informant interviews and focus
groups and reviewing documents, the Affiliate found some common themes across all target
communities and data sources. Most particularly that there is/are:
 A need for ongoing education – general breast health, screening, and treatment
information;
 An additional burden of cancer – financial costs, need for social support
 Breast health resources are available, but not accessible to all
o Health coverage/residual uninsured
o Need simple resource materials – e.g. where to go for screenings, who are
providers
 Continued need for early detection services
o Including low to no cost options
o Noting risks among diverse communities
o Promoting screening guidelines
 Opportunities for working with faith based organizations, community leaders, and
community centers
 A disconnect between education and behavior – especially in regard to pain and fear as
a barrier to screening
 Opportunities for partnership in outreach and education and bridging relationships with
key leaders and organizations in all communities
o Partnership opportunities also abound with clinical providers and hospitals
 A need for intergenerational messaging
 A continued need for Komen to promote breast health outreach, education, screening
and treatment information
Most importantly, this process allowed the Affiliate to reconnect and strengthen ties with local
community leaders and organizations who will continue to be pivotal partners as the Affiliate
continues to make strides to reduce breast cancer disparities in Central Valley.
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Mission Action Plan
Breast Health and Breast Cancer Findings of the Target Communities
Summary Findings from Quantitative Data Report
The Quantitative Data Report reflects breast health disparities with regard to rates of late-stage
diagnoses death rates, and screening behavior among specific communities in Central Valley,
California. For example, in MSSA 32 and 35 there are elevated numbers of advanced breast
cancer cases, specifically in Orange Cove, Parlier, Reedley, Squaw, Tivy and Wonder Valley,
as well as in most of the Fresno area where 30-40 percent of advanced breast cancers are
found among patients that reside in these regions. Additionally, there is a large percentage of
over 90 percent of Hispanic/Latino individuals residing in MSSA 25 and similarly in MSSA 26.
Other socioeconomic factors have been associated to health disparities and reduced access to
care that can increase a woman’s risk for late-stage diagnosis and breast cancer deaths.
Interestingly, 48 percent of the female population in the Central Valley service area are of
Hispanic/Latino descent and represent a fair number (about 20 percent) of women who have not
been screened for more than two years and/or never had a mammogram screening. Likewise,
among Black/African-American women specifically in MSSA 35, there is an increasing trend for
late-stage breast cancer incidence; however according to California Health Interview Survey
data Black/African-American women that have not been screened for more than two years
and/or never had a mammogram screening is fairly small (about 12 percent combined); in other
words, about 88 percent of Black/African-American women in Central Valley are getting
screened regularly. It became evident that these breast health disparities must be further
explored in the following section of the Community Profile.
Summary Findings from Health Systems and Public Policy Analysis
Health systems and public policy analysis highlights several key findings. Specifically, in MSSA
25 and 26, it was identified that these regions are considered to have a health professional
shortage of 3,196 civilians per primary care physician in MSSA 25, and 4,184 civilians per
primary care physician in MSSA 26 (OSPD, 2014). It was also identified that these areas are
predominately rural and have limited breast cancer screening services available. Not to
mention, access to breast cancer diagnostic and treatment services are 45 miles away from
MSSA 25 and 26, which would suggest that this would factor into a woman’s ability (or inability)
to make her breast health a priority among other life priorities.
Similar findings were identified in MSSA 32 with regard to the health professional shortage of
2,693 civilians per primary care physician (OSPD, 2014). MSSA 32 is also predominantly rural
with a large population of transient farm workers; however there are EWC providers as well as
four FQHCs or look alike community health centers to provide breast cancer screening services.
As well, in MSSA 35 breast health services are more available and accessible for Black/AfricanAmerican women in this area yet there is an increasing trend of late-stage incidence of breast
cancer within this target community.
In the public policy analysis, the preservation of the National Breast and Cervical Cancer Early
Detection Program/Every Woman Counts program was identified as an area of concern.
Moreover, the implementation of the Affordable Care Act has conceivably made access to
57 | P a g e
health care more attainable; though more data are needed to understand the actual impact of
California’s health insurance exchange on access to and utilization of the entire breast health
continuum of care. It is expected that 40,664 women in the Fresno area will remain uninsured,
with over half of the estimated number to be ineligible for coverage due to their immigration
status (Lucia et al, 2015). Other factors such as individuals being ineligible for financial
subsidies will leave many residents in the Central Valley’s service area vulnerable and they will
need to depend on the availability of safety-net programs/services.
Summary Findings from Qualitative Data Report
From the qualitative data collection process, the Affiliate’s Community Profile Team was able to
identify key commonalities in each of the target communities selected. The first commonality is
the importance in raising awareness and knowledge about available breast health screening
programs and services. Secondly, barriers to access breast health care services includes lack
of transportation, a lack of geographic proximity to diagnostic and cancer treatment facilities,
and a lack of in-language interpreters. Lastly, it was observed from all of the qualitative methods
utilized that partnerships and collaborations are important and necessary for building awareness
and visibility of Susan G. Komen and of breast health/breast cancer.
It was found that among Black/African-American women, barriers to access breast health care
are cultural and multi-factorial. Other needs such as financial assistance, transportation
assistance, and continued education about associated risk factors for breast cancer and
education about the availability of resources are highly needed among Black/African-American
women in MSSA 35. Likewise, in MSSA 32 it was shared that increasing awareness of available
programs and/or resources that provide low or no cost breast cancer screenings and
diagnostics are needed in this community to help reduce barriers and fears of the cost burden
for those who are uninsured and/or low-income.
Interestingly, findings from key informant interviews conducted for Hispanic/Latina women in
MSSA 25 and 26 confirmed information gathered during the document review process on the
effectiveness of using community health workers in rural areas as messengers of breast health.
It was suggested that the application of the promotora-model would build trust and credibility of
the community, which would enable them to increase their knowledge and awareness of
available programs and resources in a culturally appropriate manner.
Other information gathered during the qualitative data collection process were suggestions for
Komen Central Valley to improve and/or expand upon their reach by partnering with community
clinics, colleges, etc. and attend or host outreach events that are centrally located in each of the
target communities. Lastly, it all participants believed that breast health education should begin
at a young age, specifically when they are in high school. Many agreed that by learning at an
early age that many young women will know how to take care of any breast health issues,
should there be any; as well as have an increased level of comfort/confidence when talking
about their breast health concerns because they will have the knowledge and tools to be
proactive and practice early detection/risk reduction behaviors.
58 | P a g e
Mission Action Plan
The Mission Committee engaged in a strategic process to develop an action plan covering April
1, 2015 to March 31, 2019. Key findings from the quantitative, qualitative, health systems and
policy analysis were presented. From this discussion evolved the development of six
problem/need statements. The statements were presented to the committee along with
rationale of the problem/need and sample solutions via handout. Each committee member
individually developed priority statements and multiple solutions they considered relevant and
appropriate in addressing each of the need/problem statements. All the ideas/solutions were
grouped by programmatic similarity, i.e., partnerships, outreach and education, grant-making,
etc.; and then the committee engaged in dialogue to discuss the resolutions gathered for each
of the target communities.
Shortly after, the committee participated in a voting process to narrow six of the need/problem
statements down to three; prioritizing the highest problems/needs for the Affiliate to address in
the next four years. The group provided rationale for the three problem/needs statements,
which received the majority of the votes. Further discussion about the justification for the three
problem/need statements that received the least number of votes included concerns about
feasibility.
As a result, the following Mission Action plan involved the input of the CP Advisory Team, the
Mission Committee (includes key representatives in grant-making, public policy, and the
Affiliate’s special initiative efforts focused on two of the target communities selected), staff, and
the Board of Directors to help the Affiliate formulate priority statements and S.M.A.R.T.
objectives for each of the priority areas.
The following is the Mission Action Plan for Komen Central Valley to address by March 31,
2019:
HISPANIC/LATINA WOMEN IN MSSA 25 AND 26
Priority Need/Problem: From health system analysis and qualitative data there is a lack of
breast health services and information across the continuum of care.
Priority Statement: Increase knowledge and awareness of available breast cancer screening
services that is culturally and linguistically appropriate for Hispanic/Latina women in MSSA 25
and 26.
cultural/community events in MSSA 25 and 26 reaching 500 Hispanic/Latina women with
information about available breast cancer screening services.
Objective 2: In the FY18 Community Grant Request for Application, programs that link
and/or provide screening services for Hispanic/Latina women in MSSA25 and 26 will be a
funding priority.
Objective 3: By 2019, Komen Central Valley will recruit and train six to eight breast
health advocates who are bilingual, bicultural, and/or age-appropriate in Spanish to
provide breast cancer and breast health education and information on available
programs/services to Hispanic/Latina women in MSSA 25 and 26.
59 | P a g e
ALL WOMEN IN MSSA 32
Priority Need/Problem: From the health system analysis and qualitative data, there is a
substantial gap in breast services within the continuum of care, specifically in breast health
diagnostics and treatment.
Priority Statement: Build relationships with organizations/agencies to better understand the
gaps in service and how to address them appropriately.
Objective 1: By 2017, Komen Central Valley will develop three new collaborative
relationships with organizations that serve women residing MSSA 32 to understand and
learn more about how to address their breast health needs and barriers to access.
Objective 2: In the FY17, Komen Central Valley will give priority (or add weighted value
during review process) to grant applications that propose to provide breast health and
breast cancer-specific patient navigation and/or aims to reduce access barriers, such as
transportation barriers for their breast cancer diagnostic and treatment needs for women
in MSSA 32.
BLACK/AFRICAN-AMERICAN WOMEN IN MSSA 35
Priority Need/Problem: From the qualitative data, there is a lack of awareness of available
programs and services to help reduce barriers to accessing breast health care services.
Priority Statement: Partner with organizations, agencies, and/or professional associations to
help address the diverse needs and barriers to motivate for Black/African-American women in
Central Valley to obtain breast health care services.
Objective 1: By 2017, Komen Central Valley will build three to five strong local
Black/African-American partnerships that are effective, sustainable, and visible in the
community to ensure engagement in activities such as breast health outreach and
education, access to care, and advocacy efforts.
cultural/community events in MSSA 35 reaching 1,000 Black/African-American women
with information about available breast cancer screening services.
Objective 3: In the FY17 Community Grant Request for Application, programs that
address health-care decision-making to improve access to screening services for
Black/African-American women in MSSA35 will be a funding priority.
60 | P a g e
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2015 Komen Central Valley COMMUNITY PROFILE

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