Providing Free Cancer Screening Isn’t Enough to Protect Low-Income and Uninsured Women From Cancer

Bonnie Jerome-D'Emilia

Bonnie Jerome-D’Emilia

By Jeanne Leong

Having an annual physical exam and being screened for breast or cervical cancer gives women a chance to uncover potential health problems, but despite the availability of government-funded check-ups, many low-income and uninsured women don’t visit a doctor early enough to prevent serious health issues.

Two studies by Rutgers University‒Camden nursing professor Bonnie Jerome-D’Emilia reveal interesting information about the type and quality of care that low-income and uninsured breast cancer patients receive.

A study led by Jerome-D’Emilia evaluated five years of breast cancer data from Cooper University Hospital, comparing a patient’s stage of cancer at the time of diagnosis to determine the effectiveness of the New Jersey Cancer Education and Early Detection program (NJCEED).

From 2004 to 2009, 1,040 women were diagnosed with and treated for breast cancer at the hospital; 78 of these women were diagnosed through the NJCEED program at that site.

In the study, “Breast Cancer Stage at Diagnosis in a New Jersey Cancer Education and Early Detection Site,” Jerome-D’Emilia and her co-authors write, “Racial and ethnic minority women continue to be diagnosed with breast cancer at a later stage and with greater tumor size and higher-grade tumors, important predictors of cancer mortality.”

“Preventive care is not a priority for many of these women,” says Bonnie Jerome-D’Emilia, an associate professor at the Rutgers School of Nursing–Camden.

Many uninsured and low-income women only see a doctor after symptoms have appeared, says Jerome-D’Emilia. “If you are low-income and you lack health insurance, as a woman, you may put your family first, and before yourself,” she says. “It’s very difficult to figure out how to help women who have tenuous financial circumstances to prioritize themselves when they are probably thinking about putting food on the table, and missing a day of work.”

Jerome-D’Emilia is planning future research on how low-income women make decisions about their health needs. She also wants to look into ways to help those women get proper health care.

The article is available in the November 2018 issue of the American Journal of Clinical Oncology.

Jerome-D’Emilia co-authored the paper with Patricia Suplee, an associate professor of nursing, and Debashis Kushary, an associate professor of mathematics, both at Rutgers University‒Camden; Katherine Hanson of the MD Anderson Cancer Center at Cooper, Cooper University Hospital; and Sherry Burrell of the Villanova University College of Nursing.

While conducting research for that study, Jerome-D’Emilia found out information about breast cancer screening that led to a related research project.

Through screening, some women have been found to have lobular carcinoma in situ, (LCIS), which is a risk factor, but not a precursor to breast cancer.

“An LCIS finding doesn’t ensure that you are going to get cancer, but it does seem to be related in some way to the development of breast cancer,” says Jerome-D’Emilia.

In looking at breast cancer screening data, she saw that because of the LCIS finding, some women were getting bilateral mastectomies unnecessarily.

Surprised to learn that some women were having both breasts removed with a diagnosis of LCIS, the Rutgers University–Camden researcher began exploring why those patients were taking such extreme measures. Working with Evelyn Robles Rodriguez, director of outreach, prevention, and survivorship at Cooper University Hospital, Jerome-D’Emilia was able to access 10 years of New Jersey breast cancer data.

After evaluating the data, she connected with a researcher, Schelomo Marmor, at the University of Minnesota, who had ten years of similar data from California. The researchers compared the data from New Jersey and California to see what kind of treatment was being done for LCIS, and if and why women were being treated.

The standard treatment for the LCIS diagnosis is for doctors to watch to see how it progresses, and to treat it with an endocrine therapy (ET) treatment such as tamoxifen.

“A finding of LCIS is no guarantee that you are going to get breast cancer, but it may increase your risk,” says Jerome-D’Emilia. “But if you take the hormone treatment it can decrease that risk.”

The researchers found it was more common to receive the ET treatment in California than in New Jersey.

“One factor that we think might possibility explain the relatively low utilization of ET treatment for LCIS is that when you take the hormone treatment, you may have menopausal symptoms,” says Jerome-D’Emilia. “It could be that the reason that doctors don’t prescribe, or that women don’t want to take, the hormone treatment is because they don’t want to experience menopausal symptoms, so they would rather just either take their chances with no treatment, or have a mastectomy or even bilateral mastectomies, which are not recommended in any guidelines.”

They also found that uninsured women were less likely to receive the hormone treatment. Jerome-D’Emilia’s other research has shown that the type and quality of treatment a patient receives may be related to whether the patient has health insurance.

“Whether or not you are insured determines your access,” says Jerome-D’Emilia.

The article, “Trends in Lobular Carcinoma in situ Management: Endocrine therapy use in California and New Jersey,” is available in the journal Cancer Causes and Control.

The research team – which includes James Begun, Jane Yuet Ching Hui, and Ariella Altman, all of the University of Minnesota – says that further research is needed to identify the practice patterns associated with variations in ET utilization, and the most effective methods of educating physicians and high-risk women about the benefits of chemoprevention in reducing breast cancer risk.

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