Exculuding skin cancer, breast cancer is the most common cancer among women and is the second-leading cause of cancer death in women.1-3 In 2011, the American Cancer Society estimated there would be 230,480 new cases of invasive breast cancer.1 Orange County (OC) California is the third most populous county in California and has a slightly higher incidence of breast cancer than the state average.2 It is projected that by 2020, the adult female population in OC will increase by 25% from 974,643 to over 1.2 million, and this increase is reported to be mostly in women aged 55 years and older.4 Women have a 98% 5-year survival rate when cancer is localized to the breast.5,6 Evidence shows that early-stage diagnosis and intervention are directly related to decreased mortality rates for breast cancer.5,6 Nevertheless, studies have indicated that many women are not establishing routine screening schedules, are initiating screening at a later age than recommended, or are delaying follow-up after positive screening findings.6 These practices result in women being diagnosed at a more advanced stage. Further decline in mortality rates, however, can be made with improvement in routine use of mammography screening and the provision of timely access to quality care.6
Table 1 summarizes the percentages of women age 40 and over in the United States, in California, and in OC who have had a mammogram within the past 2 years. The national reported rates demonstrate a decline in mammography since 2000.3 Yet, for California and OC, data show an increase in compliance.7 However, OC reports a decline in compliance in the subset of women in the 40- to 49-year-old age group. Also, the California Health Interview Survey for OC reported in 2009 that only 71.6% of physicians examined breasts for breast lumps within the past 12 months and only 83% of physicians recommended a mammogram.7
According to a study by the Robert Wood Johnson Foundation (2007), nearly 4000 lives could be saved yearly if mammography and clinical breast exam biannual screening rates could be increased to 90%.8 Anticipating that OC will have an increase in the aging population, it is evident that the message of breast health awareness and screening needs to be conveyed to the community. Barriers to women having mammography screening and clinical breast exams have been identified. These barriers include lack of knowledge about cancer and cancer screening, deficiency in physician referral, low motivation, fear, transportation problems, lack of health insurance, and forgetfulness.9 Identifying interventions to address the barriers is imperative in order to increase compliance in breast cancer screening.
Dr Harold Freeman established the first patient navigation program in 1990 to assist the medically underserved and uninsured by providing timely access to screening and treatment.10 Programs like Dr Freeman’s that emphasize screening and outreach have demonstrated significant and measurable successes.10 The Oncology Nursing Society’s position statement for oncology navigation identifies that navigators must have education on and demonstrate knowledge about community assessment, resolution of system barriers, and cancer health disparities.11 The oncology nurse navigator has a unique opportunity to take the lead to ensure that communities have access to cancer screening and receive timely access to care. The navigator is an advocate within the healthcare system to facilitate community outreach and education.
The American College of Surgeons Commission on Cancer has established standards that focus on community outreach (Standard 1.8) and patient navigation (Standard 3.1).12 These standards require a hospital seeking accreditation to demonstrate that community needs have been assessed and health disparities identified. Community outreach programs need to be designed to address the needs and barriers. Patient navigators participate in identifying barriers and facilitating timely access to care across the care continuum.
St Jude Medical Center (SJMC) in OC began an innovative nurse navigator program in the spring of 2007. The oncology nurse navigator leads the multidisciplinary team in program development and process improvement initiatives to assure sustainable and measurable program growth using current evidence-based practices. As part of this process, the oncology navigator acts as a resource to promote cancer awareness through community events and educational activities.
The American Cancer Society states, “Further reductions in breast cancer death rates are possible by improving regular use of mammography screening and providing timely access to highquality follow-up and treatment.”6 Therefore, SJMC clearly has an opportunity to make a positive impact in the north OC communities by implementing an intervention to directly influence patient outcomes and decrease barriers to care. This can be accomplished by improving community breast health practices, increasing screening mammography, and increasing breast awareness practices, thereby diagnosing breast cancer earlier.
PLANNING AND IMPLEMENTATION
Lillie Shockney, RN, BS, MAS, discussed the BreastivalTM community outreach program at the First Annual Navigation & Survivorship Conference held in Baltimore, Maryland, September 17-19, 2010.13 The BreastivalTM event is an opportunity to creatively facilitate community outreach and education on breast health and awareness developed by Ms Shockney and the Johns Hopkins Breast Center and supported by the Johns Hopkins University sorority of alpha Kappa Delta Phi. The university hosted its first BreastivalTM event in 2001 and reported outcomes that included the number of attendees, the number of participants for group activities, and the number of attendees who reported learning the correct technique for breast self-exam on a breast model.13 A BreastivalTM Resource and Planning Kit is available to groups interested in replicating the trademarked event.14
The goal of the Breastival is to provide an enjoyable and nonthreatening atmosphere where the community can learn about breast health/ awareness and breast cancer. The event allows for local breast cancer organizations to partner and share the resources and support available in the community. Additionally, the event offers several different opportunities and activities for interacting with healthcare professionals and community organizations. The activities include opportunities to address breast health questions, interact with breast cancer community organizations, play games, and attend educational mini-seminars. Measurable program outcomes can be obtained to assess the impact of the event in the community.
The Breastival outreach program aligns with the goals of the California Dialogue on Cancer (CDOC), the American Cancer Society (ACS), the Orange County Affiliate of Susan G. Komen for the Cure, and SJMC. All these organizations place importance on and invest their resources in building relationships with community-based breast programs and hospitals in order to wage the war against breast cancer. One of the CDOC’s goals is to increase the number of women having both a clinical breast exam and mammogram by 7.5% by 2015.15 The researchers at ACS stated that it will take a coordinated effort to increase cancer awareness and move forward in preventing cancer.16 Komen literature states that efforts need to be placed on partnerships within the community to develop a comprehensive plan for outreach and education.2
The mission at SJMC is “to extend the healing ministry of Jesus in the tradition of the Sisters of St. Joseph of Orange by continually improving the health and quality of life of people in the communities we serve.”17 The hospital’s strategic goals include developing and implementing disease-specific programs to enhance presence through “perfect care,” having the “healthiest communities,” and creating “sacred encounters.” Offering community health education and awareness complements the mission of our institution by striving to achieve healthy communities.
The outreach program was presented to the Breast Workgroup at SJMC in January 2011 in order to gain their support to move forward with the implementation of this innovative program. The Breast Workgroup is an interdisciplinary breast care team that develops and sets program goals, reviews and discusses clinical practice with current evidence, and reviews quality indicators and outcomes under the supervision of the Cancer Committee. The team consists of the medical director of oncology services, the comedical directors for the St Jude Kathryn T. McCarty Breast Center, director of the SJMC Breast Center, director of oncology services, nurse navigators, clinical nurse specialist, physicians, and other interdisciplinary team members. The role of the navigator was to champion this event and build excitement and momentum to achieve approval. The committee gave its full support to implementing the community outreach program.
Strategies were designed to establish an organized process for successful execution. The BreastivalCommittee was formed to plan the outreach event. The committee members included the director of imaging, director of oncology services, manager of the breast center, breast nurse navigator, lead technologist, manager of the inpatient oncology unit, marketing representative, radiologist, SJMC executive chef, and the corporate sponsor. The radiologist was the physician chair and the navigator was the committee chair. The committee reviewed the event tool kit. It was decided to host 2 events: 1 for the SJMC staff and 1 for an SJMC community.
The committee decided to tie in the employee health campaign called “Choose Well.” The focus of this campaign is to help employees improve individual health outcomes and develop healthier lifestyles. Offering this event at the workplace gives employees easy access to cancer screening and breast health education and serves to increase awareness and support. It was decided to hold the SJMC employee event on the hospital campus October 13, 2011, because October is Breast Cancer Awareness Month.
The Oncology Services Department had previously partnered with Harley-Davidson® Anaheim-Fullerton in community outreach programs. The general manager of Harley-Davidson enthusiastically agreed to participate in Breastival by donating space at their facility in Fullerton, which has a large outdoor venue, and providing volunteers, entertainment, and additional resources. Because Harley-Davidson already had an annual event scheduled in October, the Breastival event was scheduled for November 20, 2011.
The project was divided into 6 sections and assigned to subcommittees: (1) food and venue, led by the SJMC executive chef, (2) sponsors, led by director of oncology services, (3) community organizations, led by breast nurse navigator, (4) games and educational seminars, led by manager of the SJMC Breast Center, (5) volunteers, led by lead technologist of SJMC Breast Center, and (6) marketing, with co-leaders the director of imaging and Breast Center nurse navigator. Breaking the responsibilities and details into smaller committees that reported back to the Breastival Committee made the work more manageable and time efficient. The subcommittees met as needed, and the BreastivalCommittee met monthly. The committee chair communicated frequently with the group via e-mail to keep the team updated on the subcommittees’ progress.
The Breastival tool kit describes very detailed processes on how to host the event. Also, Ms Shockney made herself available to answer any questions and give guidance. Once the venues and dates were secured, we needed to establish partnerships with community breast cancer organizations to sponsor the events. The following organizations played a vital role in the event: Orange County Breast Cancer Coalition, ACS, Susan G. Komen for the Cure, Healing Odyssey, St Jude Kathryn T. McCarty Breast Center, Virginia K. Crosson Cancer Center, St Jude Expressions Appearance Center, and Synergy St Jude Fitness Center. Each of these organizations had community resources, educational materials, and information to offer.
Marketing strategy and development of a design that would be recognizable for the 2 events were components in the planning process. The committee established a collaborative relationship with the hospital marketing department. Print media were developed that included the event logo, flyers, both internal and external advertisements, as well as event materials such as educational message boards, passports, and evaluations.
During the 9 months prior to the events, the subcommittees worked diligently to secure sponsors for food and raffle prizes. The educational content was identified, and games that were fun and interactive were created to emphasize key points. An “Ask the Doc” segment was built into the event to offer an opportunity for the attendees to ask the breast care physician team questions about breast health and breast cancer. Speakers were secured for the educational mini-seminars and topics were selected offering a cross section of breast health and self-care topics.
The educational mini-seminars were on yoga, “Taking Care of Mind, Body, and Spirit”; mammography, “To Squish or Not to Squish”; proper bra fitting, “Does Your Cup Runneth Over?”; nutrition, “ABCs of a Healthy Diet”; self-care, “Keeping Humpty Dumpty on the Wall—Hang in There Baby”; and breast self-exam, “The Breast Macarena.” There was also a booth with men’s health and cancer prevention information that was made available to attendees. Women had an opportunity to make a “pinky promise” stating they would have an annual clinical breast exam and mammogram and were given an opportunity to schedule a mammogram. If a woman did schedule a mammogram, she was given a pink ring. At each of the events, food and entertainment were supplied by our sponsors.
Booths allocated to the 8 participating community organizations were arranged around the perimeter of the space. Each organization showcased the services offered to the community. Educational posters featuring breast cancer statistics and health facts were created and placed throughout the space to capture participants’ attention. The space was designed so it was easy to navigate, allowing for participation in all event activities. Table 2 outlines the BreastivalTM event activities.
The attendees were given a passport that outlined the event and gave instructions on how to find their way through the experience; on the reverse side was the event evaluation. As the attendees visited each of the 8 booths, they were asked a breast health question, and if they answered correctly, were given a stamp on the passport. If the attendees visited all 8 booths and answered the questions correctly (as evidenced by completing their passport), they had an opportunity to submit their passport for a “booby prize.” Prior to submitting the passport, the attendee was asked to complete the evaluation on the back for feedback. Optionally, participants attended an educational mini-seminar, participated in games, and could schedule a mammogram. They then signed a banner that stated “BREASTIVALTM Celebrating Breast Cancer Awareness 2011.” After the events, the banners were hung outside on buildings at each of the venues, displaying the many signatures and special messages to the community.
The outcomes of both Breastival events are outlined in Table 3.
Each of the events was seen by the committee as a success. The SJMC staff members expressed that the event was educational and fun. A measurement of success was the number of attendees reporting new knowledge gained on the event evaluation. In addition, 42 mammograms were scheduled. Several women had not had a mammogram for 6 to 10 years, and further outcome studies must be done to assess whether these women will follow up and actually have the imaging completed as scheduled. Periodically throughout the day there were “Ask the Doc” segments during which the physicians/nurse practitioners would answer written questions addressing common concerns about breast health and breast cancer treatment. This was cumbersome and interfered with the event flow and activities. It was decided by the committee to continue to incorporate the concept at the second event but to have an “Ask the Healthcare Professional” booth that would be manned for 15 minutes on the hour throughout the event. Unfortunately, due to rain this activity was canceled.
The community event at Harley-Davidson in Anaheim-Fullerton was well attended in spite of torrential rain. Over 300 attended, and half of the attendees completed the passport. Unfortunately, the rain and wind would not let up and the event was closed 2 hours prior to the scheduled time. Regardless of the weather, people commented that they enjoyed learning about breast health, eating barbeque, and listening to a live band. The 20 members of the Positively Pink Club from Fullerton High School, which raises breast cancer awareness and education at the high school level, participated in the event.
There was high traffic at the mammogram scheduling booth, but due to the attendees having various medical homes, many needed to be referred to different facilities. St Jude Breast Center did schedule 2 mammograms. For future events, it will be imperative to identify community members who have different medical homes and identify ways in which their needs can be addressed. The event message was received, as evidenced by women inquiring about scheduling a mammogram and acknowledging the value of early detection. There were several opportunities during which services to the underinsured and underserved populations were offered by community organizations. These women were networked into programs for cancer screening and supportive care, which was one of the outcome goals for the event. Harley-Davidson asked SJMC to partner together for next year and host another Breastival event.
Additional outcome surveys from both events asked the attendees to rank their favorite parts of the event. The outcomes were as follows: (1) opportunity to ask experts and healthcare professionals questions; (2) presentations on breast health and cancer prevention; (3) convenience— easy to visit all booths and presentations; (4) games and raffles; and (5) food and entertainment. Attendees suggested that the event could be improved by extending hours, offering more men’s health information, incorporating survivor stories, having more booths, providing Spanish-language materials, and having better weather. The attendees felt that the events were well organized, fun, interactive, and informative.
The Task Force on Community Preventive Services has made some evidence-based recommendations on interventions to increase breast, cervical, and colorectal screening.18 These recommendations include the use of small media such as printed materials, one-on-one education, increasing community access, and reducing barriers, which are the methods used in the Breastival. The structure of the event allowed for many different opportunities to interact and learn, made resources available, and facilitated access to screening by reducing the barriers.
The words “boob” and “booby” have been used in design and implementation of the Breastival event. This may be offensive to some when referencing the breast. The terms were used to facilitate communicating the breast health awareness message in a fun and nonthreatening manner. The terminology is also consistent with that used in the Breastival tool kit. In hosting both a hospital employee and a community event, our committee did not receive any negative feedback or comments about the words “boob” or “booby.” In fact, the terminology created a less frightening atmosphere and broke down some barriers to talking openly about breasts.
Nurse navigators are in a key position to champion the message for breast cancer awareness and screening. The steps to implementation of a community outreach program start with identifying the current compliance rates for screening mammography, physician practices for screening mammography referrals, and clinical breast exams. Next, the navigator must identify the needs of the community and barriers related to breast cancer screening and seeking early follow-up care and treatment. Finally, the navigator develops a plan for education and outreach that aligns with plans at the national, state, and local levels as well as with the hospital organization.
To achieve success, it is imperative that the navigator receive administrative and physician support and buy-in. The vision for the Breastival event was to look for new and innovative ways to get the message and resources out to staff and the surrounding community. The challenge of this event was to step outside of what is comfortable and raise the bar in offering ground-breaking opportunities to meet the needs of the community for breast health awareness and screening. We believe that we met this challenge and look forward to repeating this successful project in the future.
Acknowledgements: I would like to thank the Breastival Committee for all the hard work and dedication that created 2 successful events. The committee team members are: Will Gotay; Gianna Laiola, RN, BS, OCN; Tom Loveland; MaryAnn Perez; Lea Powell, RN, MSN, OCN; Paula Reese, RTM; Judy Ricci, RN, BSN; Cathy Shircliff, CTR; Phillip Unger, MD; and Bertha Vargas, ARRT, RTM, RDMS, BR. Also, a special acknowledgement to my mentor Kathy Pearson, RN, CNS, AOCN, who always challenges me to pursue clinical excellence and never stop learning.
- Desantis C, Siegel R, Bandi P, et al. Breast cancer statistics, 2011. CA Cancer J Clin. 2011;61:409-418.
- Orange County Affiliate of Susan G. Komen for the Cure. Community profile report 2011. http://www.komenoc.org/atf/cf/%7B7DAE5A7D-C3F4-4C8C-BA7A-FEBDCE255920%7D/2011%20CPReport%20Final_6.7.2011.pdf. Accessed March 15, 2012.
- American Cancer Society. Breast cancer facts & figures2011-2012. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf. Accessed March 15, 2012.
- Orange County Affiliate of Susan G. Komen for the Cure® & UCI Data Project. Breast cancer incidence & prevalence in Orange County. IV. Planning for breast cancer in Orange County. http://www.komenoc.org/atf/cf/%7B7dae5a7d-c3f4-4c8c-ba7a-febdce255920%7D/MONOGRAPH%204.PDF. Accessed March 30, 2012.
- Henley SJ, King JB, German RR, et al. Surveillance of screening-detected cancers (colon and rectum, breast, and cervix) – United States, 2004-2006. MMWR Surveill Summ. 2010;59:1-25.
- American Cancer Society. Cancer prevention & early detection: facts & figures 2011. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029459.pdf. Accessed March 12, 2012.
- Mammogram Screening History 2009. California Health Interview Survey Web site. www.chis.ucla.edu. Accessed November 18, 2011.
- New study: boosting five preventive services would save 100,000 lives each year. Robert Wood Johnson Foundation Web site. http://www.rwjf.org/pr/product.jsp?id=21904. Published 2007. Accessed November 26, 2010.
- Breslow RA, Rimer BK, Baron RC, et al. Introducing the community guide’s reviews of evidence on interventions to increase screening for breast, cervical, and colorectal cancers. Am J Prev Med. 2008;35(suppl 1): S14-S20.
- Varner A, Murph P. Cancer patient navigation: where do we go from here? Oncol Issues. 2010;May/June:50-53. http://accc-cancer.org/oncology_issues/articles/mayjune10/MJ10-VarnerMurph.pdf. Accessed March 18, 2012.
- Oncology Nursing Society, Association of Oncology Social Work, National Association of Social Workers. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. Oncol Nurs Forum. 2010;37:251-252.
- Cancer program standards 2012: ensuring patient-centered care. American College of Surgeons Web site. http://www.facs.org/cancer/coc/programstandards2012.html. Published 2011. Accessed December 3, 2011.
- Shockney L. Reaching your community can be more than standard educational events. J Oncol Navigation & Survivorship. 2010;1:22. http://issuu.com/aonn/docs/jons_november2010. Published November 19, 2010. Accessed March 18, 2012.
- California’s comprehensive cancer control plan, 2011- 2015. California Dialogue on Cancer Web site. http://www.cdoc-online.org/cccp.html. Updated July 2011. Accessed March 18, 2012.
- ACS report: more collaboration needed to increase anticancer efforts. American Cancer Society Web site. http://www.cancer.org/Cancer/news/News/acs-report-more-collaborationneeded- to-increase-anti-cancer-efforts. Published May 19, 2011. Accessed November 2, 2011.
- St Jude Medical Center mission statement. St Jude Medical Center Web site. http://stjudemedicalcenter.org/content/aboutus-0. Accessed November 2, 2011.
- Task Force on Community Preventive Services. Recommendations for client- and provider-directed interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2008;35(suppl 1):S21-S25.