In the early 1990s, public health officials in Contra Costa County, California, needed some expert help. Contra Costa County had, and still has, one of the highest rates of breast cancer in the United States. Statistics have shown that, while white women have the highest incidence of breast cancer, African-American women are dying at the faster rate.

This problem is not unique to the county; the same disparity exists throughout the country. By nearly the end of the century, no county in California, or perhaps in the entire nation, had ever brought about parity in breast-cancer survival rates between black and white women. This, however, was what Contra Costa County set out to do, and county staff knew they couldn’t do it alone. They needed a dedicated, knowledgeable partner with whom they could work on the problem.

Fortunately, rather than having to look outside the locality for expert consultants, Contra Costa Health Services (CCHS), the county health department, found the help it needed in the community itself.

“The change we were looking to make couldn’t be made without participation by the community,” said Dr. Wendel Brunner, M.D., the county public health director. “Instead of going to the general public and telling them what needed to be done, we showed them the studies and asked how they would go about fixing the problem, and then we helped to do it.”

Like any public agency with limited resources, CCHS already had a full plate. It operated (and operates) a health plan, a regional medical center, 12 health centers, and many other programs serving the second largest county in the San Francisco Bay Area. The population of the county, which encompasses 800 square miles, is close to a million people whose ethnic demographics are nearly a mirror of those of the United States: census data in 2000 showed the population to be 58 percent white, 17 percent Hispanic, 11 percent Asian/Pacific Islander, and 9 percent African-American (with 5 percent other groups).

One of the causes of the higher African-American mortality from breast cancer had to be late diagnosis, the CCHS theorized. When breast cancer is diagnosed early, it is usually cured, while a late diagnosis is more likely to mean death.

The health department already had been working to promote early detection of breast cancer for several years before 1992, when detailed county statistics became available. Those 1992 numbers showed that 72 percent of white women with breast cancer had their tumors diagnosed at an early stage, when the cancer was more curable. Only 44 percent of African American women with breast cancer in Contra Costa were diagnosed early, meaning that the majority of affected black women were first diagnosed with late-stage disease. Latinas were likewise being diagnosed later than Euro-Americans.

A number of organizations and agencies offered breast health education and services in the Bay Area in the 1980s, but few extended throughout Contra Costa County. Those that did so operated independently of each other, with little collaboration, and sometimes even at cross-purposes. Consequently, one of the county’s first actions dealing with its breast-cancer health disparity was to help form the Bay Area Cancer Coalition in 1987. The coalition had been working since then on cancer control in low-income and minority communities. The 1992 statistics showed where to focus the outreach efforts.

Getting the Community Involved
By 1992, the coalition had partnered with the Northern California Cancer Center to conduct the Breast and Cervical Cancer Intervention Study (BACCIS). This study targeted low-income, uninsured, ethnic women aged 40 and older in San Francisco and one city in Contra Costa, Richmond. Not only did the study further document the existing disparity, but it also provided a vehicle for outreach into the city with the largest African-American population in the county.

“With BACCIS, African-American women in Contra Costa really got involved in our community’s health,” said Wanna Wright, a breast cancer survivor and founding member of the African American Task Group of the Contra Costa Breast Cancer Partnership. “We had homemakers, poets, health workers, secretaries, all knocking on doors and speaking at church about early detection of breast cancer.”

Thus, in 1992 CCHS identified breast cancer and the related disparity in health outcomes as a major priority for the department to address with a long-term strategy. It recognized that ending the disparity in outcomes for African-American women in Contra Costa would require a protracted community-wide effort involving a broad spectrum of strategies.

It so happened that Contra Costa Health Services already had a framework for approaching complex health issues, called the “Spectrum of Prevention.” It holds that prevention of disease is best accomplished by simultaneously applying several of the seven strategies in the Spectrum, which are:

• Influencing policy and legislation.
• Mobilizing neighborhoods and communities.
• Changing organizational practices.
• Fostering coalitions and networks.
• Educating providers.
• Promoting community education.
• Strengthening individual knowledge and skills.

In 1995, CCHS became one of the few local health departments in California to commit itself to the state-funded Breast Cancer Early Detection Program (BCEDP). This program was instituted to offer free clinical breast exams, mammograms, and additional diagnostic services to low-income, uninsured, and underinsured women of 40 and older.

Other goals included increasing community education and outreach efforts concerning breast health to targeted populations, improving the standards of medical care through provider training and technical assistance, and raising the breast-health screening rates of BCEDP-eligible women.

A Partnership Is Formed
To administer BCEDP, the county brought together an array of stakeholders to form the Contra Costa Breast Cancer Partnership, which has by now grown into a diverse coalition of nearly 400 breast cancer survivors, medical providers, health advocates, and community agencies.

The Breast Cancer Partnership applied the Spectrum of Prevention through a number of innovative approaches, including cosponsorship of an annual picnic for breast cancer survivors and their families that raises money to fund services for underinsured, low-income women. It also funded outreach efforts by workers from local community-based organizations to bring women in for screening, and organized Breast Health Days in churches and community centers.

The partnership has cosponsored and coordinated the schedule for a mobile mammography van that offers free on-site diagnostics, with the aid of the University of California at San Francisco and the Susan G. Komen Foundation. It also has offered media advocacy training and technical assistance to community groups and projects, including BACCIS and a Telly Award–winning video produced with the county cable-TV station.

To reach out further to underserved communities, the partnership formed an African-American Task Group, a Lesbian Task Force, a Latina Task Group, and an Asian/Pacific Islander Task Group, with each of these achieving substantial outreach into their respective communities. One such project was the development and production of an attractive wall calendar using local African-American breast cancer survivors as models. The calendar received extensive coverage in television, on the radio, and in daily newspapers, as well as being featured in 2001 along with the partnership in a satellite videoconference sponsored by the U.S. Department of Health and Human Resources’ Bureau of Primary Health Care.

Monolingual Spanish-speaking women seeking breast health care struggle with a language and cultural barrier in some localities, but in Contra Costa County, a unique project conceived by the Latina Task Group affords “patient navigators” to help its clients get the care they need.

“Patient navigators help low-income, Spanish-speaking women make breast-health screening appointments with a variety of services,” said Kim Cox, director of the Contra Costa Breast Cancer Partnership. “They arrange transportation to help the women attend the appointments, teach patients about breast health and breast self-examination, translate during appointments, and provide support and advocacy as the patients go through breast diagnostics and treatment.”

Patient navigator services are available at CCHS clinics and BCEDP providers in nearly every city in the county. Funded in part by a local hospital-system foundation, the patient navigator project now has become part of a new countywide Women’s Cancer Initiative designed to offer a culturally competent continuum of care to Spanish-speaking women with breast and other cancers. Other funding partners include the American Cancer Society and several community-based health and women’s organizations.

Other innovations by the partnership have included outreach to the Lesbian community through a women’s softball team, and the development and quality improvement of a BCEDP provider network to enhance access to free or low-cost breast health services, with regional clinics operated by CCHS as the largest provider of these services. Throughout these and other efforts, all the principles of the Spectrum of Prevention have been applied.

Even while breast health screening rates for minorities were rising through the BCEDP, CCHS had to deal with a different but related problem that also contributes to higher breast cancer mortality rates for African-Americans: the lack of government funding to treat all uninsured women who are diagnosed with breast cancer. Responding to this lack, the county decided to fund the treatment of all low-income, uninsured women in Contra Costa on an interim basis. Meanwhile, the county joined the statewide Breast and Gynecological Cancer Treatment Task Force to advocate for state funding for the treatment of uninsured women.

Other assorted obstacles have been overcome in the course of resolving the early screening-rate disparity, including tensions between various local organizations. CCHS also worked to overcome the stigmas of sexuality and modesty that prevent many women from getting breast health screenings. Most of all, the health department helped other agencies to direct some of their focus on resolving this disparity, rather than just stressing the narrower interests of their own organizations.

A Disparity Eliminated
In 1992 and again in the late 1990s, the Northern California Cancer Center was able to study the rates of early detection of breast cancer in Contra Costa County because the county is part of a comprehensive tumor registry. According to these data, as mentioned earlier, only 44 percent of African-American women with breast cancer in Contra Costa were diagnosed at an early stage in 1992; Latinas were diagnosed early only somewhat more often (58 percent). These rates compared unfavorably with data for women who were white (72 percent) or Asian/Pacific Islander (73 percent).

Data collected in the late 1990s by the cancer center indicated that the percentage of women in Contra Costa whose breast cancer was diagnosed at an early stage had stayed fairly static since 1992 for Caucasian and Asian/Pacific Islander women. African-American and Latina women, however, had changed from 44 percent and 58 percent, respectively, in the early ’90s to 71 and 70 percent in the late ’90s. The newer percentages for all four ethnicities were between 70 and 77 percent, indicating that the disparity had ended. It is hoped that, over time, we will witness a corresponding reduction in mortality rates among these populations.

In January 2002, after three years of lobbying through participation in the statewide Breast and Gynecological Cancer Treatment Task Force, the California Breast and Cervical Cancer Treatment Program was enacted. This program provides treatment for all low-income, uninsured, or underinsured women over 18 years old, whether they are documented citizens or not. Early detection and access to treatment will be the keys to lowering breast cancer mortality rates for all women.

The primary lesson learned in this project has been that health disparities are not inalterable facts of nature, said Brunner. Health disparities have causes; these causes can be identified; and, with persistent community-wide effort, the disparities can be eliminated. Public health and government both have roles to play in improving community health and eliminating disparities.

“Too often, a diagnosis of breast cancer has been thought of as a death sentence, and likewise the disparity between the rates of early diagnosis for varying ethnicities was thought of as inevitable,” added the public health director. “Now we know that, by partnering with the community, people of all ethnicities will embrace and act on information that improves their health and that of their community.” 

For more information on ICMA’s health programs, contact Stacie Ketchum at sketchum@icma.org.