Factors Contributing to the Development of Chemotherapy Intolerance in African American Females Age 65 Years and Older Diagnosed with Breast Cancer
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Factors Contributing to the Development of Chemotherapy Intolerance in African American Females Age 65 Years and Older Diagnosed with Breast Cancer
After years of unrestrained growth and multiplication, breast cancer cells accumulate into an unmanageable mass of tissue that eventually becomes a tumor. In addition to breast size and appearance changes, breast cancer symptoms may include changes in skin texture and appearance of the breasts. Mammography makes it possible to detect breast cancer in its earliest stages, which is extremely important. Breast cancer is the second most common cancer in women, after skin cancer, in terms of incidence. Women in their fifties and sixties are particularly vulnerable. Breast cancer can affect men as well as women. This, on the other hand, is a rare occurrence in this particular community. According to scientific research, transgender women are more likely than cisgender men to develop breast cancer. Although breast cancer is more common in women, transgender guys are at a lower risk of developing the disease than female transgender individuals. Breast cancer is slightly more common among non-Hispanic white women than non-Hispanic white women of different races and ethnicities. Non-Hispanic black women have historically been more than twice as likely as non-Hispanic white women to contract the virus. Women of Asian, Hispanic, and Native American heritage are less likely to develop breast cancer than other women.
Women over the age of 50 are at a higher risk of having breast cancer than younger women. Therefore, women 65 and over are responsible for more than half of all new breast cancer diagnoses and most breast cancer-related deaths worldwide. There is still much to learn about how breast cancer and its therapies will affect the long-term functioning abilities of breast cancer survivors. If chemotherapy hinders an older adult’s ability to maintain independence, significant side effects may result. People can better tailor treatment plans and interventions for women at risk of functional loss by identifying them and treating them. Several breast cancer institutes have provided funding for research on adjuvant treatment for older women with breast cancer. These studies’ results could help identify survivors at risk of physical function decrease and develop long-term strategies to counteract that risk. Breast cancer death rates for African American (AA) women have been higher than for white women for more than two decades, even though AA women’s disease is less common.
Background and Significance
Diagnostic and treatment delays that might negatively influence patient outcomes play a role in developing chemotherapy intolerance in African American females’ aged 65 years and older diagnosed with breast cancer. Patients with early-stage breast cancer who delay therapy by more than two months are reported to have a worse chance of surviving. Even the most generally used vocabulary and analytical techniques leave significant gaps in understanding how race affects individuals’ discrepancies when researching racial disparity. Medical consultations and diagnosis are two separate processes over a long period. Researchers frequently conduct their studies using administrative datasets or population-based breast cancer registries that do not include information on a patient diagnosed with breast cancer. Due to the absence of patient care delays from the analysis, the delay in diagnosis has been primarily disregarded. Consequently, it is possible to underestimate the amount of time required to perform a specific task due to this phenomenon. It is more common for minorities to self-identify as experiencing a delay in seeking care than for non-minorities, which may impact the results of racial comparisons of delays in seeking care.
For population research, multivariate adjustment of race minimizes risk factors that may be accounted for by other variables, which helps researchers better understand racial variations. Health disparities research should begin with unadjusted health outcomes models and then go on to race-segregated data to discover the underlying causes of disparity. A few investigations into the effect of race on breast cancer patients’ delayed diagnosis and surgical treatment have been conducted, but the findings are intriguing. Using racial stratification in epidemiological research has allowed researchers to compare risk factors between and within races in a wide range of diseases. Medical records and interviews from women with early-stage breast cancer have always been recorded. There may be disparities among races when it takes to find symptoms, identify them and treat them.
Review of Prior Studies and Literature
AA breast cancer is more common in women with a history of the disease in their families. According to Yedjou et al. (2019), 80 percent of women with breast cancer mutations have chemotherapy intolerance to triple-negative tumors and early-onset breast cancer. Only a tiny percentage of AA women diagnosed with breast cancer before age 65 and who have a strong family history have a gene mutation. One-tenth of all breast cancer patients have genetic defects that increase their likelihood of developing the disease. It is known that multiple genes, including PTEN, BARD1, STK11/LKB1, CDH1, CHEK2, ATM, MRE11, NBS1 and BRIP1, FANCA and FANCM, RAD50 and RAD51 (B and C), XRCC2 and others, are connected with an increased risk of breast cancer in the germline (Yedjou et al., 2019). Early menarche, oral contraceptive use, anovulatory infertility, being older at the time of the first pregnancy, and being in the postpartum period increase the risk of breast cancer in AA women.
Breast cancer can occur in any woman of any age who has received mantle irradiation or used alcohol. Those aged 20–44 who had smoked for more than ten years had a 1.6-fold increased incidence of estrogen receptor (ER)-positive breast cancer compared to women who had never smoked (Zavala et al., 2020). However, according to Zavala et al. (2020), gaining weight after 65 increases the risk of developing ER-negative breast cancer by a factor of two. Excessive calorie intake, a lack of physical activity, and being overweight all increase the risk of heart disease and stroke in postmenopausal women, but regular, intensive exercise minimizes the risk of chemotherapy intolerance in this population. A high-energy diet, such as one that consists primarily of red meat or fast food, increases the risk of breast cancer in postmenopausal women. However, there is some evidence that a diet heavy in whole foods and plant-based proteins can help reduce the risk of AA breast cancer in some women. Women after menopause who replace one serving of meat with one serving of beans have a 19 percent lower chance of developing breast cancer, according to Ali et al. (2018). According to research, women of all ages who have a high mammographic density are at a higher risk of developing breast cancer.
The density of postmenopausal women’s breasts is regulated by various factors, including alcohol consumption, vitamin D and calcium intake, interleukin-6 and dehydroepiandrosterone sulfate levels, and estrogen levels. Postmenopausal women with low vitamin D levels are more prone to develop breast cancers that are more severe in their progression. Genetic profiling can be used to detect and predict the outcome of aging breast tumor biology, which can be accomplished through gene expression profiling techniques. Young women under the age of 30 are more often than older women to be diagnosed with aggressive triple-negative tumors with stromal-related characteristics, according to Nayana (2020). Even after considering factors such as subtype, grade, tumor size, and nodal status, relapse risk was found to be higher among AA women. Using a candidate gene method tailored to each subtype, more than 12 gene sets were found to be associated with adolescence. Nayana (2020) evaluated more than 700 early-stage breast cancers in two cohorts for more than 700 cases of breast cancer. According to the findings, the analysis of gene set enrichment revealed 367 gene sets that were more abundant in the younger cohort. She discovered that the younger man had lower levels of estrogen receptor, progesterone receptor, her2neu, and epidermal growth factor receptor expression than the older man. After considering tumor subtype and clinicopathologic characteristics such as tumor grade, there were no longer any age-related variations in gene expression to be observed.
Later investigations by Richardson et al. (2017), using a candidate gene method to control for tumor grade and subtype, indicated that the expression of specific breast cancer genes varied over time after controlling for these variables. BUB1, KRT5, and MYCN levels were higher in AA women than in older women, although CXCL2 levels were lower in AA women than in older women. Changes in gene expression were found to impact the prognosis of specific tumor subtypes. Because AA women had a greater frequency of aggressive basal-like and Her2-enriched subtypes of breast cancer, age-related biochemical modifications may occur in the disease. AA women have a significant proportion of aggressive personalities when seen as a group. More in-depth research into this matter is required. Between 2012 and 2014, one out of every 253 American women under the age of 70 was diagnosed with breast cancer, with a mortality rate of 0.052 percent between the two years (Hair et al., 2017). Patients under the age of 35 diagnosed with breast cancer have recurrence-free survival rates of 1.70 months and 1.50 percent, which are both higher than the national average and higher than the national median. The mortality risk for AA women with early-stage breast cancer is 39 percent higher than for other women diagnosed with the disease. The fact remains that AA women have a poorer overall survival rate for breast cancer than other women, regardless of how early in the condition they are diagnosed. Women between 40 and 55 have more excellent relative survival rates for stage II-IV disease.
AA women have a worse overall survival rate than men, regardless of the stage of the disease at when they are diagnosed. According to the American Cancer Society, women who are diagnosed with stage IV breast cancer have a poor outlook. Breast cancer of any form (including invasive breast cancer) had a worse prognosis for AA women than other women, regardless of ethnicity. Although ductal carcinoma is the most frequent type of breast cancer, it can also occur in situations of medullary breast cancer, inflammatory breast cancer, and lobular breast cancer. AA women are well behind the average population (Freedman et al., 2010). Patients with ER-negative breast cancers are more likely to develop a relapse two years after completing treatment than other breast cancer patients. During the past eight years, the mortality rate for women with ER-positive cancers has decreased significantly. Since 1985, there has been a considerable improvement in the survival rates of AA women diagnosed with breast cancer compared to older women, confirmed for all stages of the disease. Improved palliative and supportive care strategies for AA women with remote disease may have led to the most substantial relative benefit experienced by these patients. It did not affect the survival of breast cancer patients with high-grade tumors and more advanced illness at the time of diagnosis. According to Freedman et al. (2010), environmental and genetic factors are likely to impact differences between geographic locations in age-related outcomes. Those diagnosed early have a more significant chance of surviving the disease and surviving to tell the tale.
Patients with early-stage breast cancer under the age of 40 are at a higher risk of getting metastatic disease than those above the age of 40. The risk of breast cancer-related death is higher among AA women with breast cancer subtypes such as triple-negative and hormone receptor-negative, HER2-enriched, than among AA women with breast cancer subtypes such as hormone receptor-positive, HER2-nonenriched. Those suffering from the hormone-receptor-negative condition are at a higher risk of dying due to their disease. Mutations in the PALB2 gene in the mother have been linked to earlier development of breast cancer and a worse outcome in the case of the disease. Breast cancer mortality may be higher in African-American women with co-existing medical conditions. Obesity and type 2 diabetes have also been related to a bad prognosis in cancer. According to the findings, patients with postmenopausal breast cancer who were obese or had diabetes were at increased risk of death (Stringer-Reasor et al., 2021).
Curing breast cancer and extending a patient’s life are the primary goals of breast cancer treatment, ensuring that patients have the highest possible standard of living during and after treatment. Examining a patient’s medical history to see if breast cancer has returned is critical to determining whether or not the patient’s breast cancer has been entirely removed. The most common reason for tumors not being able to be cured is that they have reached an advanced stage. Patients with metastatic breast cancer, for example, can be treated as chronically ill even though their breast cancer has spread far and wide (Siddharth & Sharma, 2018). To treat breast cancer, there is a wide range of treatment methods that can be employed alone or in combination, such as surgery and radiation therapy. In conjunction with standard breast cancer treatment, supportive therapies can benefit patients and their families by reducing side effects and addressing other aspects of health and well-being that are important to them and their loved ones, like sleep, nutrition, and exercise. Depending on the type of slow-growing breast cancer, delaying therapy and continuing to monitor it may be an option. This strategy can effectively treat prostate breast cancer with low risk and other blood breast cancers. Using high-energy beams or particles from outside or within the body can effectively kill breast cancer cells. Systemic medications enter the bloodstream and have the potential to impact the entire body. They use a range of methods to carry out their duties. A typical example of this is chemotherapy medications, which aim to kill fast proliferating cells.
Breast cancer risk can also be reduced with hormone therapy, which lowers or eliminates the body’s natural hormones. As the name suggests, targeted therapies target specific proteins necessary for breast cancer to grow and spread to treat it effectively. The patient’s immune system is stimulated in immunotherapy, used to treat breast cancer. A patient’s overall quality of chemotherapy intolerance outcomes is impacted by how well their breast cancer treatment manages their physical and mental symptoms and limitations. Survivors’ capacity to return to everyday life and financial stability might be severely impacted by these concerns (Release, 2018). Breast cancer rehabilitation can help patients cope more efficiently with symptoms, perform better in everyday activities, and enjoy a better quality of life during treatment. Therapy can reduce some adverse effects for some people, but for others, they remain. It may take months or even years for lymphedema to develop after breast cancer surgery. A lack of information on long-term and late-term detrimental implications has led to the most overall breast cancer-related side effects, such as pain, fatigue, and emotional distress, being the most common.
To improve long-term and late effects surveillance and early detection and treatment, information on health-related quality of life and patient-reported outcomes is integrated with data from a population-based breast cancer registry—every stage of recovery, from start to finish (Yee et al., 2017). Therapy can reduce some adverse effects for some people, but for others, they remain. As a result of their diagnosis, patients may experience long-term adverse effects from their chemotherapy intolerance, such as lymphedema following breast cancer surgery. A patient’s risk of and response to side effects are influenced by the kind of breast cancer, treatment, and other factors. A lack of information on long-term and late-term detrimental implications has led to the most overall breast cancer-related side effects, such as pain, fatigue, and emotional distress, being the most common. To improve long-term and late effects surveillance and early detection and treatment, information on health-related quality of life and patient-reported outcomes is integrated with data from a population-based breast cancer registry. According to Schneider (2020), 65 years and older African and African-American women who are obese are more likely to resist breast cancer treatment. Numerous biochemical processes have been implicated in the development of obesity. Inflammation thrives in adipose tissue because of the unique physiological conditions it provides in the body’s midsection. Other pro-inflammatory mediators are released by fatty tissue, such as TNF, interleukin-6, and retinol-binding protein-4, all contributing to inflammation (Schneider, 2020). The NF-kappa B, MAP kinase, PI3-K, and AKT signaling pathways and the PI3-K and TNF signaling pathways were stimulated by TNF in human breast cancer cells.
Metastatic breast cancer patients with elevated interleukin-6 have a significant chemotherapy intolerance rate than those with lower levels of IL-6. In the early stages of breast cancer, IL-6 can predict tumor size, progression, and metastasis. For the growth of the breast gland and the delivery of milk during lactation, Leptin, a cytokine produced primarily by fat tissue, is essential. Serum leptin levels are much more significant in obese individuals than in those of average weight. Proliferation, angiogenesis, and the production of insulin-like growth factor 1 have been activated by excess adipose tissue, leading to tumor progression and metastasis (Foy et al., 2018). As the hormone produced by adipose tissue, adiponectin blocks Leptin’s breast cancer-promoting effects. Insulin resistance and obesity affect the expression of this gene. Because of this, adiponectin levels rise, allowing breast cancer cells to proliferate and spread. It has been shown that having high serum adiponectin levels reduces one’s risk of getting breast cancer. According to Foy et al. (2018), the hormone adiponectin appears to have a role in the pathways that relate insulin sensitivity to muscle shape. In the development of metabolic diseases like obesity, high blood pressure, and type 2 diabetes, there is evidence that this heterogeneous tissue, which comprises numerous distinct fiber types with various metabolic properties, plays a role.
Type IIa and Type IIb muscle fibers are sometimes referred to as type IIx based on the properties of Type I and type II muscle fibers. As a result of their more significant myoglobin levels, capillaries, and mitochondria, order I muscle fibers have a greater aerobic metabolic capacity than type II muscle fibers. There is less myoglobin and capillaries in Type II muscle fibers than in Type I fibers, resulting in a lower aerobic capacity. A more considerable aerobic potential is found in Type IIa fibers than in type IIx fibers. In contrast, a lower aerobic potential is found in Type I fibers than in Type I fibers. Blood adiponectin levels are higher in style I muscle fibers, while these levels are lower in type IIb muscle fibers. According to the findings of Jiang et al. (2016), NH Black individuals have more anaerobic muscle fibers, while NH White people have more Type I muscle threads, In contrast to insulin-resistant type IIb (IIx) muscle fibers, which have lower insulin sensitivity, type I muscle fibers have higher insulin sensitivity. New Hampshire Blacks have myofiber type II linked to obesity, hypertension, and diabetes. Thus, type 2 diabetes is significantly increased by obesity.
Regarding BMI and body fat percentage, the percentage of type IIx (IIb) muscle fibers strongly correlates with the rate of type I muscle threads in a specific individual. A more significant percentage of type IIx muscle fibers in obese diabetics than in non-diabetics. A more substantial proportion of their muscle fibers are of type IIb in obese African American Black women than lean ones. Sreenivas (2020) shows that type I muscle fibers are less common in African American women than in obese Caucasians. Still, type IIx muscle fibers are more common in African American women. These findings support the hypothesis that African American Blacks are more likely than other ethnic groups to be obese, acquire weight rapidly, and develop insulin resistance.
African-American Blacks may have an inherited tendency to develop type 2 diabetes, leading to fat storage within muscle tissue due to decreased metabolic capacity and fat oxidation. Insulin levels, insulin resistance, and insulin resistance contribute to obesity development. High blood glucose and insulin levels and insulin resistance have been reported in breast cancer patients with poor prognoses. Evidence from human lung tumors suggests that breast cancer cells consume more glucose than usual, which could serve as fuel for the breast cancer cells. Chemotherapy intolerance, characterized by robust lipogenesis, increases aerobic glycolysis. Limited mitochondrial oxidative phosphorylation capacity, even in the presence of adequate oxygen, among other characteristics, results from increased glucose metabolism in breast cancer cells (Núñez Abad et al., 2021). In the fight against breast cancer, higher blood glucose levels and hyperinsulinemia associated with obesity and overweight may provide breast cancer cells a competitive edge. Obese adults, particularly postmenopausal women, have elevated estrogens, estrone, and estradiol levels, while the sex hormone-binding globulin binds estradiol and limits its action and has lower levels.
Since obesity increases levels of steroid hormones, this could hasten tumor growth and recurrence. SHBG levels fall due to increased androgen production in adipose tissue, contributing to tumor growth and promotion by increasing estrogen production in the bloodstream. The output of Leptin is also stimulated by estrogens, which aid in developing breast cancer cells and the spread of the disease. Núñez Abad et al. (2021) have found an association between elevated levels of insulin and IGF-1 and worse outcomes, such as obesity. Postmenopausal TNBC is more common in young African-American and Hispanic women than in other women, which may be linked to obesity’s effect on the incidence of postmenopausal. In obese black women, the percentage of tumors devoid of estrogen and progesterone should be the same in both sexes. Non-African-American women, on the other hand, are less likely to have triple-negative breast cancer tumors than obese African-American women are. Both expressions in the body appear to be influenced by the possible pathways that lead to obesity throughout the body.
Aims and Research Questions
1. The research aims to find factors contributing to chemotherapy intolerance in African American females age 65 years and older diagnosed with breast cancer.
2. The cohort study’s goal will be to understand better the impact of health care inequities on breast cancer patients of color.
1. Can breast cancer deaths among African Americans rise because of intolerance to detection and treatment?
2. Is breast cancer chemotherapy intolerance affected by situational barriers to African American females aged 65 years and older?
Research Design and Methods
Implications and Contribution to Knowledge
If a woman is aware of breast cancer awareness and education inequities, she may be less likely to get checked out or treated for the condition. This study aims to gather information regarding a group of women’s experiences, knowledge, and health behaviors before and after their breast cancer diagnosis. The study also investigates the association between participants’ degree of knowledge and demographic variables and their involvement in their breast cancer treatment.
A retrospective cohort analysis of 6oo African Americans diagnosed with invasive breast cancer in New Jersey between 2005 and 2010 will be included. Six hundred women with stage I-III breast cancer aged 65 and over will participate in the study and undergo adjuvant chemotherapy were assessed for physical function. Medical records and interviews with patients will also both conducted. It will be determined how long it will take for a symptom to be recognized and diagnosed and how long it will take for the sign to be identified and then operated on. Racism will also be included in the investigation of the delay in diagnosis.
Compliance with Ethical Principles
To get the most out of a study, this study will make every effort to ensure that participants and researchers are as safe as possible while still achieving their goals. Every volunteer in the study must be free of coercion or undue influence and must have their privacy and dignity respected throughout this study. The research will yield results worth the time and effort invested in it and benefits that outweigh any potential downsides. Patients will fill out the Organization for Breast Cancer Research and Treatment Quality of Life Questionnaire’s physical function subscale during and after chemotherapeutic treatment. Whenever a participant’s score falls by more than ten points from the baseline, it will be considered deterioration. When a person’s blood pressure rebounded to within 10 points of its initial number, it will be regarded as a sign of resilience.
To prevent any possible harm or risk, it is imperative to build strong safeguards. Regression analysis will be performed to examine the correlation between pre-treatment variables and changes in physical function following therapy. Breast Cancer cases will only be included if they meet the following criteria: Only non-melanoma skin breast cancer is found in AA or white women with no prior history of breast or ovarian cancer. Health care providers’ records will be retrieved and thoroughly analyzed to provide an accurate medical history of a patient who had previously identified all of their doctors. Records of diagnostic information, pathology reports, and operation notes will be collected, and reports of adjuvant treatment and hospital discharge summaries during the first year following the initial diagnosis. Trained abstractors will review medical records to determine when and why preoperative mammography was performed. They will document the patient’s first symptoms. When the patient misses an appointment and treatment, there will be a record of the doctor’s suggestions and the patient’s compliance with those recommendations, which will be documented.
Researchers and participants will be given appropriate information about the study to obtain informed consent. The study’s purpose must be clearly explained without undue pressure or improper enticement. Socioeconomic variables, family history of breast cancer, comorbidities, tumor and receptor characteristics, and the institution where therapy was delivered will be considered. As a result of race information being recorded in multiple places throughout medical records, abstractors will not be blinded to it, and the study’s premise will not go unnoticed. A standard training program for all abstractors will be designed to ensure completeness and avoid systematic inconsistencies in data abstraction among abstractors. As a temporary workaround, all abstractors will be provided with a copy of the course materials.
An overview of the study will be included in the resources, information on abstraction techniques, the abstraction form, and an instruction manual for coding. The protocol will dictate that group and one-on-one meetings will be held with the lead research coordinator. Each section of the manual’s abstract form and coding instructions will be thoroughly examined during these sessions. The primary investigator and lead research coordinator will closely supervise the abstractors during the medical record abstraction process to ensure they know breast cancer treatment terminology. They will also examine any differences in the first ten medical records abstracts from each medical record abstractor with the principal research coordinator.
Studies are only as good as their participants’ and groups’ wishes for anonymity and their capacity to keep data collected on them confidential. The coordinator and his team will meet weekly to discuss challenging cases and unresolved abstraction issues. If there is any doubt regarding the meetings, surgeons and doctors from oncology will be invited to the forum. There will be changes in the procedure manual and in the training of the abstractors as the group’s recommendations change. After extracting the data, it will be necessary to store it in a Microsoft Access 2010 database. Once an error is identified, the original abstractor will be contacted and asked to check their medical records. Through this technique, abstractors will be allowed to reflect on and learn from their mistakes.
Using semi-structured phone interviews, the research will acquire more information on breast cancer diagnosis while also enhancing the quality of the data gleaned from medical records. The 30-minute interviews, which will take an average of 30 minutes each, will be recorded using a telephone recording jack. After the initial, more organized consultation, a more in-depth, semi-structured interview will be conducted. As part of the structured component of the discussion, patients will be questioned on how and when their breast cancer was initially discovered, when they first saw a doctor for their breast cancer and the recommended therapies. They will also be asked yes/no questions about whether or not they had any situational impediments at the time of their breast cancer diagnoses, such as difficulties getting around or the necessity of daily care for dependents.
In-depth training in breast cancer biology, treatment, and interviewing techniques will be provided to the interviewers, who will be female. During the semi-structured interview, patients will be asked about the elements that influence their treatment choice, and the effect of situational barriers will be examined more thoroughly. Only quantitative data collected during the structured interview phase will be used to draw findings in this study.
A significant emphasis will be placed on conducting semi-structured interviews during the training. The interviewers will review the semi-structured interview questions in a small group before checking breast cancer pathology and treatment. Before training, all interviewees will be given reading material to familiarize themselves with staging and treatment terminology. Interviewers will also be given a detailed procedure manual with step-by-step instructions. The goal will be to interview half of the patients because of the smaller sample size required for qualitative than quantitative research.
The total research budget is estimated to be between $5000 and $10000 from the beginning to the end. The participants will be enumerated in every meeting. The first cohort will be reimbursed with a $50 cheque for each individual.
The project will run for two months, with the first month dedicated to collecting data from the first cohort. The group will involve the telephone responses and the physical questionnaires filled by the participants. The remaining month will be dedicated to the analysis and finalizing of the report.
Despite significant gains in understanding these issues, multidisciplinary efforts are needed to reduce or eradicate racial/ethnic disparities in breast cancer incidence, tumor biology, and outcomes. To better understand the possible heterogeneity of etiology, tumor behavior, and treatment response, several federal efforts have encouraged the participation of a broad spectrum of persons and groups in research studies and clinical trials. To reduce and eliminate breast cancer health disparities, it is necessary to gather and analyze extensive data on biological, behavioral, physical/built environment, sociocultural environment, and health care system components. The inclusion of cell lines and xenograft models from different ethnic and racial backgrounds will help researchers conduct more representative tests of human variation. When it comes to eliminating gaps in health outcomes, raising awareness of breast cancer’s causes will not be enough. To better understand breast cancer etiology and develop appropriate treatments for diverse populations, people must address the lack of sufficient data and expand culturally and linguistically tailored breast cancer awareness, education, and navigation programs, as well as programs to promote behavioral changes in at-risk groups that focus on already known modifiable factors. A structural component or policy, such as tobacco regulation, can help people change their behavior. Without systemic changes that promote health equity, universal health insurance coverage, and access to high-quality care for all individuals, eliminating health inequities will be unachievable, to put it simply.
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Appendix 1: Project budget
$50 each for 600 participants = $3000
$400 per meeting for 4 meetings = $1600
Remuneration and Miscellaneous
Appendix 2: Project Timeline
First Cohort Study
Analysis and Report
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