NINR Director’s Lecture – “Evidence-based Interventions to Address Health Disparities in Cancer”
Articles,  Blog

NINR Director’s Lecture – “Evidence-based Interventions to Address Health Disparities in Cancer”


[music playing]>>Dr. Patricia Grady: Good
afternoon everyone. I want to welcome you to
the National Institute of Nursing Research
Director’s Lecture. Several times a year, the
NIH Director’s Lecture brings to the Campus
scientists of renowned who have made great
accomplishments throughout their career, and we are
very happy to bring these individuals to campus to
describe their story, talk about their research and to speak to the larger NIH audience. So, it provides an
opportunity for exchange of ideas among us, among those,
our colleagues of other institutes as well. Now, today is the final
lecture for the Director’s Lecture of 2016. This as most of you know, has
been an anniversary year for us. I was telling Sandra this
has been a special occasion for us because it is
essentially the bookend for our anniversary year, and so
we are very happy that she could be here today to help
celebrate our 30th anniversary. So, our mission is to
improve the health of individuals, families, and
communities around the world by bringing science and
evidence based health care into people’s daily lives. The research supported by
NINR will continue to play an indispensable role
particularly in addressing the challenge of
health disparities. This is the topic of
today’s presentation. Since its establishment,
NINR has played a critical role in conducting
and sponsoring health disparities research across
our nation and across the globe, and also making the
results of this research accessible and actionable to underserved
and minority groups. All across science areas,
NINR emphasizes the important contributions of
scientific partnerships when underrepresented and
minority communities. Of particular importance
is the research addressing health disparities, sex, and
gender differences, social determinants of health, and
environmental influences. By working in close
research partnerships with communities, nurse
scientists are developing culturally congruent
feasible sustainable interventions to promote
healthy behaviors and prevent chronic conditions
across the life span. Now, today’s speaker, Dr.
Sandra Millon-Underwood, is respected for her
dedication to improving the access of women, minorities,
the disadvantaged, and the underserved, to state of the
art cancer prevention and control programs. She has also done work in
behavioral, and biomedical research in ways that are
community oriented and are easily translatable to provide
benefits for the public. Her research is focused on
cancer education, cancer prevention, early detection,
and cancer risk management. These projects have targeted
at risk, underserved populations of men, women,
and children from urban communities, world
communities, and island communities beyond the
contiguous United States. As a professor in the
College of Nursing at the University of
Wisconsin, Milwaukee, Dr. Millon-Underwood has
directed courses that focus on nursing research
foundations of health, cancer prevention and
control, cultural diversity and health care, and prospectus
of health care systems. In addition, she served as
the founding director of the University of Wisconsin,
Milwaukee House of Peace Community Nursing Center,
which provides wellness classes, intensive case
management, and support services for families
dealing with cancer. Dr. Millon-Underwood is
the recipient of numerous accolades and awards and is
a fellow of the American Academy of Nursing. She participates in numerous
professional activities and is an active member of the
American Academy of Nursing, The Association of Black
Nursing Faculty, Sigma Theta Tau International, The
Oncology of Nursing Society, and the National Black
Leadership Initiative on Cancer. Sandra has also served on a
number of advisory boards including the National
Institutes of Health Council of Councils, which as
you know helps to make determinations about the use
of common funds across the NIH and across the country. Also as the National Cancer
Advisory Board, from NCI and our National Advisory
Council for Nursing Research, and I must say, we
do miss her on the council. Today we look forward to
hearing Dr. Millon-Underwood speak Evidence Based
Interventions to Address Health Disparities
in Cancer. After about 30 plus minutes,
she will moderate a question and answer session. So please join me in welcoming
Dr. Sandra Millon-Underwood. [applause]>>Dr. Millon-Underwood:
Good afternoon. I am very honored and
humbled to have been given an opportunity to come
to present to you today. Not only because of the work
that I have done over the last 40 some years in the
mid-western part of this country, but especially
because of the work that I have been doing in the
mid-western communities in a relative to addressing
issues surrounding desperate populations that are facing
issues associated with cancer prevention
and cancer controls. Dr. Grady, I wanted to
begin this talk by first of all acknowledging
you, and all that you have contributed to the National
Institute of Nursing Research over the
last 20 plus years. Because of your work,
because of your vision, because of your commitment,
we are seeing major changes in nursing practice, nursing
science, but also within our communities; specifically,
as it relates to issues regarding health
disparities. We all are very much aware
of the vision and the role and the mission of the NINR,
but I also want to take this opportunity to focus a
little bit on the mission of the NINR as it relates to
translating research and to the lives of real people. The daily lives
of real people. Because of that, I was asked
to come and share with you today, a summary of some of
the work that I have done and some of the work that
I am doing that relates to cancer prevention, cancer
control among women, African American women, within the mid-west
part of this country. I want to highlight a little
bit about some of the disparities surrounding
breast cancer, morbidity and mortality because there are some
changes that we see on the horizon. But I also want to highlight
an innovative evidence based approach that we are using
to address the needs of inner city women,
primarily in the mid-west. But before I do that, I
want to first of all again congratulate the NINR for 30
years of excellence within the field. I also want to acknowledge
the work that has been done nationally as a result of
the Secretary’s Task Force, on black and
minority health. So much of what we do now,
related to addressing health disparities, is because of
the work of Dr. Heckler [phonetic sp] and the work
and the vision that she had relative to identifying the
disparities that we see within population groups
that are distinguished by race, ethnicity, and
social economic status. But also, relative to
cancer, I think it is also important to also
acknowledge the work of the American Cancer Society
and Dr. Harold Freeman. I mentioned these entities,
I mentioned these institutions, I mentioned
these individuals because I have had the fortune of
working alongside with them over several years, and it
is because of their insight and their wisdom that I
hopefully have gleamed from them that I better
understand the needs that they assess today. I had an opportunity to work
with Dr. Freeman almost 37 years ago, when he was the
Director, the President of the American Cancer Society,
and he chaired the hearings on cancer and the poor. I remember listening to
his concerns regarding the populations within our communities
that were facing cancer. But I also remembered his
summaries of some of the survivors regarding the
challenges that they faced, and I remember him
emphasizing again, and again, and again, the
summary, the comments of one woman, that still echoes
in the ears of many of us today. One woman who talked about
the fact that it was the system that made her feel
poor, that all too often was the impediment
that she faced. It is relevant to the work
that we are doing now related to health
disparities. I also want to echo the
works of Dr. David Satcher, and his work as the 16th
Surgeon General of the United States, and he
reminds us of the importance of addressing at risk
populations, vulnerable populations, and
unpopulations in this work facing health disparities. Especially populations that
are uneducated, uninsured, unengaged, unconcerned,
uninspired, and — all too often, unserved. Many of us have been in
talks such as this where we mention these populations,
and often describe them as hard to reach populations,
but I also want to remind many of us and remind
myself, that often times these populations are not
hard to reach, but in many instances hardly reached. I have also had the fortune
of working alongside with Dr. Otis Brawley [phonetic
sp], who now is the Chief Medical Officer of the
American Cancer Society. And one of the things that
Dr. Brawley has said again, and again, that resonates
in the back of my mind, especially as it relates to
health disparities, is that even though we have been
waging war against cancer for more than 50 years, it
is not truly a war if we have 200 thousand avoidable
casualties annually and everybody yawns. And all too often, in the midst of
our work we do not yawn. But I also want to
acknowledge the work of the Oncology Nursing Society,
who again some 30 years ago, published some of the first
articles that address cancer among minority populations,
you know, for the nursing profession. Articles published by Dr.
Vericio [phonetic sp], Dr. Antone [phonetic sp],
Dr. Gullery [phonetic sp], Dr. Cugousinger [phonetic
sp], identified some of the challenges that are facing
minority populations that had not been
identified previously. Hundreds of articles and
studies have been done since that time, but nevertheless,
there is such more work that needs to be done to
translate the findings of many of those studies
and to practice. I had the fortune of working
with this team of scientists five some years ago, and
reviewing the state of the nursing science relative to cancer
and minority populations. When we looked specifically
at research that addressed cancer prevention and cancer
control among minority populations, we saw some
very significant gaps. Gaps relative to the
focus of the science. Gaps relative to individuals
who included in science, and gaps relative to the
practice that is being completed and implemented
within our communities. Within the National
Institutes of Health, every institute and center has a
vision, has objectives, that relate to disparities. There is an NINH Health
Disparities Strategic Plan that hopefully will guide us
in affecting change through our science, through our
training, but also relative to implementation
within the communities. But Dr. Harold Freeman made
it real clear several years ago, that there appears to
be a discovery, delivery, disconnect. And here he suggests, that
even though we have got good science, strong science,
identifies barriers, identifies challenges,
oftentimes, those findings do not get implemented
into the real world. That is what I was asked to
speak a little bit about today. How a team of scientists,
and clinicians, and advocates, and survivors in
our community, are taking some of that information,
taking some of that knowledge, and translating
it into the lives and actions of real people
and communities in need. I was asked specifically to
talk about disparities, talk about the nursing science,
but specifically as it relates to breast cancer. Breast cancer is a condition
that many of us are very much concerned about. But I want to speak in the
midst of this talk and preface it based on three
letters that I received. Three letters
that I received. One letter that I received a
few years ago, happened to be just about at this time. The letter would be relevant
even today, November 1, 2016. The letter would be relevant
because it was written by one of the leaders of
our esteemed, one of our esteemed nursing
foundations, and the letter focused on Breast
Cancer Awareness Month. The letter began by reading,
by writing, “the banners will come down, the public
service announcements will disappear from the airwaves,
buildings are no longer pink and movies stars, athletes
and politicians no longer express their concern
about the disease. Today, November 1st, one
day after the end of Breast Cancer Awareness Month. But something else will
happen, nearly 700 American women will be diagnosed with
breast cancer, more than 110 women will die of the disease,
all in the next 24 hours. The toll will mount day
after day, until the time the American commemorates
Breast Cancer Awareness Month next October, more
than 40,000 American women will have died. More than 250 more will have
been diagnosed with invasive and in situ breast cancer”. This letter suggests that
there is great work that we must do beyond Breast
Cancer Awareness Month. We have seen the data
relative to the incidents of immortality of
breast cancer. We know that among US women,
breast cancer, the most common invasive cancer
accounting for nearly one of every three cancers
diagnosed, breast cancer is the second leading cause of
cancer deaths among women in the United States exceeded
only by lung cancer. We also recognize that the
American Cancer Society projects that an estimated
246 thousand new cases of invasive female breast
cancer and 40,450 deaths will occur in 2016. But when we take a look at
the data specific to black woman in the United States,
we see some startling trends. Yes, breast cancer is the
most commonly diagnosed cancer among black women. Yes, breast cancer is the
second is the second most common cause of cancer
deaths among black women, and the American Cancer
Society also projects 30,700 new cases of invasive female
breast cancer as 6,310 deaths among black
women in 2016. When we take a look closely
at the data that has been reported by the Centers for
Disease Control and the NCIC program, we are seeing some
other startling trends. Even though breast cancer
incidence is higher among white women compared with
black women, we are seeing a convergence of a gap
that we used to see. The incidence of breast
cancer among black women now almost parallels the
incidents among white women. But nevertheless, for
decades, we have seen stark disparities between
mortality by race between black and white women,
and unfortunately those disparities in mortality not
only continue, but they also are expanding. We know that breast cancer
incidents rates among black women in the United States
are increasing, and the rates between black and
white women, as I mentioned already, are converging. Much of that is
because of the science. There is a greater
awareness, screening rates among black women are
improving, the technologies that we use for screening
are improving, and there are higher rates of lifetime
overweight and obesity unfortunately among African
American women that are also impacting the incidents. We also see that breast cancer
mortality is also on the rise. More black women are likely
to die from their breast cancer. Why? We know the answer. Because black women are more
likely to be diagnosed at a later stage. Black women are more likely
to be diagnosed with triple negative breast cancer. Black women are more likely
to receive suboptimal treatment, and black women are
more likely to refuse treatment. The disparities exist in
spite of technological advances. The disparities exist
primarily because there is unequal access, in
diagnosis, and treatment. But we also know that if we
only did what we know how to do now, with populations
that are greater risk such as African American women,
we could affect a greater change. But oftentimes the question
is: are we committed to do that, to make
that difference? Healthy People 2020, you
know, has identified targets for mammography screening. African American women
screening rates among black women still are well
below that target. We also take a look at
the fact that mammography screening rates are much
poorer among women of lessor incomes, which oftentimes
many African American women are especially
vulnerable to. We also recognize that
another vulnerability relative to mammography
screening, which is especially important to
reduce mortality, women who have lessor education, high
school education, and less often have more dispirit
mammography screening rates. So, the challenge before us,
is how can we expand on the findings, and
make a difference? Because reality is, a
substantial body of research shows that breast cancer
disparities among black women, it is not only
real, but it is expanding. We know many of the factors
that negatively impact breast cancer risk, breast
cancer screening, early detection and treatment. Many of these factors are
related to the patient. Many of the factors are
related to providers. Many of the factors as we
know are related to our health care system. But what are we doing to affect
a change in those factors? To remove the barriers, to
overcome the obstacles, to increase the screening,
increasing treatment, and increasing engagement
in clinical trials. That is the key, and
that is the challenge. Too often women in our
communities come in at a later stage, and as a result
of that, mortality is significantly increased. Survival is much poorer, but
what are we doing to affect the change? As I mentioned before, the
gap, the critical disconnect that Dr. Freeman mentioned
between discovery, development of appropriate
interventions, the translation in
the community. That should be our goal, and
for most of us in this room that is the goal. You know, I am encouraged
to know that there are many leaders, you know, from
the National Institute of Nursing Research, but also
leaders within the clinical center who are actively
engaged in research, actively engaged in clinical
trial, and actually engaged in addressing issues in our
community related to breast cancer among all
populations, but especially minority populations. You are using the best
evidence, the best research, your clinical expertise, in
the midst of the patient’s values and concerns and beliefs
to impact patient outcomes. But, oftentimes, I wonder
how often are we trying to translate those strategies
and those interventions to address the needs of real
people and real communities beyond the laboratories. You know one of the
interventions, one of the programs that I had been
fortunate to develop over the last 10 years is a
program that is called Nurses Affecting Change
Partner In Pursuit of the Promise Because. Long title but very
deliberate, given the elements of the program, the
scope of the program, and the outcomes that we
are able to address. This particular intervention
is developed and designed to address the morbidity
immortality among African American women because we
know 43 percent of African American women, or black
women, are 43 percent more likely to die from breast
cancer than are white women. Many of you have seen the
reports that have been published that identify
the trends relative to disparities among black and
white women, among many of our major metropolitan cities
throughout the United States. Memphis was at the top of
the list, Milwaukee was also on the list, and most
recently studies have been developed, and had been
reported that identified some significant disparities
among African American women in Milwaukee that are
specific to geographic region. Milwaukee, as many of you
recognize, you know, has been identified as a very,
very segregated community; that is the perception. But when we took a look —
when researchers from the Medical College of Wisconsin
took a look at breast cancer survival rates within
southeastern Wisconsin, they saw some very
shocking trends. One of the trends that they
saw was a trend that we had been seeing for years, and
that trend is that many of our women who live in
densely populated, economically disadvantaged,
inner city communities in Milwaukee, are especially
underserved, and also at increased risk for breast
cancer incidents, but more importantly, breast
cancer mortality. You know, as a result of
what we have been able to glean for the last 10-some
years, we developed a collaboration with partners
within our area to address these issues, to address
these disparities, but more importantly to
affect change. A collaborative effort among
partners in the academic, clinical, public, and
private sector, including institutions and
organizations such as Wisconsin Department of
Health, The Southeastern affiliate of Susan G. Komen Foundation, The
American Cancer Society, The Kohl’s Cares Corporation,
The Wisconsin Genomics Institute, as well as the
University of Wisconsin, Milwaukee. This particular
collaboration involved the engagement of clinical
experts, research experts, and advocates, in an effort
to reach across the cancer continuum to address cancer
risk, to increase breast cancer screening, to remove
structural barriers that many of our women face in
our community, to increase and facilitate access to
quality care, but also to improve awareness and
engagement of women in our community to
clinical trials. And again, as I mentioned,
across the cancer continuum. This particular
collaborative addresses risk, addresses prevention,
addresses screening, diagnosis, treatment,
survivorship, and — if there is a need,
also, end of life. We target communities in our
area that we know have been identified as being
significantly at risk for poor survival. Especially among the
African American community. You see in the graph before
you, those specific areas, those specific zip codes,
are all congregated around a central core. One of the elements that is
so troubling, is that these are areas that have been
identified as also being socially and economically
disadvantaged, but also another reality is
oftentimes these are areas that many of the powers that
be, many of the advocates, many of the community
networks, these are areas that they do not go. That they do not attempt
to reach, and they do not attempt to engage. I have often said that it is
really important for us to identify those at-risk
populations, those vulnerable populations, as
Dr. Satcher mentioned those unpopulations, and those
hardly reached populations, because if we really want
to affect a change, that is what we need to do, and that
is what we need to grow. But it is also important
for us to recognize the importance of seeing who
those women are, and who those communities are,
because all too often, the faces that we see in the
campaigns and promotions in our communities, do not
necessarily reflect the women and the needs of those
that we honestly need to reach. That is not the case for
this particular initiative. You know, training and
education has been core to much of what I have been
doing over the last 30-some years, within in the area,
you know, recognizing that many of our clinicians
need to have a better understanding of the needs,
but also the strategies that can be implemented to affect
a change, and our Partners In pursuit of the
Promised Program. Our program is founded on
training of our clinicians, so they better understand
the needs, better understand the gaps and also better
understand how they could affectively engage
populations and screening and effective treatment. These training opportunities
not only provide detailed didactic, but they also
provide opportunities for the clinicians to better
understand the needs, better understand the strategies,
and also better enhance their clinical skills. So, they better understand
how to actually provide clinical care to address the
needs within our community. This particular program
also allows us to reach individuals, you know, using
a contingent of well trained and certified nurse
practitioners, clinical nurse specialists, community
health workers, advocates, but also, survivors. These are interventions
that target high risk, residential, occupational,
community centers, but also areas that people
fellowship, interact with, and engage with in
their daily lives. This particular intervention
also focuses on the strategies that had been
deemed to be effective by the Preventive
Health Services. Strategies are incorporated
that focus on small group education, one on one
education, reducing structural barriers,
reducing out of pocket costs for screening and treatment,
but also the importance of providers. You know, using
clinical reminders. Our nurses work directly one
on one with our patients, with our clients, with our
consumers in the community, so they better
understand their risk. Our Nurses Affecting Change,
Partners in Pursuit of The Promise, the Cause
Intervention, focus specifically on breast
cancer awareness, understanding, screening, survivor support, and empowerment. Why? Because many of our women in
our community we found, they heard the words, they know
the challenges, but they do not understand how this
information, how the data, how this knowledge,
impacts them. They don’t understand
oftentimes their risk, and how risk can affect
their health outcome. Our clinicians are
contingent, they work in the community, and they also try
to help women to understand they’re normal, one on
one, not just what normal characteristics in breasts
are, but how they are normal. What their normal is and how
they should respond if there are any changes. Our effort also works hard
to help women to address fears and concerns relative
to breast cancer detection, breast cancer screening, and
breast cancer control, and sometimes it is only when
you take a look at the faces of the women that we interact
with in our communities, do you see the need for reaching
and doing more. Our program also works hard to
facilitate access to screening. There is a lot of confusion
in our communities regarding screening guidelines as I am
sure there are across the country. Understanding the screening
guidelines and as they relate to the individual is
key in our particular area. We also try to include
within our facilitation of screening, would be referral
based on the risk, but also based on clinical
assessment. Within our program, we also
include patient reminders, patient navigation, but also
as has been deemed to be appropriate from the science,
appropriate follow-up. Access to quality care is
key because oftentimes our clients have difficulty
accessing care because of cost. We work very closely with
our CDC breast and cervical screening program. We work very closely with
our area breast cancer centers as well as our
academic medical centers to ensure that black women who
are underserved, who are at risk in our communities, can
have access to high quality care, patient navigation. And if a client is
identified with an anomaly that is deemed to be a
cancer we also provide survivor support. There are a number of
entities within our particular area that provide
that support, but also provide mentoring. Mentoring that allows the
woman to better understand her treatment, but also her
treatment options, but also opportunities within our
community to provide ongoing support as needed. Another major element of our
Nurses Affecting Change, Partners in Pursuit of
The Promise, the Cause Initiative, is engagement
in clinical trials. Just recently within our
community, we had a major community event that was
facilitated by one of our major medical centers that
focused on making clinical trials first choice in our
treatment decisions, not a last choice for
treatment decisions. It is an entity and an
opportunity that allowed more and more individuals
in our community to better understand clinical trials,
but also better understand the impact of clinical
trials on our overall outcomes. Sense of engagement is
another element that we need to keep in mind, you know,
relative to addressing cancer disparities, but
especially disparities that are effecting African
American women. Within our area, we have
been very fortunate to be able to engage with our
Wisconsin Department of Health and Family Services
and our Well Woman Program, which is part of our CDC
breast survival cancer screening program. The Wise Woman Program,
which facilitates the well-integrated screening
and evaluation for women across the nation program
that provides education and supports to address many of
the co-founders, co-factors, that are also affecting
cardiovascular disease, but also cancer as well. This particular program
focuses specifically on issues relative to
screening, issues relative to nutrition, issues
relative to obesity within our particular area. Another major national
campaign has integrated within the program is the
Insight Knowledge Campaign that raises awareness in a relative to gynecological cancer. These are opportunities that
have been integrated into this program, to again, to
address the needs that we see, you know,
within our area. Address the needs that we
see among African American women who are dying at a
disproportionate rate within our community. When we took a look, and
take a look at the data among the women that we have
been able to serve over the last six months alone within
our initiative, our nurses, our collaborators, have been
able to reach more than 1200 women within our community
over the last six months. They have been able to
provide navigation to mammography screening
for 784 women within our community. Mind you, these are women
who haven’t been reached, who have not been served,
who are at significant risk for mortality if a breast
cancer is diagnosed, and fortunately or
unfortunately, over the last six months, we have been
able to identify three women as a result of this
partnership that were in need to be diagnosed. One of the other bits of
data that I think is more telling and why an
initiative of this sort is so important, it is just
because when we take a look at the recommendations
for screening and early detection and awareness,
breast awareness, clinical examination, mammography
screening, all key, the women within our cohort, the
women within our network, only 32 percent of them have
received optimal care using those guidelines. It shows the needs, it shows
the opportunity, it shows the significant gaps that
I truly believe we need to address. We believe in our particular
cohort that we need to reach the mothers, and daughters,
and sisters, and neighbors, and colleagues, and friends,
and associates, of the women who are living
within that gap. Women who have not been
reached, who have not been adequately served, women who
all too often do not look like the women who are
within many of our promotional campaigns, but
women who are very much concerned also about their
health, about their care, and the care of others
within their community. I mentioned earlier three
letters, that in many ways undergirds much of the work
that I have been doing and continue to do. One letter from a program
director of a national breast cancer consortia. Another letter came from a
woman who we happened to serve most recently. A letter that came in
response to a program, and she shared, “The information
shared prompted me to schedule and follow through
with my mammogram, thank you. Had it not been for the
targeted and focused programs in this community
that would not have happened”. But the last letter — the
last letter, the third letter, really shows me, I think,
why this is so very important. It came about nine months
ago, and it came very unexpectedly from a woman
who apparently had been in one of our programs
in the community. It was a holiday card, but
she scripted in the corner, “Thank you for
your seminars. Because of your health
seminars I did not ignore a lump in my breast. It was cancer. Thank you for caring
for us black women”. Those words suggested that
we made a difference and continue to need, to try
to make a difference. And it also shows that there
is a hunger and a thirst in our communities for
initiatives such as this. Initiatives that educate,
initiatives that support, and initiatives that provide
the resources that are needed to affect a change. I want to close by being
mindful of what Dr. David Satcher encourages us all to
consider again and again, about this race, about this
work, about the importance of addressing health
disparities, cancer disparities among minority
populations, but also among all populations. He says that “This
enterprise is best categorized as a relay
and not a sprint”. And I say that because, what
we need to do more of, is to figure out ways that we can
pass this baton so that the work can continue
in spite of us. Pass a baton as nurse
scientists, so we can increase the numbers of
individuals who are doing the work to identify
the needs, develop the interventions to address the
needs, but also apply and translate the
findings and practice. We need to do more to train
the next generation of scientists, to get their
insight, you know, relative to how we can do this work
better, because there is much work to do. We need to disseminate the
findings in such a way that it really affects the lives of
real women in our communities. Think about those at risk,
inner city, underserved communities that need to
be addressed, that all too often we are not addressing. Dr. Grady [phonetic sp] in
your work, it is very clear that you recognize the
importance of taking the research and integrating it
and disseminating it into the lives of individuals
and families that represent those we serve. We all recognize that even
though, as we move on beyond Breast Cancer Awareness
Month, that there’s certain other elements that we need
to consider and we need to address and we need to
be mindful of as we move forward with this
particular initiative. We need to make a
difference, we are making a difference, but the key
is making a difference to greater numbers of
individuals within my community, and I think it
is important for us all to recognize my father would
say, and has said, you know, years and years ago, “If we
think these issues are not impacting us in our
communities, keep living, keep living. It will come closer to us
than we ever imagined if we keep living.” Last thought I want to share
is one that I shared with some of the clinicians just
a few moments ago, before I talked, about the importance
of this work and about the importance of seeing the
need and also responding to the need, and I was mindful
of a wise man who once said that there are none so blind
than those who have eyes but cannot see, because
they failed to look. And I say that as I look
around this room at the researchers, at the
administrators, at the clinicians, at the students,
at the survivors, make sure you look, make sure you
listen, and respond to the call in whatever
way you see fit. Thank you. [applause]>>Female Speaker: Thank
you so much for your talk. Have you considered or
examined data from mobile mammography vans that seek
to go to breast cancer dense regions and
increase screening?>>Dr. Millon-Underwood: You
know, that is a really good question because in our
particular initiative we do have a mobile mammography
unit, you know, that does work with our team, and our
team does work with that particular facility. This is a mobile mammography
unit that actually is supported by the Columbia
St. Mary’s Breast Cancer Center, and data from that
particular arena is also being gathered. That particular unit does
set aside special time to go to these inner city dense
populations, provide the screening, very
high quality care. One of the other aspects of
that particular program that is really so important is,
not only do they go to these dense populations and
provide the screening, that institution is also very
committed to ensuring that women who are under
resourced, who do not have sufficient insurance,
who are diagnosed with a problem, also receive care,
regardless of the cost, across the continuum of care. So, yes, we have, and yes, we are,
and yes, we will continue.>>Female Speaker:
Thank you.>>Male Speaker: Yes. I am impressed with all the
work that has been done to establish all these social
determinants of health, but I feel very embarrassed at
how a poor job we have done in dissemination. So, can we do more in that
regard instead of — less science and more
dissemination? Because it looks like we have done
a really poor job on that.>>Dr. Millon-Underwood:
I agree. I agree 100 percent. I agree 1000 percent,
because reality seems to be, as Dr. Freeman mentioned we
have got this disconnect. We know what some
of the issues are. We know what many
of the barriers are. We know what facilitates
the screening, the quality treatment, improving
outcomes, but we are not taking it where
the needs exist. I can’t tell you how
troubled I sometimes am when some of my colleagues, you
know, will share and say, “But we don’t go there and
we won’t go there” or “we don’t see the need” unless
they have X, Y and Z we — not just can’t, we won’t. I agree. But the question is, how
many of us are really going to commit ourselves to
affecting a change in that area? Changing that? And that is one of the
reasons why the team that works with us, and it is a
very diverse collaborative team of individuals;
physicians, nurses, community health workers,
radiologists, that really want to do their part using
the resources within their institutions, within
these communities. And we are seeing
it, we are seeing it. We are seeing it also as
it relates to many of the potential funders within
our area supporting and financing the work to
address the needs within these particular
communities. But you are right, we need
to do more to translate these findings into
practice, so that we can change the behaviors and
change the lives and change the outcomes of those
individuals in need. It is happening, as I talked
about the three women who were diagnosed as a result
of some of our work over the last six months. These are women who were
diagnosed early just by happenstance because our
team was within the arena. These are three that will
be among the ranks of the survivors, not among
those who have died. One, in particular, you
know, was in a family with multiple family members,
multiple first degree family members that have been
diagnosed with premenopausal breast cancer. One woman, you know,
recognized that she was at increased risk. One woman also had
felt a palpable lesion. This woman did
not have access. This woman did not
know where to go. The consortia that I am
talking about is one that has been developed and has
been established to address those kinds of needs if ever
they present in the community. No woman, who interacts with
us has any reason not to be serviced, because we have
resources from multiple entities that are already
in place to do just that. Insured, we can get people
connected to their service providers if they need help. Uninsured, we have resources
within our highly esteemed and high quality breast care
center to provide them care. If they are 400 percent
below the poverty level, we can connect them with our
Well Woman Program and if they are diagnosed they can
be placed on Medicaid and receive all the care that is
needed for treatment across the continuum. These are elements of the
program that we thought about up front before we
began the education, but these are elements that are
really beginning to make a big difference. One of the things that I
think we need to do even more effectively across our
region is to make sure that we can promote the efforts
in a way that the women who are in need see themselves,
so they better understand that they too are the ones
that we are trying to reach. Because all too often, what
we see in our promotions, in our campaigns, don’t
necessarily reflect those women that looks like we
are trying to reach, but I agree, I agree. And we have got resources
across the EIH to begin to address those, using a
research enterprise with the CDC to address those
issues, within our health departments to
address those issues. Now we need to have the
commitment and the political will to do just that within
the sphere of influence that we have. Thank you.>>Female Speaker: Thank
you for a very nice, very interesting presentation. I have a question and it
may be a moot question. Is — so many women in
general is having follow-up. I mean, dissemination
getting to the neighborhoods is so very important and you
are doing a marvelous job, but what are you doing or
what do you think we can do more to follow-up on those
women that even if the resources are there, they
will not follow through on what the results for
screening, or choose not to? I am not sure if you
addressed that already? And if you have I am sorry,
but I am just really curious in that because so much
is psychological too. People want to ignore, “Oh
that lump isn’t there, they really did not
find anything.”>>Dr. Millon-Underwood: You
know, that is also another very, very good question,
and as I think about the program of collaboration
and support that we have initiated, we recognize a
follow-up is key, and maybe I did not speak a lot about
that follow-up and the navigators we have engaged
in the program to do just that. NRB Cause Program and no I
did not spell it wrong, it was deliberate but hopefully
to jog your thought. Breast Cancer Awareness,
Understanding, Screening, Survivor Support,
and Empowerment. In addition to the
screening, in addition to the understanding, after
women are provided detailed information and support to
make an informed decision regarding their follow-up,
women are provided clinical assessments and are referred
for mammograms based on their risk and based on their
physical characteristics. Women also receive a call
afterwards just to check whether or not they did
follow-up, are in need of assistance following-up and
no woman in our program — the 1200 who I mentioned
before, has yet to be lost to follow-up. Now that does not
necessarily mean that some still would say that yes, I
understand, or yes, I know and I have this need and my
answer is still no I am not going to follow through. But we have clinical
nurse specialists, nurse practitioners, and community
health workers who are trained and certified and
work within our partnering agencies to do the follow-up
to ensure that we can make that connect if there is a
desire, and that has really made a difference. Because not only do we
follow-up to make sure that they are connected and can
have that appointment, we also have community health
workers that will stand side by side with them. Mentors who will stand side
by side if they need someone else to provide that physical
and that social support. You know, many of our
health institutions do have navigators and community
health workers that work, you know, within these
programs, but oftentimes that is not enough given the
volume of need within our communities. So yes, that is a part, and
that is incorporated and that too has made a
significant difference.>>Female Speaker:
Good afternoon. Thank you so much Dr.
Underwood for your lecture. My name is Tamarin Grey
[phonetic sp], I am a PACC at John’s Hopkins
University, and I had one question about what
considerations you might suggest related to immigrant
women who come into the United States and whether
you think screening practices may be
affected by immigration. Dr. Sandra Millon Underwood:
You know, that is a really good question for a number
of reasons, because in our particular area in
southeastern Wisconsin, we have a large cohort of
immigrant women that we interact with. Many from the Asian nations,
European nations, but also a large contingent from
the African nations. I am mindful of a woman who
we had a chance to interact with several years ago,
who came to one of our educational programs, and
she came with her sister. She had just gotten off the
plane, coming to Milwaukee because she needed some
assistance with hopefully, she said, a breast
reconstruction. But I happened to meet her
— she happened to be a sister of one of the
community health workers that work with us, to our
training for our nurse practitioners – sorry,
education for our nurse practitioners, and when
she came, because we had standardized patients, the
didactic, the clinical lab, but we also had real
people there for the nurse practitioners, I mean to
hone their skills, you know, relative to clinical
assessment referral, et cetera. She happened to be in the
audience, if you remember the slide before, she
happened to be in the audience and because
she knew that we had standardized patients, she
asked if she could be one of our patients. My thought was, you know, if
you have breasts, you can be one of our patients. [laughter] And so, of course we
welcomed her to do just that. However, it was not five
minutes, you know, into the assessment as one of our
standardized patients, that our instructor, who was a
nurse practitioner, who had come to me and said,
“Dr. Underwood, we have a need.” And it just so happened that
her need was so great as an immigrant woman who had come
for another reason, but she knew something else was
going on, and because of where we just happened to
be, I was able to connect with one of the providers
within the area, it just happened such that he was
there, he was willing to come, he talked with her, he
assessed her, and he said, “She does not just need
reconstruction, she needs a full metastatic workup,
because it appears as though she has got palpable
metastatic lesions”. But it was 72 hours later we
had her in the system and she got all she needed until
she returned home a year and a half later. Yes, we had even addressed
that because of our partners. There are a number of women
within our community that are immigrant, that do not
know this system, whose culture and values and
beliefs are such that it sometimes impedes
their engagement. So, we have some of our providers
are from that community. We have an array of students
that are nurses and nurse practitioners that are from
the various countries in African, Asian, Europe
etcetera, that want to give back, are trained to give
back and do a phenomenal job, and are giving back. Next week, I have nurses
who are even coming who represent community of women
who cover; women who wear the hajib, women who
are of the Muslim faith. Who often — whose values
and beliefs and culture is such that they are
concerned, but oftentimes the system of care that
we have in place does not accommodate their values and
beliefs and their religion, and so they do not come. We have got that covered as
well, and we are doing what we can based on the needs
that we see, and we are really engaging not only our
nurses but also with systems that already exist to
provide them support and provide them care. It is an Olive if I had a
chance to show you her voice and help you hear her voice
she would say, and she has said, “Don’t stop what you
are doing because you are making a difference in the lives of real people” like herself. Does that help?>>Dr. Patricia Grady: Thank
you so much Dr. Sandra Millon-Underwood. I would agree with
your last statement. Please do not stop
what you are doing. I think that you have given
us a wonderful example of what can be done to address
a really important problem. Also, thank you for
reminding us that this is a relay that we are involved
in and not a sprint. I think it is — really,
when you think about it, you know, not everybody can do
— we are all runners but some people are good at
starters and some people are good finishers. Other people can connect
what is going on in the middle and it is really
important that we all interact and that we all
play our roles in this process and I think you have
given us an extraordinary example of doing just that,
when you start at one end with a problem and with
information and you end up making an enormous
difference to real people and real communities. Thank you so much, we so
appreciate your being here today, and I do have a
certificate to present to you as a momentum. But we really, really
appreciate you so much for being here. Let me get a certificate for
you and then you get one more round of
well-deserved applause. So, have a certificate that
is presented to Dr. Sandra Millon-Underwood in
recognition of her being at the NINR Director’s Lecture. [applause] [music playing]

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