Komen-Central-Texas-2015-Community-Profile-Report

When selecting target communities, the Affiliate referred to the female breast cancer incidence rates and trends, death rates and trends, and late-stage incidence rates and trends within

SUSAN G KOMEN® CENTRAL TEXAS

Table of Contents 2

Acknowledgments 3

Executive Summary 4

Introduction to the Community Profile Report 4

Quantitative Data: Measuring Breast Cancer Impact in Local Communities 5

Health Systems and Public Policy Analysis 7

Qualitative Data: Ensuring Community Input 8

Mission Action Plan 10

Introduction 13

Affiliate History 13

Affiliate Organizational Structure 13

Affiliate Service Area 14

Purpose of the Community Profile Report 17

Quantitative Data: Measuring Breast Cancer Impact in Local Communities 18

Quantitative Data Report 18

Selection of Target Communities 31

Health Systems and Public Policy Analysis 35

Health Systems Analysis Data Sources 35

Health Systems Overview 35

Public Policy Overview 42

Health Systems and Public Policy Analysis Findings 47

Qualitative Data: Ensuring Community Input 49

Qualitative Data Sources and Methodology Overview 49

Qualitative Data Overview 50

Qualitative Data Findings 52

Mission Action Plan 54

Breast Health and Breast Cancer Findings of the Target Communities 54

Mission Action Plan 55

References 58

Table of Contents

The Community Profile Report could not have been accomplished without the exceptional work, effort, time and commitment from many people involved in the process

Susan G Komen® Central Texas would like to extend its deepest gratitude to the Board

of Directors and the following individuals who participated on the 2015 Community Profile Team:

Ashley Ferguson, CHES

Community Profile Intern

Susan G Komen® Central Texas

Destiny DeLillo

Executive Director

Susan G Komen® Central Texas

A special thank you to the following entities for their assistance with data collection and analyses, as well as providing information included in this report:

 Ramona Curtis, Baylor University

 Ashley Thornton, Baylor University

Report Prepared by:

Susan G Komen® Central Texas

Introduction to the Community Profile Report

Susan G Komen® is the world’s largest breast cancer organization, funding more breast cancer research than any other non-profit while providing real-time help to those facing the disease Komen Central Texas’ promise is to save lives and end breast cancer forever by empowering people, ensuring quality care for all, and energizing science to find the cures for the people of Central Texas The history of the Komen Central Texas is rich with many dedicated and

passionate breast cancer survivors, volunteers, and advocates who donate their time, energy, and knowledge to the mission of eradicating breast cancer as a life-threatening disease

Susan G Komen Central Texas began in 1999 with a small group of survivors and activists committed to spreading the life-saving message of early detection and supporting breast cancer programs in Central Texas In 2000, Komen Central Texas was incorporated and hosted their first Annual Race for the Cure® in 2001 Komen Central Texas has grown exponentially since and has provided the Central Texas community with an outlet to support the fight against breast cancer, remember those who have lost the battle, and celebrate those who are surviving For instance, there were over 1,600 registered participants in the 2014 Race for the Cure®,

generating a little over $100,000 in proceeds Over the past 14 years, Komen Central Texas has funded more than $2 million in local grants for life saving breast health education,

screening, and treatment for the uninsured and medically underserved The remaining net income has been contributed to the Susan G Komen Research Programs, funding cutting-edge research internationally

Susan G Komen Central Texas lies within the Heart of Texas, centrally located between the urban cities of Dallas/Fort Worth and Austin, Texas The Komen Central Texas service area is comprised of six counties to include Bell, Bosque, Coryell, Falls, McLennan, and Milam

Counties The majority of counties within the Komen Central Texas service area exceed the national average of citizens living with less than a high school education at 14.6 percent

Corresponding to poor education outcomes, the poverty level within the Komen Central Texas service area greatly exceed the national average However, unemployment percentages within the Affiliate’s region are very similar to the national average of 8.7 percent In the United States, 33.7 percent of Americans earn an income below the 250 percent poverty line Unfortunately, all six counties within the Komen Central Texas service area exceed the national average of citizens living below the 250 percent poverty line

Central Texas is comprised of many small towns causing a large number of residents in the Komen Central Texas service area to live in rural areas Only 19.3 percent of American citizens live in rural areas, whereas 81.2 percent of Bosque County residents, 67.4 percent of Falls County residents, and 56.2 percent of Milam County residents are considered rural tenants This corresponds to a large number of Central Texas residents living in medically underserved areas According to the Health Resources and Services Administration, Bosque County, Coryell County, Falls County, and Milam County are all designated as medically underserved areas The combination of high poverty levels, large percentages rural residents, and medically

underserved areas could indicate lack of health insurance or low transportation services,

Executive Summary

especially to the two counties, Bell and McLennan, with the highest density of health care

services

Currently, Komen Central Texas serves on the Community Health Improvement Plan (CHIP) Women’s Health Workgroup for McLennan County, which was formed in 2013 by City of Waco leadership after a community needs assessment revealed a need for a focus on women’s health The mission of CHIP’s Women’s Health Workgroup is to improve women’s health in McLennan County through the formation and implementation of a strategic plan as designated

by goals including to increase the number of women receiving an annual well-woman exam, increase the number of women receiving prenatal care by the end of their first trimester, and to increase the number of women receiving screening mammograms Susan G Komen Central Texas has proven to be an invaluable resource because of knowledge and resources pertaining

to screening mammograms and breast cancer The Komen Central Texas also sits on the Providence Breast Center Advisory Board to annually discuss new breast cancer knowledge, breast center logistical issues, and to collaborate with other members to continually enhance the breast center

The data obtained from comprehensive Community Profile research and analysis will be used to assist Komen Central Texas in directing the Affiliate’s activities and resources to ensure that the Affiliate’s promise of saving lives and ending breast cancer forever is kept alive within the

Central Texas community The Community Profile contains an analysis of demographic and breast cancer statistics to highlight target areas with the greatest needs and service gaps This information will be used within the Central Texas community to increase educational efforts in target areas, improve marketing awareness of Susan G Komen in targeted areas, prioritize the granting process, improve public policy efforts, and identify opportunities for partnerships and collaboration with community leaders Data collected from the Community Profile process will

be shared with the Community Health Improvement Plan, Women’s Health Work Group, and Providence Breast Health Center Advisory Board The Community Profile Report will also be shared in the community through health systems, legislators, and media outlets to market the Affiliate’s grant opportunities, as well as community outreach efforts to build partnerships with local sponsors and constituents

Quantitative Data: Measuring Breast Cancer Impact in Local Communities

In order to utilize resources most effectively, Susan G Komen Central Texas has chosen two target communities within the service area The Affiliate will focus strategic efforts on these target communities over the course of the next four years Target communities are those

communities that show an increasing chance of underserved populations not receiving proper breast health services and access to care These barriers may result in late-stage diagnosis or worse, death from breast cancer

When selecting target communities, the Affiliate referred to the female breast cancer incidence rates and trends, death rates and trends, and late-stage incidence rates and trends within Central Texas Additional key indicators the Affiliate reviewed when selecting target

communities included, but were not limited to incidence rates and trends, death rates and trends, late-stage diagnosis rates and trends, below average screening proportions, residents living below poverty level, uninsured residents, and residents living in rural areas Counties that did not meet or are not likely to meet the designated Healthy People 2020 targets are labeled as target communities Healthy People 2020 is a government initiative that provides specific health objectives for communities and the country as a whole, including goals around reducing

women’s death rate from breast cancer and reducing the number of breast cancers found at a late-stage The selected target communities are Bosque County and McLennan County With interventions in each of the two designated target counties, the Affiliate is expecting to see a decreased number of new cases found at a late-stage in Bosque County and decreased breast cancer death rates in McLennan County by 2019

Bosque County was designated within the Quantitative Data Report as being a high priority area because it is not likely to meet the late-stage rate Healthy People 2020 target Although, not significantly different from the Affiliate as a whole, late-stage trend of new breast cancer cases

in Bosque County of 4.5 percent per year indicate that new cases found in a later stage of breast cancer are increasing An increase in the number of late-stage diagnoses is concerning This suggests that more women will be diagnosed with breast cancer at a late-stage Late-stage diagnosis complicates treatment and can lead to a poorer outcome of survival

Bosque County is designated as medically underserved and has a substantially higher

percentage of rural residents A medically underserved population is one that has alarming levels of; the ratio of primary physicians per 1,000 citizens, infant death rate, percentage of citizens over the age of 65, and the percentage of the population with incomes below the

poverty level (Health Resources and Services Administration, 1995) Over one-quarter of Bosque County residents do not have health insurance The combination of high uninsured percentage, rural residencies, and limited access to medical care presents concern Future efforts in Bosque County will also take into consideration that an extremely large percentage of the population is older Breast cancer becomes more common as women grow older; increased risk of breast cancer is a result of simply being female and growing older (Susan G Komen, 2013) Bosque County has the largest percentage of women over the age of 40 within the counties the Affiliate serves The health systems analysis component of this report will take a deeper look at the available breast health services in Bosque County Due to the region’s rural nature and being designated as medically underserved, it is vitally important to gain a clear understanding of how accessible breast health services are in the region

McLennan County was designated within the Quantitative Data Report as being a medium-high priority area because of not being likely to meet the death rate Healthy People 2020 target The death rate in McLennan County is 27.9 breast cancer deaths per 100,000 citizens Death rates are also higher within Black/African-American and Hispanic/Latina populations versus any other population in McLennan County 23.3 percent of women in McLennan County are of

Hispanic/Latina origin, while 16.2 percent of women are of Black/African-American descent McLennan County not being likely to meet the death rate Healthy People 2020 target may be

associated with the county’s high rates of poverty and the large percentage of minority

culturally sensitive, and easily accessible

Health Systems and Public Policy Analysis

The programs and services assessment included completing an inventory and mapping of providers and key organizations Mapping was done in order to understand the geographical distribution of resources, such as hospitals, FDA approved mammography centers, cancer centers, health departments, and free clinics This analysis is essential to determining how the Affiliate will invest resources to improve the quality of life of women in the Central Texas

community

In Bosque County, 81.2 percent of residents live in a rural area With Bosque County being a predominantly rural county, which has access to one hospital, one mammography facility, and one satellite cancer center results in the county having breast cancer services available for screening, diagnosis, and treatment However, 26.1 percent of Bosque County residents are living with no health insurance Thankfully, Bosque County’s only mammography facility,

Goodall-Witcher Healthcare, has one reduced rate program known as Breast Care Program, which offers fully funded mammography services for women without insurance who meet

eligibility guidelines If over one-quarter of residents are living without insurance, the lack of community health centers, free clinics, and reduced rate mammography programs do bring unease

McLennan County has a comprehensive health system that has breast cancer screening, diagnostic, and treatment services available With two large hospitals, three mammography facilities, two cancer centers, and one public health district, citizens have access to options and well-rounded care Being that McLennan County is home to the second highest poverty level in the Komen Central Texas service area, having ten community health centers and two free health clinics is outstanding

Planned Parenthood of Greater Texas and Providence Breast Health Center provides women that are uninsured or low-income free or low-cost mammograms and follow-up care which

demonstrates great efforts are being made to reduce the late-stage incidence rate in McLennan County This effort is magnified by the fact that a grant provided by Susan G Komen® Central Texas catches women who may not be deemed as low-income, but still need financial

assistance for a clinical breast exam, mammography, and/or diagnostic screenings Breast and Cervical Cancer Services (BCCS) also provides mammograms to uninsured or low-income women between the ages of 40 and 64 years through the Planned Parenthood of Greater Texas

in Waco by providing a voucher to either the mammography facility at Providence Breast Health Center or Baylor Scott & White Hillcrest In addition, the Providence Breast Health Center partners with the Family Health Center to provide women that are uninsured or low-income, free

or low-cost mammograms and follow-up care It is important to note that these services offered

by the Family Health Center are only available to McLennan County residents, which excludes women from Bosque County

The health systems analysis indicated that the majority of health facilities are located in

McLennan County In fact, McLennan County is the only county within the Affiliate service area with community health centers and free health clinics Other counties with very high poverty and uninsured levels may not have access to these facilities Lack of transportation, monetary means, or knowledge of existing free health clinics or discounted health services could all be factors in women being unable to enter the Continuum of Care McLennan County is also the only county within the Affiliate service area with a clinic that receives NBCCEDP funding

Health care reform through the Affordable Care Act (ACA) aims to increase access to breast and cervical cancer screening services for many low-income, underserved women through expanded insurance coverage and eliminating cost-sharing To ensure women have access to preventive health services, the health care law requires all new, non-grandfathered, private insurance plans to cover mammograms every 1-2 years for women over the age of 40, with no cost-sharing One of the requirements for Texas women to be eligible for NBCCEDP is being uninsured or otherwise not eligible for Medicaid There is fear that the number of women

eligible for NBCCEDP may increase due to Medicaid not being expanded in the State of Texas

Texas has the highest rate of uninsured citizens in the nation According to the Quantitative Data Report, 21.3 percent of people living in the Komen Central Texas service area are without health insurance Even though the Affordable Care Act is in place, community health centers and nonprofits in Central Texas will continue serving a large uninsured population Therefore, the current access to care issues will cause Susan G Komen Central Texas to continue helping large volumes of uninsured citizens through their local grants program

Qualitative Data: Ensuring Community Input

Within the Susan G Komen® Central Texas service area, Bosque County is of the highest priority due to not being likely to meet the Healthy People 2020 late-stage incidence rate target, while McLennan County is projected to not meet the Healthy People 2020 breast cancer death rate Bosque County’s quantitative data were frequently suppressed due to small numbers Therefore, qualitative research methods were implemented within Bosque County to better

understand the situational and environmental contexts behind the lack of numerical data

Qualitative research methods were also employed in McLennan County to further explore the breast health and breast cancer issues highlighted by the quantitative data Qualitative data collection was utilized to provide insight into Bosque County and McLennan County’s personal and community perceptions of breast cancer, attitudes and beliefs about disparities, current breast health education trends, health care access and barriers, utilization and quality of

services, and other key assessment variables In addition, the qualitative process can provide the community perspective as to what is working, what is not working, and what are the various barriers that lead to gaps in access, utilization, and quality of services Both key informant interviews and focus groups were implemented to collect this information

Community stakeholders were selected to take part in twelve key informant interviews to not only provide personal statements, but to also speak on behalf of the local communities that they represent These stakeholders were selected based on their association with target

communities Six focus groups, three within each target community, were also conducted to better understand the breast cancer perceptions of community members within the target

communities Focus groups were selected as a data collection method because of their explicit use of group interactions Community members may have a greater response when interacting with other community members and commenting on each other’s experiences and points of view, rather than a researcher simply asking each participant to answer questions

Both a qualitative resource expert and the Community Profile Team conducted a hand thematic analysis utilizing the verbatim transcripts and recordings Data were processed and recorded immediately after key informant interviews and focus group discussions The thematic analysis process involved coding to record patterns and draw accurate conclusions from the data The data were reduced after all key informant interviews and focus group discussions were

implemented, processed, and coded Reduction of the data involved decreasing the number of codes to only those that were meaningful to breast health or breast cancer issues The

qualitative resource expert and Community Profile Team agreed on meaningful themes to encompass a number of codes Once the data were coded and further broken down into

themes, a demographic table was created to ensure equal representation across both target populations within the qualitative data collection Meaningful themes and codes guided the interpretation of the qualitative data The detailed interpretation can be found in the qualitative section of the Community Profile

Research participants believe that there is sufficient breast cancer awareness within Bosque County However, self-breast exams and mammograms were frequently discussed during focus group sessions Self-breast exams are not recommended as a screening tool for breast cancer because studies have proven self-breast exams to not provide the early detection and survival benefits of other screening tests (Susan G Komen, 2014) Women also expressed not knowing if there were local programs that offered mammograms to uninsured individuals or even which local clinics had mammography equipment Therefore, updated health education efforts are necessary within Bosque County Barriers to breast health within Bosque County were predominantly related to finances and insurance because participants’ insurance would

only cover certain clinics and a number of those clinics do not have mammography equipment With Bosque County having only one mammography machine to serve the entire county’s population, assessing key variables associated with the accessibility and barriers to this single mammography facility were of the utmost priority During key informant interviews, community stakeholders were mainly concerned with women living in rural communities and older women not having access to the mammography equipment at Goodall-Witcher Hospital, especially those living in Iredell, Morgan, Cranfills Gap, and other communities in northern Bosque County

McLennan County residents were not aware of any breast cancer education happening within their local communities, but were very aware of Race for the Cure However, the majority of Black/African-American participants were aware of free breast cancer screening coupons from Planned Parenthood Because of the lack of health education, participants expressed

depending on their doctors for information The majority of participants also have confidence in the medical community to remind them of scheduling breast health screenings However, these are women with access to care Participants suggested more personal educational events in smaller, intimate settings, such as potluck dinners or girl parties within neighborhoods

Barriers to breast health within McLennan County were predominantly related to lack of money, insurance, and transportation Others expressed that mammograms simply hurt One

participant also shared that, “There is a stigma to going to the doctor, especially within the Hispanic/Latino or Black/African-American culture They would rather not know if there is bad news.” With the county’s high percentages of impoverished citizens, as well as minority groups, further data collection was necessary concerning underserved neighborhoods, such as East Waco, within McLennan County Several stakeholders voiced that the increasing rates of breast cancer deaths may be occurring within these underserved regions If resources are not

developed within East Waco and other lower-income areas, then more thorough public

transportation within low-income neighborhoods to areas with health care facilities is imperative The majority of participants expressed that it would be easier to access breast health within McLennan County if there was a mobile mammogram bus that could travel to women’s church ministries, community centers, schools, and alumnae sorority events It was also suggested to normalize breast issues and make the breast health care facilities more inviting and holistic

Mission Action Plan

The triangulation of diverse data sources from the target communities creates the basis of the problem statements within Bosque County and McLennan County

Susan G Komen Central Texas priorities within Bosque County include:

 Increase Affiliate initiatives within Bosque County to develop awareness and education regarding breast health

 Increase breast health outreach to Iredell, Morgan, Cranfills Gap, and other communities

in northern Bosque County; qualitative research exposed concern for rural towns in northern Bosque County

Susan G Komen Central Texas priorities within McLennan County include:

 Increase community outreach within Black/African-American and Hispanic/Latina

communities in McLennan County

 Partner with community-based outreach/health organizations to effectively promote breast health education and services including breaking down cultural barriers for

Black/African-American and Hispanic/Latina women living in McLennan County

 Increase access to culturally competent breast health services among American and Hispanic/Latina women over the age of 40 living in McLennan County

Black/African-Bosque County Problem Statement: Quantitative Data revealed Black/African-Bosque County is not likely

to meet the late-stage rate Healthy People 2020 target The late-stage trend of new breast cancer cases in Bosque County of 4.5 percent per year indicate that new cases found in a later stage are increasing

 Priority 1: Increase Affiliate initiatives within Bosque County to develop awareness and education regarding breast health

o Objective 1.1: By 2017, collaborate with a Bosque County health care institution

to provide breast health care and outreach efforts throughout Bosque County

o Objective 1.2: In FY 2016, develop a collaborative RFA grant encouraging

providers in Bosque County to partner with other providers in the county to submit proposals that offer subsidies for mammograms for uninsured women in Bosque County

o Objective 1.3: By 2017, increase the Affiliate’s marketing and outreach of grant applications for evidence-based education and screening programs from organizations that serve Bosque County by 25 percent

o Objective 1.4: In FY 2016, partner with a Bosque County organization to arrange small group education classes on breast self-awareness in at least three

locations throughout Bosque County

 Priority 2: Increase breast health outreach to Iredell, Morgan, Cranfills Gap, and other communities in northern Bosque County; qualitative research exposed concern for rural towns in northern Bosque County

o Objective 2.1: By March 2016, meet with at least one community organization or faith community that services residents residing in Morgan, Cranfills Gap, and Iredell to discuss breast health outreach

o Objective 2.2: By March 2017, partner with at least one organization in northern Bosque County and Goodall-Witcher Hospital to provide a culturally appropriate breast health event where women over the age of 40 can sign up for a

mammography appointment

McLennan County Problem Statement: According to the Quantitative Data Report,

McLennan County has larger than average percentages of Black/African-American and

Hispanic/Latina women; these populations may be disproportionately affected by increasing death rates due to breast cancer in McLennan County

 Priority 3: Increase community outreach within Black/African-American and

Hispanic/Latina communities in McLennan County

o Objective 3.1: By January 2017, partner with a McLennan County

mammography facility to register women for breast cancer screening at two community events with a large percentage of Black/African-American or Hispanic/Latina attendees, such as the Juneteenth Celebration or the CenTex Hispanic Chamber of Commerce’s Women’s Health Fair

o Objective 3.2: By August 2016, market the need for culturally tailored health education programs within the Black/African-American and Hispanic/Latina communities in McLennan County

 Priority 4: Partner with community-based outreach/health organizations to effectively promote breast health education and services including breaking down cultural barriers for Black/African-American and Hispanic/Latina women living in McLennan County

o Objective 4.1: By September 2015, reach out to at least three predominantly Black/African-American community organizations or faith communities, with a focus in East Waco, to hold breast cancer community outreach presentations and

or arrange small group education classes on breast self-awareness in at least five locations throughout McLennan County

McLennan County Problem Statement: Qualitative research highlighted concern that

Black/African-American and Hispanic/Latina women in McLennan County have limited access to culturally competent health care services

 Priority 5: Increase access to culturally competent breast health services among

Black/African-American and Hispanic/Latina women over the age of 40 living in

McLennan County

o Objective 5.1: In 2015, develop collaborative relationships with at least three community-based organizations whose target population is Black/African-

American and or Hispanic/Latina women in McLennan County

o Objective 5.2: In FY 2016, develop a collaborative RFA grant encouraging providers in McLennan County to partner with other providers in the county to submit proposals that offer subsidies for mammograms for uninsured women in

McLennan County

Disclaimer: Comprehensive data for the Executive Summary can be found in the 2015 Susan

G Komen® Central Texas Community Profile Report

$140,000 in proceeds This event provides the community with an opportunity to support the fight against breast cancer, to remember those who have lost the battle, and to celebrate those who are surviving

Over the past 14 years, Komen Central Texas has funded more than $2 million in local grants for life saving breast health education, screening, and treatment Up to 75.0 percent of the net income raised by the Affiliate is awarded through grants to non-profit organizations providing breast cancer education, screening, and treatment for the uninsured and medically

underserved The remaining 25.0 percent of the net income is contributed to the Susan G Komen Award and Research Grant Program, which funds cutting-edge research internationally

In 2014, Komen Central Texas invested $88,611.00 in local grants and nearly $35,000.00 to the national research programs

Currently, Komen Central Texas serves on the Community Health Improvement Plan Women’s Health Workgroup for McLennan County, which was formed in 2013 by City of Waco leadership after the community needs assessment revealed a need for a focus on women’s health The mission and purpose of the group aims to improve women’s health in McLennan County through the formation and implementation of a strategic plan The goals of the group are to increase the number of women receiving an annual well woman exam, to increase the number of women receiving prenatal care by the end of their first trimester, and to increase the number of women receiving screening mammograms Komen Central Texas was asked to join this group because

of knowledge and resources when it comes to screening mammograms and breast cancer Komen Central Texas also sits on the Providence Breast Center Advisory board and as a

member the board meets yearly to discuss any issues or new knowledge the breast center experienced over the past year, and to collaborate with other members on ideas, concerns, or to provide input

Affiliate Organizational Structure

Susan G Komen Central Texas offices are located at 3000 Herring Avenue, 4E, Waco, Texas Komen Central Texas employs one full-time staff member and one part-time staff member and

is governed by a six member Board of Directors, coordinating and overseeing two working committees (Figure 1.1) The first committee that the board oversees is The Race Committee, which has the responsibility to implement the Race plan, as approved by Affiliate Board, as well

as the authority to carry out the job as described The Race Committee may not obligate the Affiliate or parts thereof to any affiliation or action without specific approval of the board and proper coordination The second committee that the board oversees is the Board Development

Introduction

Committee, which is responsible for the ongoing review and recommendations to enhance the quality and future viability of the Board of Directors It focuses most heavily on five areas: board role and responsibilities, board composition, board knowledge, board effectiveness, and board leadership The Board Development Committee’s specific duties can also vary depending upon board needs at any specific time, in addition to a focus on evolving practice

Destiny DeLillo serves as the executive director of Komen Central Texas, while Melissa

Peguero is employed as the development coordinator Gregory Barton serves as the president

of the Board of Directors, while Samantha King serves as treasurer and Jane Allen serves as secretary The at large board members consist of Cecilia Pena, Andrea Clendennen, and Shenequa Williams

Figure 1.1 Susan G Komen Central Texas organizational structure Affiliate Service Area

Komen Central Texas lies within the Heart of Texas, centrally located between the urban cities

of Dallas/Fort Worth and Austin, Texas The Affiliate region is comprised of six counties to include Bell, Bosque, Coryell, Falls, McLennan, and Milam Counties (Figure 1.2)

The majority of counties within the Komen Central Texas service area exceed the national average of citizens living with less than a high school education at 14.6 percent For instance, 23.7 percent in Falls County residents, 19.2 percent in McLennan County, 19.2 percent in Bosque County, and 18.4 percent in Milam County have earned less than a high school

education

Corresponding to poor education outcomes, the poverty levels within the Komen Central Texas service area greatly exceed the national average However, unemployment percentages within the Affiliate’s region are very similar to the national average of 8.7 percent In the United States, approximately 14.3 percent of citizens earn an income below the 100 percent poverty line, whereas a shocking 23.6 percent of Falls County residents and 21.7 percent of McLennan County residents live with means under the 100 percent poverty line 33.7 percent of Americans earn an income below the 250 percent poverty line Unfortunately, all six counties within the Komen Central Texas service area exceed the national average of citizens living below the 250

percent poverty line, such as 51.0 percent in Falls County, 43.5 percent in Milam County, 41.4 percent in Coryell County, 40.3 percent in Bosque County, 40.0 percent in McLennan County, and 37.1 percent in Bell County

Central Texas is comprised of many small towns causing a substantial number of residents in the Komen Central Texas service area to live in rural areas Only 19.3 percent of American citizens live in rural areas, whereas 81.2 percent of Bosque County residents, 67.4 percent of Falls County residents, and 56.2 percent of Milam County residents are considered rural

tenants This corresponds to a large number of Central Texas residents living in medically underserved areas According to the Health Resources and Services Administration, Bosque County, Coryell County, Falls County, and Milam County are all designated as medically

underserved areas

The combination of high poverty levels, large percentages rural residents, and medically

underserved areas could indicate lack of health insurance or low transportation services,

especially to the two counties, Bell and McLennan, with the highest density of health care services

Figure 1.2 Susan G Komen Central Texas service area

Purpose of the Community Profile Report

Susan G Komen’s promise is to save lives and end breast cancer by empowering people, ensuring quality care for all, and energizing science to find a cure The information obtained from the Community Profile will be used to assist Komen Central Texas in directing the

Affiliate’s activities and resources to better ensure that this promise is kept Data collected from the Community Profile process is currently being shared with the Community Health

Improvement Plan (CHIP), Women’s Health Work Group The published Community Profile will

be shared with the Providence Breast Center Advisory Board as a part of the Affiliate’s

grantmaking, as well as within community outreach to build partnerships with sponsors and constituents The Community Profile Report will also be shared in the community through health systems, legislators, and media outlets

The Community Profile contains an analysis of demographic and breast cancer statistics This analysis helps to highlight target areas with the greatest needs and service gaps This

information will be used to:

 Increase educational efforts in target areas

 Improve marketing awareness of Susan G Komen in targeted areas

 Prioritize the granting process

 Improve public policy efforts

 Identify opportunities for partnership and collaboration with community leaders

Quantitative Data Report

Introduction

The purpose of the quantitative data report for Susan G Komen® Central Texas is to combine

evidence from many credible sources and use the data to identify the highest priority areas for

evidence-based breast cancer programs

The data provided in the report are used to identify priorities within the Affiliate’s service area

based on estimates of how long it would take an area to achieve Healthy People 2020

objectives for breast cancer late-stage diagnosis and death rates

(http://www.healthypeople.gov/2020/default.aspx)

The following is a summary of Komen® Central Texas’ Quantitative Data Report For a full

report please contact the Affiliate

Breast Cancer Statistics

Incidence rates

The breast cancer incidence rate shows the frequency of new cases of breast cancer among

women living in an area during a certain time period (Table 2.1) Incidence rates may be

calculated for all women or for specific groups of women (e.g for Asian/Pacific Islander women

living in the area)

The female breast cancer incidence rate is calculated as the number of females in an area who

were diagnosed with breast cancer divided by the total number of females living in that area

Incidence rates are usually expressed in terms of 100,000 people For example, suppose there

are 50,000 females living in an area and 60 of them are diagnosed with breast cancer during a

certain time period Sixty out of 50,000 is the same as 120 out of 100,000 So the female

breast cancer incidence rate would be reported as 120 per 100,000 for that time period

When comparing breast cancer rates for an area where many older people live to rates for an

area where younger people live, it’s hard to know whether the differences are due to age or

whether other factors might also be involved To account for age, breast cancer rates are

usually adjusted to a common standard age distribution Using age-adjusted rates makes it

possible to spot differences in breast cancer rates caused by factors other than differences in

age between groups of women

To show trends (changes over time) in cancer incidence, data for the annual percent change in

the incidence rate over a five-year period were included in the report The annual percent

change is the average year-to-year change of the incidence rate It may be either a positive or

negative number

 A negative value means that the rates are getting lower

Quantitative Data: Measuring Breast Cancer Impact in

Local Communities

 A positive value means that the rates are getting higher

 A positive value (rates getting higher) may seem undesirable—and it generally is However, it’s important to remember that an increase in breast cancer incidence could also mean that more breast cancers are being found because more women are getting mammograms So higher rates don’t necessarily mean that there has been an increase

in the occurrence of breast cancer

Death rates

The breast cancer death rate shows the frequency of death from breast cancer among women living in a given area during a certain time period (Table 2.1) Like incidence rates, death rates may be calculated for all women or for specific groups of women (e.g Black/African-American women)

The death rate is calculated as the number of women from a particular geographic area who died from breast cancer divided by the total number of women living in that area Death rates are shown in terms of 100,000 women and adjusted for age

Data are included for the annual percent change in the death rate over a five-year period

The meanings of these data are the same as for incidence rates, with one exception Changes

in screening don’t affect death rates in the way that they affect incidence rates So a negative value, which means that death rates are getting lower, is always desirable A positive value, which means that death rates are getting higher, is always undesirable

Late-stage incidence rates

For this report, late-stage breast cancer is defined as regional or distant stage using the

Surveillance, Epidemiology and End Results (SEER) Summary Stage definitions

(http://seer.cancer.gov/tools/ssm/) State and national reporting usually uses the SEER

Summary Stage It provides a consistent set of definitions of stages for historical comparisons

The late-stage breast cancer incidence rate is calculated as the number of women with regional

or distant breast cancer in a particular geographic area divided by the number of women living

in that area (Table 2.1) Late-stage incidence rates are shown in terms of 100,000 women and adjusted for age

Table 2.1 Female breast cancer incidence rates and trends,

death rates and trends, and late-stage rates and trends

Incidence Rates and Trends Death Rates and Trends Late-stage Rates and Trends

Population Group

Female Population (Annual Average)

# of New Cases (Annual Average)

Age- adjusted Rate/

100,000

Trend (Annual Percent Change)

# of Deaths (Annual Average)

Age- adjusted Rate/

100,000

Trend (Annual Percent Change)

# of New Cases (Annual Average)

Age- adjusted Rate/

100,000

Trend (Annual Percent Change)

*Target as of the writing of this report

NA – data not available

SN – data suppressed due to small numbers (15 cases or fewer for the 5-year data period)

Data are for years 2006-2010

Rates are in cases or deaths per 100,000

Age-adjusted rates are adjusted to the 2000 US standard population

Source of incidence and late-stage data: North American Association of Central Cancer Registries (NAACCR) – Cancer in North

America (CINA) Deluxe Analytic File

Source of death rate data: Centers for Disease Control and Prevention (CDC) – National Center for Health Statistics (NCHS) death

data in SEER*Stat

Source of death trend data: National Cancer Institute (NCI)/CDC State Cancer Profiles

Incidence rates and trends summary

Overall, the breast cancer incidence rate and trend in the Komen Central Texas service area

were lower than that observed in the US as a whole The incidence rate and trend of the

Affiliate service area were not significantly different than that observed for the State of Texas

For the United States, breast cancer incidence in Blacks/African-Americans is lower than in

Whites overall The most recent estimated breast cancer incidence rates for Asians and Pacific

Islanders (APIs) and American Indians and Alaska Natives (AIANs) were lower than for Hispanic Whites and Blacks/African-Americans The most recent estimated incidence rates for Hispanics/Latinas were lower than for Non-Hispanic Whites and Blacks/African-Americans For the Affiliate service area as a whole, the incidence rate was slightly lower among Blacks/African-Americans than Whites and lower among APIs than Whites There were not enough data available within the Affiliate service area to report on AIANs so comparisons cannot be made for this racial group The incidence rate among Hispanics/Latinas was lower than among Non-Hispanics/Latinas

Non-The incidence rate was significantly lower in the following county:

Death rates and trends summary

Overall, the breast cancer death rate in the Komen Central Texas service area was slightly higher than that observed in the US as a whole and the death rate trend was not available for comparison with the US as a whole The death rate of the Affiliate service area was not

significantly different than that observed for the State of Texas

For the United States, breast cancer death rates in Blacks/African-Americans are substantially higher than in Whites overall The most recent estimated breast cancer death rates for APIs and AIANs were lower than for Non-Hispanic Whites and Blacks/African-Americans The most recent estimated death rates for Hispanics/Latinas were lower than for Non-Hispanic Whites and Blacks/African-Americans For the Affiliate service area as a whole, the death rate was higher among Blacks/African-Americans than Whites There were not enough data available within the Affiliate service area to report on APIs and AIANs so comparisons cannot be made for these racial groups The death rate among Hispanics/Latinas was lower than among Non-Hispanics/Latinas

None of the counties in the Affiliate service area had substantially different death rates than the Affiliate service area as a whole, though there were not enough data available for two counties

Late-stage incidence rates and trends summary

Overall, the breast cancer late-stage incidence rate in the Komen Central Texas service area was similar to that observed in the US as a whole and the late-stage incidence trend was lower than the US as a whole The late-stage incidence rate and trend of the Affiliate service area were not significantly different than that observed for the State of Texas

For the United States, late-stage incidence rates in Blacks/African-Americans are higher than among Whites Hispanics/Latinas tend to be diagnosed with late-stage breast cancers more often than Whites For the Affiliate service area as a whole, the late-stage incidence rate was higher among Blacks/African-Americans than Whites and about the same among APIs than Whites There were not enough data available within the Affiliate service area to report on AIANs so comparisons cannot be made for this racial group The late-stage incidence rate among Hispanics/Latinas was lower than among Non-Hispanics/Latinas

None of the counties in the Affiliate service area had substantially different late-stage incidence rates than the Affiliate service area as a whole

Table 2.2 Breast cancer screening recommendations

for women at average risk*

American Cancer Society National Comprehensive Cancer Network US Preventive Services Task Force

Mammography every other

year beginning at age 55

Mammography every year

starting

at age 40

Informed decision-making with a health care provider

mammogram in the last two years

The data have been weighted to account for differences between the women who were

interviewed and all the women in the area For example, if 20.0 percent of the women

interviewed are Hispanic/Latina, but only 10.0 percent of the total women in the area are

Hispanic/Latina, weighting is used to account for this difference

The report uses the mammography screening proportion to show whether the women in an area are getting screening mammograms when they should Mammography screening proportion is calculated from two pieces of information:

The number of women living in an area that the BRFSS determines should have mammograms (i.e women age 50 to 74).The number of these women who actually had a mammogram during the past two years

The number of women who had a mammogram is divided by the number who should have had one For example, if there are 500 women in an area who should have had mammograms and

250 of those women actually had a mammogram in the past two years, the mammography screening proportion is 50.0 percent

Because the screening proportions come from samples of women in an area and are not exact, Table 2.3 includes confidence intervals A confidence interval is a range of values that gives an idea of how uncertain a value may be It’s shown as two numbers—a lower value and a higher one It is very unlikely that the true rate is less than the lower value or more than the higher value

For example, if screening proportion was reported as 50.0 percent, with a confidence interval of 35.0 to 65.0 percent, the real rate might not be exactly 50.0 percent, but it’s very unlikely that it’s less than 35.0 or more than 65.0 percent

In general, screening proportions at the county level have fairly wide confidence intervals The confidence interval should always be considered before concluding that the screening

proportion in one county is higher or lower than that in another county

Table 2.3 Proportion of women ages 50-74 with screening mammography

in the last two years, self-report

Population Group

# of Women Interviewed (Sample Size)

# w/ Self- Reported Mammogram

Proportion Screened (Weighted Average)

Confidence Interval of Proportion Screened

SN – data suppressed due to small numbers (fewer than 10 samples)

Data are for 2012

Source: CDC – Behavioral Risk Factor Surveillance System (BRFSS)

Breast cancer screening proportions summary

The breast cancer screening proportion in the Komen Central Texas service area was not significantly different than that observed in the US as a whole The screening proportion of the Affiliate service area was not significantly different than the State of Texas

For the United States, breast cancer screening proportions among Blacks/African-Americans are similar to those among Whites overall APIs have somewhat lower screening proportions than Whites and Blacks/African-Americans Although data are limited, screening proportions among AIANs are similar to those among Whites Screening proportions among

Hispanics/Latinas are similar to those among Non-Hispanic Whites and

Blacks/African-Americans There were not enough data available within the Affiliate service area to report on Blacks/African-Americans, APIs, and AIANs so comparisons cannot be made for these racial groups Also, there were not enough data available within the Affiliate service area to report on Hispanics/Latinas so comparisons cannot be made for this group

None of the counties in the Affiliate service area had substantially different screening

proportions than the Affiliate service area as a whole or did not have enough data available

Population Characteristics

The report includes basic information about the women in each area (demographic measures) and about factors like education, income, and unemployment (socioeconomic measures) in the areas where they live (Tables 2.4 and 2.5) Demographic and socioeconomic data can be used

to identify which groups of women are most in need of help and to figure out the best ways to

help them

It is important to note that the report uses the race and ethnicity categories used by the US

Census Bureau, and that race and ethnicity are separate and independent categories This

means that everyone is classified as both a member of one of the four race groups as well as

either Hispanic/Latina or Non-Hispanic/Latina

The demographic and socioeconomic data in this report are the most recent data available for

US counties All the data are shown as percentages However, the percentages weren’t all

calculated in the same way

The race, ethnicity, and age data are based on the total female population in the area (e.g the percent of females over the age of 40)

The socioeconomic data are based on all the people in the area, not just women

Income, education and unemployment data don’t include children They’re based on people

age 15 and older for income and unemployment and age 25 and older for education

The data on the use of English, called “linguistic isolation”, are based on the total number of

households in the area The Census Bureau defines a linguistically isolated household as one

in which all the adults have difficulty with English

Table 2.4 Population characteristics – demographics

Population Group White

Black /African- American AIAN API

Non- Hispanic /Latina

Hispanic /Latina

Female Age

40 Plus

Female Age

50 Plus

Female Age

Data are for 2011

Data are in the percentage of women in the population

Source: US Census Bureau – Population Estimates

Table 2.5 Population characteristics – socioeconomics

Population Group

Less than

HS Education

Income Below 100%

Poverty

Income Below 250%

Poverty (Age:

40-64)

Un- employed

Foreign Born

ally Isolated

Linguistic-In Rural Areas

In Medically Under- served Areas

No Health Insurance (Age: 40-64)

Data are in the percentage of people (men and women) in the population

Source of health insurance data: US Census Bureau – Small Area Health Insurance Estimates (SAHIE) for 2011

Source of rural population data: US Census Bureau – Census 2010

Source of medically underserved data: Health Resources and Services Administration (HRSA) for 2013

Source of other data: US Census Bureau – American Community Survey (ACS) for 2007-2011

Population characteristics summary

Proportionately, the Komen Central Texas service area has a slightly smaller White female

population than the US as a whole, a substantially larger Black/African-American female

population, a slightly smaller Asian and Pacific Islander (API) female population, a slightly

smaller American Indian and Alaska Native (AIAN) female population, and a substantially larger

Hispanic/Latina female population The Affiliate’s female population is slightly younger than that

of the US as a whole The Affiliate’s education level is slightly lower than and income level is

slightly lower than those of the US as a whole There are a slightly smaller percentage of

people who are unemployed in the Affiliate service area The Affiliate service area has a

substantially smaller percentage of people who are foreign born and a slightly smaller

percentage of people who are linguistically isolated There are a slightly larger percentage of

people living in rural areas, a slightly larger percentage of people without health insurance, and

a substantially larger percentage of people living in medically underserved areas

The following county has substantially larger Black/African-American female population

percentages than that of the Affiliate service area as a whole:

 Falls County

The following counties have substantially older female population percentages than that of the Affiliate service area as a whole:

Healthy People 2020 forecasts

Healthy People 2020 (HP2020) is a major federal government initiative that provides specific health objectives for communities and for the country as a whole Many national health

organizations use HP2020 targets to monitor progress in reducing the burden of disease and improve the health of the nation Likewise, Komen believes it is important to refer to HP2020 to see how areas across the country are progressing towards reducing the burden of breast

cancer

HP2020 has several cancer-related objectives, including:

 Reducing women’s death rate from breast cancer (target as of the writing of this report: 20.6 cases per 100,000 women)

 Reducing the number of breast cancers that are found at a late-stage (target as of the writing of this report: 41.0 cases per 100,000 women)

To see how well counties in the Komen Central Texas service area are progressing toward these targets, the report uses the following information:

 County breast cancer death rate and late-stage diagnosis data for years 2006 to 2010

 Estimates for the trend (annual percent change) in county breast cancer death rates and late-stage diagnoses for years 2006 to 2010

 Both the data and the HP2020 target are age-adjusted

These data are used to estimate how many years it will take for each county to meet the

HP2020 objectives Because the target date for meeting the objective is 2020, and 2008 (the middle of the 2006-2010 period) was used as a starting point, a county has 12 years to meet the target

Death rate and late-stage diagnosis data and trends are used to calculate whether an area will meet the HP2020 target, assuming that the trend seen in years 2006 to 2010 continues for 2011 and beyond

Identification of priority areas

The purpose of this report is to combine evidence from many credible sources and use the data

to identify the highest priority areas for breast cancer programs (i.e the areas of greatest need) Classification of priority areas are based on the time needed to achieve HP2020 targets in each area These time projections depend on both the starting point and the trends in death rates and late-stage incidence

Late-stage incidence reflects both the overall breast cancer incidence rate in the population and the mammography screening coverage The breast cancer death rate reflects the access to care and the quality of care in the health care delivery area, as well as cancer stage at

diagnosis

There has not been any indication that either one of the two HP2020 targets is more important than the other Therefore, the report considers them equally important

Counties are classified as follows (Table 2.6):

 Counties that are not likely to achieve either of the HP2020 targets are considered to have the highest needs

 Counties that have already achieved both targets are considered to have the lowest needs

 Other counties are classified based on the number of years needed to achieve the two targets

Table 2.6 Needs/priority classification based on the projected time to achieve

HP2020 breast cancer targets

Time to Achieve Late-stage Incidence Reduction Target

Time to Achieve

Death Rate

Reduction Target

13 years or longer 7-12 yrs 0 – 6 yrs meets target Currently Unknown

13 years or

High Medium Medium Low Medium High

High Medium Medium Low Low Medium Low

Currently

High Medium Low Lowest Unknown

If the time to achieve a target cannot be calculated for one of the HP2020 indicators, then the county is classified based on the other indicator If both indicators are missing, then the county

is not classified This doesn’t mean that the county may not have high needs; it only means that sufficient data are not available to classify the county

Affiliate Service Area Healthy People 2020 Forecasts and Priority Areas

The results presented in Table 2.7 help identify which counties have the greatest needs when it

comes to meeting the HP2020 breast cancer targets

For counties in the “13 years or longer” category, current trends would need to change to

achieve the target Some counties may currently meet the target but their rates are increasing

and they could fail to meet the target if the trend is not reversed

Trends can change for a number of reasons, including:

 Improved screening programs could lead to breast cancers being diagnosed earlier,

resulting in a decrease in both late-stage incidence rates and death rates

 Improved socioeconomic conditions, such as reductions in poverty and linguistic

isolation could lead to more timely treatment of breast cancer, causing a decrease in death rates

The data in this table should be considered together with other information on factors that affect breast cancer death rates such as screening percentages and key breast cancer death

determinants such as poverty and linguistic isolation

Table 2.7 Intervention priorities for Komen Central Texas service area with predicted time to

achieve the HP2020 breast cancer targets and key population characteristics

County Priority

Predicted Time to Achieve Death Rate Target

Predicted Time to Achieve Late-stage Incidence Target

Key Population Characteristics

underserved

NA – data not available

SN – data suppressed due to small numbers (15 cases or fewer for the 5-year data period)