Sharon Bradley was going in for a biopsy to determine if a mass discovered on her mammogram was cancerous. She had just lost her job as a home-health aide and had no insurance. She was scared she was going to die.
That's when she was introduced to Debra Custer, a breast health navigator at Touchette Regional Hospital.
"I was worried about how I was going to have the finances to get treatment, how I was going to be able to see the doctors that I needed to see...," said Bradley, 48, of Cahokia. "She took my hand and said, 'I will help you get everything done.' "
Despite improvements in breast cancer survival, racial disparities in mortality have been widening in the last two decades. Across the country, black women are 40 percent more likely to die from breast cancer than white women despite lower incidence rates, according to the Centers for Disease Control and Prevention.
Many factors have been blamed for the difference. Black women often have cancers that grow more quickly, have fewer social and economic resources, are less likely to get prompt follow-up care after an abnormal mammogram and are less likely to get high-quality treatment.
The city of St. Louis, however, appears to be bucking the trend.
Area researchers and health advocates are making headway into ensuring equitable access and treatment with new research and initiatives such as pairing patients with navigators, opening a community center in a ZIP code with high death rates, and sending African-American breast cancer survivors as "buddies" to educate women in places such as salons and senior centers.
Between 2000 and 2010 in St. Louis, breast cancer mortality rates among black women have decreased by 30 percent, removing the disparity between blacks and whites in the city, according to the St. Louis Regional Health Commission. But racial disparities have continued to widen in the region, especially in St. Louis County, which has the worst breast cancer mortality disparity in the metropolitan area.
Officials are careful about touting the success in the city until further study of whether the change is the result of shifting demographics or improvements in care. But Robert Fruend, chief executive of the regional health commission, hopes the city's trend can be replicated.
"One may hypothesize that many of the wonderful breast cancer outreach efforts ... have concentrated recent efforts in North City, where disparities have traditionally been widest, and thus we have seen most progress there," Fruend said. "As a region, we can build upon these successful efforts to migrate them to other areas of need in our community. "
Dr. Heidi Miller, a primary care physician at a community health center caring for underserved patients in St. Louis, said she sees African-American patients struggling with the effects of poverty: lack of transportation, jobs with no health insurance, inability to take time off work, and a lack of awareness about programs that can help. For all these reasons, Miller said, women are scared to deal with a diagnosis.
"Fear is a big obstacle," she said, especially because diagnosis and treatment of breast cancer requires multiple visits with different providers to get mammograms, ultrasounds, biopsies, chemotherapy, radiation or surgeries. Hiring more breast health navigators has helped address the fear factor, Miller said.
"We see women fall off while trying to go through all of these steps," she said. "Only a breast health navigator can make sure they don't drop off out of fear or other obstacles."
Navigators work in health centers and hospitals providing comfort and education to patients throughout their care. Bradley said Custer calmed her by praising her for catching the lump early. She told her about a state program to cover the cost of her tests and treatments. Custer explained every step of her chemotherapy, radiation and surgery, and made sure she was able to get to her appointments. She even helped her get a wig when her hair fell out.
"I could call her at night when I was upset, and she'd come with me to my treatments," said Bradley, a five-year survivor. "She's been with me from day one to right now."
Necessary to the outreach efforts is funding, and since 1999, the St. Louis Affiliate of Susan G. Komen for the Cure has awarded more than $28 million in grants to breast health and cancer programs, helping uninsured and underinsured patients in the 17-county region. Many of the programs have used the grants to hire navigators.
Komen also helps cover gaps in funding for the state programs providing free breast and cervical cancer screening and treatment services for those who qualify. The Missouri program, called Show Me Healthy Women, has gone from serving 5,634 women a year to 11,544 a year in the past decade, according to the state health department.
Working hand-in-hand to improve care are community groups such as the Breakfast Club, a grass-roots group of African-American breast cancer survivors who meet every month for breakfast in the basement of a church in north St. Louis.
The club's efforts since 2000 have grown to include sending mobile mammography vans to church services and a "buddy" program to support newly diagnosed patients. The "buddies" also bring breast health education to area beauty and nail salons, ride on the mobile mammography vans and visit women in the St. Louis County jail.
In addition to bringing experts to speak at the monthly breakfasts, the club hosted its fifth annual day-long seminar last weekend. "We are visible," said founder Sherrill Jackson. "They feel like 'If you can make it, I can make it.' "
New efforts to reduce disparities are also under way. The St. Louis Integrated Health Network, made up of community health centers serving the uninsured and underinsured across the region, began implementing a long list of recommendations in 2010 to help improve the early diagnosis and rapid treatment of breast cancer.
An earlier study by Washington University School of Medicine had found that it took patients referred from community health centers an average of 93 days to begin treatment, while the average was two weeks for those with private insurance. About 40 percent of the underserved women had advanced-stage cancer.
The Integrated Health Network worked with the Siteman Cancer Center's Program for the Elimination of Cancer Disparities, with its nearly $4.27 million in federal funding, to streamline the referral process for patients from community health centers, expand mobile mammography services to make it easier to get mammograms and bring together breast health navigators from across the region every quarter to discuss how to best coordinate and provide care.
St. Louis University also launched last fall the SLU Center for Cancer Prevention, Research and Outreach -- a collaboration between the university's cancer center and school of public health. The center is using a $1.25 million private grant to help fund initiatives of community groups such as the Breakfast Club.
One effort involves meeting women at churches and community centers and transporting them to the SLU Cancer Center to get a mammogram, because mobile mammography vans are at a premium. Bringing women to the center would allow them to immediately get a follow-up diagnostic mammogram if their screening mammogram is abnormal, explained Dr. Mark Varvares, director of the cancer center.
"That is something we are working toward. That will help improve the whole process," Varvares said. The problem now is that someone screened in a van might not return for a diagnostic screening or may take months to do it.
Sarah Gehlert, a public health scholar at Washington University who is involved in the Siteman Cancer Center's effort to reduce disparities, has spent the last year and a half talking to women in ZIP codes with the highest death rates from breast cancer. She will present her findings next month.
Using a Komen grant, Gehlert opened a storefront in the city's Ville neighborhood. Residents can drop in to print out a resume, get tutoring or ask medical questions; and health workers use it as a base to gain trust among residents and learn their stories. They have completed in-depth interviews with 100 breast cancer survivors.
"I think it's really important to hear it from women's own lips," Gehlert said. After gathering feedback on her findings, she will develop an action plan to make care as seamless as possible.
Bradley said she was amazed at how smoothly her treatment went, with no setbacks along the way. "I am here today because I got my help," said Bradley, the mother of two and grandmother of seven. "I tip my hat to Debra Custer, because if it hadn't been for her telling me about the (financial assistance) program and walking into her office that day .... Lots of women are here today because she helped us go through the steps of doing what we have to do to be here a little longer." ___