Detection Methods and Knowledge Levels Regarding Breast Cancer

Kimberly D. Mitchell

Submitted to School of Graduate Nursing

Mountain State University
In partial fulfillment of the requirements for the degree of
Master of Science in Nursing
2008

1454154

2008

1454154

Acknowledgements
I would like to take this opportunity to thank GOD and everyone who helped me
achieve my goals. Special thanks to my family and the two most important and influential
people in my life; my daughters, Tara and Skylar. I would like to thank previous as well as
present Mountain State University instructors, faculty, preceptors, and committee members:
Wayne Ellis Ph.D, Director of Nurse Anesthesia program, Martha Richter, MSN, CRNA,
Shewana Workman, CRNA, Linda Williams, JD, CRNA, Jonnathan Bailey RN, MBA,
CRNA, Ann Bostic, CRNA, Diane Foley, RN, MSN, EDD, and Charles Milne. A big thanks
to Melody Tilley Administrative Assistant Nurse Anesthesia Program, for the endless
revisions and all of your support. Thank you to all my classmates and friends.

iii

Abstract
The purpose of the study was to examine methods that individuals in rural West Virginia use
in the discovery of breast abnormalities. Further emphasis was placed on knowledge levels as
well as personal feelings regarding breast cancer detection methods. A research questionnaire
was used to obtain data which consisted of potential risk factors, personal health practices,
health history, perceived barriers, and demographic information. One hundred and fifteen
individuals participated in the study. One hundred and two participants were familiar with
various breast cancer detection methods. Eighty-three participants performed self breast
examinations. Eighteen participants answered that knowledge in detection methods was the
most common barrier associated with detecting breast abnormalities.

iv

Table of Contents
Chapter 1
Introduction
Introduction1
Problem..2
Purpose...2
Research Questions........2
Framework.....2
Summary........4
Chapter 2
Literature Review
Introduction........5
Summary9
Chapter 3
Design and Methodology
Introduction..10
Design..10
Population....10
Method of Data Collection..11
Analysis ..........11
Protection of Human Rights11
Summary..11

Chapter 4
Data Analysis and Results
Introduction......12
Data Analysis...12
Summary..14
Chapter 5
Discussion and Conclusion
Discussion and Findings..16
Limitations...17
Implications for Future Research.....17
References19
Appendixes
A.

Site permission letter from Victoria Champion...22

B.

Questionnaire...23

C.

Subject consent form....26

D.

Site permission letter from American Cancer Society.27

E.

Security Statement ..28

F.

Institutional Review Board project review request...29

G.

Tables........................30

vi

Chapter 1
Introduction
Breast cancer is a public health problem that puts all individuals at risk. According to
the American Cancer Society, breast cancer is the second leading cause of cancer death
among women in the United States. Statistics show that one out of eight women will develop
breast cancer in their lifetime (Benedict, 1996). It is important for individuals of all ages to
understand the importance of finding and treating breast cancer early.
With the exception of skin cancer, breast cancer is the most common type of cancer
among women in this country. Each year more that 211,000 American women learn they
have this disease. According to the National Cancer Institute (NCI, 2008), estimated new
cases in the United States in 2008 are 182,460 (female); 1,990 (male) and deaths are 40,480
(female) and 45(male). The probability of breast cancer diagnosis increases by decade: from
age 30 to 40, 0.5%; from age 40-50, 1.49%; from age 50-60, 2.79%; and from age 60-70,
3.38%.
Although the breast cancer diagnosis rate has increased, the overall breast cancer
death rate has declined since the early 1990s. Statistics from the National Cancer Institute,
estimate that 12.7 percent of women born today will be diagnosed with breast cancer at some
time in their lives (National Cancer Institute, 2007).
Various methods are available for detection; however screening methods continue to
be underutilized. Although technology continues the advancement of various detection
methods, traditional methods of detection continue to be beneficial in the detection and
diagnosis of breast cancer. The importance of individuals becoming knowledgeable about
various techniques used in detecting breast cancer early is vital for survival.

Problem
Screening for breast cancer before there are symptoms is important in the early
detection of cancer. Treatments are more likely to be effective when cancer is detected at an
early stage. Various methods may be used to detect abnormalities in breasts leading to the
diagnosis of breast cancer. However, many abnormalities are not diagnosed until a
mammogram is performed. Many individuals do not perform self breast or clinical breast
exams routinely which increases the risk of late discovery through more advanced methods,
primarily mammography.
Purpose
The purpose of this study is to examine differential methods that individuals in rural
West Virginia utilize in the discovery of breast abnormalities. Further emphasis was placed
on determining how knowledgeable participants are regarding the different methods
associated with the detection of breast cancer. Questions were directed toward demographic
data, potential risk factors, breast examinations performance, and perceived barriers.
Research Questions
1.

Which method was most commonly used in detecting breast abnormalities?

2.

What were the knowledge levels demonstrated by participants in cancer detection

methods?

Framework
The Health Promotion Model originated in 1982 by Nola Pender following her
publication in 1975 A Conceptual Model for Preventative Health Behavior. This model
was a basis for studying how individuals made decisions about their health care in a nursing
context. Revisions were made in 1987, 1996, and in 2002. Penders holistic nursing

perspective comes from an extensive background in nursing, psychology, education, and

human development which served as the foundation for the Health Promotion Model.
The Health Promotion Model encompasses behaviors for enhancing health rather than
including threats or fear as a motivational source. The revised Health Promotion Model
incorporates concepts affecting health actions. The concepts are: 1) Prior related Behavior, 2)
Personal Factors, 3) Personal Biological Factors, 4) Personal Psychological Factors, 5)
Personal Sociocultural Factors, 6) Perceived Benefits of Action, 7) Perceived Barriers to
Action, 8) Perceived Self-Efficacy, 9) Activity-Related Affect, 10) Interpersonal Influences,
11) Situational Influences, 12) Commitment To A Plan of Action, 13) Immediate Competing
Demands and Preferences, and 14) Health-Promoting Behavior.
The Health Promotion Model was proposed as a framework for integrating nursing
and behavioral science perspectives on factors influencing health behavior (Pender, 1996, p.
51). Cognitive and perceptual factors are determinants of the model with a competence or
approach oriented focus. The framework was offered as a guide for exploration of the
complex biopsychosocial processes that motivate individuals to engage in behaviors directed
toward the enhancement of health (Pender, 1996, p. 51).
The Health Promotion Model incorporates economical, financial, and human burdens
which may hinder individuals from participating in healthier lifestyles. The Health
Promotion Model contributes a nursing solution to health policy and health care reform by
providing a means for understanding how consumers can be motivated to attain personal
health (Sakraida, 2006, p. 460).
The concepts used in Penders model are applicable to the present study. An
individuals personal health care beliefs play a significant role in handling a disease process.

Also an individuals lifestyle and personal habits may contribute to the disease. Certain
factors such as family history of cancer and social habits such as smoking and diet may
increase the risk of developing cancer. Socioeconomic status may explain why certain
individuals choose a particular breast cancer detection method; perhaps individuals do not
have access to certain medical technology or simply do not have financial resources to have
extensive exams.
Others may not have been properly educated on the risks associated with breast
cancer and may not practice routine breast cancer detection methods. Individuals should
commit to performing routine exams which would promote a healthier lifestyle. Proper
technique is important in detection methods. Continually educating individuals about the
dangers associated with breast cancer is an important role for the nurse.
Penders model is ideal for studying how individuals make decisions about their
health care. Individuals are more likely to comply with routine detection methods when
education regarding the topic is enhanced. This model aids individuals in understanding the
benefits to personal health.
Summary
Breast cancer is the second leading cause of cancer death in women, with highest
mortality rates in women younger than 35 and older than 75. The importance of finding
breast abnormalities through differential methods is crucial for positive outcomes. Although
many risk factors are involved, early detection is a key component in ensuring increased
survival rates. By determining which detection method is most commonly used, knowledge
gaps and target populations may be identified.

Chapter 2
Literature Review
Mortality rates have declined for white women younger than 55 (Costanza 2004, p.
342). Numerous studies (Champion, 1999; Leslie, 2003; Mahon, 2003) examined breast
cancer screening methods and modalities. Variables which were included in the studies
included race, age, socioeconomic status, personal history, knowledge and other factors as
well. Based on literature reviews, studies concluded that early detection, no matter what
method was used, was a crucial factor for survival.
In the mid 1990s, a retrospective study by Benedict was used to determine the method
of discovery of malignant breast tumors according to age, race, family history, and education
level. The study concluded that few women used all of the three methods recommend by the
American Cancer Society, which are breast self exam (BSE), clinical breast exam (CBE), and
mammography. The African American women included in the study did not utilize the three
recommended methods. BSE was the most frequent method for women in the age groups of
thirties and forties, in addition to other palpable modes. Within this study, three incidences of
breast cancer were discovered through CBE. The most frequent method of discovery was
mammography for the total sample.
Weingerg, Cooper, Lane, and Kripalani conducted a study (1993) evaluating the
screening behaviors and long-term compliance of 239 asymptomatic women over age 50 who
participated in the program. Subjects were female employees at a large hospital with various
occupations and under the age of 51 years. Data collection consisted of questionnaires and
medical records at two different intervals. Time 1 was considered at enrollment and annual

reenrollment, time 2 represented recent data. Long- term compliance with mammography
guidelines was measured by calculating a compliance quotient for each participant.
Women listed reasons why they did not receive a mammogram which included the
lack of physician recommendation or did not know that a mammogram was needed.
Additional barriers were embarrassment, radiation exposure, poor accessibility,
procrastination, lack of insurance and cost, lack of regular doctor, and fear of cancer
diagnosis. Mammography was a more commonly practiced in younger, educated, married
individuals with a, family history of breast cancer, and increased efficacy. The study reported
that clinical breast exams were utilized by younger, non-white women, with a higher level of
education, employed and with a perceived vulnerability to breast cancer.
Reports indicated from time 1 to time 2 subjects increased their use of
mammography, clinical breast exams, and breast self exams. The compliance quotient was
higher among women who remained in the program longer, were still active in the program
at the time of the study, and used screening prior to enrollment. The results showed that a
worksite program that eliminates common barriers to screening can significantly increase use
of early detection practices.
A study conducted from 1995-2002 by Eheman et al. (2006) described the results of
breast screening among low-income and uninsured women in the National Breast and
Cervical Early Detection Program which was the only national organized screening program
in the United States. Data reported included history of previous mammogram, reported breast
symptoms, clinical breast examination results, mammogram results, and final diagnosis.
Information of race, ethnicity, and age were also available and categorized. The study
analyzed mammography and diagnostic follow-up methods for 789,647 women who received

their first mammogram through the program as well as 454,754 subsequent mammograms by
the women. The results showed that women aged 40-49 years had the highest rates of
abnormal mammograms and a diagnostic follow-up, nearly 64% of the women ages 50-64
years of age and 46% were members of racial or ethnic minority groups. Cancer detection
rates were highest in women ages 60-64.
Taplin (2004) conducted another study in which data were obtained from seven health
care plans with the age group of greater than fifty years, using a retrospective chart review
and automated data 3 years prior to the breast cancer diagnosis. Three categories were used
during the prediagnostic period: absence of screening, absence of detection, and potential
breakdown during follow-up, if the interpretation of the earliest screening mammogram
during the prediagnostic period was positive but the diagnosis of breast cancer occurred more
than one year later. The women were placed into categories based on early or late stage
breast cancers. The data was collected on the three years after the time of diagnosis. The
findings were consistent in the absence of screening category had higher odds of having latestage disease. A higher portion of older women and women from neighborhoods with lower
income or less probability of college education were in the absence of screening category.
Research aimed at determining knowledge, attitudes, and practices surrounding breast
cancer screening in educated Appalachian women was conducted by Leslie in 2003.
Participants included 185 women at a mid-Atlantic university in a rural state. The type of
study was a longitudinal clinical intervention study utilizing a modified Toronto Breast
Examination Inventory tool. Research variables were demographics, knowledge of breast
cancer screening practices, adherence to breast cancer screening guidelines, motivation,
knowledge, and practice proficiency surrounding breast cancer screening.

The findings concluded that educated women had knowledge deficits about breast
cancer, breast cancer risk factors, and screening guidelines, those exhibiting greater
knowledge of breast cancer detection methods included those who had received healthcare
and cancer-screening instruction by healthcare providers and advanced practice nurses. The
study proposed that women still have knowledge deficits about breast cancer and detection
methods, as well as personal risk factors.
Research from a 2003 study by Mahon, reports that regular practice of BSE has
innate strengths. Mahon mentions that CBE usefulness is related to the skill of the healthcare
provider. Mahon also discusses the limitations of mammography in her study. Although
mammography is a good detection tool, often individuals experience discomfort.
Humphrey reports a 40-69% chance of breast cancer with a positive clinical breast
exam. Trials in which clinical breast and mammography were implemented demonstrated a
reduction in mortality by 14% to 29%. Seven large randomized clinical trials found that a
significant mortality reduction from breast cancer in women aged 40-69 who underwent
regular screening mammography (Smith et al., 2003).
A 2000 study conducted by Yarbrough and Braden assessed the utility of the Health
Belief Model as a theoretical guide for predicting breast cancer screening and guiding
intervention studies. This model specifies interactions of values and beliefs about health and
their influence on choices explaining screening behaviors. Sixteen published descriptive
studies employing the Health Belief Model were reviewed. The findings revealed multiple
issues indicating limited predictive power of the Health Belief Model for explaining breast
cancer screening concluding that the review indicates limited understanding of the social,
nonhealth care meaning of breast cancer and breast cancer control.

Recommendations from the United States Preventive Services Task Force were
published in September 2002. The article states that the goal of screening form breast cancer
is to find cancer at early, treatable stages. Methods for screening were listed as breast self
exams, clinical breast exams, and mammography. The article reported that evidence showed
women between the ages of 40-69 years who have screening mammography every one to two
years have a decreased mortality rate.
Literature Review Summary
A review of the literature related to breast cancer thoroughly examines aspects of the
disease process. Research was conducted to examine the differential methods breast cancer
survivors used in the detection of the abnormality leading to the cancer diagnosis. Evidence
supports the positive outcomes that self breast exams, clinical breast exams, and
mammography have on decreasing the mortality rate. The literature review examines
variables associated with lack of screening, as well as various types of studies.
Data obtained from combined studies indicates that further investigation is needed.
Barriers associated with each variable need to be examined. Continually encouraging the
three detection methods recommended by the American Cancer Society will increase early
detection and decrease mortality in women diagnosed with cancer.

Chapter 3
Methodology
The purpose of this study is to examine differential methods that individuals in rural
West Virginia use in the discovery of breast abnormalities. Further emphasis is placed on
determining how knowledgeable participants are regarding the different methods associated
with the detection of breast cancer.
Chapter three consists of the methods utilized to develop a research questionnaire as
well as data gathering, data organization, and data interpretation. Research design, sample,
data collection methods, data analysis, and protection of human rights will be included in this
section.
Methods examined in the study include self breast exam, clinical breast exam,
mammography and/or other in detecting a lump leading to the diagnosis of breast cancer in
individuals. Further emphasis was placed on determining how knowledgeable participants
are regarding the different methods associated with the detection of breast cancer and if
interventions such as early detection and other resources are being utilized appropriately for
an earlier definitive diagnosis.
Research Design
A comparative descriptive design was used and described differences in breast cancer
detection techniques. A questionnaire developed by Champion in 1998 and modified in 2007
for the study with permission from Champion (Appendix A) was completed by willing
participants and used (Appendix B).
The target population was a convenience sample selected from participants from the
Relays for Life, and included a minimum of 50 subjects over the age of 18 based on

10

accessibility. The participants were individuals agreeing to complete a questionnaire at the

Relays for Life sponsored by the American Cancer Society following consent (Appendix C).
Data Collection
A formal request was submitted to Richard Totten, director, at the American Cancer
Society requesting permission to distribute a questionnaire during the Logan County and
Mingo County Relays for Life. Permission was granted (Appendix D). A contact person was
designated at each location and frequent follow-ups were made to ensure continuity. By the
subjects voluntarily answering the questions, this was considered consent for the study by the
subjects.
Booths were set up at the Mingo County and Logan County Relay for Life events.
Subjects were asked to complete the questionnaire and place the questionnaire in a sealed
envelope returning it to the designated area (Appendix E). Data collections resumed until a
minimum of 50 subjects were included. The expected length of time to complete the
questionnaire was approximately 15-20 minutes.
Data Analysis
Results obtained from the questionnaire were categorized and analyzed using
descriptive statistics and percentages.
Protection of Human Rights
Following examination by Mountain State University Institutional Review Board,
permission to proceed with the study was provided (Appendix F). Permission was obtained
from all involved parties. Completion of the questionnaire acted as consent for participation.
The participants were asked to answer only the items listed on the questionnaire and not to
include additional or personal identifying information on the questionnaire.

11

Chapter 4
Results
The purpose of this chapter was to present the analysis and findings of this study. The
purpose of this study was to examine differential methods that individuals in rural West
Virginia utilize in the discovery of breast abnormalities. Descriptive research provides an
accurate portrayal of characteristics of an individual, event, or group in real-life situations for
the purpose of discovering new meaning, describing what exist, and categorizing information
(Burns & Grove, 2005).
Survey Response
Data was gathered during the Relays for Life in Logan and Mingo counties. A contact
person was designated at each location and frequent follow-ups were made to ensure
continuity. A questionnaire was distributed to willing participants. By the subjects
voluntarily answering the questions, this was considered consent for the study by the
subjects. Fifty four questionnaires were completed at the Logan County Relay for Life. Sixty
one questionnaires were completed at the Mingo County Relay for Life.
Data Analysis
A descriptive survey was used in the study for assessment. The questionnaires
consisted of potential risk factors, personal health practices, personal and family health
history, perceived barriers, and demographic information.
For the purpose of this study (n) represents the number of participants included within
the study. Tables were included for summarization of findings (Appendix G). Table I
describes the demographic data of the participants in regards to sex, race, educational level,
marital status, and pregnancy status. Table II discusses potential risk factors including

12

relatives diagnosed with breast cancer, age of first pregnancy, menarche, and menopause, as
well as the use of hormone replacement therapy. Table III discusses characteristics of self
breast examinations and performance including familiarity, detection methods, and detection
by whom. Table IV discusses several factors regarding perceived barriers that the
participants felt to be a hindrance regarding detection methods.
Participants completing questionnaires and giving more than one answer were
analyzed individually. A total of eleven participants answered question number 31 with more
than one answer. The question read: I feel that the following barriers are a hindrance to me
detecting breast cancer. Five participants answered income and insurance were barriers. Two
participants answered income, insurance and knowledge about the disease as barriers. Two
participants listed insurance and knowledge about the disease were barriers.
A total of 115 participants answered question number seven, Relatives with breast
cancer. Fifty-four participants reported no relatives with breast cancer. Seven of the
participants had mothers diagnosed with breast cancer; six participants had sisters diagnosed
with breast cancer. Fourteen participants had maternal aunts diagnosed with breast cancer,
while eight participants report paternal relatives with breast cancer, with one participant
writing they had brother with breast cancer. 13 participants stated they did not know of
relatives with breast cancer. Twelve response sheets had multiple answers. For the first
research question, which asked about which detection method was most commonly used;
eighty-three participants (72%) performed self breast examinations. Ninety-two participants
(80%) received breast examinations by healthcare providers. Fifty-one participants (44%)
had been taught by a physician and 18 participants (15%) were taught by a nurse to perform
breast examinations.

13

For the second research question, what were the knowledge levels demonstrated by
participants in cancer detection methods. One hundred and two participants (89%) were
familiar with various breast cancer detection methods. Ninety-eight participants (95%) were
shown how to perform breast examinations. Forty-three participants (37%) agreed that they
were confident in performing a breast self exam correctly. Only 10 participants (0.09%)
strongly agreed that having a mammogram or breast x-ray would be painful and only three
participants (.03) felt that it would be embarrassing. Forty-nine participants (43%) strongly
agreed that a mammogram would help find a lump before it could be felt individually or by a
health care professional. Forty participants (35%) answered that they had access to a variety
of resources which would allow the use of different methods to detect breast cancer.
Eighteen participants (16%) answered that knowledge in detection methods was the
most common answer regarding barriers associated with detecting breast cancer with 12
participants (10%) listing insurance as a hindrance in detecting breast cancer.
In conclusion 87.8% (101) participants were females. Twenty-seven percent (31) of
the participants were ages 50-59. Ninety-six (110) participants were Caucasian and five
participants (0.04) were African American with no participation from Hispanic or Asian ethic
groups. High school diploma or GED accounted for 35% (40 participants) of the participants
educational level. Sixty-six percent (76) of the participants were married.
Summary
The purpose of this study was to examine differential methods that individuals in
rural West Virginia utilize in the discovery of breast abnormalities. Questions were directed
toward demographic data, potential risk factors, breast examinations performance, and
perceived barriers. Participants included both men and women ages 18 and older. Self breast

14

examinations and examinations by healthcare providers were common detection methods. By

examining the factors that influence an individuals decisions regarding breast cancer, ideally
future education techniques will improve.

15

Chapter 5
Discussion and Conclusion
The purpose of this study was to examine differential methods that individuals in
rural West Virginia use in the discovery of breast abnormalities. This chapter discusses
research findings regarding demographic data, potential risk factors, breast examination
performance, and perceived barriers. Results were summarized based on findings.
Discussion and Findings
Early recognition of breast abnormalities is a vital component in the detection breast
cancer and increasing survival rates. The study was conducted in two counties in West
Virginia, Logan and Mingo. A contact person was designated at each location and frequent
follow-ups were made to ensure continuity. A questionnaire was distributed to willing
participants. Subjects were asked to complete the questionnaire and place the questionnaire
in a sealed envelope returning it to the designated area. Data collections resumed until a
minimum of 50 subjects were included.
Data Analysis
A descriptive survey was used in the study for assessment. The questionnaires
consisted of potential risk factors, personal health practices, personal and family health
history, perceived barriers, and demographic information
The importance of individuals becoming knowledgeable about various techniques
used in detecting breast cancer early is vital for survival. Once potential risk factors,
perceived barriers, breast examine methods, and demographic data have been identified,
future research may be directed toward preventive approaches regarding breast cancer.

16

Limitations
The study was limited to non-pregnant individuals over the age of eighteen who were
present during the Logan or Mingo County Relay for Life. The possibility of biased
responses was also an issue since the Relay for Life is an annual event which raises money
and awareness of cancer. Individuals responses may have been influenced by personal
experiences regarding cancer. Also, geographic locations may have been a limiting factor.
Implications
In retrospect, two additional questions should have been included in the
questionnaire. The first question would have been: Have you been diagnosed with breast
cancer? and the second question would have been: How was the breast cancer
discovered? The inclusion of these questions would have given a more definitive answer to
the actual research questions presented in this project.
Also, the answer to the question: Who taught you to perform a breast examination?
surprisingly the most common answer was a physician (44%). The second highest percentage
was 15 % being a nurse, and only 4 (0.03%) being a nurse practitioner. The response to this
question, in which only 0.03% indicated that a nurse practitioner was the person who had
taught them how to do a self breast examinations, points to the need for advanced practice
nurses in rural West Virginia.. These answers could also implicate another important survey
question, Who is your primary care provider?
Screening for breast cancer before there are symptoms is important in the early
detection of cancer. Although the breast cancer diagnosis rate has increased, the overall
breast cancer death rate has decreased since the early 1990s. Treatments are more likely to be
effective when cancer is detected at an early stage. Various methods may be used to detect

17

abnormalities in breasts leading to the diagnosis of breast cancer. In conclusion, based on the
findings, there is a need to continue investigating various issues regarding the detection and
diagnosis related to breast abnormalities and breast cancer.

18

References
American Cancer Society. Overview: Breast Cancer How Many Women Get Breast Cancer?
(2007). Retrieved September 26, 2007 from American Cancer Society on World
Wide Web: http://www.cancer.org/docroot/CRI/content/CRI
Benedict, S., Williams, R. D., & Hoomani, J. (1996). Method of discovery of breast cancer.
Cancer Practice, 4, 147-155.
Bickley, L. S., & Szilagyi, P.G. (2007). Bates guide to physical examination and history
taking (9th ed.). Philadelphia: Lippincott, Williams, & Wilkins.
Burns, N., & Grove, S. K. (2005). The practice of nursing research: Conduct, critique and
utilization. (5th ed.). Philadelphia: W. B. Saunders.
Champion, V. (1999). Revised susceptibility, benefits, and barriers scale for mammography
screening. Research in Nursing & Health, 22, 341-348.
Costanza, M. E. Epidemiology and risk factors for breast cancer. In Bickley, L. S., &
Szilagyi, P. G. (2007). Bates guide to physical examination and history taking (p. 342).
Philadelphia: Lippincott, Williams, & Wilkins.
Eheman, C. R., Benard, V. B., Blackman, D., Lawson, H. W., Anderson, C, Helsel, W., &
Lee, N. C. (2006). Breast cancer screening among low-income or uninsured women:
Results from the National Breast and Cervical Cancer Early Detection Program, July
1995 to March 2002 (United States). Cancer Causes and Control, 17, 29-38.
Humphrey, L. L., Helfand, M. C., Benjamin, K. S., & Woolf, S. H. (2002, September).
Screening for breast cancer: Recommendations from the U.S. Preventive Services
Task Force. Annals of Internal Medicine, American College of Physicians, 137, 347360.

19

Leslie, N. S., Deiriggie, P., Gross, S., DuRant, E. M., Smith, C., & Veshnesky, J. G. (2003).
Knowledge, attitudes, and practices surrounding breast cancer screening in educated
Appalachian women. Oncology Nursing Forum, 30, 659-666.
Mahon, S. M. (2003). Evidence-based practice: Recommendations for the early detection of
breast cancer. Clinical Journal of Oncology Nursing, 7, 693-696.
National Cancer Institute Breast Cancer. (2008) Retrieved June 17, 2008 from
National Cancer Society World Wide Web:
http:www.cancer.gov/cancertopics/types/breast
Pender, N. J. (1996). Health promotion in nursing practice. (3rd ed.) Stanford,
Connecticut: Appleton & Lange.
Sakraida, T. J. (2006). Health promotion model. In Tomey, A. M. & Alligood, M. R., (2006),
Nursing theorists and their work (pp. 452-464). St. Louis, MO: Mosby Elsevier.
Smeltzer, S. C., & Bare, B. G. (2000). Brunner and Suddarths textbook of medical surgical
nursing. (9th ed.) Philadelphia: Lippincott.
Taplin, S. H., Ichikawa, L., Yood, U., Marianne, M. M., Geiger, A. M., Weinmann, S.,
Gilbert, J. et al. (2004). Reason for late-stage breast cancer: Absence of screening or
detection, or breakdown in follow-up? Journal of the National Cancer Institute, 96,
20, 1518-1526.
Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and their work. (6th Ed.). St.
Louis, MO: Mosby Elsevier.
United States Preventative Task Force (2003). Screening for breast Cancer:
Recommendations from the U.S. Preventative Services Task Force. Annals of
Internal Medicine. American College of Physicians, 137, 344-346.

20

Weinberg, A. D., Cooper, H. P., Lane, M., & Kripalani, S. (1997). Screening behavior and
long-term compliance with mammography guideline in a breast cancer screening
program. American Journal of Preventive Medicine, 13, 29-34.
Yarbrough, S. S., & Braden, C. J., (2001). Utility of health belief model as a guide for
explaining or predicting breast cancer screening behaviors. Journal of Advanced
Nursing, 33, 677-688.

21

Appendix A

Appendix B
22

BREAST CANCER DETECTION METHODS

1.

Male___

Female___ (Please Circle)

2.

Are you pregnant:

a. yes
b. no

3.

Age (years)
a. 18-29
b. 30-39
c. 40-49
d. 50-59
e. 60-69
f. 70 and above

4.

Race or Ethnicity:
a. Caucasian (White)
b. African American
c. Hispanic
d. Asian
e. Other

5.

Education Level:
a. High School Diploma of GED
b. Some vocational or technical training or diploma
c. Some college or University
d. Some graduate study
e. Graduate degree
f. Never graduated high school

Marital Status:
a. Single
b. Married
c. Divorced
d. Separated
e. Widowed

7.

Relatives with Breast Cancer:

a. None
b. Mother
c. Sister
d. Maternal Grandmother
e. Maternal Aunt
f. Paternal Relatives
g. Do not know

8.

Do you Smoke?
a. Yes
b. No

9.

Age of Menarche (first period)

a. less than age 12

23

b. greater than age 12

10.

Age at first pregnancy:

a. no pregnancy
b. less than age 30
c. greater than age 30

11. Age at menopause:

a. Still menstruating
b. Greater that age 55
c. Less than age 55
d. hysterectomy
12. Have you used any type of hormone therapy, for example birth control, fertility regimens,
hormone replacement therapy?
a. yes
b. no
13. I am familiar with various breast cancer detection methods
a. yes
b. no
14. Do you perform self breast examinations?
a. yes
b. no
15 Do you receive breast examinations by your healthcare provider?
a. yes
b. no
16

17.

Have you ever been shown how to perform breast examinations?

a. yes
b. no
Who taught you how to perform a breast examination?
a. never taught
b. self-taught
c. non-healthcare professional
d. breast cancer screening class
e. nurse
f. nurse practitioner
g. physicians assistant
h. physician

Strongly

Disagree
24

Neutral

Agree

Strongly

Disagree

Agree

I am confident in performing a
breast self exam correctly
I feel funny doing self breast
examinations
Self breast examinations are
embarrassing
Based on lifestyle and family
history, my chances of getting
breast cancer are great
The thought of breast cancer
scares me
Having a mammogram or xray of the breast would be
painful
Having a mammogram or
breast x-ray would be
embarrassing
Having a mammogram would
take too much time
Having a mammogram will
help me find a lump before it
can be felt by myself or
health care professional
Having a mammogram would
cost too much money
I have access to a variety of
resources which will allow me
to use different methods to
detect breast cancer
Maintaining good health is
very important to me

31.
a.
b.
c.
d.
e.

I feel that the following barriers are a hindrance to me detecting breast

cancer:
income
insurance
residence
knowledge about disease
knowledge in detection methods
Appendix C
25

Subject Consent Form:

Title of Research Project: Breast Cancer Detection Methods
Principle Investigator/Department: Kimberly Mitchell RN, BSN, SRNA, MSU Nurse Anesthesia
Program
Organization/Location: Mountain State University Nurse Anesthesia Department, Beckley WV
My name is Kimberly Mitchell. I am a graduate nurse anesthesia student at Mountain State
University. As part of my requirement for completion of the MSN degree, I am required to complete a
research thesis. You are being invited to participate in my research study designed to assess breast
cancer detection methods among women in rural West Virginia. I would appreciate your assistance in
completing the attached survey. This will required approximately 15 minutes of your time.
This information may assist individuals in examining differential methods that women in
rural West Virginia utilize in the discovery of breast abnormities. Emphasis is placed on determining
how knowledgeable participant are regarding the different methods associated with the detection of
breast caner.
Your identity in this study will be kept confidential. The results of the study may be
published for scientific purposes but will not give your name or include any identifiable references to
you. However, any resources or data obtained as a result of our participant in this study may be
reviewed by the Institutional Review Board of Mountain State University, the thesis committee and
statistician, by any relevant government agency, or by the person completing this study provided that
such inspectors are legally obligated to protect any identifiable information form public disclosure.
Complete surveys will be stored at a secure location designated by the researcher and maintained in a
locked fireproof safe for a minimum of five years.
You are free to choose whether or not to participate in this study, and there is no penalty if
you decide to participate or choose to complete the attached survey questions regarding breast camera
detection methods?
Please contact the Intuitional Review Board with further questions regarding this study
which will be answered by the principle investigator,
Kimberly Mitchell RN, BSN, SRNA
Mountain State University, P.O. Box 9003 Beckley, WV 25802-9003
Any questions you have about your rights as a research subject will be answered by:
Wayne Ellis, Ph.D., Chair, IRB committee at Mountain State University Beckley, WV
Authorization:
Return of the questionnaire will be deemed as your consent to participate in this study. In giving your
consent, Understand that consent does not take anyway any legal rights in the case of negligence of
legal fault of anyone who is involved in this study.

_____________________________________________________________________________
Investigator Signature
Date

Appendix D
26

To whom it may concern,

I have been in contact with Kim Mitchell and she has the American Cancer Societys
permission to do the Breast Cancer questionnaire at the Relay For Life on June 8th. If you need
any additional information please feel free to contact me at 1-800-288-3618.

Richard D. Totten
Community Manager
American Cancer Society
Kanawha,Boone,Logan, Mingo
Richard.totten@cancer.org

Appendix E
Security Statement
27

Disclosure of Raw Data

All collected data will be kept in a fireproof locked storage box at the principle investigators
site. Access to this storage will be limited to myself, Kimberly Mitchell, and will be
maintained for a minimum of 5 years and a maximum of ten years before destruction via
shredding.
Disclosure of Completed Data
Once all the data has been processed and completed, a copy of the data collected will be
maintained in the form of a completed thesis study which shall be available in the Graduate
Nursing Office and in the Mountain State University Library

Appendix F

28

29

Appendix G
Table I. Demographics
Characteristic________________________________________ n ________

%____

Sex (n=115)
Female
Male

101
14

87.8
12.1

Pregnant (n = 115)
Yes
No

0
115

0
100

11
19
29
31
21
4

0.10
0.17
0.25
0.27
0.18
0.03

Age (years) (n = 115)

18-29
30-39
40-49
50-59
60-69
70 and above
Race/Ethnicity (n = 115)
Caucasian
African American
Hispanic
Asian
Other

110
5
0
0
0

0.96
0.04
0.00
0.00
0.00

Education Level (n = 115)

High school Diploma or GED
Some Vocational or technical training or diploma
Some college or university
Some graduate study
Graduate Degree
Never graduated high school

40
6
36
3
25
5

0.35
0.05
0.31
0.03
0.22
0.04

Marital Status (n = 115)

Single
Married
Divorced
Separated
Widowed

15
76
11
2
11

0.13
0.66
0.09
0.02
0.10

30

Table II Potential Risk Factors

Characteristic

%____

Relatives with breast cancer

None
Mother
Sister
Maternal Grandmother
Maternal Aunt
Paternal Relatives
Do not know
Multiple answers

54
7
6
see narrative
14
8
13
12 see narrative

Smoker (n = 115)
Yes
No

22
93

0.19
0.81

Age of menarche (first period) (n = 115)

Less than age 12
Greater than age 12
No answer

31
70
14

0.27
0.61
0.12

Age at first pregnancy (n = 115)

No pregnancy
Less than age 30
Greater than age 30
No answer
Multiple answers

20
77
4
13
1

0.17
0.67
0.03
0.11
0.00

Age at menopause (n = 115)

Still menstruating
Greater than age 55
Less than age 55
Hysterectomy
No answer

38
11
26
23
17

0.33
0.09
0.23
0.20
0.15

Have you used any type of hormone therapy?

for example birth control pills, fertility regimens,
hormone replacement therapy? (n = 115)
Yes
No
No answer

59
52
4

0.51
0.45
0.03

31

Table III Breast Examination Performance

Characteristic
I am familiar with various breast cancers
detection methods (n = 115)
Yes
No
No answer

102
10
3

0.89
0.08
0.03

Do you perform self breast examinations? (n = 115)

Yes
No
No answer

83
30
2

0.72
0.26
0.02

Do you receive breast examinations by your

healthcare provider? (n = 115)
Yes
No
No answer

92
22
1

0.80
0.19
0.00

Have you ever been shown how to perform breast

examinations? (n = 115)
Yes
No
No answer

98
16
1

0.85
0.14
0.00

Who taught you how to perform a breast

examination? (n = 115)
Never taught
Self taught
Non-healthcare professional
Breast cancer screening class
Nurse
Nurse practitioner
Physician Assistant
Physician
No Answer
Multiple answers

12
10
2
4
18
4
3
51
5
6

0.12
0.08
0.01
0.03
0.15
0.03
0.20
0.44
0.04
0.05

32

Table IV Perceived Barrier

Strongly
disagree
n

Disagree

Neutral

Agree

Strongly
agree

No
Answer
n

I am confident in performing
a breast self exam correctly

0.08

0.06

14

0.12

43

0.37

37

0.32

0.04

I feel funny doing breast

examinations

37

0.32

33

0.29

17

0.15

12

0.10

0.03

12

0.10

Self breast examinations

are embarrassing

46

0.4

36

0.31

18

0.16

0.07

0.02

0.02

Based on lifestyle and family

history, my chances of getting
breast cancer are great

22

0.19

19

0.17

33

0.29

20

0.17

14

0.06

The thought of breast

cancer scares me

10

0.09

0.06

10

0.09

Having a mammogram or
breast x-ray would be
painful

28

0.24

28

0.24

22

0. 19

22 0.19

Having a mammogram or
breast x-ray would be
embarrassing

42

0.37

28

0.24

20

0.17

Having a mammogram
would take too much
time

56

0.48

40

0.35

Having a mammogram will

help me find a lump
before it can be felt by
myself or health care
professional

0.06

0.06

Having a mammogram would

cost too much money

40

0.36

45

I have access to a variety of

resources which will allow me
to use different methods to
detecting breast cancer

0.03

Maintaining good health is

Important to me

0.03

0.37

0.04

10

0.09

0.04

18 0.16

0.03

0.03

0.08

0.01

0.05

14

0.12

35 0.30

49 0.43

0.03

0.39

11

0.09

9 0.08

0.05

0.03

0.05

23

0.2

40 0.35

35 0.30

0.07

0.01

33

0.03

40

0.35

0.12

0.03

32 0.28

43

73

0.63

0.02

I feel that the following

barriers are a hindrance to me
detecting breast cancer (n = 115)
Income
Insurance
Residence
Knowledge about disease
Knowledge in detection methods
No answer
Multiple answers

n
8
12
2
8
18
56
11

34

%
0.07
0.10
0.02
0.07
0.16
0.49
0.09