Barriers to Mammography Screening among Black Women at a Community Health Center in South Florida, USA
Main Article Content
Abstract
Background: In the United States (US), Black/African American women suffer disproportionately from breast cancer health disparities with a 40% higher death rate compared to White women. Mammography screening is considered a critical tool in mitigating disparities, yet Black women experience barriers to screening and are more likely to be diagnosed with advanced-stage breast cancer. The purpose of this study was to assess the relative frequency of mammography screening and to examine perceived and actual barriers to screening among women who receive care in our nurse-led community health center.
Methods: We conducted a survey examining frequency of mammography screening and beliefs about breast cancer including perceived susceptibility, perceived benefits, and perceived barriers to mammography screening, guided by the Champion Health Belief Model.
Results: A total of 30 Black/African American women completed the survey. The mean age of the participants was 54.3 years ± 9.17 (SD); 43.3% had a high school education or less; 50% had incomes below $60,000 per year; 26.7% were uninsured; 10% were on Medicaid; and only 50% were working full-time. We found that only half of the participants reported having annual mammograms 16 (53.3%), 1 (3.3%) every 6 months, 8 (26.6%) every 2-3 years, and 5 (16.7%) never had a mammogram in their lifetime. Frequently cited barriers included: ‘getting a mammogram would be inconvenient for me’; ‘getting a mammogram could cause breast cancer’; ‘the treatment I would get for breast cancer would be worse than the cancer itself’; ‘being treated for breast cancer would cause me a lot of problems’; ‘other health problems would keep me from having a mammogram’; concern about pain with having a mammogram would keep me from having one; and not being able to afford a mammogram would keep me from having one’. Having no health insurance was also a barrier.
Conclusion: This study found suboptimal utilization of annual screening mammograms among low-income Black women at a community health center in Florida and women reported several barriers. Given the high mortality rate of breast cancer among Black/African American women, we have integrated a Patient Navigator in our health system to reduce barriers to breast cancer screening, follow-up care, and to facilitate timely access to treatment, thus ultimately reducing breast cancer health disparities and promoting health equity.
Article Details
How to Cite
JONES, Tarsha et al.
Barriers to Mammography Screening among Black Women at a Community Health Center in South Florida, USA.
Medical Research Archives, [S.l.], v. 11, n. 4, apr. 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3814>. Date accessed: 23 nov. 2024.
doi: https://doi.org/10.18103/mra.v11i4.3814.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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3. Aday LA. Health status of vulnerable populations. Annual review of public health. 1994;15:487-509.
4. Percac-Lima S, Ashburner JM, Bond B, Oo SA, Atlas SJ. Decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. Journal of general internal medicine. 2013;28(11):1463-1468.
5. Giaquinto AN, Miller KD, Tossas KY, Winn RA, Jemal A, Siegel RL. Cancer statistics for African American/Black People 2022. CA Cancer J Clin. 2022;72(3):202-229.
6. Society AC. Breast Cancer Facts and Figures 2022-2024. Atlanta2022.
7. Chinn JJ, Martin IK, Redmond N. Health Equity Among Black Women in the United States. Journal of women's health (2002). 2021;30(2):212-219.
8. The Center for American Progress (CAP). The Basic Facts about Women in Poverty: Factsheet. https://www.americanprogress.org/article/basic-facts-women-poverty/. Published 2020.
9. Siegel SD, Brooks MM, Lynch SM, Sims-Mourtada J, Schug ZT, Curriero FC. Racial disparities in triple negative breast cancer: toward a causal architecture approach. Breast cancer research : BCR. 2022;24(1):37.
10. Churpek JE, Walsh T, Zheng Y, et al. Inherited predisposition to breast cancer among African American women. Breast cancer research and treatment. 2015;149(1):31-39.
11. Jones T, McCarthy AM, Kim Y, Armstrong K. Predictors of BRCA1/2 genetic testing among Black women with breast cancer: a population-based study. Cancer medicine. 2017;6(7):1787-1798.
12. Jones T, Trivedi MS, Jiang X, et al. Racial and Ethnic Differences in BRCA1/2 and Multigene Panel Testing Among Young Breast Cancer Patients. Journal of cancer education : the official journal of the American Association for Cancer Education. 2021;36(3):463-469.
13. Jones T, Lockhart JS, Mendelsohn-Victor KE, et al. Use of Cancer Genetics Services in African-American Young Breast Cancer Survivors. American journal of preventive medicine. 2016.
14. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):727-737, W237-742.
15. Siu AL, Force USPST. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296.
16. Society AC. Breast cancer facts and figures 2019-2020. 2019.
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18. Siu AL. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of internal medicine. 2016;164(4):279-296.
19. Schwartz C, Chukwudozie IB, Tejeda S, et al. Association of Population Screening for Breast Cancer Risk With Use of Mammography Among Women in Medically Underserved Racial and Ethnic Minority Groups. JAMA network open. 2021;4(9):e2123751.
20. Monticciolo DL, Newell MS, Hendrick RE, et al. Breast Cancer Screening for Average-Risk Women: Recommendations From the ACR Commission on Breast Imaging. Journal of the American College of Radiology : JACR. 2017;14(9):1137-1143.
21. Healthy People 2030 (HP). Increase the proportion of females who get screened for breast cancer — C‑05. https://health.gov/healthypeople/objectives-and-data/browse-objectives/cancer/increase-proportion-females-who-get-screened-breast-cancer-c-05. Published 2022.
22. Peek ME, Han JH. Disparities in screening mammography. Current status, interventions and implications. Journal of general internal medicine. 2004;19(2):184-194.
23. Sheppard VB, Huei-yu Wang J, Eng-Wong J, Martin SH, Hurtado-de-Mendoza A, Luta G. Promoting mammography adherence in underserved women: the telephone coaching adherence study. Contemp Clin Trials. 2013;35(1):35-42.
24. Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. Cancer. 2020;126(22):4957-4966.
25. Florida Department of Health (FDo). The Florida Breast Cancer Early Detection and Treatment Referral Program Report. 2018.
26. Fayanju OM, Kraenzle S, Drake BF, Oka M, Goodman MS. Perceived barriers to mammography among underserved women in a Breast Health Center Outreach Program. Am J Surg. 2014;208(3):425-434.
27. Miller BC, Bowers JM, Payne JB, Moyer A. Barriers to mammography screening among racial and ethnic minority women. Soc Sci Med. 2019;239:112494.
28. Rebner M, Pai VR. Breast cancer screening recommendations: African American women are at a disadvantage. Journal of Breast Imaging. 2020;2(5):416-421.
29. Aleshire ME, Adegboyega A, Escontrías OA, Edward J, Hatcher J. Access to Care as a Barrier to Mammography for Black Women. Policy, politics & nursing practice. 2021;22(1):28-40.
30. United States Census. Quick Facts: Florida. https://www.census.gov/quickfacts/FL. Published 2020.
31. Champion VLaS, C.S. The Health Belief Model. Health Behaviour and Health Education; Theory, Research, and Practice. San Francisco: Jossey-Bass; 2008.
32. Davis CM. Health Beliefs and Breast Cancer Screening Practices Among African American Women in California. International quarterly of community health education. 2021;41(3):259-266.
33. Juárez-García DM, de Jesús García-Solís M, Téllez A. Adaptation and Validation of the Health Belief Model Scale for Breast Self-Examination in Mexican Women. Value in health regional issues. 2020;23:30-36.
34. Htay MNN, Schliemann D, Dahlui M, et al. Validation of the Champion Health Belief Model Scale for an Investigation of Breast Cancer Screening Behaviour in Malaysia. International journal of environmental research and public health. 2021;18(17).
35. Zhang J, McGuinness JE, He X, et al. Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women. American journal of preventive medicine. 2023;64(1):51-60.
36. American College of Radiology (ACR). Mammograpghy Save Lives. https://www.acr.org/Practice-Management-Quality-Informatics/Practice-Toolkit/Patient-Resources/Mammography-Saves-Lives#:~:text=Mammography%20Guidelines,approach%20saves%20the%20most%20lives. Published 2022.
37. American Cancer Society (ACS). Breast Cancer Death Rates Are Highest for Black Women—Again. https://www.cancer.org/latest-news/breast-cancer-death-rates-are-highest-for-black-women-again.html. Published 2022. Accessed.
38. Siu AL. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of internal medicine. 2016;164(4):279.
39. Walsh SM, Zabor EC, Flynn J, Stempel M, Morrow M, Gemignani ML. Breast cancer in young black women. The British journal of surgery. 2020;107(6):677-686.
40. Young JML, Postula KJV, Duquette D, Gutierrez-Kapheim M, Pan V, Katapodi MC. Accuracy of Perceived Breast Cancer Risk in Black and White Women with an Elevated Risk. Ethnicity & disease. 2022;32(2):81-90.
41. Katapodi MC, Dodd MJ, Lee KA, Facione NC. Underestimation of breast cancer risk: influence on screening behavior. Oncology nursing forum. 2009;36(3):306-314.
42. Peek ME, Sayad JV, Markwardt R. Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system. Journal of general internal medicine. 2008;23(11):1847-1853.
43. Fasaye GA, Liu Y, Calzone K. Nurse practitioners have a vital role in achieving health equity in clinical cancer genetics. Journal of the American Association of Nurse Practitioners. 2021;33(10):763-765.
44. Jones T, Silverman T, Guzman A, et al. Qualitative analysis of shared decision-making for chemoprevention in the primary care setting: provider-related barriers. BMC medical informatics and decision making. 2022;22(1):208.
45. Allicock M, Gray K, Graves N, et al. What Health Care Providers Know and How They Communicate Breast Cancer Risk to Patients. Medical Research Archives. 2017;5(7).
46. Kim S, Molina Y, Glassgow AE, Berrios N, Guadamuz J, Calhoun E. The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women. Med Res Arch. 2015;2015(3).
47. Jose O, Stoeckl EM, Miles RC, et al. The Impact of Extreme Neighborhood Socioeconomic Deprivation on Access to American College of Radiology-accredited Advanced Imaging Facilities. Radiology. 2023:222182.
48. Farmer D, Reddick B, D'Agostino R, Jackson SA. Psychosocial correlates of mammography screening in older African American women. Oncology nursing forum. 2007;34(1):117-123.
49. Grindel CG, Brown L, Caplan L, Blumenthal D. The effect of breast cancer screening messages on knowledge, attitudes, perceived risk, and mammography screening of African American women in the rural South. Oncology nursing forum. 2004;31(4):801-808.
50. Phillips JM, Cohen MZ, Moses G. Breast cancer screening and African American women: fear, fatalism, and silence. Oncology nursing forum. 1999;26(3):561-571.
51. Spurlock WR, Cullins LS. Cancer fatalism and breast cancer screening in African American women. The ABNF journal : official journal of the Association of Black Nursing Faculty in Higher Education, Inc. 2006;17(1):38-43.
52. Thomas EC. African American women's breast memories, cancer beliefs, and screening behaviors. Cancer nursing. 2004;27(4):295-302.
53. Wallington SF, Oppong B, Iddirisu M, Adams-Campbell LL. Developing a Mass Media Campaign to Promote Mammography Awareness in African American Women in the Nation's Capital. Journal of community health. 2018;43(4):633-638.
54. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1655-1663.
55. Lee JH, Fulp W, Wells KJ, Meade CD, Calcano E, Roetzheim R. Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL. PloS one. 2013;8(9):e74542.
56. Reece JC, Neal EFG, Nguyen P, McIntosh JG, Emery JD. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC cancer. 2021;21(1):373.
57. Markossian TW, Darnell JS, Calhoun EA. Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1691-1700.
58. Raich PC, Whitley EM, Thorland W, Valverde P, Fairclough D. Patient navigation improves cancer diagnostic resolution: an individually randomized clinical trial in an underserved population. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1629-1638.
2. Stringer-Reasor EM, Elkhanany A, Khoury K, Simon MA, Newman LA. Disparities in Breast Cancer Associated With African American Identity. American Society of Clinical Oncology educational book American Society of Clinical Oncology Annual Meeting. 2021;41:e29-e46.
3. Aday LA. Health status of vulnerable populations. Annual review of public health. 1994;15:487-509.
4. Percac-Lima S, Ashburner JM, Bond B, Oo SA, Atlas SJ. Decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. Journal of general internal medicine. 2013;28(11):1463-1468.
5. Giaquinto AN, Miller KD, Tossas KY, Winn RA, Jemal A, Siegel RL. Cancer statistics for African American/Black People 2022. CA Cancer J Clin. 2022;72(3):202-229.
6. Society AC. Breast Cancer Facts and Figures 2022-2024. Atlanta2022.
7. Chinn JJ, Martin IK, Redmond N. Health Equity Among Black Women in the United States. Journal of women's health (2002). 2021;30(2):212-219.
8. The Center for American Progress (CAP). The Basic Facts about Women in Poverty: Factsheet. https://www.americanprogress.org/article/basic-facts-women-poverty/. Published 2020.
9. Siegel SD, Brooks MM, Lynch SM, Sims-Mourtada J, Schug ZT, Curriero FC. Racial disparities in triple negative breast cancer: toward a causal architecture approach. Breast cancer research : BCR. 2022;24(1):37.
10. Churpek JE, Walsh T, Zheng Y, et al. Inherited predisposition to breast cancer among African American women. Breast cancer research and treatment. 2015;149(1):31-39.
11. Jones T, McCarthy AM, Kim Y, Armstrong K. Predictors of BRCA1/2 genetic testing among Black women with breast cancer: a population-based study. Cancer medicine. 2017;6(7):1787-1798.
12. Jones T, Trivedi MS, Jiang X, et al. Racial and Ethnic Differences in BRCA1/2 and Multigene Panel Testing Among Young Breast Cancer Patients. Journal of cancer education : the official journal of the American Association for Cancer Education. 2021;36(3):463-469.
13. Jones T, Lockhart JS, Mendelsohn-Victor KE, et al. Use of Cancer Genetics Services in African-American Young Breast Cancer Survivors. American journal of preventive medicine. 2016.
14. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):727-737, W237-742.
15. Siu AL, Force USPST. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296.
16. Society AC. Breast cancer facts and figures 2019-2020. 2019.
17. American Cancer Society (ACS). American Cancer Society Recommendations for the Early Detection of Breast Cancer. https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html. Published 2022. Accessed.
18. Siu AL. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of internal medicine. 2016;164(4):279-296.
19. Schwartz C, Chukwudozie IB, Tejeda S, et al. Association of Population Screening for Breast Cancer Risk With Use of Mammography Among Women in Medically Underserved Racial and Ethnic Minority Groups. JAMA network open. 2021;4(9):e2123751.
20. Monticciolo DL, Newell MS, Hendrick RE, et al. Breast Cancer Screening for Average-Risk Women: Recommendations From the ACR Commission on Breast Imaging. Journal of the American College of Radiology : JACR. 2017;14(9):1137-1143.
21. Healthy People 2030 (HP). Increase the proportion of females who get screened for breast cancer — C‑05. https://health.gov/healthypeople/objectives-and-data/browse-objectives/cancer/increase-proportion-females-who-get-screened-breast-cancer-c-05. Published 2022.
22. Peek ME, Han JH. Disparities in screening mammography. Current status, interventions and implications. Journal of general internal medicine. 2004;19(2):184-194.
23. Sheppard VB, Huei-yu Wang J, Eng-Wong J, Martin SH, Hurtado-de-Mendoza A, Luta G. Promoting mammography adherence in underserved women: the telephone coaching adherence study. Contemp Clin Trials. 2013;35(1):35-42.
24. Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. Cancer. 2020;126(22):4957-4966.
25. Florida Department of Health (FDo). The Florida Breast Cancer Early Detection and Treatment Referral Program Report. 2018.
26. Fayanju OM, Kraenzle S, Drake BF, Oka M, Goodman MS. Perceived barriers to mammography among underserved women in a Breast Health Center Outreach Program. Am J Surg. 2014;208(3):425-434.
27. Miller BC, Bowers JM, Payne JB, Moyer A. Barriers to mammography screening among racial and ethnic minority women. Soc Sci Med. 2019;239:112494.
28. Rebner M, Pai VR. Breast cancer screening recommendations: African American women are at a disadvantage. Journal of Breast Imaging. 2020;2(5):416-421.
29. Aleshire ME, Adegboyega A, Escontrías OA, Edward J, Hatcher J. Access to Care as a Barrier to Mammography for Black Women. Policy, politics & nursing practice. 2021;22(1):28-40.
30. United States Census. Quick Facts: Florida. https://www.census.gov/quickfacts/FL. Published 2020.
31. Champion VLaS, C.S. The Health Belief Model. Health Behaviour and Health Education; Theory, Research, and Practice. San Francisco: Jossey-Bass; 2008.
32. Davis CM. Health Beliefs and Breast Cancer Screening Practices Among African American Women in California. International quarterly of community health education. 2021;41(3):259-266.
33. Juárez-García DM, de Jesús García-Solís M, Téllez A. Adaptation and Validation of the Health Belief Model Scale for Breast Self-Examination in Mexican Women. Value in health regional issues. 2020;23:30-36.
34. Htay MNN, Schliemann D, Dahlui M, et al. Validation of the Champion Health Belief Model Scale for an Investigation of Breast Cancer Screening Behaviour in Malaysia. International journal of environmental research and public health. 2021;18(17).
35. Zhang J, McGuinness JE, He X, et al. Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women. American journal of preventive medicine. 2023;64(1):51-60.
36. American College of Radiology (ACR). Mammograpghy Save Lives. https://www.acr.org/Practice-Management-Quality-Informatics/Practice-Toolkit/Patient-Resources/Mammography-Saves-Lives#:~:text=Mammography%20Guidelines,approach%20saves%20the%20most%20lives. Published 2022.
37. American Cancer Society (ACS). Breast Cancer Death Rates Are Highest for Black Women—Again. https://www.cancer.org/latest-news/breast-cancer-death-rates-are-highest-for-black-women-again.html. Published 2022. Accessed.
38. Siu AL. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of internal medicine. 2016;164(4):279.
39. Walsh SM, Zabor EC, Flynn J, Stempel M, Morrow M, Gemignani ML. Breast cancer in young black women. The British journal of surgery. 2020;107(6):677-686.
40. Young JML, Postula KJV, Duquette D, Gutierrez-Kapheim M, Pan V, Katapodi MC. Accuracy of Perceived Breast Cancer Risk in Black and White Women with an Elevated Risk. Ethnicity & disease. 2022;32(2):81-90.
41. Katapodi MC, Dodd MJ, Lee KA, Facione NC. Underestimation of breast cancer risk: influence on screening behavior. Oncology nursing forum. 2009;36(3):306-314.
42. Peek ME, Sayad JV, Markwardt R. Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system. Journal of general internal medicine. 2008;23(11):1847-1853.
43. Fasaye GA, Liu Y, Calzone K. Nurse practitioners have a vital role in achieving health equity in clinical cancer genetics. Journal of the American Association of Nurse Practitioners. 2021;33(10):763-765.
44. Jones T, Silverman T, Guzman A, et al. Qualitative analysis of shared decision-making for chemoprevention in the primary care setting: provider-related barriers. BMC medical informatics and decision making. 2022;22(1):208.
45. Allicock M, Gray K, Graves N, et al. What Health Care Providers Know and How They Communicate Breast Cancer Risk to Patients. Medical Research Archives. 2017;5(7).
46. Kim S, Molina Y, Glassgow AE, Berrios N, Guadamuz J, Calhoun E. The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women. Med Res Arch. 2015;2015(3).
47. Jose O, Stoeckl EM, Miles RC, et al. The Impact of Extreme Neighborhood Socioeconomic Deprivation on Access to American College of Radiology-accredited Advanced Imaging Facilities. Radiology. 2023:222182.
48. Farmer D, Reddick B, D'Agostino R, Jackson SA. Psychosocial correlates of mammography screening in older African American women. Oncology nursing forum. 2007;34(1):117-123.
49. Grindel CG, Brown L, Caplan L, Blumenthal D. The effect of breast cancer screening messages on knowledge, attitudes, perceived risk, and mammography screening of African American women in the rural South. Oncology nursing forum. 2004;31(4):801-808.
50. Phillips JM, Cohen MZ, Moses G. Breast cancer screening and African American women: fear, fatalism, and silence. Oncology nursing forum. 1999;26(3):561-571.
51. Spurlock WR, Cullins LS. Cancer fatalism and breast cancer screening in African American women. The ABNF journal : official journal of the Association of Black Nursing Faculty in Higher Education, Inc. 2006;17(1):38-43.
52. Thomas EC. African American women's breast memories, cancer beliefs, and screening behaviors. Cancer nursing. 2004;27(4):295-302.
53. Wallington SF, Oppong B, Iddirisu M, Adams-Campbell LL. Developing a Mass Media Campaign to Promote Mammography Awareness in African American Women in the Nation's Capital. Journal of community health. 2018;43(4):633-638.
54. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1655-1663.
55. Lee JH, Fulp W, Wells KJ, Meade CD, Calcano E, Roetzheim R. Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL. PloS one. 2013;8(9):e74542.
56. Reece JC, Neal EFG, Nguyen P, McIntosh JG, Emery JD. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC cancer. 2021;21(1):373.
57. Markossian TW, Darnell JS, Calhoun EA. Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1691-1700.
58. Raich PC, Whitley EM, Thorland W, Valverde P, Fairclough D. Patient navigation improves cancer diagnostic resolution: an individually randomized clinical trial in an underserved population. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1629-1638.