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Running head: BREAST CANCER EDUCATION 1
Breast Cancer Education for Women Aged 29-39 in Madison County
Rachael Petersen
NURS 433C
Joann Dalling
Brigham Young University-Idaho
March 2, 2018
BREAST CANCER EDUCATION 2
Breast Cancer Education for Women Aged 29-39 in Madison County
Part 1: Defining the Population
Breast Cancer as a Health Issue
Breast cancer is a type of cancer that originates in the breast tissue of both men and
women, although more commonly in women. Cancer results from various genetic mutations
within cells that cause rapid proliferation and loss of differentiation ability. This means that the
cells not only forget what their purpose is, but will also multiply quickly, taking over space
meant for healthy cells. If untreated, the affected cells can relocate, or metastasize, to other
organs and tissues, interfering with normal cell function in both the originating tissues and
metastasis sites. Eventually, normal body processes are compromised, causing health decline
and subsequent death.
Breast cancer is no exception to this process, but it does have higher survival rates than
other cancers, if caught early enough. Five-year survival rates are as high as 98.9% for females
when breast cancer is diagnosed while in the localized stage, or when the cancer cells are still
localized to the breast tissue (National Cancer Institute, 2018b). This is because breast tissue is
not essential to life so more aggressive treatments can be used on the originating tissues. The
aggressive treatments decrease the probability of metastasis if it has not already occurred.
The prevalence of breast cancer is staggering. It is the most common cancer for women
and it is estimated that 266,120 women in the United States will be diagnosed in 2018,
representing 30% of all cancer diagnoses in women (American Cancer Society, 2018c).
Additionally, the National Cancer Institute states 12.4% of women, or one in eight, will be
diagnosed with breast cancer in their lifetime (2018b), illustrating the significance of this public
health concern.
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Death rates are significantly higher for women if diagnosed at later stages when cancer
cells have successfully relocated to more distant tissues beginning in surrounding and then
regional lymph nodes. At this point the cells can continue to metastasize even farther and can
reach tissues including, but not limited to, the brain, bones, or liver. The five-year survival rate
for women diagnosed in distant metastasis stages is only 26.9% (National Cancer Institute,
2018b). Early detection has the biggest influence on survival rates, making it clear why
education about the disease is imperative for optimal women’s health. Furthermore, breast
cancer is the second leading cause of cancer deaths in women when compared to all types of
cancer, regardless of gender specificity (National Cancer Institute, 2018b). This is substantial,
considering that breast cancer affects women significantly more often than it does men, which
illustrates the severity of this population health concern.
Healthy People 2020
Cancer, in general, is a population health concern, and the United States government has
addressed it in the Healthy People 2020 goals and initiatives. The cancer goal presented in this
initiative states, “Reduce the number of new cancer cases, as well as illness, disability, and death
caused by cancer” (Healthy People 2020, 2018). Objectives listed under this goal specific to
breast cancer include objective C-3 and C-11 which read, “reduce the female breast cancer death
rate” and “reduce late-stage female breast cancer,” respectively (Healthy People 2020, 2018). In
2007, there were 23.0 women who died from breast cancer per 100,000 females in the United
States (Healthy People 2020, 2018). The national Healthy People 2020 target for breast cancer
death rates is 20.7 deaths per 100,000 females, representing a 10% improvement rate (Healthy
People 2020, 2018). Additionally, in the United States there were 44.5 new late-stage breast
cancer diagnoses per 100,000 females reported in 2007 (Healthy People 2020, 2018). The
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Healthy People 2020 target for this objective is 42.2 new cases per 100,000 females (Healthy
People 2020, 2018). As illustrated in Figure 1, in 2015 there were 21.7 per 100,000 females who
died from breast cancer in Idaho. Figure 2 shows that there were 42.4 per 100,000 new late-
stage diagnoses in Idaho in 2013. Both figures demonstrate that Idaho has yet to reach the
Healthy People 2020 national target goals for either of these categories.
Figure 1. Female breast cancer deaths by state (Healthy People 2020, 2018)
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Figure 2. New Cases of late-stage female breast cancer by state (Healthy People 2020, 2018).
Specific Population
Gender and Age
Women aged 29-39 years will be assessed for access to information regarding breast
cancer. Figure 3 shows breast cancer prevalence by ages within the United States. As noted in
the figure, there is a spike in the breast cancer diagnosis rates between this target age range of
29-39 years old with the peak of the spike hitting between the ages of 30-34 years. This is
problematic since the current mammography recommendations for females living within the
United States begin at age 45; although it is optional to begin at age 40 (American Cancer
Society, 2018a). Without proper education for women aged 29-39 in the United States,
diagnosis could be prolonged, adversely affecting survival rates.
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Figure 3 - Age-Specific Rates of Breast Cancer in the US (Susan G. Komen Foundation, 2018).
Females comprise 49.5% of the population in Madison County (County Health Rankings
and Roadmaps, 2018). The target age range for this assessment encompasses a large portion of
the population. Figure 4 shows age distribution for all genders within the county. It is important
to recognize that nearly 23% of the population in Madison County is between the ages of 25-44
years, correlating to the target age range for this assessment which is women aged 29-39 years.
Figure 4 - Age Groups in Madison County (Community Commons, 2018b).
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Ethnicity, Race, and Language
All ethnicities and races within Madison County will be included in the assessment.
Particular attention will be given to the ethnicity populations of African-American and Caucasian
women due to the fact that Caucasian women are at highest risk for breast cancer overall and
African-American women are at greatest risk for breast cancer at younger ages (American
Cancer Society, 2018b). Current racial demographics in Madison County are included in Figure
5, which shows that 99.32% of the population is considered White with the next highest single
race being Asian at 1.10%. Additionally, 1.66% of the population is comprised of multiple races
and only 0.69% are Black. All other races are negligible in comparison. Because most of the
population is white (Community Commons, 2018b), it can be assumed that although there will
be no races excluded from the assessment, most of the women involved will be Caucasian.
Figure 5- Madison County Race Distribution (Community Commons, 2018b)
Ethnic demographics for Madison County are represented in Figure 6. The majority of
the population is non-Hispanic. Although there are not any ethnic requirements for the
assessment, assessments done within this community will reflect the more prevalent non-
BREAST CANCER EDUCATION 8
Hispanic population. This is important to note as other communities try to relate the assessment
findings to their own demographics.
Figure 6 - Ethnic Demographics in Madison County (Community Commons, 2018b)
Language preferences will not be a consideration for this assessment. All females within
the 29-39 age range will be considered, regardless of spoken language. It is important to note
that 9.9% of the population speak a language other than English in their home (United States
Census Bureau, 2018). Eventually, community assessments may need to focus on breast cancer
information available to women for whom English is not a primary language.
Mammography Screenings and Breast Cancer Incidence
Mammography screening rates within Madison County are lower than state and national
rates. Figure 7 shows the disparities between the rates. Except in 2013, Madison County has
consistently scored low and has not followed state and local trends for mammography screening
in the past (Community Commons, 2018d).
Figure 7- Mammography Rates in Madison County (Community Commons, 2018d).
BREAST CANCER EDUCATION 9
Despite the lower rate of mammography, Madison County does have a lower breast
cancer incidence rate. As noted in Figure 8, incidence rates are well below the state and national
rates (Community Commons, 2018b). Even with these good statistics, it is still important to
provide easily accessible information about breast cancer to women to ensure better health
outcomes in the event of a cancer diagnosis.
Figure 8 - Breast Cancer Incident Rates (Community Commons, 2018b).
Community
People
Madison County income rates are poor. As shown in Figure 9, median family income is
nearly half of the national average and only 60% of the median income for all of Idaho. With a
median income of only $34,783, it must be questioned whether residents take advantage of
regular check-ups with primary care physicians. Similarly, 35.65% of the population currently
lives in poverty, representing 2.3 times the state and national levels (Community Commons,
2018e). Economically disadvantaged communities may not be as proactive in their health care
needs. There are also excessive income inequalities when compared with state and national
levels (Community Commons, 2018e). This means that income is not spread evenly throughout
BREAST CANCER EDUCATION 10
the community or that fewer homes are responsible for earning a majority of the local income.
This creates larger differences in classifications of socioeconomic status. Both the lower median
income and the larger income inequalities may be reflective of the large student population that
attend the local University in Madison County. The students would not be earning the same
amount as local community members and could potentially skew these results.
Figure 9- Income levels (Community Commons, 2018e).
The population of people residing in Madison County does have high rates of health
insurance. Only 10.3% of the population is uninsured, well under the state and national levels of
14.71% and 12.98% respectively (Community Commons, 2018e). Additionally, 17.33% of the
population receives Medicare, which is comparable to state and national percentages. This may
mean that despite the lower incomes, health management is still possible. However, there is no
information available with regard to co-pay amounts or the quality of the health insurance (high
deductibles and lower pay-outs vs. low deductibles and higher pay-outs) which are also
determining factors to health care accessibility.
People within Madison County are generally health conscious. According to the
Community Health Needs Assessment reports provided by Community Commons, residents of
Madison County scored far below the state and national averages in adverse health behaviors,
including alcohol consumption and expenditures, soda expenditures, physical inactivity, tobacco
expenditure, and current tobacco users (2018c). Residents of Madison County also scored well
above the state and national averages in walking or biking to work, but scored above the national
BREAST CANCER EDUCATION 11
average for inadequate fruit and vegetable consumption (Community Commons, 2018c). The
Madison County Population scored similarly in rates of obesity as state and national averages
(Community Commons, 2018d). These statistics are promising for the population of Madison
County, considering the fact that alcohol consumption, obesity or being overweight, and
sedentary lifestyles are some of the many risk factors for breast cancer (American Cancer
Society, 2018d).
Place
Madison County is located in East Idaho, outlined in red in Figure 10. It is located within
about 90 miles of the West entrance of Yellowstone National Park and Jackson Hole, Wyoming,
and is close to the St. Anthony sand dunes, making it centrally located to diverse ecological
settings. Much of Madison County is a shield volcano (Madison County, 2018) and there is
evidence of volcanic rock in many of the surrounding areas. The total land area is 473.36 square
miles with only 0.39% comprising water (Madison County, 2018).
Figure 10 - Madison County Idaho (United States Census Bureau, 2018).
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Function
There is not only a shortage of primary care physicians, but also mental health providers
within Madison County. Figures 11 and 12 show how Madison County measures up with state
and national provider ratios. Additionally, 100% of the population in Madison County lives
within a health professional shortage area (Community Commons, 2018a). This could be
indicative of poor access to health care. However, Madison County also scores low in
preventable hospital events (Community Commons, 2018a), or events that are preventable if
primary health care providers are seen before hospital admittance become necessary. Thus, it
may be that the population is healthier as a whole and may not need as many health professionals
as other areas.
Figure 11 - PCP Ratios (CHNA, 2018).
Figure 12- Mental HCP Ratios (CHNA, 2018).
Madison County is home to Madison Memorial Hospital in Rexburg, ID (as pictured in
Figure 13). The hospital has greatly expanded since its opening in 1951. It began as just a 29-
bed facility but now offers many additional services including an emergency department,
surgical center, physical therapy center, maternity center, radiology, laboratory, cancer care
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center, infusion center and more (Madison Memorial Hospital, 2018b). It is a great resource for
the community and surrounding areas.
Figure 13 - Madison Memorial Hospital (Madison Memorial Hospital, 2018b).
Madison County is home to a variety of educational resources. Within the first year of
settlement back in March 1883, an academy was established for the purpose of education. Since
that time, the academy has made several transitions to compile what is currently Brigham Young
University – Idaho (City of Rexburg, 2018). Madison County has several museums, including
the Legacy Flight Museum and the Rexburg Museum. The Madison County library, located in
Rexburg, provides over 90,000 items as resources for patrons (Madison Library District, 2018).
These establishments provide valuable informational and educational resources for community
members.
Figure 14 – Brigham Young University – Idaho in 2013 Figure 15- Madison County Library (Madison Library District, 2018). (Brigham Young University – Idaho, 2018).
BREAST CANCER EDUCATION 14
Plan
A nurse who works in a primary health care provider’s office within Madison County
Idaho will be interviewed as a key informant. She will be questioned regarding breast cancer
information available to women aged 29-39 who come into the office she works at. Information
can include, but is not limited to, routine education, pamphlets, and or flyers. The key informant
will be assessed if this information is provided to all women within that age group or only if
specific risk factors are present. For example, is any special attention given to women that are
African American, those who drink alcohol, are obese or overweight, or live sedentary lifestyles.
The rate of female patients between the ages of 29-39 years who are either uninsured or have
incomes below the national poverty line that visit the office will also be assessed. Assessment of
additional resources for the uninsured and low-income females aged 29-39 years will also be
included.
A woman who was diagnosed with breast cancer between the ages of 29-39 years who
resided in Madison County at the time of diagnosis will also be interviewed. She will be
assessed for information regarding her personal breast cancer knowledge base prior to her breast
cancer diagnosis. She will also be asked about opportunities provided to her by her health care
provider prior to her diagnosis that contributed to her knowledge base or health status. These
opportunities include assessment of risk factors, clinical breast exams, and evaluation of
understanding of breast cancer signs and symptoms. Lastly, she will be given the opportunity to
provide any information she wished all women aged 29-39 years knew.
A windshield survey will include driving around Madison County and looking for
billboards or any other signs located in the community that offer information about breast cancer.
Any mention of breast cancer will be included whether it refers to primary, secondary, or tertiary
BREAST CANCER EDUCATION 15
prevention measures. Observations will be made at the Rexburg Medical Center, District Health
Office, and Season’s Medical Center offices in Madison County. These facilities will be
assessed for pamphlets or flyers in waiting rooms that provide information about breast cancer.
Resources to support responses include Community Commons, Eastern Idaho Public Health
District, American Cancer Society, and the National Cancer Institute.
Part 2: Assessment
Primary Data
Primary data was gathered through interviews, a windshield survey, and other
observations. The first interview was with a key informant who currently works at Rexburg
Medical Center in Madison County as a nurse. She has been employed there for the last 8 years.
The second interview was with a woman who was diagnosed with breast cancer 4 years ago at
the age of 37 years. She has resided in Madison County for 40 years. The windshield survey
involved driving around Madison County to see if there were any billboards or other signs that
provided information about breast cancer. Other observations included assessing for pamphlets
and flyers in waiting rooms of medical care facilities in Madison County. These facilities
included Season’s Medical Center, the District 7 Health Office, and Rexburg Medical Center.
Key informant interview.
1. Q: What kind of breast cancer information is provided to women aged 29-39 that come
into your clinic?
A: I believe we don’t routinely give them anything. We should. I am sure as the doctor
visits with each patient that is coming in, especially for a women’s physical, he would
ask if she had noticed any breast changes. Then, if they were doing a pap he would ask
her if she would want to do a clinical breast exam. I would have to ask all of the doctors
BREAST CANCER EDUCATION 16
if they routinely do that on that age group. I know they would do that on an older
woman, but for that age group, I am just not sure.
2. Q: Is this information provided (or not provided) to all women in that age range or are
any risk factors taken into consideration? For example, for that age group, African
American women are at greater risk for breast cancer whereas Caucasian women have a
greater risk over the course of a lifetime. So, do you pay attention to those kinds of
things and are more proactive with those women at greater risk, or is the information
provided the same regardless of the risk factors?
A: Our clinic sees very few African Americans. So, we probably don’t see enough to
have that routinely kept in mind, would be my guess. Strangely enough, during the
month of October, we are more proactive on these things just because we become more
aware. We are very proactive with any woman over the age of 40 and make sure she has
her mammogram ordered and that she gets in to do that. But, that younger age group,
um… only if they have a family history or if the person herself is very adamant that she
wants a mammogram done because she wants a baseline done at an early age – especially
if the family member had it at a young age, then we are more proactive. So, I would say,
in that age group, it is left more up to the patient and her awareness before we take any
big steps. Like I said, the doctor would probably offer a breast exam while she was there
but if she refused or didn’t want it, he obviously wouldn’t encourage her to do that.
3. Q: Does your office have any pamphlets, flyers, or any other informational resources that
could be provided to women aged 29-39 years?
A: Yes, we do have some right at the triage area that we could hand out. We don’t
routinely hand them out to each well woman that comes in for a check-up. But, we do
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have them should anyone ask for more information. I wouldn’t say we had enough to
hand them out to every single person, but it is there if someone is interested.
4. Q: Do you feel like the information provided to this younger age group is adequate or
would you like to see changes?
A: I think we should probably be more proactive in teaching the self-breast exams. In
our triage process, we ask a lot of personal questions about mental health and
immunizations and history or family history. Maybe there should be a little box we could
check. I was thinking about that this morning and I think there should be a question there
where we can ask “Do you know how to do self-breast exams?” and “Would you like
more information?” or something like that. We ask people about their living wills and
blood transfusions and all kinds of stuff. So, on a woman, that is something that could
definitely be looked into, I think - for a wellness visit for a woman, or any woman over
the age of 20, really.
5. Q: Based on your observations, how frequent is a breast cancer diagnosis in the women
aged 29-39 in your clinic?
A: Hmm… for the younger age group…Probably from our patient client group. Maybe 1
every 18 months or something like that. So, not real often. And then in the older group
maybe 1 a year, or maybe 2 a year in the women 40 and older.
6. Q: What other concerns, if any, take priority over addressing breast cancer in the younger
age group?
A: Like I said, I think it would be wise if we asked those questions we talked about right
upfront just like all the others. So, I can see maybe there is a lack there. I mean we ask
someone if they ever feel depressed, so we should ask if they ever do self-breast exams or
BREAST CANCER EDUCATION 18
have any questions about how to do that. I am sure that the doctors address that more
behind closed doors when the nurses aren’t in there. So, it might be good for you to ask
one of the doctors, actually. But, that would be my perception, that we become more
forthcoming about what their feelings are about that or if they have any questions or want
to be taught more or want to learn more or something like that. We ask so many other
personal questions there is no reason why we couldn’t ask those kinds of questions. It is
not built into our program, but we’ve only had our program for 6 months, so I think that
would be a good thing to look into… I will ask someone!
7. Q: How often in this age group come into your office?
A: I think we get a lot of that age group. I don’t think they come in as much for wellness,
but our clinic delivers a lot of babies, so we see a lot of women in that age group for
pregnancies. Or, they may be in with their children, but they will ask questions about
themselves while they are there. I would say they are a big hunk of our clientele - more
so than their spouses of the same age.
8. Q: Do you see clients of this age who do not have insurance?
A: Oh, yeah! We get a lot of self-pays. In recent years because the Medicaid was
boosted, we had a lot of Medicaid patients – which was great. But I am afraid that is
going to cut back with recent changes. But, yeah, we do see a lot of women who are
uninsured. I know there is a program through the …um… I don’t think it is through
District 7 Health… but there is a women’s health clinic that is a free clinic if they meet
certain criteria for finance. I don’t think it has anything to do with age, just finance. But
we do have information that we can give women that they could go get a pap, a breast
exam, or a mammogram, especially if the woman came in that is a high risk (not
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necessarily for breast cancer) but more for other female problems like STDs. They can
get help and not have to pay for it if they qualify for it based on income. I know there is
some help out there. You have to fill out the paperwork to get it, but there is some help
and we definitely have women who fit into that category.
Follow-up Q: Do you find that the women take the time to fill out the paperwork and take
care of their health needs?
A: I think if they are really worried about something then they do. Then they’ll take the
time to do that. If it’s just more of a routine type thing, then probably not. But if it’s
something that they are afraid that they may have contracted something, then they would
be more willing to follow through with that.
Revision. A few days after the interview, the key informant provided additional
information after speaking to the doctors she works with. Both doctors that work in the clinic
said they do not do routine manual breast exams in women under age forty and that the newest
data suggests that clinical breast exams don’t catch hardly any breast cancer. Recommendations
are lengthening years between such exams to two or more. They also reported that the clinic
catches breast cancer in a younger patient only once in every three to five years whereas it is as
many as three per year in the older population.
Survivor interview.
1. Q: Prior to your diagnosis, had you been given the opportunity to assess your breast
cancer risk factors with a medical professional (nurse, doctor, etc.)? If not, would you
have taken the time to assess your risk if given the opportunity? Why or why not? If so,
what came out of the risk assessment?
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A: I had no thought of assessing the risks of breast cancer. When I felt my lump, I was
strongly impressed that I needed to get into someone as soon as possible. I was in shock
and alone at the time of diagnosis. My husband at the time was out of town and I had no
one around to think of this.
2. Q: Prior to your diagnosis, were you ever asked by a medical professional if you were
comfortable in recognizing changes in your breast tissue? Or if you wanted more
information about breast self-exams?
A: I always had a breast exam at each of my OB visits. However, I was never asked if
there were any changes in my breasts. I thought it was silly that we had to go through
that exam in the first place.
3. Q: What kind of exposure did you have to information about breast cancer prevention
and/or risk factors before your diagnosis? And, was this information enough that you felt
comfortable knowing what kind of breast changes required further evaluation by a
medical professional?
A: Prior to my breast cancer, I don’t ever remember thinking about breast cancer or
cancer in general. It doesn’t run in my family.
4. Q: Do you feel the knowledge you had prior to breast cancer was adequate enough to
help you get an early diagnosis?
A: I always knew that if you felt a lump that you should have it checked out. I now
know that finding a lump is not the only thing you should look for. The doctors and
others need to be more specific with this to everyone at every visit. I can’t believe what I
was absent to.
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5. Q: Did you or your primary care physician initially feel your breast cancer lump?
A: I was the one who found my lump. I was so scared, because I swear that I had done a
breast exam the week prior and nothing was there. I know nothing was there.
6. Q: As best as you can remember, had you ever had a clinical breast exam (one performed
by your primary care provider) prior to your diagnosis?
A: Breast exams were done every year except not so much after I had my hysterectomy
in years earlier. I think that was 2010?
One other thing – Dr. Dickson [a local oncologist] later told me that he likes to see his
patients prior to any surgery. The OB doctors need to know this and let their patients
know this.
7. Q: What information do you know now that you wish had been provided to you before
your diagnosis (i.e. What breast cancer information would you feel is important enough
to be given to all women aged 29-39 years)?
A: Even though breast cancer doesn’t run in a person’s family, there is still a chance of
them getting it. I am the only one in my family ever to have breast cancer or any type of
cancer. I feel deeply things should change when it comes to when one gets their first
exam and mammogram. I feel that breast exams, as well as mammograms, should be
mandatory prior to marriage and at each birth so that everyone involved knows the tissue
and can see changes.
Windshield survey. A windshield survey was conducted in Madison County. Billboards
and signs provided throughout the community were assessed for breast cancer information that
was readily available to community members. Although there were no billboards or signs that
were specific to breast cancer, there were several signs throughout the community on banks,
BREAST CANCER EDUCATION 22
restaurants, and other local establishments that were promoting “Hello” week. This campaign is
put on by an organization created by the local school district in Madison County called Madison
Cares. This specific campaign is an effort to encourage not only reaching out to others, but to
also notice signs of isolation in children. It is meant to promote social inclusion. Having
multiple establishments promoting this campaign is evidence of community caring and
involvement. The windshield survey was conducted in the month of February. Based on the
local involvement for “Hello” week, it may be more applicable to repeat the survey during the
month of October when breast cancer information is more likely to be promoted.
Other observations. Assessments were made at a few of the local medical
establishments with the specific intent to see what kind of pamphlets or flyers were readily
available to community members that addressed breast cancer information or resources. At the
Season’s Medical Center in Rexburg, three different clinics were assessed, including the Adult
and Family Care, Family Medicine, and The Women’s Center offices. Out of the three clinics
assessed, there were no breast cancer-related resources in the waiting rooms. There were other
pamphlets and flyers available, just not any that referenced breast cancer. In the Women’s
Center, there was one pamphlet about what to expect after a positive cervical cancer screening,
but that is as close to breast cancer as it got.
At the District 7 Health Office, there were several flyers that gave information about the
Women’s Health Check. This is an organization that will provide free pap smears,
mammograms, and STD testing for women who qualify based on income requirements. Not
only was there a flyer for the Women’s Health Check, there was also a small poster and a paper
that had the contact information for the primary nurse overseeing the program on tabs at the
bottom of the paper that could be torn off. Even though there were plenty of flyers for the
BREAST CANCER EDUCATION 23
Women’s Health Check, there were no other flyers or pamphlets that addressed breast cancer
besides those already mentioned.
The Rexburg Medical Clinic had no pamphlets or flyers of any kind in the waiting room.
However, at the nurse’s triage area there were several pamphlets available for clients. One of
these was a flyer for Teton Radiology that advertised mammograms. Other than that, there were
no other breast cancer-related resources readily available.
Secondary Data
Secondary data has been gathered from local, state, and national governmental agencies
that provide information on breast cancer. Both life-style-related and non-modifiable risk factors
are addressed. Additionally, local, state, and national information about the number of cases,
incidence rates, mortality rates, and available breast cancer information is provided.
Life-style-related risk factors. There is a lot of information about breast cancer and
specific risk factors that has yet to be discovered. Despite this knowledge deficit, there are a few
risk factors that have been shown to be correlated with breast cancer. Some are related to
personal behaviors while others are out of individual control. One of the life-style related risk
factors is alcohol consumption. According to the American Cancer Society, drinking one
alcoholic drink per day only increases the risk of breast cancer a very small amount (American
Cancer Society, 2018d). However, women who drink 2-3 alcoholic beverages a day increase
their chance of being diagnosed with breast cancer by 20% compared to those who don’t drink
alcohol (American Cancer Society, 2018d).
Other modifiable risk factors include being overweight or obese and having a sedentary
life-style. Interestingly, research suggests that weight distribution and age of obesity or
overweightness onset are contributing factors to breast cancer (American Cancer Society,
BREAST CANCER EDUCATION 24
2018d). Excess fat in the mid-section is a higher risk factor than having similar amounts of fat in
lower-body portions. The risk is higher for women who gained weight as an adult rather than
being overweight since childhood. There is evidence building that correlates decreased breast
cancer risk to being physically active. This is still a topic that is being studied to find out if there
is an optimal level of activity to achieve the best protection, but preliminary findings suggest that
although a few hours a week might provide some benefits, it would be best to do more
(American Cancer Society, 2018d). It is important to watch for further research in this area so
optimal benefits can be obtained.
There are multiple risk factors associated with reproductive life-styles. These risk factors
are especially applicable to women aged 29-39 years, since they are in their reproductive years
and may participate in these activities without fully understanding the risk it puts them in for
incurring breast cancer. Women who do not have children or who do not have a first child until
after age 30 years are at an increased risk for breast cancer (American Cancer Society, 2018d).
There have been a few studies that suggest breastfeeding lowers breast cancer risk, particularly if
done for 18 to 24 months (American Cancer Society, 2018d). However, this topic is hard to
study in the United States since most mothers do not typically breastfeed that long.
One last risk factor that involves reproductive life-style is birth control use. Oral
contraceptive use has been shown to slightly increase the risk of breast cancer but this increase
returns to normal after 10 years of stopping the medication (American Cancer Society, 2108d).
There is also an increased risk with the Depo-Provera injection, with normal risk being
reestablished after 5 years of stopping the injections (American Cancer Society, 2108d). Other
less common forms of birth control such as implants, patches, and rings have not been studied as
BREAST CANCER EDUCATION 25
intensely as the other forms. It is unclear what effect, if any, these types of birth control have on
a woman’s risk of getting breast cancer.
Non-modifiable risk factors. Non-modifiable risk factors are factors that cannot be
manipulated or changed. For example, women are 100 times more likely to get breast cancer
than men (American Cancer Society, 2018b). Age is also a big contributing factor. The rates of
new cases of breast cancer based on age in the United States were shown previously in Figure 3.
It is apparent from the graph that the older a woman gets, the more likely she is to be diagnosed
with breast cancer. Most breast cancers are found in women age 55 years and older (American
Cancer Society, 2018b).
There is also a strong genetic link to breast cancer. However, even though the link is
strong, less than 15% of women that are diagnosed with breast cancer have a family member
with the disease (American Cancer Society, 2018b). Research has shown that having a first-
degree relative with breast cancer doubles the risk and having two first-degree relatives with the
disease triples it (American Cancer Society, 2018b). Just keep in mind that there are other
unknown causes of breast cancer that play a role in a majority of the breast cancer cases.
Additionally, there have been certain gene defects that can be identified as increasing the risk for
cancer significantly. The genes BRCA1 and BRCA2 have the biggest impact compared to other
genes. If a woman has a mutation in the BRCA1 or BRCA2 genes, her chance of getting breast
cancer by age 80 is 7 in 10 (American Cancer Society, 2018b). These women are also more
likely to be diagnosed at a younger age, have cancer in both breasts, and have a higher risk of
developing ovarian cancer. Even with these significant risk factors, only 5-10% of breast cancer
cases are thought to be directly related to gene defects (American Cancer Society, 2018b).
Women with genetic mutations need to understand how significant these mutations are, while
BREAST CANCER EDUCATION 26
those without the mutations need to realize that the odds of getting breast cancer are still fairly
high.
National data. As mentioned previously, a woman’s risk for breast cancer is
approximately 12% in the United States. Based on data collected from 2010-2014 throughout
the United States, breast cancer incidence rates are 123.5 per 100,000 (Community Commons,
2018d). Whites are most likely to get breast cancer with Blacks following in a close second. The
national incidence rate for Whites is 124.5 per 100,000 and 122.8 per 100,000 for Blacks in the
United States (Community Commons, 2018d). Other races and ethnicities are still susceptible.
In the United States, Asian and Pacific Islanders have incidence rates of 90.2 per 100,000,
American Indian and Alaskan Natives of 72.7 per 100,000, and Hispanic or Latino of 92.3 per
100,000 (Community Commons, 2018d).
There are approximately 190,301 Whites that are diagnosed with breast cancer annually
in the United States (Community Commons, 2018d). National annual new cases for Blacks is
26,354 and for Hispanic/Latinos it is 17,547 (Community Commons, 2018d). Of the Asian and
Pacific Islander populations, 8,603 are diagnosed in the United States every year, while 1,254
American Indian and Alaskan Natives will be. Figure 16 shows national, state, and local cancer
mortality rates by race and ethnicity. Although mortality rates from all cancers are included in
the figure, it is apparent that Blacks and Whites are most at risk for cancer-related deaths.
BREAST CANCER EDUCATION 27
Figure 16 - National, State, and Local Cancer Mortality Rates (Community Commons, 2018d).
There are many resources available online through national government websites that
provide information about breast cancer. One of the websites is organized by the National
Cancer Institute. This website offers a public tool that assesses breast cancer risk. Figure 17
provides the assessment questions used in the tool. Each question highlights the biggest risk
factors. However, there are limitations to this tool. The tool is not advised for those with a
history of breast cancer or who have tested positive for the BRCA1 or BRCA2 genes. The tool
is also only designed for women who are at least 35 years old or older, restricting applicability to
those women who are younger (National Cancer Institute, 2018a).
BREAST CANCER EDUCATION 28
Figure 17 - Breast Cancer Risk Assessment Tool (National Cancer Institute, 2018a).
State data. Breast cancer incidence rates are only slightly lower in the state of Idaho
compared to national levels. Data collected in 2010-2014 suggests that the incidence rate in
Idaho is 120.5 per 100,000 population (Community Commons, 2018d). There are multiple
differences in state and national incidence rates based on race and ethnicity. In Idaho, Whites
have a 120.5 per 100,000 incidence rates, Asian or Pacific Islanders have 76, American Indian
and Alaskan Natives have 103.5, and Hispanic or Latinos 89.1 (Community Commons, 2018d).
All rates are based on population per 100,000 people. There is no data available on the state
level for incidence rates for Blacks. All other incidence rates are lower than the national statistics
BREAST CANCER EDUCATION 29
besides the American Indian and Alaskan Natives. This ethnicity has a significantly higher
incidence rate in Idaho compared to the national rates.
Across the state of Idaho, there are approximately 1,026 new cases of breast cancer in
Whites reported each year (Community Commons, 2018d). There is no state data for Blacks, but
average annual new cases for Asian or Pacific Islanders is 10, for American Indian or Alaskan
Native it is 11, and for Hispanic or Latino is 40 (Community Commons, 2018d). Mortality rates
for cancer in general within Idaho can be noted in the previously mentioned Figure 16. Mortality
rates are comparable between state and national statistics for Whites and Hispanic or Latino
populations. Mortality rates are decreased in Asian or Pacific Islander ethnicities in Idaho but
significantly increased in the American Indian and Alaskan Native populations, when compared
to national statistics. There is no mortality rate data available for Blacks in Idaho.
There are limited online resources specifically for breast cancer within the State of Idaho
beyond the national governmental websites. However, there is some beneficial information
provided by the Susan G. Komen Foundation of Idaho/Montana. Figure 18 shows an image
provided on this website that illustrates the breast changes that should be reported to a health-
care provider. This information can be useful to all women within the state of Idaho, regardless
of age. Therefore, women in the target age range of 29-39 years included in this assessment can
also benefit from this resource.
BREAST CANCER EDUCATION 30
Figure 18 - Reportable Breast Changes (Susan G. Komen Foundation of Idaho/Montana, 2018).
Local data. Breast cancer incidence rates are significantly lower in Madison County
compared to both state and national levels. The overall incidence rate is 74.5 per 100,000 people
based on data collected from 2010-2014 (Community Commons, 2018d). However, there is no
data available for any race or ethnicity incidence rates in Madison County besides for Whites. In
this case, the incidence rates for Whites is 71.8 per 100,000 (Community Commons, 2018d).
There is an average of 8 White people diagnosed with breast cancer annually in Madison County
BREAST CANCER EDUCATION 31
(Community Commons, 2018d). Again, there is no data available for other races or ethnicities
for comparison with state and national annual new case rates.
Mortality rates from cancer in general for Non-Hispanic Whites in Madison County are
significantly lower when compared to state and national rates. Again, Figure 16 provides cancer
mortality rates of local, state, and national statistics. Note there is no data on the local level for
those of different races or ethnicities other than Non-Hispanic White.
There is very little information online about breast cancer available to Madison County
residents on the local level. The Eastern Idaho Public Health website, which serves Madison
County and other surrounding Idaho counties, provides some information about cancer in
general, but focuses mainly on colorectal and skin cancer programs (Eastern Idaho Public
Health, 2018). There is a cancer support group offered by Madison Memorial Hospital located
in Rexburg. Contact information for the team-lead person and meeting times can be found on the
hospital website, but this is not specific to breast cancer and encompasses all ages and cancer
types (Madison Memorial Hospital, 2018a). The lack of online information available on the
local level is drastic in contrast to that offered at the national level.
Part 3: Data Interpretation
After assessing the data on breast cancer information availability, specifically for women
ages 29-39 years in Madison County, it is apparent that there are several community resources
available; although, it takes proactive effort to locate and utilize these resources. Breast cancer is
a national concern with risks that span a lifetime. Though the rates of breast cancer are lower in
Madison County compared to state and national rates, this may be due to the lower median age in
Madison County, since breast cancer incidence rates increase with age. Because breast cancer
can be life-threatening if not caught soon enough, it is imperative that women of all ages are
BREAST CANCER EDUCATION 32
aware of what breast changes need to be followed up with a primary care physician. Discerning
atypical breast changes is an area that needs to be better addressed for women aged 29-39 that
reside in Madison County.
Data Similarities
Lack of readily available information. The windshield study and other observational
assessments indicated that there are limited educational resources about breast cancer available
throughout Madison County. Even local websites were lacking information about breast cancer.
The breast cancer survivor that was interviewed as part of the assessment also indicated that her
knowledge about the signs and symptoms of breast cancer was severely limited to only knowing
that a lump in the breast tissue was not a good thing. She had been a Madison County resident
for nearly forty years at the time of her diagnosis, indicating the lack of readily available
information for women aged 29-39 in Madison County.
Decrease in risk factors equates to decrease incidence. There is a decreased incidence
of breast cancer incidence in Madison County. Not surprisingly, Madison County scored low for
alcohol use, obesity rates, and sedentary lifestyles. All of those factors are considered to increase
breast cancer risk. Thus, it is not surprising that breast cancer rates are decreased in Madison
County when those risk factors are also decreased.
Call for more proactive medical care. Both interviewees concurred that Madison
County needs to encourage more proactive care when it comes to breast cancer information and
screenings for women aged 29-39 who are Madison County residents. The key informant, or the
nurse working at Rexburg Medical Center, saw the need to include self-assessment questions as
part of the triage questionnaire. The breast cancer survivor thought it would be beneficial to
BREAST CANCER EDUCATION 33
increase mammography frequency so patterns could be more readily detected over a lifetime.
Either way, both informants called for a change in the community’s current standard of care.
Data Differences
Lower local occurrence. Differences exist between the rates of breast cancer incidence
in Madison County, the State of Idaho, and within the United States. Overall rates are increased
on the national level, with state levels being slightly lower than that. Breast cancer incidence
rates are significantly lower in Madison County. However, some of this may be due to the fact
that the median age is also significantly lower in Madison County compared to state and national
median ages, and breast cancer incidence increases with age.
Genetic emphasis. There is a strong emphasis on genetics being a major contributing
risk factor. A woman’s risk for breast cancer dramatically increases if she has a family history of
the disease or tests positive for the BRCA1 or BRCA2 genetic mutations. However, even though
those women are at an increased risk, genetic factors only account for less than 15% of all breast
cancer diagnoses (American Cancer Society, 2018b). The survivor that was interviewed had no
history of breast cancer, or of any cancer. The genetic risk factor is emphasized so strongly that
women can get the false impression that the risk is minimal without a genetic history. In fact, the
second question provided on the risk tool on the National Cancer Institute’s website as seen in
Figure 17, asks about testing positive for the BRCA1 or BRCA2 genetic mutations (National
Cancer Institute, 2018). Being listed as the second question indicates how strongly genetic
factors are underscored when it comes to risk factors. It comes second only to a previous
diagnosis of breast cancer. The survivor that was interviewed admitted to not ever thinking
about breast cancer because she had no family history of it. Information resources need to be
clearer on this differentiation.
BREAST CANCER EDUCATION 34
Decreased mammography and screening guidelines. In 2015, the American Cancer
Society loosened mammography guidelines from age 40 for the first mammogram to age 45, as
well as from every year to every other year starting at age 55 (CBS News, 2015). Additionally,
the nurse from the Rexburg Medical Center mentioned the doctors she works for said current
guidelines are no longer emphasizing clinical breast exams either. Contrarily, the survivor that
was interviewed strongly felt that mammograms should be done more frequently, not less. For
those who have experienced cancer, the reality of it shapes how firmly they want other women to
be protected from late diagnoses.
Population Strengths
Doctor visits. Women aged 29-39 in Madison County visit the doctor more regularly
than their male counterparts, at least according to the nurse that works at Rexburg Medical
Center. They are often seen by their physician for reproductive health. If a woman is pregnant,
she will be visiting her physician fairly regularly if she follows the current recommendations for
prenatal care. If she is not pregnant, there is a good chance she sees her physician for other
reproductive health concerns like birth control. Because of these factors, women aged 29-39 in
Madison County may have a greater opportunity to express concerns about breast changes or
other health issues that they may not have otherwise made an appointment for.
On-line resources. Although there are limited on-line resources available on a local
level, women aged 29-39 in Madison County have access to information from national databases
like the American Cancer Society and the National Cancer Institute, just to name a few. These
online resources are incredibly valuable in recognizing concerning breast changes and
understanding risk factors. Women in Madison County aged 29-39 years are generally
comfortable using computers and accessing online information. As long as they are willing to be
BREAST CANCER EDUCATION 35
forward thinking, they should be able to access the information they need to gain a good
knowledge base about breast cancer.
Supportive community. Madison County represents a strong and supportive
community. Several businesses were observed supporting “Hello” week, as mentioned
previously. That support shows the strong commitment which community members have to
community health and education. Women who live in Madison County and are 29-39 years old
are more apt to have exposure to these kinds of community programs. There is a good chance
that as the year progresses, there will be support for breast cancer awareness and other health
issues that are more relative to women aged 29-39 years within Madison County.
Population Weaknesses
Limited resources. Although there are sufficient on-line resources for women aged 29-
39 who reside in Madison County, a woman must be proactive in her health education efforts in
order to access the information. This means she has to look the information up on her own and
that it won’t be readily provided to her. Similarly, there is very little information available to
these same women within the community itself. There were few flyers, pamphlets, and no
billboards or signs that were placed for these women to see with minimal effort. Women who
are not proactive in their health status are at a severe disadvantage for gaining valuable
information about breast cancer and personal risk factors.
Reproductive health decisions. Women aged 29-39 are in the prime of their
reproductive years. There are many breast cancer risk factors tied to reproductive health
decisions. Pregnancy before age 30 is a protective factor, whereas most birth control measures
are considered contributing factors (American Cancer Society, 2018d). Many of the decisions
BREAST CANCER EDUCATION 36
which women aged 29-39 years make regarding their reproductive health impact their risks for
breast cancer. This is also true for the women aged 29-39 years in Madison County.
Low-income. As previously established, income rates in Madison County are poor.
Although those results may be skewed due to the college student population, women aged 29-39
years may still be working on establishing themselves financially. They may also have added
expenses as they are in the age range where they may be growing their families. Low income
rates or other financial setbacks may limit how often women aged 29-39 years in Madison
County access health care.
Significant Information Validating Health Issue
Increased susceptibility. Although most breast cancers are diagnosed in women over 55
years old within the United States, there is a spike in incidence between 29-39 years of age as
previously illustrated in Figure 3 (Susan G. Komen Foundation, 2018). Mammography
recommendations begin as optional at age 40 years, after the initial spike. Because of this,
women aged 29-39 years may go undiagnosed before significant signs and symptoms appear,
indicating diagnosis during later stages.
Limited local promotion. As evidenced in the key informant interview and other
observations, there is severely limited breast cancer informational resources readily available in
Madison County. Physicians in Madison County may not be as proactive in assessing the risk
factors for breast cancer in women aged 29-39 years either. If a woman aged 29-39 years in
Madison County is not actively curious or seeking information about breast cancer, she may not
have access to crucial, life-saving information.
Early detection needed for successful outcomes. Breast cancer is a highly prevalent
and serious disease, sometimes ending in death. With 12.4% of women in the United States
BREAST CANCER EDUCATION 37
being diagnosed at some point in their lifetime, it is important that all women are familiar with
the signs and symptoms of breast cancer (National Cancer Institute, 2018b). The sooner
suspicious breast changes are followed up with a health care provider, the better. Success rates
are dramatically increased with early breast cancer diagnoses.
Part 4: Population Health Plan
Population Plans
Greater confidence in identifying adverse breast changes. Women aged 29-39 years
who reside in Madison County may not be getting the breast health education they need to
properly recognize symptomatic signs of breast cancer. The breast cancer survivor that was
interviewed for this assessment admitted to knowing very little concerning other signs of breast
cancer besides a lump in the breast tissue. It is important that the women in Madison County
that are between the ages of 29 and 39 years become confident in recognizing all signs and
symptoms of breast cancer so that diagnosis is not prolonged.
In order to fulfill this need, it is recommended that the accessibility of concerning breast
changes improves. Creating and distributing pamphlets with information similar to that provided
in Figure 18 could be incredibly valuable for all women within Madison County, but especially
for those aged 29-39 years as the primary care doctors may not be as proactive with this age
range as compared with women over 40 years. These pamphlets should be made available to as
many women as possible that are 29-39 years old and live in Madison County, and should be
offered to clients at doctors’ offices, the District Health Office, and the WIC office. Each client
will be asked if they would like a pamphlet describing worrisome breast changes. Those who are
interested will be given the pamphlet.
BREAST CANCER EDUCATION 38
Evaluating the effectiveness of this intervention will include offering a Likert scale
survey encompassing how comfortable and confident each woman surveyed feels about
recognizing breast changes that need to be followed up with a health care provider before the
pamphlet is provided. A second survey, identical to the first, will be given at the next
appointment and a comparison will be made between the before and after surveys.
Increase proactive health care. One area of improvement in Madison County for
women aged 29-39 years is for primary care physicians to become more proactive in teaching or
asking about breast health. Both key informants, the nurse working at Rexburg Medical Center
and the breast cancer survivor, felt that physicians in Madison County were not forthcoming
enough in approaching their clients that are women aged 29-39 years in regards to breast health
and breast cancer information.
To remedy this problem, it is recommended that questions regarding breast cancer risk
factors as well as specifically addressing breast changes be incorporated into client triage and
health histories. Asking specific questions to women aged 29-39 years in Madison County will
make knowledge gaps more apparent as well as draw attention to important risk factors that may
not be addressed otherwise.
Data on cancer stage at diagnosis for women aged 29-39 years in Madison county will be
collected. This will need to be a long-term study since diagnoses in this demographic isn’t as
common as in women older than 40 years. Data from the previous 10 years will be compared to
the succeeding 10 years post-implementation.
Clarify genetic risk factors. Women aged 29-39 years in Madison County may not
fully understand the role genetics play as a breast cancer risk factor. The breast cancer survivor
that was interviewed mentioned that she had never really thought about breast cancer previous to
BREAST CANCER EDUCATION 39
her diagnosis since it did not run in her family. Although family history does heavily influence a
woman’s personal risk for breast cancer, genetics are only responsible for 15% of all breast
cancer diagnoses (American Cancer Society, 2018b). Women aged 29-39 years in Madison
County need to be aware that this means that 85% of women diagnosed with breast cancer have
no family history or other genetic link to breast cancer. This will help avoid a false sense of
security and bring more knowledge and awareness to one’s own personal risk for developing
breast cancer.
Awareness and education about breast cancer risk and genetic factors can be brought to
the community via a simple billboard. The billboard can present the above-mentioned statistics
in a location where a majority of the community will see it. Evaluating the effectiveness of the
billboard may be difficult; however, physician’s offices and other health care facilities in
Madison County can keep track of the number of women aged 29-39 years who ask more
questions regarding their personal risk factors both before and after the billboard
implementation. If there is an increase in the number of women aged 29-39 years in Madison
County who ask more questions, indicating an increase in proactive health education, then it may
be that the billboard was effective in its purpose.
Reflection
I really enjoyed completing this project. As a breast cancer survivor, I am passionate
about wanting every woman to be aware of her own body and what changes need to be followed
up with by a primary care physician. I will be forever grateful that I sought medical attention
quickly and that my doctor did not just brush it off since I was only 30 and had no family history
of breast cancer, or any cancer for that matter. Although I am passionate about this topic, I
recognize that my personal crusade may not be as important or as powerful as I think it should
BREAST CANCER EDUCATION 40
be. The statistics for being diagnosed at the younger age group is relatively low. However,
being a fighter and then a survivor has put me in unique opportunities to meet other younger
women who were diagnosed at later stages. It is heartbreaking to me to know these young
mothers and women who should have much life left in them become forever fighters – or those
who end up fighting for the rest of their (shortened) lives and never reach survivor status. Being
able to research the topic, helped me better realize what exactly could be done to help other
younger women out. It also helped me realize that although I feel like breast cancer information
should be available EVERYWHERE, there may be other community needs that take priority
over this demographic and problem. Researching the topic helped me truly assess the
community needs and come up with more realistic goals to improve breast cancer education for
younger women, without going overboard or just jumping in and implementing all these
unneeded and unnecessary strategies.
I can take these skills and be more successful in the workforce by remembering to assess
the specific needs and goals of a target population. This can be true for individuals as well. I
will not get very far with a patient if I do not take the time to figure out what he or she already
knows and what they are willing to try. I can’t just jump in and start implementing all these
interventions without a good foundational knowledge base of my client (whether an individual or
a community).
Most of my assessments focused on what was available in clinics or at the District Health
Office. I realize that there may be a portion of the target population that have never visited one
of these places or at least do not visit very frequently due to low incomes or other stressors. This
project helped me realize where health disparities exist, or at least where the weaknesses are and
that effort needs to be placed to reinforce those areas.
BREAST CANCER EDUCATION 41
This project helped change my thought processes by really focusing on what the
community needs the most. If my implementations save a few lives over the course of several
years, those implementations will be valuable. But if those resources were spent somewhere else
and could make a better life for more people, then I need to be okay with letting my crusade go
for the time being. It was personally beneficial for me to see how important it is to use evidence-
based practice to solidify goals and reinforce the needs of the community. Resources are
valuable and need to be used in a way to help the most community members.
BREAST CANCER EDUCATION 42
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BREAST CANCER EDUCATION 44
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