New · 2011. 1. 14. · in breast cancer. The researchers examined links among neighborhood characteristics; demographics; and details of breast cancer cases, such as incidence,

www.ihrp.uic.edu

A D D R E S S I N G H E A LT H D I S PA R I T I E S

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Annual Report 2010

http://www.ihrp.uic.edu

As a whole, Americans have experienced notable gains in life expectancy over the past several decades. In 2006, life expectancy at birth was 77.7 years for all races and men and women combined, up from 70.8 in 1970. These gains in overall health were driven mostly by declines in mortality from heart disease, stroke and unintentional injuries. For example, in 2006, the rate for the leading cause of death, heart disease, was 66 percent lower than the rate in 1950.1

Yet despite these positive statistics, some segments of our population may not be experiencing health gains as quickly as others, or might even be declining. In fact, notable disparities exist among mortality and disease rates in the United States.

Disparities in health outcomes are particularly apparent for individuals of lower socioeconomic status and for some ethnic or minority populations. Black children, for example, face a significantly lower life expectancy at birth than do white children (see graph). By age 65, a gap in life expectancy remains between blacks and whites, although it is much smaller than at birth. Cancer survival rates also show marked racial differences. For whites, between 1999 and 2005, the five-year relative survival rate for cancer of all types was 69.1 percent, compared to 59.4 percent for blacks.1

Risk factors for disease, including tobacco use, obesity and physical inactivity, also differ among races, ethnicities and socioeconomic levels. These disparities are the product of complex interactions among factors at multiple levels, from

biology to individual differences in beliefs and health behaviors, and societal and environmental factors, including neighborhood influences, access to care and discrimination.

IHRP researchers are committed to understanding the causes of health disparities, and to developing and implementing innovative programs that reduce them. We strategically address the problems of disparities by approaching the issues from a multidisciplinary perspective with faculty from multiple campus units; by engaging communities in all phases of the research process; and by training and mentoring students, postdoctoral fellows and faculty from underrepresented groups. IHRP’s work is central to the mission of UIC with our emphasis on conducting collaborative

cutting-edge research that makes a difference in people’s lives by helping to prevent premature death and disability for all groups. By working to improve approaches to health care, help all people develop and maintain healthy lifestyles, and address policy and societal barriers to better health, we hope that this next decade brings greater strides toward eliminating health disparities.

Reference

1. National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technolog y. Hyattsville, Md. 2010.

Health Disparities Common Theme of IHRP Research

F R O M T H E D I R E C T O R

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FEMALESSource: CDC/NCHS, Health, United States, 2009, Figure 16. Data from the National Vital Statistics System.

Annual Report 2010 • Institute for Health Research and Policy • www.ihrp.uic.edu

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Odds are, a woman from a racial or ethnic minority in Chicago will delay seeking medical advice about a lump in her breast. Perhaps she lacks a regular health care provider or health insurance or misunderstands the nature of breast lumps. When she does get a screening appointment, odds are she gets her mammogram at a facility without radiologists who specialize in breast imaging. If she lives in one of the city’s gentrifying neighborhoods, her breast cancer will more likely be diagnosed at a later stage. Odds are, if the nearest mammography facility to her is in an area with a high homicide rate, she will be diagnosed with an advanced stage of breast cancer, regardless of her age, race or income.

The odds are not good for many women at risk for breast cancer in Chicago.

Such are the findings of a team of researchers at the Institute for Health Research and Policy as they try to learn why African American women in Chicago are twice as likely to die of breast cancer as white women, despite comparable screening rates and lower incidence of the disease.

Since 2003, when it was first awarded funding from the National Cancer Institute (NCI)—as a Center for Population Health and Health Disparities—this team of faculty from epidemiology, nursing, sociology and medicine has conducted several studies to identify the factors that contribute to these disparities in breast cancer. The researchers examined links among neighborhood characteristics; demographics; and details of breast cancer cases, such as incidence, stage and care, using advanced statistical analyses and interviews of 1,000 patients about their symptoms, diagnosis and treatment.

“We found that, yes, there was a disparity by race, but when we included poverty as a factor, the racial differences disappear,” said Richard Warnecke, the lead researcher and UIC professor emeritus of sociology, epidemiology and public administration. Regardless of race or ethnicity, he said, poverty strongly increases the probability of a late-stage diagnosis of breast cancer.

Throughout their research, from design development through implementation and presentation of findings, the researchers consulted residents, health care providers and health advocates in predominantly African American communities in southwest Chicago.

“We are focused on getting the information that we find to members of the community—both practitioners and women who are at risk,” Warnecke said.

This approach brought the researchers and their partners together with community advocates and researchers at other Chicago-area universities, which led to the formation of the Metropolitan Chicago

Breast Cancer Task Force and contributed to a major report by the Sinai Urban Health Institute on the disparities of breast cancer diagnosis and treatment in Chicago. The public response led to policy directives that increased screening rates among poor women.

The research also has inspired new studies that have built on population-based approaches taken by the Center for Population Health and Health Disparities and that now address other cancers. In 2010, the center received a renewal grant from NCI to deepen the researchers’ inquiries:

• Looking at whether patient navigation services help women keep their mammography appointments and ensure they receive proper diagnosis and treatment if cancer is detected.

• Testing a strategy for breast cancer screening among African American and Latina women who receive their primary care at federally qualified health centers.

• Looking at how environmental factors play a role in aggressive breast cancers that disproportionately affect women of color.

Elizabeth Calhoun, professor of health policy and administration, will codirect the center’s new work with Warnecke. Carol Ferrans, professor and associate dean for research in the College of Nursing, is leading the center’s efforts to disseminate its findings to professional groups and policymakers through a series of presentations.

For more information about this research, see http://go.uic.edu/cphhdfindings.

Working to Improve Survival Odds in Chicago

D I S PA R I T I E S I N B R E AST C A N C E R

Regardless of race or

ethnicity, poverty strongly

increases the probability

of a late-stage diagnosis

of breast cancer.

—Richard Warnecke, UIC professor emeritus of

sociology, epidemiology and public administration

Advancing Health Practice and Policy through Collaborative Research

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http://go.uic.edu/cphhdfindingshttp://www.chicagobreastcancer.org/

The Institute for Health Research and Policy has long focused on research that addresses health disparities. Starting in the late 1980s, our researchers conducted a series of studies focused on improving smoking cessation interventions for women, particularly those who were least likely to be successful in their attempts to quit and to access evidence-based treatments. Community partnerships and tailoring interventions to meet the needs of special populations were hallmarks of these studies. Study participants included African American women with children in Head Start programs, residents of Chicago Housing Authority buildings and women who had no more than a high school education.

Today, IHRP researchers continue to work with community partners to develop programs that address the needs of underserved populations that bear greater burdens of disease. At the institute, researchers examine the complex interactions among the multiple levels of influence on health disparities, from genes to society, to help build evidence for new approaches and to develop and test evidence-based programs that address health challenges across the lifespan.

Several IHRP studies focus on the problem of obesity. Obesity and its associated health complications,

including diabetes, cardiovascular disease, and some cancers, disproportionately burden people from low-income backgrounds and some ethnic minority groups. IHRP researchers are addressing the obesity epidemic with a range of approaches, from examining the environmental and policy influences on diet and physical activity to developing community-based interventions using scientific evidence of what promotes healthy lifestyles. Following are a few examples of that research.

I N F L U E N C E S O N

P R O D U C E I N T A K E

Three of every four American adults report eating less than the recommended daily minimum of five servings of fruits and vegetables. At least for young, low-income adults, one reason for this low consumption may be cost, according to IHRP health economist Lisa Powell. For this population, higher prices were “significantly associated with” lower intake of fruits and vegetables, she reported in Health & Place in December 2009. Powell suggests that subsidies for fruits and vegetables may improve the diet of young adults, especially those with lower incomes.

From Identifying Environmental Influences to Fostering Healthy Lifestyles

D I S P A R I T I E S I N O B E S I T Y

Compared with whites,

African Americans had

51% higher and Latinos

21% higher obesity rates.

—Centers for Disease Control and Prevention, April 2010

RESEARCH ON DISPARITIES IN CANCER INCIDENCE AND SURVIVALIn addition to the studies covered on page 3, IHRP researchers are focused on other forms of this deadly disease:

• IHRP researchers will participate in the largest study to date to learn why African American women are more likely to die of ovarian cancer than white women, despite lower incidence rates. Under the direction of Therese Dolecek, research associate professor of epidemiology, IHRP will recruit about 135 of 1,000 study participants. Duke University and research centers in seven other regions with large African American populations will enroll the rest. Until now, a cohort of only 144 African American women was the largest to participate in a study about this cancer.

• Researchers in the Center of Excellence in Eliminating Health Disparities are recruiting 600 African American and white patients newly diagnosed with colon cancer. Under the direction of Garth Rauscher, associate professor of epidemiology, the study will identify patterns in colon cancer screening, diagnosis and treatment that might help to explain why African Americans are diagnosed at later stages of the disease and experience higher mortality because of it.


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F A T A N D C A N C E R

S U R V I V A L

Prostate cancer is the most common cancer for men of all races, but its highest incidence occurs in African Americans, who are more likely to die of it than any other group. Obese men with this cancer—even those with small, localized tumors—are more likely to develop progressive or fatal forms of this disease. UIC researchers led by Dr. Vincent Freeman, assistant professor of epidemiology, are working to identify the biological factors responsible for these poor outcomes.

Over two years, the researchers will track approximately 400 men diagnosed with early-stage prostate cancer. They will conduct biochemical and molecular studies of samples of their tumors and surrounding fat tissue. The findings will point to new approaches for preventing the recurrence or progression of prostate cancer after treatment, which could involve drug therapies, lifestyle changes or both. With a large recruitment of African American patients, the study also could shed light on the role of race on prostate cancer progression.

W E I G H T

M A I N T E N A N C E

Marian Fitzgibbon, professor of medicine and deputy director of IHRP, conducted one of the largest randomized trials— a high standard of scientific scrutiny—of a weight loss and maintenance program that focused exclusively on African American women. About 200 women participated either in a six-month, culturally sensitive weight-loss program followed by a 12-month maintenance program, or in a control group. After 18 months, 24 percent of the intervention participants and 12 percent of the control group were at least 5 percent below their baseline weight.

The findings were similar to those of other weight-loss studies in which African American women participated. To improve rates of weight loss and maintenance may require more than behavior changes of individuals, Fitzgibbon concluded. “We need to be far more creative,” she said, suggesting that changes in public policy and social norms are needed to support healthy lifestyles.

For more information about these and other studies addressing health disparities, visit www.ihrp.uic.edu.

PROMOTING HEALTHY LIFESTYLESImproving nutrition and physical activity among Americans would reduce the incidence of chronic disease and the risk of further complications among those who have diabetes, some cancers and cardiovascular disease. IHRP researchers are trying a variety of strategies to promote healthier lifestyles, especially among populations burdened with these diseases.

• Older minority adults have poorer outcomes with chronic disease attributed to a host of factors, including lower levels of education and income and residence in disadvantaged neighborhoods. Improving the health, function and quality of life of these people is the mission of the Midwest Roybal Center for Health Promotion and Translation. It supports pilot projects that examine barriers to walking for older Latinos; promote the use of tai chi to reduce stress among older Latinos with diabetes; increase the physical strength of homebound older adults at risk for nursing home admission; and adapt Fit and Strong!, an exercise program proven effective for older adults with arthritis, for use with Latinos.

• Dr. Ben Gerber, associate professor of medicine, is evaluating the effectiveness of a weight maintenance program including Internet-enabled digital video players in the homes of obese African American women. Previously, he studied the use of text messages in weight maintenance of African American women. Study participants received healthy eating tips, reminders to exercise, and messages of encouragement on their cell phones.

• Laurie Ruggiero, professor of community health sciences, is working on several studies that aim to improve the health of minority adults at risk for, or living with, diabetes. In one study, Ruggiero is determining whether low-income Latinos and African Americans with diabetes can improve their health and behaviors such as medication adherence and healthy eating habits with coaching from specially trained, certified medical assistants, in addition to the care they receive from their regular health care providers.

Previously, Ruggiero worked with Latino residents near Chicago’s Marquette Park to adapt a lifestyle program proven effective in reducing diabetes in a national study for group delivery in English or Spanish in community settings, led by trained community members. She is now analyzing the results.

In another study, Ruggiero is examining the health behaviors and outcomes of African Americans with diabetes after they participate in an online virtual world in which they use a computer character representative, or avatar, to participate in educational and support activities regarding diabetes self-care and problem-solving.

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H E A L T H I N S U R A N C E

F O R K I D S

About 95.5 percent of Illinois children under age 19 were covered by health insurance in late 2009 and early 2010 as a result of the state’s All Kids program, reported Dianne Rucinski, an IHRP senior scientist, to the state in June 2010.

Illinois’ experience offers important lessons for national policy, Rucinski said. Most families used employer-sponsored insurance for their families even when they qualified for public plans, she found. Further, the program may do a better job at preventive care than employer-based programs. Parents of children in All Kids were more likely to report having a “medical home” for their child, and 80 percent reported their child had a well-child visit in the previous year.

S C H O O L A N T I -

O B E S I T Y P O L I C I E S

While school districts have improved their wellness policies over the past three years, guidelines for foods and drinks outside meal plans do not comply with national standards or mandates, found scientist Jamie Chriqui and others in the Health Policy Center. Guidelines restricting sugar-sweetened beverages and sodium content of snacks were especially weak, they reported in a comprehensive review of school district wellness policies nationwide.

S M O K I N G A M O N G

C O L L E G E S T U D E N T S

In states that invested in tobacco control at higher levels, college students who smoked daily were much more likely to try to quit in the following year, reported Frank Chaloupka, distinguished professor of economics and Health Policy Center director, and colleagues in Health Economics. States that spent more on tobacco control programs also saw reductions in daily smoking and cigar use among college students in the next year.

As of 2009, only one state (North Carolina) was spending the minimum level recommended by the Centers for Disease Control and Prevention for comprehensive state tobacco control programs, according to the American Lung Association.

A N T I - S M O K I N G

C O M M E R C I A L S

Illinois residents saw fewer state-sponsored anti-tobacco commercials than residents of most other states, even at a time when the economy was strong and state coffers were newly flush with money from the Master Tobacco Settlement Agreement. In 2003, when residents in the largest 75 U.S. media markets saw 3.35 state-sponsored, anti-tobacco commercials a month, the average Illinois resident saw only 0.06 of such commercials, according to a study of the broadcasts from 1999 to 2007 by Sherry Emery, an IHRP economist.

To see reductions in smoking among a state’s population, at least one anti-

smoking commercial must be seen on average by residents every month over a year, according to Emery. For broadcast coverage of such commercials over the nine-year period, Illinois ranked among the four lowest states.

I N - H O M E S E R V I C E S

F O R O L D E R A D U L T S

The Illinois Community Care Program—the state program that provides in-home, community-based services to large numbers of older housebound adults—is a “very economical alternative to nursing home placement,” reported the Center for Research on Health and Aging to the state Department on Aging in late 2009. The researchers said funding for more intensive services could further reduce nursing home admissions among high-risk participants and allow them to stay in their homes.

For more information about these studies, including links to reports, go to www.ihrp.uic.edu.

Selected Health Policy Findings 2009–10

S E L E C T E D P U B L I C A T I O N S

B Y I H R P R E S E A R C H E R S

» Dierker L, Mermelstein R. Early emerging nicotine-dependence symptoms: a signal of propensity for chronic smoking behavior in adolescents. J Pediatr. 2010;156(5):818-822.

» Fitzgibbon ML, Beech BM. The role of culture in the context of school-based, BMI screening. Pediatrics. 2009;124(suppl 1):S50-S62.

» Gerber BS, Cho YI, Arozullah AM, Lee SY. Racial differences in medication adherence: A cross-sectional study of Medicare enrollees. Am J Geriatr Pharmacother. 2010;8(2):136-145.

» Muramatsu N, Yin H, Hedeker D. Functional declines, social support, and mental health in the elderly: does living in a state supportive of home and community-based services make a difference? Soc Sci Med. 2010;70(7):1050-1058.

» Powell LM, Han E, Chaloupka FJ. Economic contextual factors, food consumption, and obesity among U.S. adolescents. J Nutr. 2010;140(6):1175-1180.

» Rauscher GH, Ferrans CE, Kaiser K, et al. Misconceptions about breast lumps and delayed medical presentation in urban breast cancer patients. Cancer Epidemiol Biomarkers Prev. 2010;19(3):640-647.

» Seymour RB, Hughes SL, Campbell RT, et al. Comparison of two methods of conducting the Fit and Strong! program. Arthritis Rheum. 2009;61(7):876-884.

» Stolley MR, Sharp LK, Arroyo C, et al. Design and recruitment of the Chicago Healthy Living Study: a study of health behaviors in a diverse cohort of adult childhood cancer survivors. Cancer. 2009;115(18)(suppl):4385-4396.


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http://www.ihrp.uic.eduhttp://www.ihrp.uic.eduhttp://www.ihrp.uic.edu/content/early-emerging-nicotine-dependence-symptoms-signal-propensity-chronic-smoking-behavior-adolehttp://www.ihrp.uic.edu/content/role-culture-context-school-based-bmi-screeninghttp://www.ihrp.uic.edu/content/racial-differences-medication-adherence-cross-sectional-study-medicare-enrolleeshttp://www.ihrp.uic.edu/content/functional-declines-social-support-and-mental-health-elderly-does-living-state-supportive-hohttp://www.ihrp.uic.edu/content/economic-contextual-factors-food-consumption-and-obesity-among-us-adolescentshttp://www.ihrp.uic.edu/content/misconceptions-about-breast-lumps-and-delayed-medical-presentation-urban-breast-cancer-patiehttp://www.ihrp.uic.edu/content/comparison-two-methods-conducting-fit-and-strong-programhttp://www.ihrp.uic.edu/content/design-and-recruitment-chicago-healthy-living-study-study-health-behaviors-diverse-cohort-adhttp://www.ihrp.uic.edu/content/almost-all-illinois-children-covered-health-insurance-study-findshttp://www.ihrp.uic.edu/content/new-report-shows-school-district-wellness-policies-fail-provide-strong-guidelineshttp://www.ihrp.uic.edu/content/do-state-expenditures-tobacco-control-programs-decrease-use-tobacco-products-among-college-shttp://www.ihrp.uic.edu/content/do-state-expenditures-tobacco-control-programs-decrease-use-tobacco-products-among-college-shttp://www.ihrp.uic.edu/content/report-traces-broadcast-reach-states-anti-smoking-commercialshttp://www.ihrp.uic.edu/content/report-traces-broadcast-reach-states-anti-smoking-commercialshttp://www.state.il.us/aging/1athome/oasa/resources/DON.pdf

C H I S I N A K A P U N G U , assistant professor in obstetrics and gynecology, was awarded a federally funded career development grant, or K grant, to develop and evaluate a faith-based, developmentally appropriate, culturally sensitive intervention that aims to reduce risky sexual behavior among African American girls ages 13–16 by strengthening their relationships with their mothers. The $795,000 grant will support this study while Kapungu develops new skills and establishes her credentials as an independent health researcher specializing in HIV/AIDS prevention.

Kapungu is a clinical psychologist with over 10 years’ experience conducting HIV family-based interventions. As an IHRP federally funded postdoctoral fellow, she developed her research proposal and built relationships with two African American churches in Chicago that will partner in her study.

African Americans experience 59 percent of the HIV/AIDS cases in the United States, although they make up only 13 percent of the population, according to the Centers for Disease Control and Prevention.

S A N D Y S L A T E R ,research assistant professor in health policy and administration, completed the career development phase of a new hybrid grant from the National Institutes of Health, called the K99/R00. In November 2009, the NIH awarded her $745,100 for three years of research, focusing on how the built environment, or manmade features, of a community foster or inhibit physical activity among its children. Slater’s work examines areas surrounding schools and homes of youth most vulnerable to obesity—those in rural and low-income urban areas.

In May, she published the first study to simultaneously examine environmental data collected directly from neighborhoods of eighth- and tenth-graders with data from youth self-reports about their weight, height and physical activity. Among their findings, Slater and her colleagues found no association between the presence of parks and sports fields and self-reports of higher levels of exercise or lower weight for this age group. The authors conclude that such settings may be more important for younger kids, but more research is needed in this area.

IHRP Fosters Growth of New Investigators The Institute for Health Research and Policy cultivates the development of tomorrow’s innovative researchers in health behaviors, policy and practice. IHRP mentors graduate students, postdoctoral fellows, junior faculty members, and more senior faculty members making their first ventures into the competitive field of federally funded health research. Here are some significant milestones for our colleagues over the past year.

Sandy J. Slater, PhD

Kath

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Chisina Kapungu, PhD

D I S S E R T A T I O N S

D E V E L O P E D

W I T H I H R P

R E S E A R C H

From August 2009 through May 2010, the University of Illinois at Chicago conferred doctoral degrees to five IHRP research staff members who developed their dissertations using data collected in IHRP studies:

» Pankaja Desai, PhD, Community Health Sciences, “Impact of Telephone Reinforcement on Exercise Maintenance Predictors among Older Adults with Arthritis”

» Ruby Hoyem, PhD, Sociology, “Self-Rated Health among the Elderly: Age, Period, and Cohort Effects”

» Renu Joseph, PhD, Economics, “The Economics of Youth Tobacco Use in India”

» Xue Li, PhD, Epidemiology and Biostatistics, “A 3-Level Mixed-Effects Location Scale Model with an Application to Ecological Momentary Assessment Data”

» Yashika Watkins, PhD, Health Policy and Administration, “Spirituality, Religion, and Diabetes Self-Care Activities in African Americans”


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I H R P E X T R A M U R A L R E S E A R C H F U N D I N G , F Y 2 0 1 0 ( TOTA L : $ 1 5 ,0 6 5 , 4 6 1 )

F I N A N C E S

» Governmental, nonprofit and private agencies awarded IHRP projects $15.1 million in new and continuous grants in FY2010, including grants and contracts awarded to the IHRP-affiliated Health Promotion Research Section in the College of Medicine ($1.2 million), whose grant portfolio IHRP does not manage.

» For every dollar of state support received over the past five fiscal years, IHRP generated an average of $25 in research funding.

» The institute has been awarded $181 million in research grants since it was established in 1997.

» IHRP manages the health services portfolio of the UIC Neighborhoods Initiative of the College of Urban Planning and Public Administration, which received $3 million in grants and $600,000 in patient revenue in FY2010.

C A M P U S R E L A T I O N S H I P S

» UIC schools and colleges whose faculty members conduct research at IHRP: 9

» UIC departments whose faculty members conduct research at IHRP: 29

» Collaborating faculty: 98

M E N T O R I N G A N D T R A I N I N G

» Doctoral dissertations based on IHRP studies: 5» Trainees funded by National Institutes

of Health training grants: 11» Other postdoctoral fellows employed on research: 6» Graduate students employed on research studies: 63» Undergraduate student employees: 16

G R A N T A C T I V I T Y

» Proposal submissions (managed by IHRP): 83» Active research studies: 61

I H R P L E A D E R S H I P

Robin J. Mermelstein, PhD Director, IHRP Director, Center for Health Behavior ResearchDirector, Novel Translational & Collaborative Studies,

UIC Center for Clinical and Translational Science Professor of Psycholog y Clinical Professor of Community Health Sciences

Marian L. Fitzgibbon, PhD Deputy Director, IHRP Director, Health Promotion Research Program Director, Section of Health Promotion and Research,

Department of Medicine, College of Medicine Associate Director, Cancer Control and Population

Science Research Program, UIC Cancer CenterProfessor of Medicine and Health Policy and Administration

William Baldyga, MA, DrPH Associate Director, IHRP

Michael L. Berbaum, PhD Director, Methodolog y Research CoreDirector, Design and Analysis Core, UIC Center

for Clinical and Translational ScienceDirector, Shared Biostatistical Core, UIC Cancer Center

Frank J. Chaloupka, PhD Director, Health Policy Center Distinguished Professor of Economics

Susan L. Hughes, DSW Codirector, Center for Research on Health and Aging Professor of Community Health Sciences

Thomas R. Prohaska, PhD Codirector, Center for Research on Health and Aging Professor of Community Health Sciences

Glen T. Schumock, PharmD, MBA Director, Center for Pharmacoeconomic Research Professor of Pharmacy Practice

INSTITUTE FOR HEALTH RESEARCH AND POLICY University of Illinois at Chicago, M/C 275 Westside Research Office Building 1747 West Roosevelt Road Chicago, IL 60608 (312) 996-7222

www.ihrp.uic.edu

© 2010 Board of Trustees of the University of Illinois

Fiscal Year 2010

Federal Government$10,173,244 (67%)

Associations, Foundations and Private Agencies$4,630,048 (31%)

State Government$262,169 (2%)


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Documents

New · 2011. 1. 14. · in breast cancer. The researchers examined links among neighborhood characteristics; demographics; and details of breast cancer cases, such as incidence,