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Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities

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Title: Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities


1
(No Transcript)
2
Prevention, Diagnosis, and Treatment of Breast
Cancer in Women with Disabilities
  • Part 2 Screening and Diagnosis

Women with Disabilities Education Project
3
Overview
  • Part 1Incidence and Risk
  • Part 2Screening and Diagnosis
  • Part 3Treatment, Rehabilitation, and Ongoing
    Care

www.womenwithdisabilities.org
4
  • Screening

5
Most Common Screening Tests
  • Mammography
  • Clinical breast exam
  • Breast self-exam

6
Mammography
  • 7 Statistical Models
  • Mammography reduces the rate of death from
    breast cancer by 723, with a median of 15.1

1. Berry DA, et al. N Eng J Med.
20053531784-1792.
7
Mammography
  • Age
  • Regular screening lowers breast cancer mortality
    by
  • 1520 in women aged 4049
  • 2530 in women aged 5069
  • Limited evidence for effectiveness in women aged
    70
  • Interval
  • Optimal interval unknown
  • Reductions in mortality have occurred at
    intervals ranging from 1233 months
  • Many organizations recommend annual screenings
    for women aged 4049

8
Magnetic Resonance Imaging and Ultrasound
  • MRI
  • Annual MRI screening recommended for women with
    genetic mutations for breast cancer or with other
    factors that put them at very high risk
  • Ultrasound
  • Effectiveness not yet demonstrated
  • Used primarily to
  • Evaluate breast abnormalities identified through
    CBE or mammography
  • Guide breast biopsies and FNA

9
Ultrasound? Not a Good Stand-Alone Option
3 Studies of Women with Hereditary Risk1
  • 2 of 83 cancers detected solely by annual
    ultrasonography
  • 2 additional cancers detected through screenings
    at 6-month intervals

Accessible Mammography Remains Best Screening
Option for All Women
1. Berry DA, et al. N Eng J Med.
20053531784-1792.
10
Mammography Disparities
  • Of Women Aged ? 50 Years
  • 63.5 with no mobility problems vs.
  • 51.5 with moderate mobility problems
  • and
  • 43.3 with major mobility problems
  • Had mammogram within previous 2 years1

1. Iezzoni LI, et al. Am J of Public Health.
200090955-961.
11
Reasons for Screening Disparities
  • 1. Inadequate access to facilities and equipment
  • 2. Lack of accessible transportation
  • 3. Difficulty positioning for exams
  • 4. Inability to remain still for exams
  • 5. Lack of provider knowledge and sensitivity
    about serving women with disabilities
  • 6. Financial restraints, including a lack of
    adequate health insurance
  • 7. Lack of patient knowledge of breast cancer
    risk and the need for screening
  • 8. Patient unawareness of free screening programs

12
Removing Informational Barriers
25 of women with disabilities were not told by
their doctor to get a mammogram
13
Helping Your Patient Prepare
  • Explain what to expect
  • Discuss any concerns

14
Breaking Down Barriers to Mammography Screening
An Accessible Imaging Center Should Have
  • Fully accessible equipment
  • Staff trained to properly assist women with
    disabilities
  • Systems in place for successful
    positioningduring screening
  • Systems in place for successful communication
    during screening

15
www.WomenWithDisabilities.org
16
Clinical Breast Examination
  • May identify 4.510.7 of breast cancers that
    mammography misses1
  • Clinician proficiency impacts effectiveness1
  • Recommendations vary
  • American Cancer Society2
  • Every 3 years for average-risk women in 20s and
    30s
  • Annually for women aged 40
  • U.S. Preventive Services Task Force3
  • No recommendation/Not enough evidence
  • McDonald S, Saslow D, Alciati MH. CA Cancer J
    Clin. 200454345-361.
  • Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J
    Clin. 20055531-44.
  • U.S. Preventive Services Task Force. Screening
    for Breast Cancer Recommendations and Rationale.
    2002.

17
Clinical Breast Exam (CBE) Protocol
7. Breast Palpation Does client have difficulty
positioning arms (due to tremors, contractures,
involuntary movement or paralysis)? Does client
have difficulty raising arms?
  • Determine if attendant/friend/and/or family
    member can be present during exam
  • Explain each step in simple terms, offer frequent
    reassurance and praise
  • Consider demonstrating breast exam on yourself
    (the provider), if necessary, to assist client in
    understanding procedure and purpose
  • Consider recommending taking any prescribed
    anti-spasmotic, analgesic or anti-anxiety
    medication 1-2 hours prior to exam or as
    prescribed

1. Introduction to Exam Is client highly
anxious, fearful or uncomfortable due to
cognitive impairments, prior history of sexual
abuse, or other reason? Is client likely to
experience significant pain or spasticity during
the exam?
  • 2. Preparing for Exam
  • Does client need assistance with undressing upper
    body?
  • Does client refuse to remove or allow clothing to
    be removed?
  • Ask permission to position hand above head
  • Use non-examining hand and/or pillows to
    stabilize clients arm at 90angle
  • If attendant/friend/ and/or family member is
    available, he/she may assist in stabilizing arm
  • If client refuses all of above, perform CBE with
    arms at sides
  • Ask client for directions, provide assistance as
    needed
  • Consider performing CBE with shirt lifting for
    visualization
  • Consider performing modified CBE through clothing
    with plan to perform thorough CBE at next visit
    or after client trust becomes established

3. Visual Inspection of the Breasts May be done
standing, seated in wheelchair, or seated on exam
table based on physical ability (balance,
posture, endurance, involuntary movement, and
transfer)
  • Offer assistance to hold arms above head
  • Modify hands on hip position as needed to achieve
    pectoral muscle contraction
  • Use support devices to assist client in leaning
    forward if necessary (e.g., walker or chair)
  • Offer the client the opportunity to undress in
    private. If client chooses to undress in your
    presence, closely observe client when undressing
    arms are above head when shirt comes off, and
    often the pectoral muscles are relaxed and
    tightened during this process. Often the 4
    positions can be observed without intentional
    client cooperation if the client is anxious.

8. Completion of Exam Does client need
assistance to get off table or dress?
  • 4. Performing the 4 Positions
  • Does client have difficulty?
  • Can the client assist?
  • 5. Lymph Node Exam
  • Client seated on table with side rails up, or in
    wheelchair if has poor balance
  • Can be performed with shirt pulled above breasts
    and around neck, or beneath loose clothing when
    visualization is possible

Offer assistance
  • Ask client for directions, provide skilled
    assistance as needed.2
  • Provide extra pillows or wedges for support as
    necessary
  • Encourage client to lie on flat exam table
  • Try having client sit on exam table then slowly
    recline back with a good pillow support beneath
    the head
  • Consider semi-reclined position with goal of
    greatest recline as tolerated
  • Consider performing exam in upright position
  • Finally
  • Praise clients efforts throughout the exam
    (especially for women with cognitive intellectual
    limitations)
  • Discuss findings with client
  • Describe follow-up schedule and plan to client
  • Communicate with clients primary care physician
    if necessary and appropriate, and if appropriate,
    her attendant/friend and/or family member
  • 6. Position on Exam Table
  • Does client need assistance?1
  • Can client lie down?
  • Recommend electrically controlled, high-low exam
    table with side rails
  • Client may prefer to bring own attendant/friend/
    and/or family member, or provider has assistance
    from trained personnel.

Source Breast Health Access for Women with
Disabilities, January 2008.
18
Introducing the Patient to the CBE
Yes
1. Introduction to Exam Is client highly
anxious, fearful or uncomfortable due to
cognitive impairments, prior history of sexual
abuse, or other reason? Is client likely to
experience significant pain or spasticity during
the exam?
  • Determine if attendant/friend/and/or family
    member can be present during exam
  • Explain each step in simple terms, offer frequent
    reassurance and praise
  • Consider demonstrating breast exam on yourself
    (the provider), if necessary, to assist client in
    understanding procedure and purpose
  • Consider recommending taking any prescribed
    anti-spasmotic, analgesic or anti-anxiety
    medication 1-2 hours prior to exam or as
    prescribed

Source Breast Health Access for Women with
Disabilities, January 2008.
19
Preparing the Patient for the CBE
  • 2. Preparing for Exam
  • Does client need assistance with undressing upper
    body?
  • Does client refuse to remove or allow clothing to
    be removed?

Yes
  • Ask client for directions, provide assistance as
    needed
  • Consider performing CBE with shirt lifting for
    visualization
  • Consider performing modified CBE through clothing
    with plan to perform thorough CBE at next visit
    or after client trust becomes established

Source Breast Health Access for Women with
Disabilities, January 2008.
20
Visual Inspection of the Breasts
3. Visual Inspection of the Breasts May be done
standing, seated in wheelchair, or seated on exam
table based on physical ability (balance,
posture, endurance, involuntary movement, and
transfer)
  • Offer assistance to hold arms above head
  • Modify hands on hip position as needed to achieve
    pectoral muscle contraction
  • Use support devices to assist client in leaning
    forward if necessary (e.g., walker or chair)
  • Offer the client the opportunity to undress in
    private. If client chooses to undress in your
    presence, closely observe client when undressing
    arms are above head when shirt comes off, and
    often the pectoral muscles are relaxed and
    tightened during this process. Often the 4
    positions can be observed without intentional
    client cooperation if the client is anxious.
  • 4. Performing the 4 Positions
  • Does client have difficulty?
  • Can the client assist?

Yes
  • Recommend electrically controlled, high-low exam
    table with side rails
  • Client may prefer to bring own attendant/friend/
    and/or family member, or provider has assistance
    from trained personnel.

Source Breast Health Access for Women with
Disabilities, January 2008.
21
Positioning the Patient on the Exam Table
  • 5. Lymph Node Exam
  • Client seated on table with side rails up, or in
    wheelchair if has poor balance
  • Can be performed with shirt pulled above breasts
    and around neck, or beneath loose clothing when
    visualization is possible
  • Ask client for directions, provide skilled
    assistance as needed.2
  • Provide extra pillows or wedges for support as
    necessary
  • Encourage client to lie on flat exam table
  • Try having client sit on exam table then slowly
    recline back with a good pillow support beneath
    the head
  • Consider semi-reclined position with goal of
    greatest recline as tolerated
  • Consider performing exam in upright position
  • 6. Position on Exam Table
  • Does client need assistance?1
  • Can client lie down?

Yes
Source Breast Health Access for Women with
Disabilities, January 2008.
22
Breast Palpation
7. Breast Palpation Does client have difficulty
positioning arms (due to tremors, contractures,
involuntary movement or paralysis)? Does client
have difficulty raising arms?
Yes
  • Ask permission to position hand above head
  • Use non-examining hand and/or pillows to
    stabilize clients arm at 90angle
  • If attendant/friend/ and/or family member is
    available, he/she may assist in stabilizing arm
  • If client refuses all of above, perform CBE with
    arms at sides

Source Breast Health Access for Women with
Disabilities, January 2008.
23
Completion of the Exam
8. Completion of Exam Does client need
assistance to get off table or dress?
Yes
Offer assistance
Source Breast Health Access for Women with
Disabilities, January 2008.
24
Breast Self-Exam
  • Not shown to have an effect on breast cancer
    mortality rate1
  • U.S. Preventive Services Task Force Not enough
    evidenceto recommend for or against BSE2
  • ACS and others Teach women the procedure and
    give them the option of using it3
  • Kosters JP, Gotzsche PC. Cochrane Database of
    Systematic Reviews. 20032CD003373.
  • U.S. Preventive Services Task Force. Screening
    for Breast Cancer Recommendations and
    Rationale. 2002.
  • Smith RA, Cokkinides V, Eyre HJ. CA Cancer J
    Clin. 20055531-44.

25
Breast Self-Exam Accommodations for Women with
Disabilities
  • Exam can be modified for women who have use of
    only one hand
  • Thumbs, palms, or back of fingers can be used
    instead of finger pads to feel for lumps
  • Exam can be broken into smaller parts for women
    who tire easily
  • Women whose limited mobility precludes breast
    self-exams may opt for more frequent clinical
    breast exams

Source Breast Health Access for Women with
Disabilities.
26
Breast Health Access for Women With Disabilities
www.bhawd.org
27
Diagnosis
28
Percutaneous Diagnostic Biopsies
  • Have largely replaced surgical biopsy as initial
    diagnostic biopsy procedure
  • Are guided by stereotactic mammographic imaging,
    ultrasound, or MRI
  • Are less invasive than surgical biopsy and often
    reduce need for further surgical procedures
  • Improve planning for patients treatment

29
Biopsy Barriers
  • A Woman Must be Able to
  • Remain still for 4560 minutes, either sitting,
    prone, or supine
  • Hyperextend arm
  • Turn neck
  • Get up onto the biopsy table

30
Biopsy Accommodations Stereotactic Add-on Devices
Stereotactic Biopsy Table
Digital Mammogram Unit
31
Biopsy Accommodations Ultrasound in Seated
Position
Stretcher for supine or semi-upright biopsy
32
Summary
  • Using an accessible format, communicate the need
    for regular mammograms to your patients with
    disabilities
  • Identify fully accessible mammography centers in
    your area. Alert them to a patients mobility or
    communication issues before the patient goes to
    the screening
  • Adapt the clinical breast exam to meet the
    special needs of your patients with disabilities
  • Teach your patients how to modify the breast
    self-exam to accommodate their particular
    disability
  • Help ensure that accommodations are made for your
    patients with disabilities so they have
    successful breast biopsies

33
Resources
34
Breast Health Access for Women with Disabilities
(BHAWD)Call 512-204-4866TDD
510-204-4574www.bhawd.org Center for Research
on Women with Disabilities (CROWD)Baylor College
of MedicineCall 800-442-7693www.bcm.edu/crowd
Health Promotion for Women with
DisabilitiesVillanova University College of
NursingCall 610-519-6828www.nursing.villanova.e
du/womenwithdisabilities Magee-Womens
FoundationStrength Courage Exercise DVD (a
compilation of exercises helpful to breast cancer
patients)http//foundation.mwrif.org/

35
National Breast and Cervical Cancer Early
Detection ProgramCenters for Disease Control and
PreventionCall 1-800-CDC-INFOTTY
1-888-232-6348www.cdc.gov/cancer/nbccedp National
Center of Physical Activity and DisabilityCall
1-800-900-8086TTY 1-800-900-8086www.ncpad.org
The National Womens Health Information
CenterCall 1-800-994-9662TDD
1-888-220-5446www.4women.gov/wwd Susan G. Komen
for the Curewww.cms.komen.org Women with
DisabilitiesCenters for Disease Control and
Preventionwww.cdc.gov/ncbddd/women
36
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