Title: Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities
1(No Transcript)
2Prevention, Diagnosis, and Treatment of Breast
Cancer in Women with Disabilities
- Part 2 Screening and Diagnosis
Women with Disabilities Education Project
3Overview
- Part 1Incidence and Risk
- Part 2Screening and Diagnosis
- Part 3Treatment, Rehabilitation, and Ongoing
Care
www.womenwithdisabilities.org
4 5Most Common Screening Tests
- Mammography
- Clinical breast exam
- Breast self-exam
6Mammography
- 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.
7Mammography
- 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
8Magnetic 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
9Ultrasound? 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.
10Mammography 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.
11Reasons 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
12Removing Informational Barriers
25 of women with disabilities were not told by
their doctor to get a mammogram
13Helping Your Patient Prepare
- Explain what to expect
- Discuss any concerns
14Breaking 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
15www.WomenWithDisabilities.org
16Clinical 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.
17Clinical 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.
18Introducing 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.
19Preparing 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.
20Visual 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.
21Positioning 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.
22Breast 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.
23Completion 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.
24Breast 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.
25Breast 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.
26Breast Health Access for Women With Disabilities
www.bhawd.org
27Diagnosis
28Percutaneous 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
29Biopsy 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
30Biopsy Accommodations Stereotactic Add-on Devices
Stereotactic Biopsy Table
Digital Mammogram Unit
31Biopsy Accommodations Ultrasound in Seated
Position
Stretcher for supine or semi-upright biopsy
32Summary
- 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
33Resources
34Breast 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/
35National 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
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