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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 3 Treatment, Rehabilitation, and Ongoing
    Care

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

www.womenwithdisabilities.org
4
Treatment
5
Treatment Options for Noninvasive Cancers1
  • LCIS
  • 1. Observation after diagnostic biopsy
  • 2. Tamoxifen to decrease the incidence of
    subsequent breast cancers
  • 3. Bilateral prophylactic total mastectomy,
    without axillary node dissection
  • 4. Clinical trials testing cancer prevention drugs
  • DCIS
  • 1. Breast-conserving surgery and radiation
    therapy with or without tamoxifen
  • 2. Total mastectomy with or without tamoxifen
  • 3. Breast-conserving surgery without radiation

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
6
Treatment Options for Early Breast Cancer (Stages
I, II, IIIA, and Operable IIIC)1
  • Primary
  • Breast-conserving surgery lymph node dissection
    and radiation therapy
  • Modified radical mastectomy
  • Adjuvant
  • After surgery radiation therapy
  • Systemic chemotherapy
  • Hormone therapy (tamoxifen, aromatase inhibitors)
  • Trastuzumab (Herceptin) systemic chemotherapy

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
7
Treatment Options for Stage IIIB, Inoperable
Stage IIIC, Stage IV, Recurrent, and Metastatic
Breast Cancer1
Stage IIIB and Inoperable Stage IIIC
Stage IV and Metastatic
  • Hormone therapy
  • Chemotherapy
  • Surgery with lymph node dissection and radiation
    therapy
  • Targeted therapies (e.g., lapatinib, trastuzumab
    (Herceptin), bevacizumab (Avastin))
  • Clinical trials testing new drugs/treatments
  • Hormone therapy
  • Chemotherapy
  • Targeted therapies (e.g., lapatinib, trastuzumab
    (Herceptin), bevacizumab (Avastin))
  • Palliative radiation therapy and/or surgery
  • Clinical trials testing new drugs/treatments

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
8
Disparities in Breast Cancer Treatment
Breast-Conserving Surgery Radiation Therapy
  • Women with Disabilities Were1
  • 20 less likely to receive breast-conserving
    surgery
  • 19 less likely to receive lymph node dissection
  • 17 less likely to receive adjuvant radiation
    therapy
  • 29 more likely to die from the breast cancer

1. McCarthy et al. Ann Intern Med.
2006145637-645.
9
Disparities in Breast Cancer Treatment
Chemotherapy
  • Chart Review1
  • Women with disabilities less likely to receive
    neoadjuvant chemotherapy compared to women
    without disabilities (13 of the time vs. 29 of
    the time), but
  • Difference was not statistically significant

1. Caban ME, et al. Cancer. 2002941391-1396.
10
Making the Treatment Decision
  • Avoid assumptions
  • Discuss medical and logistical pros and cons of
    each treatment option

11
Determining Medical Decision-Making Capacity
(Ability to Give Informed Consent)
  • So long as the patient appears to adequately
    understand and appreciate the personal
    significance of the following
  • That she has a general medical or mental
    disorder,
  • The nature and course of the disorder, and
  • The risks and benefits of the proposed
    intervention and of the alternative, including
    the alternative of no intervention and
  • So long as the patient makes a non-coerced
    choice that does not appear to be unduly
    influenced by a mental disorder, then the patient
    may be considered to possess capacity even if her
    choice appears to the physician to be
    unreasonable.1

1. Moore RF. Medscape General Medicine. 19991(3).
12
Resources for Determining Ability to Give
Informed Consent
  • State medical associations
  • National Association of Developmental Disability
    Councils www.nacdd.org
  • Assessment tools for women with limited verbal
    skills
  • Hopkins Competency Assessment Test
  • Competency Interview Schedule
  • MacArthur Competence Assessment Tool

13
Special Concerns Surgery
  • How will surgery affect the patients disability
    and quality of life?
  • What are the patients current assistive and
    adaptive needs, and how will surgery affect those
    needs?

14
Overcoming Surgical Barriers
  • Anticipate and plan for any special needs that
    the patient might require during the surgery
    itself
  • Make sure patient will have assistance after the
    operation
  • Make sure patient has transportation to the
    surgery and to post-op medical appointments
  • Consider sending patient to a PT or OT
    consultation before surgery

15
Special Concerns Radiation Therapy
  • Is patient physically able to lie still and
    abduct arm for treatment?
  • Will patient have daily transportation to and
    from radiation therapy facility?
  • Will patient have necessary level of home care to
    address medical and daily living side effects of
    radiation therapy?

16
Overcoming Barriers to Radiation Therapy
  • Anticipate transportation and other access
    barriers make sure these issues are resolved
    before patient shows up for treatment
  • Consider shorter treatment course

17
Special Concerns Chemotherapy
Will patient have necessary level of home care to
address medical and daily living side effects of
chemotherapy?
Possible Side Effects
18
Special Concerns Chemotherapy
Side Effects Pose Potentially Debilitating
Consequences for Women with Disabilities
  • Fatigue May severely limit mobility for women
    with existing mobility limitations
  • Increase in Urine Output May cause significant
    problem for women with existing continence
    problem
  • Bone Loss Increases osteoporosis risk for women
    already at increased risk

19
Special Concerns Hormone Therapy
Will patient have necessary level of home care to
address medical and daily living side effects of
hormone therapy?
Possible Side Effects Tamoxifen/Raloxifene
20
Special Concerns Hormone Therapy
  • Aromatase Inhibitors
  • Increased risk of bone loss and fractures
  • Consider adjuvant use of bisphosphonates

21
Overcoming Barriers to Chemotherapy and Hormone
Therapy
  • Ensure full patient participation in treatment
    decisions
  • Tailor treatment based on side effect and risk
    profile
  • Identify and address patients needs before
    treatment begins
  • Increase home nurse visits, if needed
  • Monitor patients bone density and evaluate
    treatments to attenuate bone loss
  • Instruct patient on symptoms of thromboembolism

22
Support Patient During Treatment
  • Identify barriers to care
  • Identify resources to overcome those barriers
  • Prepare patient for possible side effects and
    their impact on her daily activities
  • Make sure she will have the proper assistance to
    deal with those side effects
  • Coordinate care with other specialists
  • Have a system in place that enables you and your
    patient to communicate easily throughout the
    treatment process
  • Ask patient if she would like to include a friend
    or family member in her care

23
Rehabilitation
24
Rehabilitation Strategies
  • Treat related diagnoses that increase the
    disability
  • Treat unrelated diagnoses that increase the
    disability
  • Manage pain
  • Improve fatigue
  • Increase strength and cardiovascular fitness
  • Prescribe adaptive equipment

25
Treat Related Diagnoses Lymphedema
  • Symptoms
  • Swelling, aching, tightness in arm
  • Hardening/thickening of skin
  • Restricted range of motion
  • May lead to cellulitis
  • 630 of survivors self-report lymphedema
    symptoms1
  • Symptoms may develop up to 20 years after
    initial treatment2
  • National Cancer Institute. NCI Cancer Bulletin.
    200745-6.
  • Petrek JA, et al. Cancer. 2001921368-1377.

26
Complete Decongestive Physiotherapy
  • Manual lymphatic massage
  • Inelastic compression bandaging
  • Remedial exercises
  • Meticulous skin care

27
Treat Related Diagnoses Rotator Cuff Tendinitis
  • Common disorder among breast cancer patients1
  • Results from weakness of the rotator cuff
    musculature
  • Radiation therapy and chemotherapy contribute to
    the disorder
  • Associated with lymphedema2
  • Stubblefield MD, Custodio CM. Arch Phys Med
    Rehabil. 2006S96-S99.
  • Herrera JE, Stubblefield MD. Arch Phys Med
    Rehabil. 2004851939-1942.

28
Treating Rotator Cuff Tendinitis
  • Stretches and range-of-motion exercises to
    increase flexibility
  • Exercises to stabilize shoulder

29
Treat Related Diagnoses Overuse Injuries on
Unaffected Side
  • Women with disabilities are at increased risk of
    overuse injuries
  • Risk increases after cancer treatment

30
Treating Overuse Injuries
  • Early and aggressive physical therapy is
    essential
  • Patient should be evaluated for adaptive
    equipment and/or assistive devices

31
Treat Related Diagnoses Neck Pain
  • Second most common musculoskeletal condition
    among women
  • After breast cancer treatment, deconditioning
    increases risk

32
Treating Neck Pain
  • Restore range of motion
  • Maintain/improve upper body strength

33
Treat Unrelated Diagnoses That Increase the
Disability
To Avoid Diminished Function
  • Treat early
  • Treat aggressively

34
Manage Pain
  • Treatment goals
  • Ameliorate pain
  • Maintain optimal function
  • Closely follow patient for detrimental side
    effects of medication
  • Refer patient to PT and/or OT
  • Integrative treatments (e.g., acupuncture) may
    help

35
Improve Fatigue
  • Possible Causes of Fatigue in Women
  • Inadequate sleep
  • Side effects from medications
  • Depression
  • Anemia
  • Thyroid illness
  • Poor nutrition
  • Deconditioning

36
Increase Cardiovascular Fitness
  • Exercise Improves1
  • Quality of life
  • Cardiorespiratory fitness
  • Physical functioning
  • Fatigue
  • Exercise May Improve2
  • Breast cancer survival
  • Greatest benefit Walking 35 hours per week at
    average pace (or equivalent)
  • McNeely ML, et al. CMAJ. 200617534-41.
  • Holmes MD, et al. JAMA. 20052932479-2486.

37
Increase Muscle Strength
  • Twice Weekly Strength Training
  • Improves quality of life1
  • Increases muscle mass2
  • Reduces body fat2
  • Reduces IGF-II levels2
  • Ohira T, et al. Cancer. 20061062076-2083.
  • Schmitz KH et al. Cancer Epidemiol Biomarkers
    Prev. 2005141672-1680.

38
National Center on Physical Activity and
Disability
www.ncpad.org
39
Prescribe Appropriate Adaptive Equipment
  • The choice of equipment should involve patient,
    medical team, and PT/OT
  • An assessment should be made of womans needs at
    home and at work

The Alliance for Technology Access
www.ataccess.org
40
Ongoing Care
41
Goals of Regular Follow-up Visits
  • Find local or distant recurrence of cancer
  • Find any new breast tumors that have developed
  • Find any treatment-related side effects (e.g,
    lymphedema, bone loss, cardiovascular problems)
  • Identify effects of the disease and its treatment
    on the patients disability and quality of life

42
Recommendations for Follow-up Care for Breast
Cancer1
  • Khatcheressian JL, et al. J Clin Oncology
    2006245091-5097.

43
Work Collaboratively
  • Ask questions
  • Anticipate problems
  • Create solutions
  • Have mechanism in place to alert you if the
    patient does not return for follow-up within
    recommended interval

44
Create a Teachable Moment
  • Provide information on healthy behaviors
  • Ascertain if patient needs help with depression
    or other mental health issue
  • If applicable, discuss the option of a genetics
    referral

45
Summary
  • Breast cancer treatment poses added practical
    issues for women with disabilities.
  • Present all the medical and logistical pros and
    cons of treatment options to your patients with
    disabilities.
  • Know state laws regarding informed consent.
  • Discuss with your patients with disabilities how
    treatment may affect their adaptive and assistive
    needs. Help arrange support services to meet
    those needs.

46
Summary (continued)
  • Tailor each womans treatment to minimize its
    effect on worsening the patients existing
    disability.
  • Refer the patient to physical and/or occupational
    therapy before her treatment starts.
  • During follow-up care, identify and address the
    effect that the cancer and its treatment has had
    on the womans disability.
  • Make sure the patients follow-up plan addresses
    how she will access and/or receive the care. Have
    a mechanism in place to alert your clinic or
    office if the patient does not return within the
    recommended interval.

47
  • Resources

48
Breast Health Access for Women with Disabilities
(BHAWD) Call 512-204-4866 TDD
510-204-4574 www.bhawd.org Center for Research
on Women with Disabilities (CROWD) Baylor College
of Medicine Call 800-442-7693 www.bcm.edu/crowd
Health Promotion for Women with
Disabilities Villanova University College of
Nursing Call 610-519-6828 www.nursing.villanova.e
du/womenwithdisabilities Magee-Womens
Foundation Strength Courage Exercise DVD (a
compilation of exercises helpful to breast cancer
patients) http//foundation.mwrif.org/

49
National Breast and Cervical Cancer Early
Detection Program Centers for Disease Control and
Prevention Call 1-800-CDC-INFO TTY
1-888-232-6348 www.cdc.gov/cancer/nbccedp National
Center of Physical Activity and Disability Call
1-800-900-8086 TTY 1-800-900-8086 www.ncpad.org
The National Womens Health Information
Center Call 1-800-994-9662 TDD
1-888-220-5446 www.4women.gov/wwd Susan G. Komen
for the Cure www.cms.komen.org Women with
Disabilities Centers for Disease Control and
Prevention www.cdc.gov/ncbddd/women
50
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