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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 1 Incidence and Risk

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
  • Incidence

5
Breast Cancer in the United States Incidence
  • 182,000 new cases diagnosed annually1
  • One-third of all new cancers diagnosed in
    American women2

1. American Cancer Society. Cancer Reference
Information. Revised September 13, 2007. 2.
Ahmedin J, et al. CA Cancer J Clin. 20075743-66.
6
Breast Cancer in the United States Mortality
  • ? 24 since 19901
  • Claims 40,000 womens lives annually
  • Second-leading cause of cancer-related death in
    American women2

1. Ismail J, et al. J of Clin Oncology.
200725TK-TK. 2. American Cancer Society. Cancer
Reference Information. Revised September 13,
2007.
7
  • Women with disabilities have the same risk of
    breast cancer as women without disabilities.
  • 1 in 8 lifetime risk1

1. American Cancer Society. Breast Cancer Facts
Figures 2007-2008.
8
  • Women with disabilities are one-third more likely
    to die from their breast cancer than women
    without disabilities1

1. McCarthy EP, et al. Ann Intern Med.
2006145637-645.
9
Why the Disparity?
  • After surgery for breast cancer, women with
    disabilities are less likely to receive1
  • Radiotherapy
  • Axillary lymph node dissection
  • They are also less likely to receive
  • Screening mammograms2
  • Does lack of exercise play a role?

1. McCarthy EP, et al. Ann Intern Med.
2006145637-645. 2. Iezzoni LI, et al. Am J of
Public Health. 200090955-961.
10
  • Coming to Terms

11
  • What does disability mean?

12
Americans with Disabilities Act
A Person Has a Disability if He or She
  • Has a physical or mental impairment that
    substantially limits one or more of the major
    life activities of such individual
  • Has a record of such an impairment or
  • Is regarded as having such an impairment1

1. Americans with Disabilities Act of 1990.
13
U.S. Surgeon Generals Call to Action to Improve
the Health and Wellness of Persons with
Disabilities
  • Disabilities Are
  • characteristics of the body, mind, or senses
    that, to a greater or lesser extent, affect a
    persons ability to engage independently in some
    or all aspects of day-to-day life.
  • Disabilities Are Not Illnesses.
  • Just as health and illness exist along a
    continuum, so, too, does disability. Just as the
    same illnesses can vary in intensity from person
    to person, so, too, can the same condition lead
    to greater or lesser limitation in activity from
    one person to another.1

1. Office of the Surgeon General. Surgeon
Generals Call to Action to Improve the Health
and Wellness of Persons with Disabilities. 2005.
14
Disability Models
  • Medical Model
  • Individual problem
  • Directly caused by disease
  • Social Model
  • Does not reside in individual
  • Created by environmental barriers

15
Words Matter
  • Handicapped
  • Disabled ? Crippled
  • Defective

16
The Importance of Language
17
  • Risk Factors

18
Relative Risk Factors for Breast Cancer
  • Increasing age
  • Family history of breast cancer in first-degree
    relative
  • BRCA gene mutations
  • Early menarche, late menopause
  • Nulliparity or 35 years old at birth of first
    child
  • No history of breast-feeding
  • Personal history of breast cancer or certain
    noncancerous breast diseases/conditions,
    including higher breast density
  • Being overweight
  • Not getting regular exercise
  • Long-term use of hormone replacement therapy
  • Use of oral contraceptives
  • Alcohol consumption (more than one drink a day)
  • Treatment-dose radiation to the breast/chest

19
Factors That Put Women at High Risk
  • A BRCA gene mutation
  • A very strong family history of breast cancer,
    such as a mother or sister who was diagnosed with
    breast cancer at age 40 or younger
  • A personal history of breast cancer, LCIS, or
    atypical hyperplasia
  • Past exposure to treatment-dose ionizing
    radiation during childhood or young adulthood

20
Risk-Reduction Strategies for Women with
Disabilities
  • All women should have a breast cancer risk
    assessment and be offered appropriate
    risk-management strategies

21
Identifying High-Risk Women
  • Encourages Women to
  • Have more rigorous screening
  • Be counseled about preventive therapies
  • Assessment Tools
  • Epidemiologic risk-assessment models (e.g., Gail
    model)
  • Genetic testing

22
The Modified Gail Model
  • Risk Factors Used In Calculation1
  • Current age
  • Age at menarche
  • Age at first live birth or nulliparity
  • Number of first-degree relatives with breast
    cancer
  • Number of previous benign breast biopsies
  • Atypical hyperplasia in a previous breast biopsy
  • Race

1. National Comprehensive Cancer Network (NCCN).
Risk factors used in the modified Gail Model
2007.
23
The Modified Gail Model
  • 5-year Gail risk
  • 5-year Gail risk 1.66 high risk

NCIs Breast Cancer Risk Assessment Tool
www.cancer.gov/bcrisktool
24
Genetic Testing
  • May predict risk more accurately than family
    history alone1
  • 510 of women who develop breast cancer have
    BRCA gene mutations1
  • Women with BRCA mutations havelifetime risk of1
  • Up to 85 for breast cancer
  • Up to 60 for ovarian cancer
  • BRCA carriers at highest risk have family history
    of2
  • Breast cancer diagnosis age 35
  • Contralateral breast cancer
  • Myers MF, et al. Genetics in Medicine.
    20068361-370.
  • Begg CB, et al. JAMA. 2008299194-201.

25
Clinical Options for Managing Women at High Risk
  • Increased surveillance
  • Clinical breast exam
  • Mammography
  • MRI
  • Chemoprevention
  • Tamoxifen
  • Raloxifene
  • Prophylactic surgery

26
(No Transcript)
27
Tamoxifen and Raloxifene AssessingRisks for
Women with Disabilities
  • Increased risk of stroke and thromoboembolic
    events (women with limited mobility already at
    risk)1
  • Increased risk of uterine cancer1
  • Other risks2
  • Cataracts and other eye problems
  • Bladder problems
  • Vaginal problems

1. Vogel VG, et al., for the National Surgical
Adjuvant Breast and Bowel Project (NSABP). JAMA.
20062952727-2741. 2. National Cancer Institute.
Reviewed May 13, 2002. Available at
www.cancer.gov/cancertopics/factsheet/Therapy/tamo
xifen.
28
Managing Women with Disabilities on Tamoxifen and
Raloxifene
  • Assess patients individual risk for
    thromoboembolism
  • Advise and assist patient with
  • Quitting smoking
  • Lowering blood pressure
  • Maintaining a healthy weight
  • Exercising regularly
  • Follow patient closely

29
Prophylactic Breast Surgery Assessing Risks for
Women with Disabilities
  • Reduces breast cancer risk by 90 in high-risk
    women1
  • Most high-risk women report satisfaction with
    decision to have the surgery2
  • Patient satisfaction is more variable regarding
    cosmetic results and body image2

Special concern for women with disabilities How
will the surgery affect my mobility and quality
of life?
1. Hartmann L, et al. N Engl J Med.
199934077-84. 2. Lostumbo L, et al. Cochrane
Database of Systematic Reviews. 20044CD002748.
30
Managing Women with Disabilities Who Chose
Prophylactic Surgery
  • Discuss with patient how surgery will affect her
    adaptive and assistive needs
  • Make sure patient has sufficient home care after
    surgery
  • Start physical therapy before surgery
  • Postsurgical physical therapy essential for
    restoring function and quality of life

31
Modifiable Risk Factors
  • Being overweight
  • Women overweight at age 5050 increase in
    risk1
  • Not getting enough exercise
  • 1.252.5 hours of brisk walking 18 decrease
    in risk2
  • Consuming alcohol daily
  • Each 10 g of daily alcohol 7.2 increase in risk3

1. Ahn J, et al. Arch Intern Med.
20071672091-2102. 2. McTiernan A, et al. JAMA.
20032901331-1336. 3.Chen WY, et al. Ann Intern
Med. 2002137798-804.
32
  • Women with disabilities often have more
    difficulty altering modifiable risk factors

33
Distribution of Barriers to Improving Eating
Habits (n359)
Participants were able to cite more than one
barrier. Source Hall L, Colantonio A, and
Yoshida K. Int J of Rehabilitation Research.
200326245-247.
34
Barriers to Increasing Physical Activities
  • Lack of transportation
  • Lack of money
  • Lack of time
  • Inaccessible fitness centers
  • Healthcare and fitness professionals who are
    inexperienced with working with people with
    disabilities
  • Lack of social support
  • Fatigue and pain

35
Barriers to Increasing Physical Activities
  • Lack of self-knowledge about capabilities for
    exercise and/or skills needed to engage in
    physical activity

36
  • Equip your facility with a weight scale that
    accommodates wheelchairs
  • Refer patients with disabilities to a dietician
    with experience addressing their unique dietary
    and exercise issues

37
National Center on Physical Activity and
Disability (NCPAD)
www.ncpad.org
38
Alcohol Use Among Women with Disabilities
  • Alcohol use is as prevalent among women with
    disabilities as among the general female
    population1
  • Discuss alcohol use and its breast cancer risk
    with all patients
  • Patients at high risk of breast cancer must
    carefully weigh risks and benefits of moderate
    alcohol use

1. Li L, Ford JA. Applied Behavioral Sci Rev.
1996499-109.
39
Summary
  • Women with disabilities have same breast cancer
    risk as other women, but are one-third more
    likely to die from the disease
  • Reasons for this disparity in survival are
    unknown, but women with disabilities are less
    likely to undergo standard chemo and/or radiation
    therapy after breast-conserving surgery and are
    less likely to have regular screening mammograms
  • All women with disabilities should be assessed
    for their breast cancer risk and offered
    risk-reduction strategies
  • Risk-reduction strategies raise special issues
    for women with disabilities that need a thorough
    clinician-patient discussion
  • Helping women with disabilities alter modifiable
    risk factors and adopt a more healthful lifestyle
    may require special tools and strategies

40
  • Resources

41
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/

42
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.komen.org Women with
DisabilitiesCenters for Disease Control and
Preventionwww.cdc.gov/ncbddd/women
43
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