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Women with Disabilities. educational programs. Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities. Part 2: Screening and Diagnosis. Women with Disabilities Education Project. Overview. Part 1: Incidence and Risk Part 2: Screening and Diagnosis

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slide1

Women

with

Disabilities

educational programs

prevention diagnosis and treatment of breast cancer in women with disabilities

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

Part 2: Screening and Diagnosis

Women with Disabilities Education Project

overview
Overview

Part 1:Incidence and Risk

Part 2:Screening and Diagnosis

Part 3:Treatment, Rehabilitation, and Ongoing Care

www.womenwithdisabilities.org

most common screening tests
Most Common Screening Tests
  • Mammography
  • Clinical breast exam
  • Breast self-exam
mammography
Mammography

7 Statistical Models:

Mammography reduces the rate of death from breast cancer by 7%–23%, with a median of 15%.1

1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.

mammography1
Age

Regular screening lowers breast cancer mortality by

15%–20% in women aged 40–49

25%–30% in women aged 50–69

Limited evidence for effectiveness in women aged 70+

Interval

Optimal interval unknown

Reductions in mortality have occurred at intervals ranging from 12–33 months

Many organizations recommend annual screenings for women aged 40–49

Mammography
magnetic resonance imaging and ultrasound
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
ultrasound not a good stand alone option
Ultrasound? Not a Good Stand-Alone Option
  • 2 of 83 cancers detected solely by annual ultrasonography
  • 2 additional cancers detected through screenings at 6-month intervals

3 Studies of Women with Hereditary Risk:1

Accessible Mammography Remains Best Screening Option for All Women

1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.

mammography disparities
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. 2000;90:955-961.

reasons for screening disparities
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

removing informational barriers
Removing Informational Barriers

25%of women with disabilities were not told by their doctor to get a mammogram

helping your patient prepare
Helping Your Patient Prepare
  • Explain what to expect
  • Discuss any concerns
breaking down barriers to mammography screening
Breaking Down Barriers to Mammography Screening
  • 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

An Accessible Imaging Center Should Have:

clinical breast examination
Clinical Breast Examination
  • May identify 4.5%–10.7% 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. 2004;54:345-361.
  • Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44.
  • U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002.
clinical breast exam cbe protocol

Yes

Yes

No

No

Yes

No

Yes

No

Yes

No

Yes

No

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 client’s arm at 90°angle
  • 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 client’s 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 client’s 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.

introducing the patient to the cbe
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.

preparing the patient for the cbe
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.

visual inspection of the breasts
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.

positioning the patient on the exam table
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.

breast palpation
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 client’s arm at 90°angle
  • 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.

completion of the exam
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.

breast self exam
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. 2003;2:CD003373.
  • U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002.
  • Smith RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44.
breast self exam accommodations for women with disabilities
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.

percutaneous diagnostic biopsies
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 patient’s treatment
biopsy barriers
Biopsy Barriers

A Woman Must be Able to…

  • Remain still for 45–60 minutes, either sitting, prone, or supine
  • Hyperextend arm
  • Turn neck
  • Get up onto the biopsy table
biopsy accommodations stereotactic add on devices
Biopsy Accommodations: Stereotactic Add-on Devices

Digital Mammogram Unit

Stereotactic Biopsy Table

biopsy accommodations ultrasound in seated position
Biopsy Accommodations: Ultrasound in Seated Position

Stretcher for supine or semi-upright biopsy

summary
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 patient’s 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
slide34

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.edu/womenwithdisabilities

Magee-Women’s Foundation“Strength & Courage Exercise DVD” (a compilation of exercises helpful to breast cancer patients)http://foundation.mwrif.org/

slide35

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 Women’s 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

references
References

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American Cancer Society. American Cancer Society issues recommendation on MRI for breast cancer screening. March 28, 2007. Available online.

American Cancer Society. Breast Cancer Facts & Figures 2007-2008. Atlanta: American Cancer Society, Inc.; 2007.

American Cancer Society. Detailed guide: breast cancer: what are the key statistics for breast cancer? Cancer Reference Information. Revised: September 13, 2007.

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Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Eng J Med. 2005;353:1784-1792.

slide37
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slide38
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slide39
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slide40
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slide41
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slide42
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