Battling Breast Cancer in Older Women:
Where Do We Stand? Although age is the greatest risk factor for breast cancer, older w o m e n are not receiving the mammographic screenings they need. By
MARGE
DRUCAY
R E A S T CANCER. More than 99% of the cases -occur in women. It is the second leading cause of cancer mortality in all women over the age of 55. In 1992, 180,000 new cases are expected to be diagnosed, with 43% of these in women over 65. An estimated 46,000 deaths are expected to occur this year) According to the General Accounting Office of the federal government, the past 20 years have seen no gains in prevention. 2 Many premenopausal women are terrified they will develop it, and there have been reports of "prophylactic" mastectomies. The risk of developing this disease within a lifetime has risen to 1 in 9, which reflects both the rising incidence and the burgeoning aging population. Physicians often misinterpret these statistics, by inaccurately representing individual risk, causing further a l a r m ) The media has contributed to the escalating hysteria, often with sensationalistic reporting and little research into the real issues. Breast cancer is the plague of the aging American woman.
Bb
P r e v e n t i o n and Detection Strategies The American Cancer Society was instrumental in the implementation of a nationwide program intended to demonstrate the benefits of breast cancer detection to physicians and women. From 1986 through 1989 the Breast Cancer Detection Demonstration Project (BCDDP), involving 280,000 women in 29 locations, offered screening mammography and clinical breast examinations for a 5-year period. A study is underway with
MARGE DRUGAY, MS, RN,C, is an associate faculty member at Rush University in Chicago, where she is a doctoral student. 34/1/39395
240 Geriatric Nursing September/Oct0ber 1992
high-risk premenopausal women using the drug tamoxifen citrate in the hopes of preventing the development of breast cancer. Mammography, or x-ray of the breast, in conjunction with clinical breast examination facilitates early diagnosis of cancer at a more treatable stage, thereby reducing the risk of untimely death. 4 In the first publication of findings from the BCDDP, results indicated that mammography and clinical breast examination together confirmed cases not detected by either one alone but that the diagnostic role of mammography was greater. Mammography alone found 40% of all breast cancer cases, compared with 10% discovered by clinical e x a m i n a t i o n alone. 5 Despite American Cancer Society guidelines for annual screening of women over the age of 50--especially for those who are considered at higher risk--most women over the age of 50 do not undergo regular, routine screening mammography. In one recent study, less than 47% of women over age 50 performed regular (monthly) self-examination of the breasts, a n o t h e r technique to detect abnormalities. 6 There is a direct relationship between increasing age and rising incidence of breast cancer; indeed, it has been said that the greatest risk factor for developing cancer is aging. An unreserved recommendation for periodic physical breast examination and mammographic screening for older women is supported in the literature. 5, 7, 8 Epidemiology, Research, and Public Policy There is no known cause of breast cancer and no means of preventing it. Recognized factors that increase risk are many (see box). Diet has been a prime target of those researching a cause, and the potential relationshi p between a high-fat diet and breast cancer has sparked controversy in lay and professional publications. 9-12 Proponents of the
FACTORS THAT INCREASE RISK FOR BREAST C A N C E R Age History of previous breast cancer History of breast cancer in a first-degree female relative (mother, sister, grandmother) Obesity, greater than 40% above normal weight Menarche before age 12 First pregnancy after age 30 Never pregnant Late menopause after age 50
sis of breast lesions, despite claims by its defenders) 4 UItrasonography is also not a definitive modality for this diagnosis, but is used to differentiate between cystic and solid lesions. There may be a future role for magnetic resonance imaging, but it is not now the diagnostic tool of choice. Mammography enables caregivers to detect early stage, nonpalpable lesions. For these reasons, the emphasis for early detection efforts in older women should be primarily through mammographic screening. Secondary Prevention
Breast self-examination. Several studies have explored c o m p l i a n c e with r e c o m m e n d a t i o n s for b r e a s t selfdietary theory stress that a high-fat diet, consumed by examination (BSE). Although women over 60 have been many American women, causes the production of excess included in study samples, they have typically repreestrogen, which in turn has been linked to breast cancer. sented a small percentage of the total participants. In adIndeed, the westernization of dietary habits in devel- dition, few published studies have focused on older oping countries, which have long had a low-fat content, women and B S E ) 5"18 has been related to an increased incidence of breast, coNot enough studies have assessed the proficiency of relon, and prostate cancers in those countries. This phe- ported BSE or the effect of functional or tactile deficits, nomena has been termed the "overnutriti0n of afflu- combined with possible sensory and m e m o r y impairence. ''12 Conflicting research findings have done nothing ments, in some older women. Stefanek and Wilcox 15 to clarify the dilemma for found that even with women consumers. The dietary recwho identified themselves as ~_ER1GAN ~ANCE_R5~1EI¥ ~GUII)E_L1NE~ ommendations agreed on by being at moderate or high ON DI~ET,NUTRIIION~ AND, C~NCER several agencies, including risk (because of first-degree the American Cancer Socir e l a t i v e s with d i a g n o s e d ety, National Cancer Insti- 2'. Ea~a ~arZeddi~r~ breast cancer), BSE profitute, and the United States 3. laCJude~ vQrle~ of,~I~t~ ~egefables, an~ fruits ~,tbe da'd~ ciency was poor despite fredet Department of Health and quent performance and con4. ~ t more htgh-b'~er foods. ~ ~s ~liolegra-m, cemals, Human Services, among fidence in their technique) 5 |egu.mes, vegetab/~, attd |nfat. o t h e r s , a r e shown in the In a V e r m o n t study the 5. Cu~ dctvaton t~tCll ~ ~italte, "Guidelines" b o x . A t 6. I ~ a ¢.G~n~pti~ Gt Gle,ohoIi©l ~ S , |f you drink at ~1}. average tumor size detected present, however, there is no Z Umit ¢omompli0n Ot surf-cured, smoked; afa~ngn3¢~ was 1.9 cm for those perfirm scientific evidence conforming monthly BSE, verfirming the relationship besus 2.47 cm for those pertween diet and cancer. forming BSE less frequently, and 3.59 cm for those who Recent news reports noted that basic research under- never performed B S E ) 9 Clearly those individuals perway in Japan has uncovered a possible chromosomal link forming BSE monthly had a distinct advantage in detectto the development of breast cancer. Basic research in our ing their cancers at an earlier point. Mammography, howown country has been deficient, according to many breast ever, detects tumors significantly smaller than 1.9 cm. cancer advocacy groups. In 1989, $17 million was approWhat of radiation from repeated mammograms causpriated for breast cancer research. The 1992 federal bud- ing breast cancer? It is estimated that one additional get estimate is $30 million for basic research into the breast cancer per million women per year, with a 50% cause of this deadly disease. By way of contrast, the bud- mortality rate, has been associated with mammographyget for basic AIDS research is $1.8 billion. In February of this year, 140 groups dedicated to breast cancer advoSELECTED BREAST C A N C E R cacy brought their concerns to Washington, D.C., in the ADVOCACY GROUPS hopes of stirring legislators to action to designate more dollars for research (see "Advocacy Groups" box). 13 Detection Techniques Because we do not know how to prevent breast cancer, secondary prevention, in the form of early detection and diagnosis, is the primary defense. Clinical breast examination and self-examination are dependent on the presence of palpable abnormalities and so have inherent limitations related to technique and breast size. Thermography, or detection of areas of increased temperature, is considered an unscientific and unreliable tool for diagno-
The National Alilance of Breast Cancer Organizations 1180 Avenue of the Americas, 2nd floor New York, NY 10036
Y-Me Organization for Breast Cancer information and Support 18220 Harwood Avenue Homewood, IL 60430
(800) 221-2141 Breast Cancer Action P. O. Box 460185 San Francisco, CA 94146 (415) 922-8279
Geriatric Nursing September/October 1992 241
related radiationfl ° Newer radiographic techniques use even less radiation exposure. Because of limitations inherent in BSE and the implication that the practice of BSE does not reduce mortality, the technique has not been universally advocated as a means of self-screening for breast c a n c e r ) 6. 2t Older women in particular may not accept the practice readily, 22 and may not exhibit proficiency or consistency for a number of reasons. Further research is needed to provide the data to determine an appropriate recommendation for the practice of BSE with older women. Until that time, the practice of monthly BSE as one modality should continue to be taught, reviewed, and encouraged for all women. It is another educational tool to help promote personal responsibility for health and well-being. Clinical breast examination. Women who have an identified physician or primary health care provider have reported examinations to be more frequent than women who have no reliable source of health care. Studies are being conducted to determine the efficacy of this detection modality as well. As expected, women who have a regular source of health care and clinical breast examination as part of their routine care also have mammography recommended more frequently, particularly if they are younger. Nevertheless, as age increases, frequency of clinical breast examinations in conjunction with routine health care tends to decline. Mammographic screening. In 1984, 11% of physicians recommended mammography; in 1989 that figure had risen to 37%--stii1 surprisingly low. 23 Studies have indicated that some physicians screen elderly women less frequently, regardless of family history of breast cancerfl 4 Y o u n g e r women u n d e r g o m a m m o g r a p h y m o r e frequently than do older women, are more knowledgeable and fearful about breast cancer and risk factors, and are more assertive about requesting the procedure. An older c l i e n t ' s l a c k of u n d e r s t a n d i n g of risk f a c t o r s - particularly that of increased incidence with increasing a g e - - a n d poor understanding of the potential value of m a m m o g r a p h y may lead to fewer older women being screened. 25 Mammographic screening is a term used when obtaining limited x-ray views, usually two, of both breasts in asymptomatic women. Minute cancers may be detected by this relatively pain-free procedure, and the rate of false-positive findings is approximately 2%. Predictors for compliance with screening have repeatedly been shown to be the physician attitudes and practices toward mammography--specifically, a recommendation for the procedure.5-8, 25-27 Women who have not participated in screening efforts have identified that their physician had not recommended the procedure, and the women therefore felt it was unnecessary for them. Other reasons for nonparticipation with mammographic screening have been cited as lack of symptoms, inconvenience, cost, embarrassment, fear of radiation exposure, and fear of discovery of malignant disease. Part of the reluctance of physicians in recommending mammography to their asymptomatic patients has been
242 Geriatric Nursing September/October 1992
the cost of the procedure, which many women were unable or unwilling to bear. a, 24 Recent legislation has changed that factor. As of January 1991 Medicare reimbursement was extended to include mammographic screening for eligible women. Annual mammograms are covered for disabled women between 50 and 64; for other eligible woman over 65, biennial procedures are partially reimbursable. Previously, mammography was reimbursable for diagnostic or treatment purposes only. Arguments for this legislation became heated about the time of N a n c y Reagan's mastectomy in the mid1980s. She was the third first lady to undergo some intervention for breast disease (Betty Ford had a mastectomy, and Rosalynn Carter underwent a biopsy), and the topic was a charged one. Hearings took place in late 1987, and Medicare coverage of m a m m o g r a p h y was signed into law in July 1988.
Barriers t o S c r e e n i n g Barriers to participation in mammographic screening include those that bar access to other health care services as well. Access to care includes more than entry to the facility that provides the procedure. Lack of transportation, medical insurance, a physician or health care provider, knowledge, literacy skills, or belief in the effectiveness of the procedure--all may inhibit an older woman from requesting or complying with this procedure. Mammographic screening is not without some risk. There are those who are concerned that expanding mammographic screening will do one of two things. First, an increase in the rate of false-positive findings might occur, causing these women to require further diagnostic studies, including additional x-ray, biopsy, and possibly surgical procedures. This would produce a negative psychologic effect on the woman involved, as well as increasing health care costs. Second, an increase in the rate of falsenegative findings would induce a false sense of security in some women and delay diagnosis and treatment until a later stage in the disease. Both of these arguments appear logical, but there is insufficient evidence to indicate that either outcome will occur. At present, the benefits of early diagnosis and treatment for greater numbers of older women far outweigh the risks of misdiagnosis in a very small percentage (2%) of the procedures. There is a significant cost savings in the early treatment of the disease as well. The medical, nursing, socioeconomic, and psychologic costs of endstage breast cancer care are staggering by comparison.
Underserved W o m e n Minority women. Many factors influence a woman to seek (or not to seek) cancer screening. The National Health Interview Survey ( N H I S ) describes the differences in behaviors between race, ethnic, and socioeconomic strata. It has been documented that utilization of all cancer screening procedures increases with education and income levelfl8 Conversely, those in minority or
economically disadvantaged populations may lack access to preventive services. Breast cancer is the leading cause of cancer mortality in African-American women, and the second leading cause of cancer mortality for African-American women over 55. 29 Younger African-American women frequently have breast cancer detected at a later stage. Older women of all races frequently have a later stage of the disease diagnosed. Ensuing interventions and treatment therefore may be more extensive and more expensive, require longer recovery time, and are potentially more psychologically harmful than cancers detected and treated at an early stage. Differences in cultural and social mores, as well as language and economic barriers, may prohibit some minority women from seeking mammography. Developing a cancer screening program for a specific cultural, racial, or ethnic group may provide certain challenges, but successful programs have been implemented) °, 3t Development of effective, culturally sensitive information is crucial to this effort. An American Cancer Society demonstration project currently underway in Illinois is specifically targeting African-American and Hispanic women, with the intent of exploring and removing barriers to mammog r a p h i c s c r e e n i n g ( p e r s o n a l c o m m u n i c a t i o n , J. Sauerzapf, April 2, 1992).
Being female, old, a minority, and poor are criteria for not having access to adequate cancer prevention services. Aging women/poorwomen. Jecker 32 writes effectively about issues of rationing health care based on age. In addition to a "feminization of poverty," there is a feminization of aging occurring. More women survive to older age (over 85 years old) than do men, and this trend is expected to continue. Rationing of publicly funded health care is a passionately debated issue, and age-based rationing is one of the alternatives discussed. With aging, women tend to require more publicly funded health care. In 1986 they constituted 71% of the population entitled to both Medicare and Medicaid funding. 32 If funding for health care will be rationed by age, women will suffer disproportionately because there are more of them. Breast cancer does not differentiate between independently wealthy and economically disadvantaged older women. Being female, old, a minority, and poor and uninsured are criteria for not having access to adequate cancer prevention services.33 Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute indicates that there is a greater likelihood that older women will have distant metastases at the time of diagnosis of breast cancer. If current estimates hold true, there will be approximately 1.4 million breast cancer pa-
tients and breast cancer survivors in the year 2030. 8 Statistics of this magnitude require thoughtful, ethical, and equitable formulation of health care policy for aging women. The forgotten women. If older women in general underutilize preventive services because of access barriers, then "forgotten" women fare even worse. These are the women abandoned in long-term custodial facilities, those who are chronically mentally ill, homeless, socially isolated, imprisoned, neglected, or abused. T h e y are the women that families, communities, and society have scarce resources to support. They are women for whom preventive health care is a luxury; for such women a breast examination or mammography are virtually unheard of. In an unpublished review of the use of mammography in a retirement community, it was discovered that there had been no recommendations for mammography in 63% of the 72 women reviewed. This group represented a 25% random sampling of ambulatory women (aged 65 to 98) on the campus and was the second review within 1 year. These dismal results reflected a higher utilization than in the associated long-term care nursing facility (Drugay M. Unpublished findings). This finding is consistent with results reported on breast cancer detection methods in long-term care facilities. 34
Nursing Implications Nurses are in an unparalleled position to assume a proactive stance for efforts at early detection and diagnosis of breast cancer in older women. Treatment options have been well defined elsewhere and are not necessarily limited related-to age. s, 35, 36 Those who work with older women in all settings must heighten their awareness of the recommended modalities for cancer detection. Routine breast self-examination is a simple technique that should be encouraged as one aspect of the overall context of health maintenance. Annual mammography should be stressed, and women should be encouraged to request the procedure if their physician fails to recommend it. The American Cancer Society has numerous leaflets and brochures about breast cancer issues that should be made available to these women. Client education regarding risk factors, and the value of m a m m o g r a p h y to detect abnormalities at an early stage may be critical in altering or modifying health behaviors. Positive reinforcement and feedback, clarification of misconceptions and cancer myths, and nursing interventions sensitive to the age, ethnicity, and skills of the older woman provide a positive atmosphere in which learning may take place. Identifying women who have never been screened and discussing this in the framework of patient advocacy may assist family members and physicians reluctant to burden the older patient with "unnecessary" testing. Given and Given 37 explore an agenda for cancer research for the elderly from a nursing perspective. This agenda details areas in need of nursing research and requires action n o w if we are to improve outcomes for older women. We must promote early breast cancer detection efforts for aging Geriatric Nursing September/October 1992 243
Privacy. Safety. Security. The c o m m o d e comfort support ,~ system that provides safety and ;;.;~ ..... ~ privacy for the user and " ~ g ~ ~ ~ " ~ m o r e freedom for ~,~-:.
44:
nursing
told, up ;,,,,y ............
.
I)I f :
I]
Re,cac,ab1
-----"~3~J .paddeaslide I
I POSitionto assure
] l /
/
3. Patent
riding
lotalsupport u*tbout U sacrificing comfort
:ST A S S U R E D , I N C . P.O. Box 4 8 )sholt, S D 5 7 2 6 0 - 0 0 4 8
FINALLW A Comprehensive Nursing Inservice Program
For
LONG-TERM CARE. O N VIDEO C A S E T F E
• IMPROVES ASSESSMENT SKILLS • IMPROVES CLINICAL DECISIONMAKING SKILLS • IMPROVES PATIENT OUTCOMES • AFFORDABLE • LONG-TERM CARE PERSPECTIVE . WRITTEN GUIDE Geriatric Video Productions is committed to providing today's Iong4erm care nurse with the most up-to-date information avai/ab/e.
Geriatric Video Productions RO. BOX 1757, SHAVERTOWN, PA 18708-0757 (717) 8 2 9 - 1 0 9 5
244
G e r i a t r i c N u r s i n g September/October 1992
women. This challenge is a responsibility we all share as we look to the f u t u r e - - a n d our own aging. • REFERENCES 1. Boring C, Squires TS. Tong T. Cancer statistics, 1992. CA Cancer J Clin 1992;42:19-38. 2. [Anonymous.] Little progress against breast cancer, G A O report says. Am Med News 1992 Jan 27:8. 3. Blakeslee B. Women alarmed by cancer statistics. San Diego Union-Tribune 1992 Mar 17. 4. Thompson GB, Kessler LG, Boss LP. Breast cancer screening legislation in the United States: a commentary. Am J Public Health 1989;79:1541-3. 5. Fink DJ. Community programs: breast cancer detection awareness. Cancer 1989;64(I 2 suppl):2674-8 I. 6. Kaplan KM, Weinberg GB, Small A, tterndon JL. Breast cancer screening a m o n g relatives of women with breast cancer. Am J Pub Health 1991; 81:1174-9. 7. Beers M H , Fink A, Beck JC. Screening recommendations for the elderly. Am J Public tlealth 1991;81:1131-40. 8. Yancik R, Ries LG, Yates JW. Breast cancer in aging women. Cancer 1989;5:976-81. 9. Gorbach SL, Morrill-LaBrode A, Woods hlNo et al. Changes in food patterns d u r i n g a l o w - f a t d i e t a r y i n t e r v e n t i o n in w o m e n . J Am Diet A s s o c 1990;90:802-9. 10. Lee HP, Gourley L, Duffy SW, Est~ve J, Lee J, Day NE. Dietary effects on breast-cancer risk in Singapore. Lancet 1991;337:1197-200. I I. Ewertz M, Gillanders S, hleyer L, Zedeler K. Survival of breast cancer patients in relation to factors which affect the risk of developing breast cancer. Int J Cancer 1991;49:526-30. 12. Kritchevsky D. Diet and cancer. CA Cancer J Clin 1991;41:328-33. 13. Nunn C, Solomon D. A c a r to action on breast cancer. Chicago Tribune 1992 Feb 27;sect 1:25. 14. [Anonymous]. A M A ' s Council on Scientific Affairs takes a fresh look at thermography. J A M A 1992;267:1885-7. 15. Stefanek hiE, Wilcox P. Breast self-examination among women at increased risk: assessment of proficiency. Cancer Prevention 1991 ;I :79-83. 16. Scanlon EF. Secondary prevention of cancer. In: Eluman behavior and risk reductlon conference, part I1. Cancer Prevention. 1990;9:115-16. 17. Mayer J, Fredericksen L. Encouraging long-term compliance with BSE: the evaluation of prompting strategy. J Behav Med 1990;9:179-89. 18. Champion VL. The relationship of selected variables to breast cancer detection behaviors in women 35 and older. Oncol Nurs Forum 1991;18:733-9. 19. Foster RS, Lang SP, Costanza MC, Worder JK, tlaines CR, Yates JW. Breast self-examination practices in breast cancer stage. N Engl J Med 1987;299:205-70. 20. Feig SA. Breast carcinoma: current diagnosis and treatment. New York: Masson Publishing, 1983:69-76. 21. [Anonymous.] Report of work group on secondary prevention/early detection. In: Human behavior and cancer risk reduction: unmet research priorities; Work group reports. Cancer Prevention 1990;1:26-8. 22. Sawyer PF. Breast self-examination: hospital based nurses aren't assessing their clients. Oncol Nurs Forum 1986;13:44-8. 23. Mettlin C, Dodd GD. The American Cancer Society guidelines for the cancer-related check-up: an update. CA Cancer J Clin 1991;41:279-82. 24. Weinberger M, Saunders AF, Samsa GP, et al. Breast cancer screening in older women: practices and barriers reported by primary care physicians. J Am Geriatr Soc 1991;39:22-9. 25. tlarris RP, Fletcher SW, Gonzalez J, et al. Mammography and age: are we targeting the wrong women? Cancer 1991;67:2010-14. 26. Taplin S, Anderman C, Grothaus L. Breast cancer risk and participation in mammographic screening. Am J Public Health 1989;79:1494-98. 27. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Med 1991;151:50-6. 28. Christenson GM, Baquet C. What is known about the conditions and behavior of those people disproportionately affected by cancer? Cancer Prevention 1990;1:59-65. 29. Bal DG. Cancer in African Americans. CA Cancer J Clin 1992;42:5-6. 30. Lovejoy NC, Jenkins C, Wu T, Shankland S, Wilson C. Developing a breast cancer screening program for Chinese American women. Oncol Nuts Forum 1989;16:181-7. 3 I. Stein JA, Fox SA. Language preference as an indicator of mammography use among ttispanlc women. J Nail Cancer Inst 1990;82:1715-6. 32. Jecker NS. Age-based rationing and women. J A M A 1991;266:3012-15. 33. Steiner CB. Access to cancer prevention, detection and treatment. Cancer 1991;6:1736-40. 34. Kenny JC, Keenan PW. A survey of breast cancer detection methods in longterm care facilities. J Geriatr Nuts 1991;17:20-2. 35. Nielsen BB, East D. Advances in breast cancer: implications for nursing care. Nurs Clin North Am 1990;25:365-75. 36. Knobf hiT. Early-stage breast cancer: the options. Am J Nurs 1990;90:28-30. 37. Given B, Given CW. Cancer nursing for the elderly: a target for research. Cancer Nuts 1989;12:71-7.
Where Do We Stand? Although age is the greatest risk factor for breast cancer, older w o m e n are not receiving the mammographic screenings they need. By
MARGE
DRUCAY
R E A S T CANCER. More than 99% of the cases -occur in women. It is the second leading cause of cancer mortality in all women over the age of 55. In 1992, 180,000 new cases are expected to be diagnosed, with 43% of these in women over 65. An estimated 46,000 deaths are expected to occur this year) According to the General Accounting Office of the federal government, the past 20 years have seen no gains in prevention. 2 Many premenopausal women are terrified they will develop it, and there have been reports of "prophylactic" mastectomies. The risk of developing this disease within a lifetime has risen to 1 in 9, which reflects both the rising incidence and the burgeoning aging population. Physicians often misinterpret these statistics, by inaccurately representing individual risk, causing further a l a r m ) The media has contributed to the escalating hysteria, often with sensationalistic reporting and little research into the real issues. Breast cancer is the plague of the aging American woman.
Bb
P r e v e n t i o n and Detection Strategies The American Cancer Society was instrumental in the implementation of a nationwide program intended to demonstrate the benefits of breast cancer detection to physicians and women. From 1986 through 1989 the Breast Cancer Detection Demonstration Project (BCDDP), involving 280,000 women in 29 locations, offered screening mammography and clinical breast examinations for a 5-year period. A study is underway with
MARGE DRUGAY, MS, RN,C, is an associate faculty member at Rush University in Chicago, where she is a doctoral student. 34/1/39395
240 Geriatric Nursing September/Oct0ber 1992
high-risk premenopausal women using the drug tamoxifen citrate in the hopes of preventing the development of breast cancer. Mammography, or x-ray of the breast, in conjunction with clinical breast examination facilitates early diagnosis of cancer at a more treatable stage, thereby reducing the risk of untimely death. 4 In the first publication of findings from the BCDDP, results indicated that mammography and clinical breast examination together confirmed cases not detected by either one alone but that the diagnostic role of mammography was greater. Mammography alone found 40% of all breast cancer cases, compared with 10% discovered by clinical e x a m i n a t i o n alone. 5 Despite American Cancer Society guidelines for annual screening of women over the age of 50--especially for those who are considered at higher risk--most women over the age of 50 do not undergo regular, routine screening mammography. In one recent study, less than 47% of women over age 50 performed regular (monthly) self-examination of the breasts, a n o t h e r technique to detect abnormalities. 6 There is a direct relationship between increasing age and rising incidence of breast cancer; indeed, it has been said that the greatest risk factor for developing cancer is aging. An unreserved recommendation for periodic physical breast examination and mammographic screening for older women is supported in the literature. 5, 7, 8 Epidemiology, Research, and Public Policy There is no known cause of breast cancer and no means of preventing it. Recognized factors that increase risk are many (see box). Diet has been a prime target of those researching a cause, and the potential relationshi p between a high-fat diet and breast cancer has sparked controversy in lay and professional publications. 9-12 Proponents of the
FACTORS THAT INCREASE RISK FOR BREAST C A N C E R Age History of previous breast cancer History of breast cancer in a first-degree female relative (mother, sister, grandmother) Obesity, greater than 40% above normal weight Menarche before age 12 First pregnancy after age 30 Never pregnant Late menopause after age 50
sis of breast lesions, despite claims by its defenders) 4 UItrasonography is also not a definitive modality for this diagnosis, but is used to differentiate between cystic and solid lesions. There may be a future role for magnetic resonance imaging, but it is not now the diagnostic tool of choice. Mammography enables caregivers to detect early stage, nonpalpable lesions. For these reasons, the emphasis for early detection efforts in older women should be primarily through mammographic screening. Secondary Prevention
Breast self-examination. Several studies have explored c o m p l i a n c e with r e c o m m e n d a t i o n s for b r e a s t selfdietary theory stress that a high-fat diet, consumed by examination (BSE). Although women over 60 have been many American women, causes the production of excess included in study samples, they have typically repreestrogen, which in turn has been linked to breast cancer. sented a small percentage of the total participants. In adIndeed, the westernization of dietary habits in devel- dition, few published studies have focused on older oping countries, which have long had a low-fat content, women and B S E ) 5"18 has been related to an increased incidence of breast, coNot enough studies have assessed the proficiency of relon, and prostate cancers in those countries. This phe- ported BSE or the effect of functional or tactile deficits, nomena has been termed the "overnutriti0n of afflu- combined with possible sensory and m e m o r y impairence. ''12 Conflicting research findings have done nothing ments, in some older women. Stefanek and Wilcox 15 to clarify the dilemma for found that even with women consumers. The dietary recwho identified themselves as ~_ER1GAN ~ANCE_R5~1EI¥ ~GUII)E_L1NE~ ommendations agreed on by being at moderate or high ON DI~ET,NUTRIIION~ AND, C~NCER several agencies, including risk (because of first-degree the American Cancer Socir e l a t i v e s with d i a g n o s e d ety, National Cancer Insti- 2'. Ea~a ~arZeddi~r~ breast cancer), BSE profitute, and the United States 3. laCJude~ vQrle~ of,~I~t~ ~egefables, an~ fruits ~,tbe da'd~ ciency was poor despite fredet Department of Health and quent performance and con4. ~ t more htgh-b'~er foods. ~ ~s ~liolegra-m, cemals, Human Services, among fidence in their technique) 5 |egu.mes, vegetab/~, attd |nfat. o t h e r s , a r e shown in the In a V e r m o n t study the 5. Cu~ dctvaton t~tCll ~ ~italte, "Guidelines" b o x . A t 6. I ~ a ¢.G~n~pti~ Gt Gle,ohoIi©l ~ S , |f you drink at ~1}. average tumor size detected present, however, there is no Z Umit ¢omompli0n Ot surf-cured, smoked; afa~ngn3¢~ was 1.9 cm for those perfirm scientific evidence conforming monthly BSE, verfirming the relationship besus 2.47 cm for those pertween diet and cancer. forming BSE less frequently, and 3.59 cm for those who Recent news reports noted that basic research under- never performed B S E ) 9 Clearly those individuals perway in Japan has uncovered a possible chromosomal link forming BSE monthly had a distinct advantage in detectto the development of breast cancer. Basic research in our ing their cancers at an earlier point. Mammography, howown country has been deficient, according to many breast ever, detects tumors significantly smaller than 1.9 cm. cancer advocacy groups. In 1989, $17 million was approWhat of radiation from repeated mammograms causpriated for breast cancer research. The 1992 federal bud- ing breast cancer? It is estimated that one additional get estimate is $30 million for basic research into the breast cancer per million women per year, with a 50% cause of this deadly disease. By way of contrast, the bud- mortality rate, has been associated with mammographyget for basic AIDS research is $1.8 billion. In February of this year, 140 groups dedicated to breast cancer advoSELECTED BREAST C A N C E R cacy brought their concerns to Washington, D.C., in the ADVOCACY GROUPS hopes of stirring legislators to action to designate more dollars for research (see "Advocacy Groups" box). 13 Detection Techniques Because we do not know how to prevent breast cancer, secondary prevention, in the form of early detection and diagnosis, is the primary defense. Clinical breast examination and self-examination are dependent on the presence of palpable abnormalities and so have inherent limitations related to technique and breast size. Thermography, or detection of areas of increased temperature, is considered an unscientific and unreliable tool for diagno-
The National Alilance of Breast Cancer Organizations 1180 Avenue of the Americas, 2nd floor New York, NY 10036
Y-Me Organization for Breast Cancer information and Support 18220 Harwood Avenue Homewood, IL 60430
(800) 221-2141 Breast Cancer Action P. O. Box 460185 San Francisco, CA 94146 (415) 922-8279
Geriatric Nursing September/October 1992 241
related radiationfl ° Newer radiographic techniques use even less radiation exposure. Because of limitations inherent in BSE and the implication that the practice of BSE does not reduce mortality, the technique has not been universally advocated as a means of self-screening for breast c a n c e r ) 6. 2t Older women in particular may not accept the practice readily, 22 and may not exhibit proficiency or consistency for a number of reasons. Further research is needed to provide the data to determine an appropriate recommendation for the practice of BSE with older women. Until that time, the practice of monthly BSE as one modality should continue to be taught, reviewed, and encouraged for all women. It is another educational tool to help promote personal responsibility for health and well-being. Clinical breast examination. Women who have an identified physician or primary health care provider have reported examinations to be more frequent than women who have no reliable source of health care. Studies are being conducted to determine the efficacy of this detection modality as well. As expected, women who have a regular source of health care and clinical breast examination as part of their routine care also have mammography recommended more frequently, particularly if they are younger. Nevertheless, as age increases, frequency of clinical breast examinations in conjunction with routine health care tends to decline. Mammographic screening. In 1984, 11% of physicians recommended mammography; in 1989 that figure had risen to 37%--stii1 surprisingly low. 23 Studies have indicated that some physicians screen elderly women less frequently, regardless of family history of breast cancerfl 4 Y o u n g e r women u n d e r g o m a m m o g r a p h y m o r e frequently than do older women, are more knowledgeable and fearful about breast cancer and risk factors, and are more assertive about requesting the procedure. An older c l i e n t ' s l a c k of u n d e r s t a n d i n g of risk f a c t o r s - particularly that of increased incidence with increasing a g e - - a n d poor understanding of the potential value of m a m m o g r a p h y may lead to fewer older women being screened. 25 Mammographic screening is a term used when obtaining limited x-ray views, usually two, of both breasts in asymptomatic women. Minute cancers may be detected by this relatively pain-free procedure, and the rate of false-positive findings is approximately 2%. Predictors for compliance with screening have repeatedly been shown to be the physician attitudes and practices toward mammography--specifically, a recommendation for the procedure.5-8, 25-27 Women who have not participated in screening efforts have identified that their physician had not recommended the procedure, and the women therefore felt it was unnecessary for them. Other reasons for nonparticipation with mammographic screening have been cited as lack of symptoms, inconvenience, cost, embarrassment, fear of radiation exposure, and fear of discovery of malignant disease. Part of the reluctance of physicians in recommending mammography to their asymptomatic patients has been
242 Geriatric Nursing September/October 1992
the cost of the procedure, which many women were unable or unwilling to bear. a, 24 Recent legislation has changed that factor. As of January 1991 Medicare reimbursement was extended to include mammographic screening for eligible women. Annual mammograms are covered for disabled women between 50 and 64; for other eligible woman over 65, biennial procedures are partially reimbursable. Previously, mammography was reimbursable for diagnostic or treatment purposes only. Arguments for this legislation became heated about the time of N a n c y Reagan's mastectomy in the mid1980s. She was the third first lady to undergo some intervention for breast disease (Betty Ford had a mastectomy, and Rosalynn Carter underwent a biopsy), and the topic was a charged one. Hearings took place in late 1987, and Medicare coverage of m a m m o g r a p h y was signed into law in July 1988.
Barriers t o S c r e e n i n g Barriers to participation in mammographic screening include those that bar access to other health care services as well. Access to care includes more than entry to the facility that provides the procedure. Lack of transportation, medical insurance, a physician or health care provider, knowledge, literacy skills, or belief in the effectiveness of the procedure--all may inhibit an older woman from requesting or complying with this procedure. Mammographic screening is not without some risk. There are those who are concerned that expanding mammographic screening will do one of two things. First, an increase in the rate of false-positive findings might occur, causing these women to require further diagnostic studies, including additional x-ray, biopsy, and possibly surgical procedures. This would produce a negative psychologic effect on the woman involved, as well as increasing health care costs. Second, an increase in the rate of falsenegative findings would induce a false sense of security in some women and delay diagnosis and treatment until a later stage in the disease. Both of these arguments appear logical, but there is insufficient evidence to indicate that either outcome will occur. At present, the benefits of early diagnosis and treatment for greater numbers of older women far outweigh the risks of misdiagnosis in a very small percentage (2%) of the procedures. There is a significant cost savings in the early treatment of the disease as well. The medical, nursing, socioeconomic, and psychologic costs of endstage breast cancer care are staggering by comparison.
Underserved W o m e n Minority women. Many factors influence a woman to seek (or not to seek) cancer screening. The National Health Interview Survey ( N H I S ) describes the differences in behaviors between race, ethnic, and socioeconomic strata. It has been documented that utilization of all cancer screening procedures increases with education and income levelfl8 Conversely, those in minority or
economically disadvantaged populations may lack access to preventive services. Breast cancer is the leading cause of cancer mortality in African-American women, and the second leading cause of cancer mortality for African-American women over 55. 29 Younger African-American women frequently have breast cancer detected at a later stage. Older women of all races frequently have a later stage of the disease diagnosed. Ensuing interventions and treatment therefore may be more extensive and more expensive, require longer recovery time, and are potentially more psychologically harmful than cancers detected and treated at an early stage. Differences in cultural and social mores, as well as language and economic barriers, may prohibit some minority women from seeking mammography. Developing a cancer screening program for a specific cultural, racial, or ethnic group may provide certain challenges, but successful programs have been implemented) °, 3t Development of effective, culturally sensitive information is crucial to this effort. An American Cancer Society demonstration project currently underway in Illinois is specifically targeting African-American and Hispanic women, with the intent of exploring and removing barriers to mammog r a p h i c s c r e e n i n g ( p e r s o n a l c o m m u n i c a t i o n , J. Sauerzapf, April 2, 1992).
Being female, old, a minority, and poor are criteria for not having access to adequate cancer prevention services. Aging women/poorwomen. Jecker 32 writes effectively about issues of rationing health care based on age. In addition to a "feminization of poverty," there is a feminization of aging occurring. More women survive to older age (over 85 years old) than do men, and this trend is expected to continue. Rationing of publicly funded health care is a passionately debated issue, and age-based rationing is one of the alternatives discussed. With aging, women tend to require more publicly funded health care. In 1986 they constituted 71% of the population entitled to both Medicare and Medicaid funding. 32 If funding for health care will be rationed by age, women will suffer disproportionately because there are more of them. Breast cancer does not differentiate between independently wealthy and economically disadvantaged older women. Being female, old, a minority, and poor and uninsured are criteria for not having access to adequate cancer prevention services.33 Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute indicates that there is a greater likelihood that older women will have distant metastases at the time of diagnosis of breast cancer. If current estimates hold true, there will be approximately 1.4 million breast cancer pa-
tients and breast cancer survivors in the year 2030. 8 Statistics of this magnitude require thoughtful, ethical, and equitable formulation of health care policy for aging women. The forgotten women. If older women in general underutilize preventive services because of access barriers, then "forgotten" women fare even worse. These are the women abandoned in long-term custodial facilities, those who are chronically mentally ill, homeless, socially isolated, imprisoned, neglected, or abused. T h e y are the women that families, communities, and society have scarce resources to support. They are women for whom preventive health care is a luxury; for such women a breast examination or mammography are virtually unheard of. In an unpublished review of the use of mammography in a retirement community, it was discovered that there had been no recommendations for mammography in 63% of the 72 women reviewed. This group represented a 25% random sampling of ambulatory women (aged 65 to 98) on the campus and was the second review within 1 year. These dismal results reflected a higher utilization than in the associated long-term care nursing facility (Drugay M. Unpublished findings). This finding is consistent with results reported on breast cancer detection methods in long-term care facilities. 34
Nursing Implications Nurses are in an unparalleled position to assume a proactive stance for efforts at early detection and diagnosis of breast cancer in older women. Treatment options have been well defined elsewhere and are not necessarily limited related-to age. s, 35, 36 Those who work with older women in all settings must heighten their awareness of the recommended modalities for cancer detection. Routine breast self-examination is a simple technique that should be encouraged as one aspect of the overall context of health maintenance. Annual mammography should be stressed, and women should be encouraged to request the procedure if their physician fails to recommend it. The American Cancer Society has numerous leaflets and brochures about breast cancer issues that should be made available to these women. Client education regarding risk factors, and the value of m a m m o g r a p h y to detect abnormalities at an early stage may be critical in altering or modifying health behaviors. Positive reinforcement and feedback, clarification of misconceptions and cancer myths, and nursing interventions sensitive to the age, ethnicity, and skills of the older woman provide a positive atmosphere in which learning may take place. Identifying women who have never been screened and discussing this in the framework of patient advocacy may assist family members and physicians reluctant to burden the older patient with "unnecessary" testing. Given and Given 37 explore an agenda for cancer research for the elderly from a nursing perspective. This agenda details areas in need of nursing research and requires action n o w if we are to improve outcomes for older women. We must promote early breast cancer detection efforts for aging Geriatric Nursing September/October 1992 243
Privacy. Safety. Security. The c o m m o d e comfort support ,~ system that provides safety and ;;.;~ ..... ~ privacy for the user and " ~ g ~ ~ ~ " ~ m o r e freedom for ~,~-:.
44:
nursing
told, up ;,,,,y ............
.
I)I f :
I]
Re,cac,ab1
-----"~3~J .paddeaslide I
I POSitionto assure
] l /
/
3. Patent
riding
lotalsupport u*tbout U sacrificing comfort
:ST A S S U R E D , I N C . P.O. Box 4 8 )sholt, S D 5 7 2 6 0 - 0 0 4 8
FINALLW A Comprehensive Nursing Inservice Program
For
LONG-TERM CARE. O N VIDEO C A S E T F E
• IMPROVES ASSESSMENT SKILLS • IMPROVES CLINICAL DECISIONMAKING SKILLS • IMPROVES PATIENT OUTCOMES • AFFORDABLE • LONG-TERM CARE PERSPECTIVE . WRITTEN GUIDE Geriatric Video Productions is committed to providing today's Iong4erm care nurse with the most up-to-date information avai/ab/e.
Geriatric Video Productions RO. BOX 1757, SHAVERTOWN, PA 18708-0757 (717) 8 2 9 - 1 0 9 5
244
G e r i a t r i c N u r s i n g September/October 1992
women. This challenge is a responsibility we all share as we look to the f u t u r e - - a n d our own aging. • REFERENCES 1. Boring C, Squires TS. Tong T. Cancer statistics, 1992. CA Cancer J Clin 1992;42:19-38. 2. [Anonymous.] Little progress against breast cancer, G A O report says. Am Med News 1992 Jan 27:8. 3. Blakeslee B. Women alarmed by cancer statistics. San Diego Union-Tribune 1992 Mar 17. 4. Thompson GB, Kessler LG, Boss LP. Breast cancer screening legislation in the United States: a commentary. Am J Public Health 1989;79:1541-3. 5. Fink DJ. Community programs: breast cancer detection awareness. Cancer 1989;64(I 2 suppl):2674-8 I. 6. Kaplan KM, Weinberg GB, Small A, tterndon JL. Breast cancer screening a m o n g relatives of women with breast cancer. Am J Pub Health 1991; 81:1174-9. 7. Beers M H , Fink A, Beck JC. Screening recommendations for the elderly. Am J Public tlealth 1991;81:1131-40. 8. Yancik R, Ries LG, Yates JW. Breast cancer in aging women. Cancer 1989;5:976-81. 9. Gorbach SL, Morrill-LaBrode A, Woods hlNo et al. Changes in food patterns d u r i n g a l o w - f a t d i e t a r y i n t e r v e n t i o n in w o m e n . J Am Diet A s s o c 1990;90:802-9. 10. Lee HP, Gourley L, Duffy SW, Est~ve J, Lee J, Day NE. Dietary effects on breast-cancer risk in Singapore. Lancet 1991;337:1197-200. I I. Ewertz M, Gillanders S, hleyer L, Zedeler K. Survival of breast cancer patients in relation to factors which affect the risk of developing breast cancer. Int J Cancer 1991;49:526-30. 12. Kritchevsky D. Diet and cancer. CA Cancer J Clin 1991;41:328-33. 13. Nunn C, Solomon D. A c a r to action on breast cancer. Chicago Tribune 1992 Feb 27;sect 1:25. 14. [Anonymous]. A M A ' s Council on Scientific Affairs takes a fresh look at thermography. J A M A 1992;267:1885-7. 15. Stefanek hiE, Wilcox P. Breast self-examination among women at increased risk: assessment of proficiency. Cancer Prevention 1991 ;I :79-83. 16. Scanlon EF. Secondary prevention of cancer. In: Eluman behavior and risk reductlon conference, part I1. Cancer Prevention. 1990;9:115-16. 17. Mayer J, Fredericksen L. Encouraging long-term compliance with BSE: the evaluation of prompting strategy. J Behav Med 1990;9:179-89. 18. Champion VL. The relationship of selected variables to breast cancer detection behaviors in women 35 and older. Oncol Nurs Forum 1991;18:733-9. 19. Foster RS, Lang SP, Costanza MC, Worder JK, tlaines CR, Yates JW. Breast self-examination practices in breast cancer stage. N Engl J Med 1987;299:205-70. 20. Feig SA. Breast carcinoma: current diagnosis and treatment. New York: Masson Publishing, 1983:69-76. 21. [Anonymous.] Report of work group on secondary prevention/early detection. In: Human behavior and cancer risk reduction: unmet research priorities; Work group reports. Cancer Prevention 1990;1:26-8. 22. Sawyer PF. Breast self-examination: hospital based nurses aren't assessing their clients. Oncol Nurs Forum 1986;13:44-8. 23. Mettlin C, Dodd GD. The American Cancer Society guidelines for the cancer-related check-up: an update. CA Cancer J Clin 1991;41:279-82. 24. Weinberger M, Saunders AF, Samsa GP, et al. Breast cancer screening in older women: practices and barriers reported by primary care physicians. J Am Geriatr Soc 1991;39:22-9. 25. tlarris RP, Fletcher SW, Gonzalez J, et al. Mammography and age: are we targeting the wrong women? Cancer 1991;67:2010-14. 26. Taplin S, Anderman C, Grothaus L. Breast cancer risk and participation in mammographic screening. Am J Public Health 1989;79:1494-98. 27. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Med 1991;151:50-6. 28. Christenson GM, Baquet C. What is known about the conditions and behavior of those people disproportionately affected by cancer? Cancer Prevention 1990;1:59-65. 29. Bal DG. Cancer in African Americans. CA Cancer J Clin 1992;42:5-6. 30. Lovejoy NC, Jenkins C, Wu T, Shankland S, Wilson C. Developing a breast cancer screening program for Chinese American women. Oncol Nuts Forum 1989;16:181-7. 3 I. Stein JA, Fox SA. Language preference as an indicator of mammography use among ttispanlc women. J Nail Cancer Inst 1990;82:1715-6. 32. Jecker NS. Age-based rationing and women. J A M A 1991;266:3012-15. 33. Steiner CB. Access to cancer prevention, detection and treatment. Cancer 1991;6:1736-40. 34. Kenny JC, Keenan PW. A survey of breast cancer detection methods in longterm care facilities. J Geriatr Nuts 1991;17:20-2. 35. Nielsen BB, East D. Advances in breast cancer: implications for nursing care. Nurs Clin North Am 1990;25:365-75. 36. Knobf hiT. Early-stage breast cancer: the options. Am J Nurs 1990;90:28-30. 37. Given B, Given CW. Cancer nursing for the elderly: a target for research. Cancer Nuts 1989;12:71-7.
