Barriers to breast cancer screening in older women

BARRIERS TO BREAST CANCER SCREENING IN OLDER WOMEN A Review

William F. McCool,

CNM, PhD

~.

With the shift in population in the United States toward older age coho&. commonly refered to as the “graying of Amelica,” a greater emphasis is betng placed on the health care needs of the elderly. Evidence of this empbasii is reflected in the proposals forth in President C&ton’s Health Care Reform Package, in which there is a call for expanding the coverageand easing the costs of prescription drugs and long-term care, both of which are health care expenses felt primarily by older indtviduals (1). Although there are many additional health care issues that affect older Americans, one that has re-

put

ceived iii&eattentionin comparison with its prevalence has been breast cancer in older women. It has been. until recently. a 4bsue that is re: tlected in the dhninished number of women over age 65 who receive breast cancerscreeningand of health care providers who recommend or implement this screening (Z-4). Indeed, one of the ob&iives proposed In the Public Health Service’s .Hoolthy People 2000 report on health promotion and disease prevention IS to Increaseeffmts to screen older women for breast cancer (5). Wtth more than 46.000 deaths due to breast cancer projected to have occurred in 1993 (6). and with greater than 50% of breast cancer dea!hs found in women over the age of 65 (71. the need for improved breast cancer screening in older women, especially by nurse-

midwives and other primaq health care prwiders, warmnts attention.

silent

BREAsl CANCER M OLDER WOMEN Incidence In Americanwomen. breast canceris second only to skin cancer in inctdence and second oniy to lung cancer as a cause of death by carcinogenie professes (6). The most recent estimates are that nearly one in eight American women will experience breast cancer over the course of a Ii&me. This figure can at tinw.s be misleading. For a woman currenUy 40 years of age, chancesof dew&pin&! breast cancer are one in 217, whereas for a woman who lives to be 85. chancesincrease to one in nine In other words. the longer one lives.

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the gmter chance of developir.3 not only breast cancer, but any number of serious diseases or illnesses.Although these statisticscan be quite alarming, not all news is bleak. In the 15-year period from 1973 to 1988 breast cancer mortalfor wome; under the age of 65 actuallv decreased 4.7% (81. Although’ well-designed resea& has yet to be conducted to examine the reasons for this decline, factors thought to contribute to this encow a@ng change have been broader education efforts about breast cancer, increased availability of screening technology bnammcgmphy). and refinement of screening and treatment modalities that have led to improved outcomes Unfortunately, a similar wsitive trend has not been realized in older women. In the same time period of 1973-1988, moti&y rates due to breast cancer increased 11.0% in women ased 65 and older (8). The inddenca of breast cancer has long been known to increase with age. As seen in Figure 1, the number of cases of breast cancer rise5 with every age 5oup until tho age of 80. after which there is only a slight decrease in incidence (9). This fact alone contributes to the increased mortality with age that is found. However, with the improvements in txeahnentof breast cancer, increasing age alone cannot entirely explain the poorer outcomes related to the age variable. A review of the literature reveals that differences in sutival rates between younger and older women with breast cancer are related to the btolcgy of the disease itself, to issues of screening in various age groups. and to dishibution of treatment modaliUes across the life span.

ity

BiOlogy Breast cancers, whether pdmay or metastatic tumors, are desnibed as estmg~n-receptor paitw or negafive, and as prcgesteronweceptor Positive or negative (10). Normal manlmaly cells contaill receptor sites for hormones, including estrogen and progesterone, that influenw the 5owth and function of the mammaty gland. These hormones also can promulgate the 5owth of breast cancer if the tumor cells are estmgen or progesterone dependent. The hormone attachesto a specificreceptor protein in the cell. causina a chanw In the cell “de& that tile” pro&es BJmar arowih (11). Endocrine theraw for b;east can&r is based on off& to block access of particular hormones, such as eslmgen. to spedflc receptor cells. Tamoxifen, an e&ogen antdgcmist,is a conlnl0” agent used in therapy for estrogen-receptor positive tumors. Concentrations of estrogen-receptor positive ceUsin pdmay breast cancer hnnors increase with age, a.5 do proaestercme-recenta ucsitive cells’in &bnenopausaiwom~n (12). Evidence indicates that ~~)sbnenopamI women have a &her incidence of estrogen-receptor positive tumors (5 60%) than premeno-

pausal women (30%). This has a direct bearing on treatment choice and outcome. Higher homwne-receptor content of hmmrs has been conelated with greater tinor rpsp0ns.eto hormonal theraw (12. 131. Thus. one would q&that older women with breast cancer would have a better pngnoais than younger women because of the greater number of hormone-dependent turnon in the elderly and tbo relatively nontoxic nature of the treatment associated with ihls typz of cancer. In addition to the gmatertendency of older women to have a hmmcmerecelWr positive tumor, evidence show that breast cancel twnors in older women have a lower pmllfemtive rate and more well-differennated histolac grades (Hi&lo@ gmding Kcoltnts for growth pattems and cyfeahrres of cancer cells, tiib more well-dlfferentlated cells being associated with more positive prcq. nose* IllI.) Thus. at least In theoN. older women are more likely to ha& slower grotiing, more Indolent tumars. From a bialogic peupeciiw, therefore. one would expect that when compared with younger women. older women would have better survival rates from taast cancer. They do not (14). As stated ear. lier. even though < 50% of

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newly dlagnossd breast cancers each year are found in women over the ago of 65, > 60% of the deaths due to breast cancer occur in this age group (7). Akhough there is some specu!ation that bio!ogy still plays a role, as a result of such factors as a decline in immune surveillance with age l16), evidence suggests that explanations for the poorer prcglw?.t* of breast cancer in older women lie with iswe of screening and treatment. SC”~ There are three “aim “ethcds of for breast cancex breast rolf.oxamination @SE: visual and tactlle exam!!Ett~~ of !z?zs! t&we performed by the woman herself), clinical breast examination (CBE: breast exmntnation performed by an individual’s health care praetittoner), and mammcgmphy (MAM: radiogaphic image of the breask). The use and efficacy of these methods varies considerably when comparing older women with younger women. and the reasons for these differences am related to hxlluldual clknt, health care pmvider. and health care system factolx.

screening

Breast w&examination. Breast self-examfnatfon was Rrst recommended as a widespread detection method for brsast cancer in the early 19Ws (10). More than 4 decades fater, the effkacy of this detectton method continues to be debated. Btwdprkwflyononeofthefkst Won oi &E to can& detection (16). clinicfans commonly have aught cllenis that 90% of all palpable breast tumors will be detected bv women themsplws (11). However, asa1985revkwofthalfte?ahtlebu O'Malky and Fletcher noted, on; mustlwkattheskeandstagetageofa newly detected tumor to best gauge the efftcacy of any screentng method_ including BSE. These reviewers

found that the mostly desclipttve studies of BSE UD to that time dem onstrated no sig&icant assodations of this screening method to tumor stze or stage. And when cornparting BSE with a combination screening method of CBE and MAM, the former is only one-third as sensitive as the latter in detecting breast cancer (26% and 75% sensitivibg. respectively) (17). This work did not minimtze the importance of BSE. but simply cautioned clinicians from making gmndiose claims regarding the efflcay of BSE and from relying too heavily on BSE as the primary screening tool. In defense of BSE, what the literature has shown both before and since the CSMalky and Fletcher meview has been that when compared with no BSE by wom.m. mutina and even swradic BSE have reduced mortality by breast cancer anywhere fro” 8% to 30% 116-19). In addttion. no investigation has demons&ted negative effects for BSE de@to fears by some that BSE could lead to either false positives (increasing anxiety and medical coskl 01 false nqlativos (leading to false reassurances and increased mortality) (.2Oj. In fact. the first extensive prosuedw randomized conh9led tdal of BSE, &ch is ongoing, has generated early &dence demonstrating that women who practice BSE have been five times as lik*ly as nonpracticers to seek mnsulWion regxdtng breast masses. And when tlimors have been found in women from either of these hw groups. the masgeg diszwered in the group of nonpmcLicers have beer. at least 1 cm larger in sire than thee -es found in the gmup of BSE practicers (21). Thus, BSE has definite benefits in the effort to screen for breast cancer. Despite the advantages of BSE, older wane” have not benefited from this xreenins techniaue as much as have you&r w&en. In One of the first in”esii9al&ls into the relaticn of BSE to breast cancer de-

tection, Foster et a: conducted a retmwactive review of 335 breast cancer patitr’ records and dixovered that older women (7cL98 years of age) conducted BSE at much lower rates than did the total sample of women in the study: 5% monthly for the older women versus 18% for the total group; 16% less than monthly versus 20%; and 50% never versus 35% (221. These findings have been supported in more recent tnwsiigatians W-26). with tbz trend being that the older the woman. the less likely she has been to conduct BSE, either monthly or ever at all. In additton, even when olaa women do practice ELSE, they have hen less than proficient in conducting the exam as recommended by the Amaican Cancel Safety. In a study of 93 women 65 and older, Champion discovered that 82% of the women compteted the entire ESE in less than 5 minutes, 50% used the tips, not the pads, of their fingers, only98 looked in a minor as pat of the examtnatfon, and fewer than 2.9% followed a recommended systemanc pattern for examining the breast or performed the BSE in a supine position (26). Thus,eventb0ugbtherekwne.?+ ldence of the effkacy of BSE as a rreening tad, it will only work if it is impletnented, and implemented pm fictently. Why has BSE not been as eft?cient a breast cancer screening method in older women as it has been in younger women? As previously mentkmed, the reasons are related to individual &ant health care provider, and health care system factors. lndividuai client faaors. At f?rtt, BSEwwidseemtobemoreefficactowtnck?%rLwnnenbecauseofanatomical and phystologtc developments that ofcur wfth aging. The breast structure of ycunger women is more complex with regard to the -nce and nature of mammary duck, shnb, and in many cases, fibrocysttc tissue. In addition, men-

strml rprle changas cor.t*.bu” to tluctuations in breast tissue over relatively short periods of time. In postmenopausal women. especially those not using hormone replacement therapy, atiophy of ducts and glands, along with the ending of mensbual cycle changes, results in lesscomplex@ of breast tissue, theoretically allowing for greater discdmination behveen fatty tissue and any messes that may be present 120). However, other psychological and social factors override this putative advantage. A qualitative investigation by Leat;,ar and Roberts of 136 women from ages 40 to 65 revealed that the older subjectsviewed BSE as a diftcult task because of embarrassment about examining their breasts, lack of confidence in completing the task, and beliefs that for the most part no abnormal findings would be evident anyway (27). These findings of embarrassment,lack of confidence. and disbelief in potential for abnormal findings have been substantiated in Champion’s suweying of 93 women 65 and older. In addltlon, the relation of performmg %E to their own fear of cancer was mentioned by some women as contributing to :heir untillingness to perform the examination (26). This unusual mix of fear of cancer with a disbelief in the passibi:ity of one actually contracting the disease creates a complex line of thinking in older indlviduak that conhibutes to less-than-recommended us of BSE. In an empiric study of women over age 60, Williams reported that 30% of the variance In BSE frequency was explained by such factors as women’s beliefs in perceived barriers to BSE and their suweolibilitv to breast cancer (28). These’findiigs concur with broader investigationsinto older individuals’ amtides and knowledge about cancer in general. As a whole, older persons have diminished knowledge about cancer, including issuesabout detection, symptomatol-

ogy, and early

Wrs”S late treabnent (29, 30). The relatively few symptoms associated with early breast cancer have been shown to contibute to this diminished ability or desire of older women to perform BSE. Because there is little patn or generaliied illness associated with early stages of breast center (IO, 111, many inditiduak do not routinely screen themselves for abnormal conditions. “or do they seek health care if a nonpainful, nondebilitating massis found. Often symptoms such es a palnless ma% are attributed by older inditiduals to normal aains Dmcessesrather than to illness (31, 32). Additional individual client factors that can contribute to older women’s diminished or lack of BSE practice are the normative physical aid mental changes of e&g. Alterations in joint mobillty, visual acuity, and balance have been wstulated althouqh not empirically Lted, to affect ol+:r women’s ability to perform BSE (33. 34). Also, although no scientific evidence to date has related memoty changes to BSE, it has been proposed that alterations in memory associated with aging could render difficult the remembering of the tlmlng of BSE and the constitution and consistency of breast tissue from one exa,,o%x,tionto the next 120). Thus, a number of individual client factors have been demonstrated or postulated to coniribute to older women not conducting BSE as frequently or efficiently as younger women. A decline In BSE practice with eSe alw, has been attributed to health care provider factors.

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Health core provider factors. What role do clinicians olau in influencing the practice of f% in older women? A National Cancer Institute study of individuals aged 60-75 years revealed that older clients view physicianses being problem oriented and not prevention or detection oriented (30). Certainly, this perception

matches *be philosophic bask of the medical model. To date, there is no evidence coraming how the elderly view other providers, including nurse-midwives and nurse-pmctitionen, with regard to their health care orientation. It has been prowsed. however, that the general &blic’s stereo~cal attitudes toward the elderly es being increasingly and inwitably ill with age may play a role I” professional caregivers’ i-lot aggres sively promolitrg sueming techniques such as BSE with older climb (31). What is of interest has been the tendency for health care providers, especially physicians, to focus primarily on MAM, and to some dwee on CBE, as screening took, while @tins little attention to BSE, especially es clients age Published papers focusing on breast cancer screening in the elderly from the perspectivesof family practice physicians. geriatdciansIintemi&, and even consumers fail to address SSE as a screening techniaue f35-373. Scholerlv work has d&&rated that dder women are less likely than youngx women to have BSE taught or ever, mentioned by their providers 118, 23. 38). And despite evidence that havRg BSE taught by providers can markedly lncrea?e the use of BSE by individual clients (2B.381, thk technique mntinues to remain an underemphasized method of breast center screening in older women. One author has suggested that BSE teaching, CBE, and MAM referral for the elderly could be accompUshed &.ciendy in 5 minutes or less (351, even though others have pointed out that cognitive and physical impairments of old ag+ typ!caUy prolong the implementing of breast cancer screenmg techniques (20, 36). Overall, the dearth of published Infomwtion regardingthe prtidefs role in BSE prcmotion in the elderly is @iculerly ~OtW.3rthy.

Health care system factors. Fieyond individual clients and their pro.

Journal of Nurse-h!idwUe,y . Vol. 39. No. 5. SeptemberKktobzr 1994

viders. there are barriers in the greater society. specifically in the health care system, that contribute to less than optimal use of BSE as a breast cancer screening tool for older women. One major difficulty has been related to finances. Altho~igh there has been evidence that teaching older women specifically about BSE improves its use (28, 38), programs designed to promote BSE may be inaccessible to older women whose limited financial status precludes their ability to take advantage of screening services (341. This has especially been the case with women who live alone or with their families i” areas where sewices are not immediately available, as often is the case with individuals living in rebremat communities or long-term care fXilitleS. Another system benier to BSE in older women has been the tendency for teaching guidelines. brochures, and programs to be geared toward women of youth and middle age. For example, the protocol for monthly BSE has been established to coincide with the cyclic changes in breast tissue associated with menses: yet cancerous tumors in older women are theodzed to be indolent and slowgrowing, potentially making detection more proflcie”t if examination inten& were greater than 1 month (2G). Likeuise. the act;~al technique for exantning one’s breasts does not take Into condderation physical impairments. such as arthritis or osteothxxis. that are common among older individuals. Health fair programs that promote BSE or bmchures daisned to appeal to clients to wrfo”” BSE will have minimal effect on the older woman if she is not physically able to catty out the steps recommended. In addttfon, breasts with primarily fatty ti we, such as is the case in older wome”, are best examined from a supine positton. Although thtt is one of several positions recommended in standard BSE insmtctto”s, it may be benefxial to

,oem?J

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place greater emphasis on this paition for older women so as to enhance the sensitivity of BSE in this age group. Obviously. any changes in conceptualizing and promoting BSE for older women should be validated by increased research on the effeas of breast cancer screening on older women. especially for those in their 70s and beyond. Clinical breast exam. Research findings into the efficacy of CBEs have bee” varied. althbugh most studies have noted at leest some benefit to CBEs. especially when cot”bined with MAM, in screening for breast cancer. Investigations originating in the United States (39). Canada (40), and the United Kingdom (41) have generated sensitivity figures with regard to CBE and the ability to screen lor cancerous breast masses. Rates of sensitivity range from a low of 45% (39) to a high of 80% @IO), with most subsample figures found in the 65% to 75% range. Equally es difficult to interpret have bee” findinm that ooint to the abiliti of CBE al& when compared 4th other types or combinations of screening modalities, to detect cancerous masses. The range for the percent of breast cancer cases discovered by CBE alone has been reported from es little as 3.4% (41) to as high as 44.7% (42). Indeed, in one major Eurowan screeninq mowam. CBE was &continued b&u& of its perceived inadequacy in detecting cancer (43). Yet, others have spoken against abandoning CBE es a screening modality because there has ‘se” at least indirect evidence that it helps to reduce mortalr~ at a greater rate than BSE (44) and because there have bee;) estimates that 10% to 15% of cancerous tumors are missed by MAM. many of which are too hrge for detection by MAM and yet would be felt on physical examination (45). Although the value of CBE in detectt”g breast cancer masses contin-

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ues to be debated. what is evident from the literature is that little of the scientific information available regerding CBE. whether pro or con. addresses breast cancer in older women. Major studies and programs dealino with CBE have noted that most investigators have used 65 years as an upper limit in participant a*, with only one study reaching beyond this limit to include subjects up to age 74 (46). Theoretically, as with BSE, atrophy of breast ducts and glands with aging would make CBE r, more efficadous exam. Yet, no evidence that this is the case has bee” presented What is know” from the literature is that with increasing age. women are less likely to have undergone CBE for cancer screening. I” a survey of women of a v;ide mnge of ages. We&man and colleagues diicnvered that those individuals greater than 65 years of age were more likely than younger groups never to have had a breast exam (47). Statistics from a 1987 Public Health Service national health survey indicated that with increasing age, the percentage of women having had a CBE decreases. For example, 86% of wt”en aged X&554 reported ever having had a CBE. whereas for wane” aged 7C-79 the percenege was 72%. and for women aged 80 and older the figure d>opped to 63% (48). A similar pattern of CBE use was found in a survey of 3,507 women from New York state: 56% of women aged SIX54 reported having received a recent CBE, whereas this was the case for only 47% of women aged 7C-75 (2). The reasons for this decline in CBE use with increasing age are vatied, but as with BSE they can be categori2ed as individual cUent, he&h care provider, and health care system factorr.

agi

Indivldud

client factors. There

are

a number of factors related to the decreased use of CBE in older women. Surveying sevew! reviews that ad-

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dress cancer screening in older papuletions, it becomes clear that vafiabler contributing to decreased screening for breast cancer also are see” in decreasedscreening for other forms of cancer. In general, older individuals do not perceive cancer es 2) major health concern, and mistekenly assofiate symptoms of cancer with the aging profess and not a disease state. This can lead to delays in the seeking of medicel screening or care. In addition. many forms of cancer, including those that afflict the breast, are without symptoms in the early stages of the d&ease, thus further delaying detection and treatment. Lack of symptoms is even nwre ominous when one recognizes that older clients in general have a limited knowledge and awareness of screening tests 1491. Rimer et al minted to evidence demonstrating that e “umber of individual client factors are related to underuse c’ breast cancer screening in older women. These factors include less use of prewntive care, less knowiedge about screening examinations and tests, lower levels of edi?cation and income, unexplained procrastination, wcelved lack of Ume, and beliefs ihet provider contact is only newssq when symptoms of a diseaseare present (3). Additional individual client factors have bee” intimated to play e role in the dlmlnished use of cancer screening in the elderly. These include denial or fear of findings and embermsement. In examining the health practicesof more than 400 individue!s aged 54-97. Jrom representative households ecross America, Antonucd et al (501 closelv examined e sububsem;!e & ii0 p&icipa”ts who expressedhaving had et least one of 13 syn~phxnsof possible cancer. Exploring reasons why many of these people did not seek medical attention for symptomJsj. researchers discovared a predictive relation between one’s not wanting to know about a potentielly serious condition and not seeking attention. Although this in-

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ring en examination unless a specific complaint related to a perticular a”atomical area or phyeiolcgic process is expressed (36). Because breast cancer seldom is accompanied in early stagesby symptoms, gnd es has been “reviouslv dixuwd. BSE is a far-Jr&-routine practice I” older women. chances are that in busy precticesCBE will not be conducted on 8 regular basis. Gender isaes appear to be related to dhniniehed use of breast center screening with age. Feminist scholars have long noted and. n-ore recently, the popular press and the federal government have concurred that there existe a bias in health care research and delivery away from women and toward the need& me” (55. 56). Althowh attern~te at the policy level have-&e” &de to reverse this trend, the bias mntinues to pTeve0,including at the cli”icel level. Assessmentof breast cancer in older worne” is no excepticiri b this phenomenon. Evidence of this can be see” in the health care of worn+++ Health care provider factors. in long-term care facilities, where There has been a wwrej leek of inbreast ce”cer xree”kq occurs ten sistencefor CBE b;providers astheir frequently for these wome” than for dients age. Several surveys have those in the general pop&&ion (57). demonstrated that the older a However, d&ease sates that effect both me” and women, such es hy. ~01~11. the less likelv she Is to have had a dBE, either v&in her lifetime ~neion and diabetes, continue to (47.48) or wlwn the I& veer of bebe screened for and tmeted in resihg’sukeyed (48, 53j:Although dents of nursing homes. And this is the case even though breast cancer is there has been little research rp~cific to the reesom for diminlshlng use of a dfsabllng and painful disease when k&d In the early stages(10, CBE by providers with the Increase in clients ases. swculation from in571. Certain diseases. !n Dartrcukr direct evid&e 4” be made. ihme that cause the imajmi& of marThere is a tendencv for health care bldity and mortality in me”, receive providers to spend-lees time with greater attention from the medical esolder female cl?ent5and to give more tebhhment. Breast cancer, almost abbreviated explanations of health exclusively a women’s disease, hadicere pmceesee end problems (54). IionaUy has not obtained this attenPart of thii may be related to the protion. vider’s time availability because the Providers’ perceptions of prodiminished physical abilities that ofjected life span and quaOty of We of ten accompany older age can add older women are likely to pley en adconsiderably to the time needed lore ditional role in dimlnished use of client to undress when at a clinleian’s CBE. In a survey of primary care office. In busy offlce prectices, this physicians, close to one-third did not can lead to the practitioner’s deferbelieve that e 75~year-old woman

vestigetionwes no! specific to breast cancer “or CBE, it does point out what has been anecdotelly evident to hen conpractitioners for yhonted with the pus.sibiSiyof a pa teniielly zevere illness such es cancer. many clients prefer a heed-in-thesend approach dmt often reflects denial or fear. The rmbarressment of having a CBE also has bee” shown to have an eifect on the use of this screening tool. This has bee” parUculerly evident in various subculh~resof Americe” women. especially Hispanics. Two etudies in Be Los Angeles region eve: the M decade have suggested that embarrassment has played a role in the low r&s of CBE found in samples of Hispanic women, eepecielly among the older women in these groups (51.52). This evidence hints et individual client issues, such es body image and mcdesty, which may reflect cuhuml variationq es playing a role In the “se of CBE es a xreeil for breast cancer.

not

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Vol. 39. No. 5. !Septemberl0ct&er 1994

could expect to live a” additional 1CL 15 years beyond her cunent age, despite life-expectancy figures ?hat demo”strate othenuise (4) In addition. it is ironic Rat breast cancer prevention, which is the onderlvino ouroose of CBE. has not bee” viewed as a priority within physician-based practices. The reasons for this were hinted at by Weinberga et al when they explored physicianrelated barriers to breast cancer screening in older women. Their as sessmwt of this issue of preventive pracbce focused not on risks and benefits to the client, “or on the eff&iveness of the phydclan in conducting CBE, but instead on the cost to the physician in terms of tie and money: “implementing preventive care orotocd: is time consumins. and the health care system in u;; United States does not movide adequate reimbursement tdr physicians’ tlme svznt In mwention or counselii-@ (58). understandable. then, that older Individuals have tended to wrceive physicians es problem oriented rather the” prevention odented (49) a”d have expressed opinions of physicians w being too hunied or too focused on fi”ancid concerns (59). There has been some evidence that other pmctiao”as, such es nurses. call have a positive i”flue”ce o” clienk’ perceptions of the CBE and subsegusnt desire for repeat aa”+ nations. (n the Canadian National Breast Screening Study, which involved 90,000 subjects over a” 8-yearpedod. CBEs were paformed bu “uses who were ce”kallv trained b&d on a standardized CiE protocol (60). More than 90% of the wo”~e” surveyed after szreening by both CBE and MAM stated their WI& lngnese to accept future CBE -ening, citi”g the compesslonate, rea5swing, and informativs netore of the examiners as favorable eszpocts of their oxamh-&ions 146). One could pmject that like-gender of client and pactitiner was a factor in this finding, although this vadabk was “ot di-

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Joemel d Ne,ee-w

rectly assessed. Whereas there has bze” some evidence reported that even amo”g physicians. fanale prw viders are more tuned in to issues of o&etion and support with regard to breast cancer wreening (59). others have more broadly intimated that it is less the gender of the practitioner that is related to client-orovida con“ectedness. end more the type of ir.edical training and background of the clinician (56) This issue of the ‘ype of kaining of providers may indeed contibute to the diminished use of CBE in older women. Screening CBEs are periormed by any number of pmctitio“em. including nurse-midwives. nurse practitioners, gynecologists, family physicians. Intemlsts, and mdiooraohen. The ohilosoohies and for these- professions ten vary considerably and can be retlected in the manner in which physical examinations occur. For aampk. in discussing breast cancer screening in older women from a fanfly medicine pelspectie, Fmme ornooses that the conductino of a tiBh, the teaching of BSE, aid the referral for MAM could occur within a 5.minute time frame, noting that -even five available luxuw if the maciice is not sbuctwed so t&t prevention is a pior@/” (351.

depending on the @pz and location o! the practice at which the examinaSo” o&z-, and on the force of inflaBon. Nevertheless, no matter what the cost, there are indicetions that older women often cannot afford the funds required to have a routine CBE (34) or. as is often the case, any form of preventive medicill care (62). These cost !imitatjons xe asxociated not only with the actual peyment of provider, but also with travel exp0nse.s and ~tentid caret&taking costs required to ge: to an appointment or screening center. Although various nationwide health organizations. such as the American Cancer Society (63) and the Natio”ai Cancer Institute (64). have called for CBE to be performed on a” annual or biennial basis for women over M veal? of Fg+, there often has bpcn difficulty imp!ementing these suggested guidelines. One weso” is the global nature of tnese guidelines, with !ittk reco@ion of the divers& individual natures of the w~me” of t&s larqely heterogeneous group (36). Older women range in health and activity level from very self-reliant to completely dependent. Should the individuej with severe im,.wdmmk and comotid disease receive the same focus of breast ca”ce~ screening as tbo same-aged individuel who continues to work, lives independently, and has no functional dkability? There k obsemational evHealth core system factors. As idence that phwcians do not perwith any screening prows5 or interform as manv CBEs as tkv themvention in the United States, one of selw report hating done in older the fundamental baniers to ehiciencv women 0.5j, and it has been sugand compliance is cost Typically, the gested that physicians have &ays cost for a CBE “aties considerably tailored screening care to their pmthroughout t!x cowhy. Studies infesrional assasment of the perwIved vestigating outcomes and costneed for such evaluative measures as effectiveness of CBE have estrmated CBE (36). Thii I”dMdualketion of prices to be in the $20 to $25 range sneening, along with a lack of more for CBE alone 161, 62). These suecific gufdellnes from groups such amounk are dfh‘it to ge”diZZ bsai the Aiietin Cancer Society and cause CBE usueliy is pert of a more National Cancer Institute. has cwextensive examination. the breakated confusion among conwmers down of which into individual deand pmcUlioners alike about how ofscriptions for pricing puwows hes tea to conduct CBG. been herd to accomplish. In addition. Availability also has been a” issue there can be a wide range of cosix

t&i,

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with regard to CBE. Not al! older individuals have, or can afford, a ‘esular pmctitioner, one who can regulady promote cancer screening and achmlly conduct CBE (651. In addition, it is unlikely that a consistency in techniqueand quality of examination among various praciitioners exists (46). A related factor to consider is tl& many older women receive their primay care from generel internists and geriatricians. There are no data to address the issue of how much tining and experience these prectitloners have in wnductina CBE. And the question needs to be r;lised about the extent of their skills in assessins breast tissue when CBEe may not b; a regular component of their clinical regimen. There has been evidence from the Canadian National Breast Screening Study that those in&idu.&. who have conducted greater numbers of CBEs have had an increased chanceof diagnosing a cancerous breast mass (60). Thus, from the wrspect+.veof the general health care systems, inconsistency among prectitioners with regard to CBE can be viewed as a major obstacle to efficiency in breast cancerscreening in older women. Finally, an additional health care system barrier for older women has been a general lack of wellability of promotional information regarding breast cancerscreening. Public education program and literature have been geared toward middle-aged women, and usually have focused on cel&dtles who have experienced breast cancer,rather than presenting a lame range of twes of individuals who&e been &&ted with this dlsease. Also, what information has been disbursed has been geared toward more educated consumers, who typiilly already are more inclined to have had breast cancer scrrzaing on their owr, (37). This is addhional evidence that when it mmes to breast cancerscreening.the focus is away from low income, less educated.older women.

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Mammography. A review of the literare offers abundantevidenceof where the emphasis lies within the medical and scientific community in regardto wreening for breast cancer, and that is with mammography. There are an extensive number of publications that address everything from the efftcacy of various manmcgraphy equipment to the ethics of mammographicexaminations in residents of long-term care facilities. When examining scholarly works that purport to address breast cancer screenine one notes that the maiority of issues raised or date colle&ed involve MAMs, often with simply a passing mention of BSE or CBE. Desptte all of this emphasis, the use of MAM in older women is limited by the eeme baniers that confront BSE and CBE. Unlike BSE and CBE. a one-time mamrnoprilm can detect hnnors less than 1 cm, and maws as small es l-2 mm can be found when MAMs are used on a regular basis (45, 66, 67). Of canceroustumors exemined by MAM before actual diagnosis, 85% to 90% have been detectable ti this technology, titb many of the missed masses being too large for this refined screening technique (451. This speaks to tke importance of us= ing MAM with CBE, becausethe latter is the more efficacious method of detecting large breast messes. Indeed, a number of large-scaleinvestigations into the use of MAM and C3E as breast screening methods have wncluded that the most efficient approach Is a combination of these hyo technioues(41,42,6X$691. As with BSE and CBE, there is lees use of MAM with older women. Whereas 60% of women suweyed nationwide in 1990 reoated ever having had a mammogrdm(701, several investigations have noted that with increasing age, there is less likelihood that women will have ever had this roen$enographic exeminadon (47, 71). Perhaps the most speciflc evidenceof this trend camefrom

_.

the National Health lntetiew Survey in 1987, which noted that although 44% of women aged5&59 reported ever having had a mammogrem, the retes for ages 7G74 were 32%. for ages 75-79. 30%, and for ages SO and over, 19% (48). What could be viewed as ironic about these figures is that the abiliy to detect early breast cancersby MAM is actuaUyincreased in older women. The 10% to 50% of breast cancersundetectableby MAM (45) are often, whether small or large In size. similar in radiolo& attenuation to normal fibmolendular breast tissue. meaning that &hen one view the MAM film the shadows of the tumars are indistinguishable from surrounding breast tissue. In an older woman. unless she has been on a regimen of hormone replacement therapy, fibrcglandular breast tissue has been reduced considerably, and most of the breast Is corn@ of fat. Because fat has a much lower mdioI@ attenuation than do cancemue turrlors. even wy 3nlall masse3 are distinguishable In MAMs of older women (72). Thus. one wouki exwxt MAM to be at least as effective. if not more IO, in screening breast cancer in older women as it 1s in midlife women. Yet, the use of MAM is decreasedin older women. and the two most commonly reported bardas to its we have bden the following: 1) the belief by women that they did not need on& especially when no breest wptoms were pxesent and 2) the lackof recommendationby tllelt pracnno~ (73, 741. lndiufduol client fociore. Many older individuals do not percalve cancerto be a major health concern. In a survey of more than 900 women aged 50-74 conducted by Rimer et al (31, older women were significantly less aware of the increased lncidenco of breast cancer with age: the oldest age group of women in the study 17C-74 yeare) were more likely than those in younger groups (50-69 years) to believe lhat MAM was only

Journal of Nurse-Midwifety l Vol. 39. No. 5. SeptpmberK)&d,er 1994

“ecessaly if symptom-. of cancer were oresent In iheir review of the literatcre. Rimer et al noted that many of rhe variables related to diminished use of CBE in older women are also related to a decreased “se of MAM (31. These factors “icluded less use of oreventive care durino advancins bge,less knowledge of P&M in older :wme” than in midlife individuals. a greater lack of belief by older women in the benefits of MP_M, unexplained prccraetination, and a perception of a lack of time in which to have testing done. Similar variables have been noted I” studies of African-American (75) and Hispanic (51, 52) women. There has been evidence that for the latter group, embarrassment also olavs a sim&ant role in the under;&of M&, as it does for CBE (51, 52). Fi~lly, the fear in older individuals of discovering a potentially serious condition such as cancer (511 ap pears related to the decreased we of MAM during advanced age (59). T-here are additional client-related factors that are more uniquely related to MAM itself, two of which invoive fear. In a qualitative study by Zapka and B+rkowik (59). one commonly expressed concern of older women was the queaon of the effect of cumulaiive radtoactivity from the suecessive annual or biennial MAMs that are currently recommended for breast can&screening. This fear is not totally unfounded. Asch and Haagens& presented evidence from 14 l”vestigati~s coverklg a period of more then 50 yeare that showed a” increaeed risk of breast cancer in wornon who were exposed to ionhing radiation from a variety of sources (66). The authors pointed out that, although current dosages of radiation due IO MAM are less than dosaca from roost standard radioltx$c ewrntnatt.ans, the risk of ca”cer from ionizing radtaiton te cumulative over time. It is unreesonabk to think, @,a cument evidence, that a few MA& in a lifetime would induce

~--

I~~

cancer. However, it remai”i unclear whether the routine use of MAM for many years is a causalilie factor 1” the acquisition of breast ca”cer Gohagan et al projected that the typical screening dose of MAM ccntributes to one to three new breasr cancers per year out of 1 million women (76), a risk that the authors considered acceptable when weighed apinst the number of early breast cancers detected by MAM Thus. the etidence winh to the fact that rhere is indeed y~me risk of inducing cancer through the use of MAM, but how much of a risk is unclear. ‘This confusion ce” certainly contribute to the fear in older ~“vz” oi :he cancer-causing aspects of routine MAM screenins A second fear of older womerz that has been recognized concerning MAM screening has been pain during the procedure. Despite assertions by the National Cancer Intitute that a mammogram “may be slightly uncomfortable” (77). older women who have had a mammogram have deeatbed the examination as everything from discomforting to painful. And although not grounded i” actual experience. women who have not had a man,n,ogram and yet fear the procedure have commented that others described the examination to +&em as beI” very painful (59). Inter&in”lv enouqh. in the Zaoke and Berkowitr shrdy,“one of the-women who had had a mammogram and reported pain or diiomfort with the procedure said that they would retw to have another mammoqrem in the future. On the other hand. in the Canadian National Breast Screening Study. only 69% of the women involved were willing to have a repeat mammogram. whereas 94% were willing to have repeat CBE. with discomfort of the m&mxgrem being ;u#ed as a major reaxm for the lack of desire for a second mamnwgram 140). Thus. whether pain. like radiologic exposure. is or is not an actual ask for most women obtaining a mammogram. the fear of

these factors can be significant mough client-related variables to contnbua to the lack of use of MAM in older women hr breast cancer screening. Health care provider factors.It appears that some health care providers consciously set a” upper age limit at which they stop ordering MAM based on biologic years and not on inditidual developrnentel status. Their expressed concerns include the following: 1) whether the screening and testi”gprocedl;res are worth the time and discomfort for the older woman, and 21 whether preexisting medical conditions are mme of a threat to the woman’s health and welfare than breast cancer, and thus warrant greater attention. As one physician stated, “She would have died of something else before she would have died of cancer” (59). This approach to health care dehvey for older won?en is a good example of the paternalism that has dominated the medical cere system in this iountry and which has been particularly a force in the care of older women, who were raised in a” em when the physician was not to be questioned or doubted (55). Whereas younger women today are increasingly more inclined to take steps toward controlling their own health cere. if phy+ ciens do not recommend xreening tests. older clients generally do not ask for them. Related to this lack of recommendation is lack of a regular provider. Evidence points to the situafion in which having a regular sowce of care is related to higher mte~ of MAM. Zapka et al reported that hating a reqular clinician. espeally a gynecdogist was more predictive of having a mammouram than were variables such as client knowledge of need or cost of the orcxedure 1781. Similarlv. Burg et al’noted that women u~l;o had regular physical examinations with ~ecologists were more likely to have CBEe and MAMs then those

291

indlvlduals who received sporadic care (79). Alth,xtgh older women visit phystctansmore frequently than do younger women (58). there is evidence that in the forma cohort, especially I” women 70 and older, Ule visitsare more episodic and Iw regular (31. Thus. without “se of a regular &wider ihere 1sless Ukelthood for screening recommendations such asMAM. Additional factors related to lack of recommendations for MAM for older wanen by providers have been clinictans’ p~eptions of perceived low yield of MAM rwatng, concernsregarding the reliability of mdtolcgy repa& perceived lack of time for making a recommendation. forgetfulness, and co”cems about the costs to clients and about the lack of compliance by clients (36, 58.59, 80.811. Unfortunately, these clinician concerns, which have become barriers to breast cancer screening dting advanced age, are not entirely based on fact For example, despite legitimate complaints about the wide-ranged and typically overpriced costs of MAM (35, 37, 82), the issue of cost as a banier to MAM is more often mentioned by physicians than by cltents themselves (59, 811. Also. evidew regarding client compliance Is v&able. In a review of studies that have examined complttnce in settings ranging from family practice offices to hospital-sponsoredscreening prcgmnx. Frame reported actual client follow-up to MAM referral es ranging from 35% to 95% (35). Thus, clinicians’ decisionsnot to muttnely recommend MAM to certain clients, such as older women, can serve as a major banier to this aspect of breast cancer screening, espectally in light of the evidence reported eattier that lack of a physician’s reccenmendatton Is a ma)or reason why many older women do not receive a m?.nlmcgra”l. Health care system factors. Many of the barriers ta MAM rreenina in older women are similar to th&for

7.92

CBEs. One of these impediments concerns a lack of cc.“senw about how often MAM should be offered, espectally for older women. Several national health gmups, i”cludt”gNCl and AC5. have promoted banning annual screening anywhere from ages 40-50. There are no age ceiliigs mentioned in these ref~mme”dations @3.-88~. On the other hand, the American Geriatrics Stietv and the Unlted States Preventive S&ices Health Task Force have suggested Mennial MAM, with no mention of screening beyond ago 85 by the Society or beyond 75 by the Task Force (89, 90). Finaliy, the Forum for Breast Cancer Screening In Older Women recommended that MAM be offered “approximately every 2 wars” for women aaed 65-74. although it was noted & rexa& has shown sched&s ranging anywhere from 1233 months to be effective In screening for cancer (91). For women 75 years of age and older, the Forum recommended biennial M4M for any individual “whose general health and life ape--are saod,” em~hhasiztns that the decision screenI& be “I& by the vmma” he&f or in conjunction with her physician and family (91). Therefore, lf confusion exists among older women and their practitlone~ about remembering and implomentlng screeningschedules,it is Ukely due In part to the !ack of consensusamongrt health care organizations and task forces on how frequently and up to what age MAM should be performed. A s&ond “war syste”~-banierhas been the cost of MAM. The price of a screening mammogram in the last decade has ranged from $40 to $300, with mosi tesk falUng within the $100 to $160 rango (35,37,82). Only recently, and mostly because of prossure from newly emted state laws, have health insurance carriers offered MAM screening as a beneflt for members. Medicaid coverage for MAM is only found in a few states, and because most women of midlIfe or older years do not qualify for this

in

health care bnefit, it has had little effect on MAM screening (371. Perhaps the most impartant funding for MAM screening in advanced age is Medicare. Until 1991, Medicare did not fund MAM, and it was only the result of pdtttcal p”ure that the benefit was initiated at that time. However. a biennial reknbwsement fee &a&e of $55 was the “Iaxkn”m amount first permitted by the Fedoral Govemmenf and since then the cap has only been raised to $59.63. (It should be noted that Medicare acblally only reimburses 80% of t&t fee, and that the remaining 20% can ettier be waived by the prmider or charged to the client 137, 92, 931.) Because the average mammogmm costs greater than this amount and because most health care organizattons recommend an annual MAM. eve” this benefit often necesettatos out-of-pocket payment by tndividual cltents. Thts fact does not bode well for aging women. Despite older women’s tendencies ndtodlscusscoskofMAMwltbthelr provtders (59,811. the economic statatus of this age cohort of wane” in A”wrkx” mlely Is far from great. Three of four elderly poor are women. As they gmw okz-er,wane” becane i”crea&& poor. And outof-pocket cask fo;-&senUal “wdkaf care. which averwed $1.237 an”“diyin199Ofor&“ler;lborsofsoctety,havebee”co”&redtobea @“Ifkant contributor to a powriy rate a”m”g dder A”l&ca”¶ that ap proaches 20% (37, 92). There has boo” evidence presented that these eco”antc reaUtia contribute to dtmlntsbed breast smeentng In older women. Mar et al. in andwins data from the Natto”&Center ior f&&h Statisttcs, reported that for w~nen fmmages65to84,merehasbee” anywhere from one-third to one-half IessweofMAMbythosewhoare below the pawty level when cornpared with individuals above this economic marker (94). Thus, although its dtrect effect is dlfecult to gauge, the casteof MAM -likely

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to be conhibuting to the diminished use of this screening tool in o!der wonlen.

Related to the issue of costs in the use of MAM are availablli~ and aceessibility. Just as with CBi. not alI elderly individuals have, or cd” afford, a regular pr.ciitio”rr. This can be a banier especially in rural and -one, city areas of the counhy. where the numbers of primary care prowiders can be vey small (59). In addinon, Lndividuals in these regions are often without safe and affordable hansnwtati~“. and as with the older pop&ion in general, may have functional disabilitks that limit their ability to tmvel independently (62, 9:). People fivklg in I~-term are facilws can be mast affected by this barrier ff the facilfties themselw do sponsor MAM programs designed to reach these individuals (36). In gznemf, community-based outreach programs using mobile va”s or central&d Screening locaUON have demonsbated success in inaeasfng MAM use (95); but their auailabiity nationwIde Is sporadic, and their abflfty to increase screening In ofder w”w” has bee” undednv&g&d or u”repolt~. A major concern wfth a~ilabtlfty is not only whether MAM scree”fng is convenient. but also whether the equipment, toch”kian, and radkdc. gfst avaikble are r&able. Over the partwupleofyea,newsmedfaexp&s have pointed to the wfde vatiety in MAM OwaminatioM ad interpretations. and these issues nive been r&xl In rchobdy publications as well f9699). Ir&ed. one limited but &alfng study haci 10 radiolo gis&fraamkedbackgmimdofpdvate pm&e and academia interpret a safes of mammographk images. There were .zowdemble dixrepancks in their Andmss and suwesUons forfolhw-up &with fzdsG*m hadIng ran& from 20% 63% (971. The impllcanons of these questkms of relfabfiity can bo prorWnd Fake-positive readf”gs can lead to

not

to

u”“ece55ary surgery and psychological trauma. False-negative interpreiations m” ths risk of undiagnosed carcinoma and subsequent morbidity and mortalitv. as well as potential kgal co”lplic&ns (45.94,lOO. 101). The inabiitu of the medical world to oversee quality as3”m”ce of hwl wreening has kd to a lack of confidence in the general public regarding this testing and helped to bring about the congressional passage of the Mammography Quality Standards Act of 1992, which implements Food and Drug Adminisbatio” regulaikn of the MAM screening indusby (99). How these issues of reliabiihJ and quality assulilllce affect MAM use by older wane” is unknown, but it is unlikely that these matters p*o”mte screening during advancing age. Bxause obtaining MAM is linked to being recommended for this testing by ; health care provider 131, the fact that many alder individuals do not have, or ¬ afford, a regu!a pmctitionet (65) means that there is decreased chance that members of thii age cohort are Ed” aware of the opp-or~~“ity for this farm of breast cara screening. This emphasizes the need for awssfng older women through other means. specifically public &canon and outreach. rfauover, It has only been recently that such moulls as NCI and ACS have b+guRto mget older individuals for xreening, as etidenced by brochures now available that are specfiic to older members of the general public (102,103). Any outreach to o!der women, however, needs to recog”ize psst ba”iers to knowledge dissemination among these individuals. These baniers have included use of languag-z that is not easiiy underst.xd,thatiswdtte”intwetcormall to be legible, and that is not tarWed to specific populatio”s, especially n&E”gUsh spealdng groups. In addltlon. any screening infonnatfon needs to be better disseminated al gecqmphic locations that older indivfduals are likely to frequent 195).

ipL&fidy

overcoming

are vital stepsin health care system baniers of MAM in older warnen

There

to the we

Treatment If a” individual has been screened for breast cancer and subsequently is found to have a ma&ant tumor. the treabnent that follows can “a~ considerably, depending on the type and extent of carcinoma. the availability of various fcmns of treat”w.nt, the recommendations of various health care providers, and the choices the woman n-&es concaning her own health state and future well-being. It is beyand the scope of this article to raiew the literature concerning the &button of treahnent mod&es forbreasicanceranwmgoIdawomen. It should bz stated, however, that there has been evidence reported that notes dislineSons in the diagnos_ ing and +xeealme”t of breast taxer b&wen older and younger women. As pointed out in reviews by Clark (12) and Sdariano (104). older women with breast cancer are more likely than younger women to present with advanced disease and to have poorer survival rates. Many older women da not receive complete workups for stagfng of their cancer and often do not undergo optimal therapy for the disease. Part of the re?.so” far thii is the existalce of comorbid conditions, such as diabetes or heal disease, that are deemed by medical pewnnel to be preclusive to extensive keahnent of the canw for fear of complications *el&d to the presence of the coedsting d&eases. However, although research is limited, there has been sOme evide”ce suggesting that many older wume” ca” both tolerate and benefit from “vxt treatment modalities. incfuding sulgey (lumpectomy. mastectomy). radiothempy. chemotherapy, and endocrine therapy. Again, as with screening. Vestment of older w-amen varies because of in-

293

ditidual client, health care provider, and health care system factors, many of which are related to a general lack of information about breast cancer in older women, or misinterpretation of existing information by clients and providers alike.

SCREENHG CONSlDER.AllONS With regard to breast cancer screening in older women, the various barriers discussed earlier wint to the heterogeneity of this &up of individuals. Many complicated, interrelated factors ire involved in the dirnJnishingamount of screening that occurswith aging because, like other phases of the life span, aging does not mean conformity or homaneKy. There are a range of issuesfor the nurse-midwife, nurse pracdtioner, or any health care provider working with older women to consider with regard to breast cancer screening. These issuesrange from reexamining the tech”ique of BSE to questioning whether MAM should be recommended at all past a certatn age. Breast Exam The examination of the older woman’s breasts, whether via BSE or CBE. should account for anatomical and physiologic changes of aging, as well as the hme of breast diseases found most &mmo”ly during advanced age (201. Because of the theory that breast cancer found in older wo”~e” is likely to be more indolent and slow-growing, consideration may be given to lengthening the interval between BSEs anywhere from 2-3 months to maximize detection of changes. Indeed. there is evidence that too frequent examinations of the breast create as much difficulty in detecting growths as do too inhequent examinations (105). It has been suggestedthat lengthening the interval of BSE could create a problem with memory, because the woman is required to compare

one examination to the next for acrumte asseSSme”tto occur, and because she needs to remember actually to perform the examination et a dve” interval. The latter potential problem could be addressedwith the use of calendars and temporal cue% such as holidays. dates of seasonal changes, or family members’ blrthdays, that could be mapped cut for individual clients. The difficulty of mmembering breast composition from one BSE to the next may be handled by using e descriptivelog or BSE record in which the client would des&be findings in wlting for future reference. This typp of memory aid has been used as pari of broader investigations,but there has bee” little reported evidence as to its effectiveness (20). Grady has sugg.&d that BSE instructions are too detailed, with too many steps, to foster acceptability to women, especially those who are older (201. Rather than promote the current guidelines, which call for the use of several positions (standing. lyino. bendlns at the waistl and D&XItion with the finger pads, perhaps instructions could be simditied bv first emphasizing only the lying-down positio”. For older women, whose breasts are primarily composed of fatty tissue. this may be the best method of spreadtnq the tissue over the chest wall, thus &easing the effectiveness of oal~atton. Simllarlv. the suggestion ihe w of a par&ular part of the fingers, palpating according to a very specific pattern, may be too burdensome for someone who may have arthritis or some other condition that Umits mobility or sensitivity of the hands. Emphaslzlng a more general palpation technique that focusesless on details and more on total coverage of breast tissue may be less intimidating or more practical to particular individuals. Certainly, these suggested changes warrant research to examine their efficacy. If ament guidelines are prohibitive to BSE in older women, however, considering optional tech. “.

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for

Journal of Nurse-hfidwiky

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“iques may at least encourage some form of self-examination rather than none at all.

Clinical Breast Exam Although, as noted earlier, there has been some question as to the value of CBE in screening for breast cancer. it is difficult to argue against maintaining this healthasse&ent tool. Certalnlv. the cost of annual examinattons ii an issue that needs to be addressed for many clients. However, including CBE in a general physical has not appeared likely to have added significantly to the costof thtt examination: and the opporlunity during thtt contact for praciitic“ers to teach and uodate clients on stepstoward healthyiivingis one that should not be take” lishtlv. Also. if MAM is, as recomm&d;d sub&quently. to be used less frequently than annually, and because MAM testing results I” a false-negative rate of 10% to 15%. certafnly there is argument for maintatning annual CBE as a part of breast cancer screening.

Mammography Because there IS no Dvldence as to the effectiveness of breast cancer screening during advanced age. especially after age 75, should current NCI and ACS recommondalions for ammel MAM be followed? Several practicing clinicians and research scholarsthink not (59.63.94). If lumars ln o4derwomen are more lndolent and slower growing, and if women in general are less apt to rehim for MAM testing then, for example, CBE because of the &comfort, cost, and technologically “cold” Mhire of MAM, then it would be beneficial to detection and compliance to recommend this screening test at greater Intervals, such as bttnial~ or hiennta!ly. Research would be required to assea the effeck of these changed suggestions on morbid@ and mortality related to breast can-

Vol. 39. Na. 5. Septembe&ctdxr

1994

cer. However, as with BSE, some form of testing seems likely to be better than none. Part of the clinician’s role in adequately screening for breast cancer should be assisting clients in receiving safe and reliable MAM. Beginning this year, each of the approximately lO.OOa U.S. facilities offering MAM will need to meet minimum standards set by the Food and Drug Administration as a result of the Mammogmphy Qua!@ Standards Act of 1992 (99). Each clinician, especially if using e single facilii for referml, needs to keep abreast of the certification states of the testing site so that the clients’ needs will be best met. Also important is recognizing the training, experience. and skill level of the radiologist who interprets the findings, as this is Information that is sometimes difficult for clients to access. or even to recognize as being important to their h&h. It should be noted that other forms of technological screening for breast cancer have bee” proposed. induding ultrasound. magnetic resonance imaging. and thermography (45). Although each of these presents some benefits to the detection of cancer, they each present caveats that prevent thefr use as pli”laly vreening tools: for example, sonogmphy most accurately determines the size of tumore, but does not detect breast microcalclffcations. Thus, only BSE. CBE, and MAM continue to be considered the three main breast cancer screening procedures. Public EducatloniRcenotfon Perhaps the greatest sewice “usemidwives, nurse pmctitioners, and other health care providers can offet regarding breast cancel screening to older clients is to 1) sort through the litemtwe and suggested guidelines; 2) establish as clear a picture as pasable, acmunting for the beliefs of clients, dlnlcians themselves, and the medical community as a whole; and 3) communicate this information to

the public. This latter task is one that needs to account for the heterogeneity of older women. and one to which practitioners can contibute considerably. Several researchers and health care groups have worked to promote breast cancer screening among older women. Suggestions have included using the following:

ethical, legal, and political questions that abound. Breest cancer screening in older women is no exceotion to this. On the surface, it wodd seem that there would be little oppositio” to at least some form of screening for breast center in women of env we. indeed, the general tone of iis ;eview is that this screening is beneficial and that there are a number of barriers that limit its use during adl Group discussions, audiovisual vanced age. However. the question materials. modeling, and guided must be raised as to whether this practice to improve BSE 1106) screening is for everyone, and if not, l Coupons and prompts as incenthen for whom should it occw. tives to increase MAM use (107L Ethically, are practitioners able to l Trained. accessible wen. such as decide who should and who should hair stylists, to promote use of not be sueened? On what basis do MAM and act as a social supcat they make that de&ion? Evidence network for women u”de&ng reported earlier indicates that many testing (3). providers set age cut-offs for the ofl Small groups for presentation5 ferins of MAM. If a WQ”V.” who ts &?a about screening, using witten mayears old today has a life expectancy ted& with large W; visual mateof more than 7 years (95), and cliniriels with simple, clear graphics cians only promote MAM up to the and quality sound; active parti& age of 75 or 80, could thts not be pation of group members; and a” viewed as a disserv%e to older entertaining approach that is clear women? But, then, one needs to adand unambiguous and recogniw dress issues of comorbidily and qualthe need for respect and indepenity of life, If a 78.yew-old woman has dence in older individuals (3. lOB, extensive cardiovascular disease and 109). diabetes, and is projected to live only Clinicians need to be aware of what a short lime. Is she a” individual who cancer screening programs are availwarrants screening for breast cancer? able in their geogmphic areas, to Or what of the woman with dementia which groups these programs are tarwho is nonambulatory and living in geted, and how accessible they are to an extended care facilitv? Are CBE the older women with whom the cliand MAM taking the i&e of screennicians work. Also, if practitioners are ing too far? Initially, this question usingtitten materials in conjunction would seem to warrant a” affinnatlve with their promotion of breast cancer response. Yet, terminal disease setscreening. it is important for the onday to breast cancer is usually caregiws to know what Information very painful and not necessarily is contained in any handouts and to moid. Not to discover a” earlv-stage see that it is in accordance with what c&nmnain this woman may-be d& is verbally being sug+ted. Just as ing her a great dissewice. This raises kmpcetant. information directed to CIIthe always difficult question of quality mts, whether verbal or written, reof fife. Who should define this for inquires recognition of their social, culdividuals? It would wan the individtwal, and educational backgrounds. uals themselves. Yet. when a proand should be teilored accordingly. vider has an age cut-off for recommending screening, is not the clinician the one who is at least part&&y deciding? With any medical screening tool. test Beyond concerns about the inditherapy. or procedures, there are

295

vidual, ethical questions also ere raised regarding the issues of costs and rationing or care. With the inevitebility of health care reform. it appears that difficult choices will need to be made rega%ng who is screened for what. and to what extent. Will limits be on breast cancer screening and keatment? If so, till cornparab!+ Emits be set on prostate cancer vreenlng and treatment? Who will decide, and by what parameters? Certainly, these are broad issues that cannot be directly dealt with by a clinician who is counseling a client But they are issues about which the clinician should be ware when fonninq the bash of that counseling. The number of lawsuits related to failure to diagnose breast cancer have bee” on the rise (100). Although it is important clinical practice be driven by professional standards and not by fear of lawsuits, one must recognize that litigation proceeding often are related either to a practitioner’s not having followed the cummt standards of practice or to the legitimacy of the Standards being questioned LllO). Wlth regard to for breast cancer, it is difficult for practitioners to know what the standaids of practice are for older women. As noted earlier, var. ous medlcal organizations have either differinn recommendations for screenbg d&r women or have no specific recommendations at all. On the one hand, this can make it difficult for clinicians to know whet to recommend to older clients. On the other hand. this should allow both the client and clinician to make screening decisions based on the individual needs of the wrson. although just one legal de&ion based on the lack of screening for breast cancer could alter this practice considerably. Pojiticauy as well as Ie@uy, there are researchers, practitioners, and health care groups alike that question the current recommendations for breast cancer screening and the motie behind them (59, 111, 112). Al-

iet

that

though the National Cancer Institute and American Cancer Society have based their recommendations for xreening on the evidence that use of BSE, CBE, and MAh3 has had some effect on detecting ca”cexous tumors in early stages, the incidence of breast cancer in Amelica wntfnues to rise. and mortelitv rate due to this fon;l of cancer l&s not decreased over the last several decades. This being the case, questIons have been raised as to why so much of the emphasis in research and education has been on screening and treating breast cancer and not on prevention (113). Some hew suggested that this is due in part to the eoanon~lcs of fighting cancer. For example, the American Cancer Society receives funding from manufactures of MAM machinery and film products, and these indusbies have a financial bterest in maintaining high “urn& of individuals who use thii technology (114). Following the publication from the Canadian National Breast Screening Study of findings that routine MAM in women aged 40-49

contributed nothlng to the reduction of from breast cancer 1115), several he& organizations, most notably the National Cancer Institute. event&ly withdrew their recornmendatlons for annual MAM testing in women of this age group who had no contributing fisk factors (116). However, the American Cancer Sodeiy to date bs refused to change Its suidelines. and has been accused of iobbying tiCI and the White House to have the U.S. Federal Govemment reinstate recommendations for mutine MAM screening in women aged 40-49 (1141. critiques of the Canadian study have generated consider&z conkowsy, with questions raised in response to these aitiques about the possible economk motives behind dehys or wfusals to act on the studgs findings by major U.S. health care oraenizetionr indudina the National C&Y Ins&e and th; Arn&an Cancer S&&J 1116. 117). Thus, as nm-Ini&& c&e tends beyond the childbeaiing ages to include wch health care pmmo. lion es breast cancer screening dw

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TABLE 1

Am&an CuMer Soaety 1599 Qbn Road NE Ati”@ GA 30329 Tel. (ml 320.3333

NaUod Women’s He&b Newark 1325GStreetNW washfngtofl.DC 2Ooa5 Tel. (202) 347.1140

centerlor

Medical Consumea and Health Care lnfomxation 237 Thompson Sheet New York, NY 10012 Tel. (21216747105

Pm@& M&f S&&y 462 walnut Ske=et Auontwm. PA 18102 Tel. (2151770.1670

National Breast Cancer Ccalitlon P.O. ee% 66373 Washington,IX 20035 Tel. @OOl9350434 or (202) 296.7477

Washington,DC 20036 Tel. ~202l833-3lMo

National Cancerinstitute Cantor lnfcematlon5elace Tel. @OOlCCANCER National Coalition of Feministand L.esbianCancerPro]& P.O. Box 90437 Washingto”.DC 20090 Tel 12021332.55%

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Women’sHealtb Infomleiion Center BostonWomen’sHealth Book Co!Jec% 240 Elm Street Somewilk. MA 02144 Tel 16171625~0271

. Vd. 39. No. 5. SqtembaFJctobcr 1994

ing advancedage. there are complicated, yet essential 155~s to consider. When working with older women and sstabkhing a plan of health care maintenacce with individual cltents. the matter of breast cancerwaning needs to be addressed. F’ractttioners must wc.ognfze only the banters to screening reviewed before, but also the ethical, legal, and political factor5 that can influence a woman’s decisions regarding screening. Much remains to be discovered. Investigations into breast cancer screening as it affects older women, especUly past the age of 75. have been nonexistent and need to be initiated. Likewise, studies that place greater emphasis on preventing breast cancer, rather than detecting or attempting to cure it, require more attention Indeed. despite very ltmited spending on investigating the causes of breast caocer, there has been fncreasfn~evidencethat dteta~ and enufmnm&l factors, lncludin~ the we of MAM itwff. &au a sicmtficant role in the d&&&t of breast cancer, and calls have been made to shift the emphasis in research from managementof this acinogenic process to preventtng it (112114). The klfommtton that U”folds from research that addresses advanced age and that focuses on causative factols must be Inaorporated hto evey dinictan’s practiceso that the most thorough informed choke by ofdsr cftents can be made regardfng breast cancer wreening and prevention. Nurse-midwives need to maintain awareof the latest recommendanons for screening and p~w~ntion from such tntluential groups as the National Cancer Inslttute and the American Cancer Saciety,aswUasfmmadvucxy/ watchdog otganizatk~twsuch as the NaUonaf Warnen’s He&b Notwwk [Table 1). As nwe-midwives do so well in caring for younger w7mx?“, health care maintenancemust betalored to the individual needs and wants of older cfknk to optimtze the rsmafnkq years of living these tndt-

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uiduals have. As noted by DoresssWorters and Siegel in The New Ourseluea, Growi& Older, “Older VJomenare S”Ni”Ors. living a” average of eight years longer than men, enjoying longer life spans than we might as young wc.men have expected to or planned for. .At any aae. we mav have disease or disabilto co&d with, but we also have resiliency and reccway. We can still be as healthy and active as possible” w31.

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399