Screening and Diagnosis - Women with Disabilities Educational Programs

2. Welcome to this presentation on the Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities, which is part of the Women with Disabilities Education Project, an innovative, multifaceted effort to significantly raise the quality of health care for women with disabilities. Welcome to this presentation on the Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities, which is part of the Women with Disabilities Education Project, an innovative, multifaceted effort to significantly raise the quality of health care for women with disabilities.

3. Overview Part 1:Incidence and Risk Part 2:Screening and Diagnosis Part 3:Treatment, Rehabilitation, and Ongoing Care This presentation has been developed to help identify and eliminate the disparities in diagnosis, treatment, and aftercare for women with disabilities. This is Part 2 of the presentation. It discusses special issues and concerns regarding breast cancer screening and diagnosis for women with disabilities. Parts 1 and 3 are also available on the Women with Disabilities Education Project’s Web site. Part 1 provides an overview of breast cancer–related disparities faced by women with disabilities and a discussion of breast cancer incidence and risk. Part 3 explains the particular treatment, rehabilitation, and ongoing care needs for women with disabilities who have breast cancer. At the end of each presentation, you’ll find a resource section that’s helpful for healthcare providers and patients alike. This presentation has been developed to help identify and eliminate the disparities in diagnosis, treatment, and aftercare for women with disabilities. This is Part 2 of the presentation. It discusses special issues and concerns regarding breast cancer screening and diagnosis for women with disabilities. Parts 1 and 3 are also available on the Women with Disabilities Education Project’s Web site. Part 1 provides an overview of breast cancer–related disparities faced by women with disabilities and a discussion of breast cancer incidence and risk. Part 3 explains the particular treatment, rehabilitation, and ongoing care needs for women with disabilities who have breast cancer. At the end of each presentation, you’ll find a resource section that’s helpful for healthcare providers and patients alike.

4. Screening We’ll begin this presentation by examining breast cancer screening and the special concerns it raises for women with disabilities. We’ll begin this presentation by examining breast cancer screening and the special concerns it raises for women with disabilities.

5. Most Common Screening Tests Mammography Clinical breast exam Breast self-exam The three tests most commonly used to screen for breast cancer are mammography, the clinical breast exam, and the breast self-exam. The three tests most commonly used to screen for breast cancer are mammography, the clinical breast exam, and the breast self-exam.

6. Mammography 7 Statistical Models: Mammography reduces the rate of death from breast cancer by 7%–23%, with a median of 15%.1 Mammography is the primary screening tool for cancer. Findings from seven independent statistical models of breast cancer incidence and mortality showed that mammography screening as practiced in the United States reduced the rate of death from breast cancer by 7% to 23%, with a median of 15%.1 While acknowledging that mammography trials have had important methodological limitations, all major North American health organizations support mammographic screening. 1. Berry DA, et al. N Eng J Med. 2005:353:1784-1792. Mammography is the primary screening tool for cancer. Findings from seven independent statistical models of breast cancer incidence and mortality showed that mammography screening as practiced in the United States reduced the rate of death from breast cancer by 7% to 23%, with a median of 15%.1 While acknowledging that mammography trials have had important methodological limitations, all major North American health organizations support mammographic screening. 1. Berry DA, et al. N Eng J Med. 2005:353:1784-1792.

7. Mammography Age Regular screening lowers breast cancer mortality by 15%–20% in women aged 40–49 25%–30% in women aged 50–69 Limited evidence for effectiveness in women aged 70+ Interval Optimal interval unknown Reductions in mortality have occurred at intervals ranging from 12–33 months Many organizations recommend annual screenings for women aged 40–49 Health organizations sometimes differ in their recommendations for the age to begin screening and for how often the screenings should be done. The effectiveness of mammographic screening among women aged 40 to 49 is less than in older women, although it is still significant.1 Evidence for the effectiveness of mammography screening in women older than 70 is limited, but recent research has led the American Cancer Society to recommend that all women aged 40 and older receive annual mammograms for as long as they are in good health and would be a candidate for treatment should a cancer be found.2,3 The optimal interval for mammography screening is unknown. Reductions in breast cancer mortality have occurred in screening programs with intervals ranging from 12 to 33 months.1 Because breast cancers tend to grow more rapidly in premenopausal women and because the sensitivity of breast cancer screening is lower in this age group, many major North American health organizations recommend annual screening for women aged 40 to 49. All organizations, however, recommend yearly screening from age 50 to 70. 1. Humphrey LL, et al. Ann Intern Med. 2002;137:344-346. 2. Randolph WM, et al. Ann Intern Med. 2002;137:783-790. 3. Smith RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2007;57:90-104.Health organizations sometimes differ in their recommendations for the age to begin screening and for how often the screenings should be done. The effectiveness of mammographic screening among women aged 40 to 49 is less than in older women, although it is still significant.1 Evidence for the effectiveness of mammography screening in women older than 70 is limited, but recent research has led the American Cancer Society to recommend that all women aged 40 and older receive annual mammograms for as long as they are in good health and would be a candidate for treatment should a cancer be found.2,3 The optimal interval for mammography screening is unknown. Reductions in breast cancer mortality have occurred in screening programs with intervals ranging from 12 to 33 months.1 Because breast cancers tend to grow more rapidly in premenopausal women and because the sensitivity of breast cancer screening is lower in this age group, many major North American health organizations recommend annual screening for women aged 40 to 49. All organizations, however, recommend yearly screening from age 50 to 70. 1. Humphrey LL, et al. Ann Intern Med. 2002;137:344-346. 2. Randolph WM, et al. Ann Intern Med. 2002;137:783-790. 3. Smith RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2007;57:90-104.

8. Magnetic Resonance Imaging and Ultrasound MRI Annual MRI screening recommended for women with genetic mutations for breast cancer or with other factors that put them at very high risk Ultrasound Effectiveness not yet demonstrated Used primarily to Evaluate breast abnormalities identified through CBE or mammography Guide breast biopsies and FNA The American Cancer Society now recommends annual screening magnetic resonance imaging (MRI) for women at very high risk for breast cancer, such as those with genetic mutations for the disease.1 (For a discussion of assessing and managing risk in women with disabilities, see Part 1: Incidence and Risk of this presentation.) There is little evidence to support the use of ultrasound for screening asymptomatic women.2 Currently, ultrasound’s role in breast cancer detection is primarily to evaluate breast abnormalities identified through clinical breast exam or mammography, and to guide breast biopsies and fine-needle aspiration. 1. American Cancer Society. CA Cancer J Clin. 2007;57:75-89. 2. Irwig L, Houssami N, van Vliet C. Brit J Cancer. 2004;90:2118-2122. The American Cancer Society now recommends annual screening magnetic resonance imaging (MRI) for women at very high risk for breast cancer, such as those with genetic mutations for the disease.1 (For a discussion of assessing and managing risk in women with disabilities, see Part 1: Incidence and Risk of this presentation.) There is little evidence to support the use of ultrasound for screening asymptomatic women.2 Currently, ultrasound’s role in breast cancer detection is primarily to evaluate breast abnormalities identified through clinical breast exam or mammography, and to guide breast biopsies and fine-needle aspiration. 1. American Cancer Society. CA Cancer J Clin. 2007;57:75-89. 2. Irwig L, Houssami N, van Vliet C. Brit J Cancer. 2004;90:2118-2122.

9. Ultrasound? Not a Good Stand-Alone Option 2 of 83 cancers detected solely by annual ultrasonography 2 additional cancers detected through screenings at 6-month intervals If a woman cannot have a successful mammogram, ultrasound may be considered. However, ultrasound has yet to be proven as a good stand-alone option. In three studies of women with a hereditary risk of breast cancer, only 2 of 83 cancers were detected solely by annual ultrasonography. Two additional nonpalpable cancers were detected by ultrasounds performed at 6-month intervals.1 Accessible mammography remains the best screening option for all women. Robson M, Offit K. N Engl J Med. 2007;357:154-162.If a woman cannot have a successful mammogram, ultrasound may be considered. However, ultrasound has yet to be proven as a good stand-alone option. In three studies of women with a hereditary risk of breast cancer, only 2 of 83 cancers were detected solely by annual ultrasonography. Two additional nonpalpable cancers were detected by ultrasounds performed at 6-month intervals.1 Accessible mammography remains the best screening option for all women. Robson M, Offit K. N Engl J Med. 2007;357:154-162.

10. Mammography Disparities Of Women Aged ? 50 Years 63.5% with no mobility problems vs. 51.5% with moderate mobility problems and 43.3% with major mobility problems Had mammogram within previous 2 years1 Breast cancer screening recommendations apply to all women, regardless of ability. Yet, studies have shown that women with mobility disabilities are often less likely to participate in regular breast screening.1 This is particularly true if the women are older and have a major mobility disability.1,2 One study found that among women older than 50 years, 63.5% of those who had no mobility problems reported having had a mammogram within the previous 2 years compared with 51.5% of those with moderate mobility problems and 45.3% of those with major mobility problems.2 Smeltzer S. Family & Community Health. 2006;29:35S-43S. Iezzoni LI, et al. Am J of Public Health. 2000;90:955-961. Breast cancer screening recommendations apply to all women, regardless of ability. Yet, studies have shown that women with mobility disabilities are often less likely to participate in regular breast screening.1 This is particularly true if the women are older and have a major mobility disability.1,2 One study found that among women older than 50 years, 63.5% of those who had no mobility problems reported having had a mammogram within the previous 2 years compared with 51.5% of those with moderate mobility problems and 45.3% of those with major mobility problems.2 Smeltzer S. Family & Community Health. 2006;29:35S-43S. Iezzoni LI, et al. Am J of Public Health. 2000;90:955-961.

11. Reasons for Screening Disparities 1. Inadequate access to facilities and equipment 2. Lack of accessible transportation 3. Difficulty positioning for exams 4. Inability to remain still for exams 5. Lack of provider knowledge and sensitivity about serving women with disabilities 6. Financial restraints, including a lack of adequate health insurance 7. Lack of patient knowledge of breast cancer risk and the need for screening 8. Patient unawareness of free screening programs The reasons for these screening disparities are many. They include inadequate access to facilities and equipment; lack of accessible transportation; patient difficulty with positioning or remaining still for the exam; lack of provider knowledge and sensitivity about serving women with disabilities; and financial restraints, including a lack of adequate health insurance. In addition, many women with disabilities are unaware of breast cancer risk and the need for regular screening. They may also be unaware of free screening programs in their area. The reasons for these screening disparities are many. They include inadequate access to facilities and equipment; lack of accessible transportation; patient difficulty with positioning or remaining still for the exam; lack of provider knowledge and sensitivity about serving women with disabilities; and financial restraints, including a lack of adequate health insurance. In addition, many women with disabilities are unaware of breast cancer risk and the need for regular screening. They may also be unaware of free screening programs in their area.

12. Removing Informational Barriers Women with disabilities, like all other female patients, should be informed and counseled by their clinician about the need for regular mammograms. In one study, 25% of the women with disabilities reported that a major reason why they had not received a mammogram was because they were not told to have one by their doctor.1 Offer information about mammography to your patients with disabilities in a form that is easily accessible to them—an audio version, for example, to a patient who is blind. Such materials are available. For more information about these materials and about how you can better communicate medical information to women with disabilities, see The Women with Disabilities Education Program’s two communication learning modules at www.womenwithdisabilities.org. 1. Nosek MA, Howland CA. Arch Phys Med Rehabil. 1997:78 (12 Suppl 5):S39-44.Women with disabilities, like all other female patients, should be informed and counseled by their clinician about the need for regular mammograms. In one study, 25% of the women with disabilities reported that a major reason why they had not received a mammogram was because they were not told to have one by their doctor.1 Offer information about mammography to your patients with disabilities in a form that is easily accessible to them—an audio version, for example, to a patient who is blind. Such materials are available. For more information about these materials and about how you can better communicate medical information to women with disabilities, see The Women with Disabilities Education Program’s two communication learning modules at www.womenwithdisabilities.org. 1. Nosek MA, Howland CA. Arch Phys Med Rehabil. 1997:78 (12 Suppl 5):S39-44.

13. Helping Your Patient Prepare Explain what to expect Discuss any concerns Be sure to explain to your patients with disabilities how to prepare for and what to expect during the mammography procedure. The physical and psychological discomfort that many women experience when undergoing a mammogram is often exacerbated among women with disabilities.1 Thoroughly discuss with your patients any concerns she may have—such as how she will be assisted during the procedure. Women with disabilities that limit their ability to stand, for example, should be reassured that mammograms can be taken from a seated position. Poulos AE, et al. Arch Phys Med Rehabil. 2006;87:304-307. Be sure to explain to your patients with disabilities how to prepare for and what to expect during the mammography procedure. The physical and psychological discomfort that many women experience when undergoing a mammogram is often exacerbated among women with disabilities.1 Thoroughly discuss with your patients any concerns she may have—such as how she will be assisted during the procedure. Women with disabilities that limit their ability to stand, for example, should be reassured that mammograms can be taken from a seated position. Poulos AE, et al. Arch Phys Med Rehabil. 2006;87:304-307.

14. Breaking Down Barriers to Mammography Screening Fully accessible equipment Staff trained to properly assist women with disabilities Systems in place for successful positioningduring screening Systems in place for successful communication during screening Many women with and without disabilities encounter cost, transportation, and other barriers that make it difficult to receive mammography screening. Women with disabilities, however, experience additional barriers that are specific to having a disability, such as problems with physical access to mammography equipment and difficulty in obtaining appropriate personal assistance throughout the procedure. Be sure to refer your patients with disabilities to fully accessible mammography centers. Full accessibility includes having a mammography unit that can accommodate wheelchairs. It also means having systems in place to ensure that women with spasticity, contractures, or pain can be successfully positioned during mammography. In addition, the staff should have experience assisting and communicating with women with different disabilities. Find out which mammography centers are fully accessible in your area. Talk to the center’s staff before your patient’s mammography appointment. Alert them to any mobility or communications issues that may require special attention. Many women with and without disabilities encounter cost, transportation, and other barriers that make it difficult to receive mammography screening. Women with disabilities, however, experience additional barriers that are specific to having a disability, such as problems with physical access to mammography equipment and difficulty in obtaining appropriate personal assistance throughout the procedure. Be sure to refer your patients with disabilities to fully accessible mammography centers. Full accessibility includes having a mammography unit that can accommodate wheelchairs. It also means having systems in place to ensure that women with spasticity, contractures, or pain can be successfully positioned during mammography. In addition, the staff should have experience assisting and communicating with women with different disabilities. Find out which mammography centers are fully accessible in your area. Talk to the center’s staff before your patient’s mammography appointment. Alert them to any mobility or communications issues that may require special attention.

15. Appropriate communication can alleviate much of the discomfort and apprehension associated with mammography screening. Although many technologists and other healthcare personnel at imaging centers are well trained and empathetic to the needs of women with disabilities, many others are not. The Women with Disabilities Education Program’s two communication learning modules are designed to help train medical personnel to communicate appropriately and effectively with women with disabilities. They can be accessed at www.womenwithdisabilities.org. In addition, the Breast Health Access for Women with Disabilities (BHAWD) organization has developed a training DVD module and booklet for mammography technologists to help them provide quality mammography services to women with disabilities. It can be ordered through their Web site: www.bhawd.org.Appropriate communication can alleviate much of the discomfort and apprehension associated with mammography screening. Although many technologists and other healthcare personnel at imaging centers are well trained and empathetic to the needs of women with disabilities, many others are not. The Women with Disabilities Education Program’s two communication learning modules are designed to help train medical personnel to communicate appropriately and effectively with women with disabilities. They can be accessed at www.womenwithdisabilities.org. In addition, the Breast Health Access for Women with Disabilities (BHAWD) organization has developed a training DVD module and booklet for mammography technologists to help them provide quality mammography services to women with disabilities. It can be ordered through their Web site: www.bhawd.org.

16. Clinical Breast Examination May identify 4.5%–10.7% of breast cancers that mammography misses1 Clinician proficiency impacts effectiveness1 Recommendations vary: American Cancer Society2 Every 3 years for average-risk women in 20s and 30s Annually for women aged 40 U.S. Preventive Services Task Force3 No recommendation/Not enough evidence When compared with current mammography technology, the clinical breast exam has been found to identify 4.5% to 10.7% of cancers that mammography misses.1 Given that more than 180,000 women are diagnosed in the United States each year, that means that the clinical breast exam may annually help identify as many as 18,000 otherwise undetected cancers. The ability to detect breast cancer by clinical breast exam appears to be related to the experience and training of the clinician performing the test. The factor most strongly associated with the clinical breast exam’s sensitivity is time spent on the exam.1 Recommendations for how often women should undergo a clinical breast evaluation vary widely. For example, the American Cancer Society recommends the exam every 3 years for average-risk women in their 20s and 30s and every year for women aged 40 and older2 whereas the U.S. Preventive Services Task Force (USPSTF) says the evidence for or against routine clinical breast exams is too insufficient to make any recommendation.3 1. McDonald S, Saslow D, Alciati MH. CA Cancer J Clin. 2004;54:345-361. 2. Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44. 3. U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002. When compared with current mammography technology, the clinical breast exam has been found to identify 4.5% to 10.7% of cancers that mammography misses.1 Given that more than 180,000 women are diagnosed in the United States each year, that means that the clinical breast exam may annually help identify as many as 18,000 otherwise undetected cancers. The ability to detect breast cancer by clinical breast exam appears to be related to the experience and training of the clinician performing the test. The factor most strongly associated with the clinical breast exam’s sensitivity is time spent on the exam.1 Recommendations for how often women should undergo a clinical breast evaluation vary widely. For example, the American Cancer Society recommends the exam every 3 years for average-risk women in their 20s and 30s and every year for women aged 40 and older2 whereas the U.S. Preventive Services Task Force (USPSTF) says the evidence for or against routine clinical breast exams is too insufficient to make any recommendation.3 1. McDonald S, Saslow D, Alciati MH. CA Cancer J Clin. 2004;54:345-361. 2. Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44. 3. U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002.

17. Clinical Breast Exam (CBE) Protocol The Breast Health Access for Women with Disabilities (BHAWD) organization has developed an effective protocol for conducting clinical breast exams.1 It can be downloaded from the group’s Web site: www.bhawd.org. 1. Breast Health Access for Women with Disabilities (BHAWD). January 2008. The Breast Health Access for Women with Disabilities (BHAWD) organization has developed an effective protocol for conducting clinical breast exams.1 It can be downloaded from the group’s Web site: www.bhawd.org. 1. Breast Health Access for Women with Disabilities (BHAWD). January 2008.

18. Introducing the Patient to the CBE The protocol begins with the clinician assessing whether the patient is highly anxious, fearful, or uncomfortable, or if she is likely to experience significant pain or spasticity during the exam. If so, the clinician should determine if a trusted significant other or caregiver can be present during the exam; explain the steps of the exam while offering frequent reassurance; consider demonstrating the exam to help the patient better understand what will be involved and its purpose; consider recommending that the patient take a prescribed antispasmodic or analgesic medication 1 to 2 hours before the exam; consider having two shorter exams, if possible.The protocol begins with the clinician assessing whether the patient is highly anxious, fearful, or uncomfortable, or if she is likely to experience significant pain or spasticity during the exam. If so, the clinician should determine if a trusted significant other or caregiver can be present during the exam; explain the steps of the exam while offering frequent reassurance; consider demonstrating the exam to help the patient better understand what will be involved and its purpose; consider recommending that the patient take a prescribed antispasmodic or analgesic medication 1 to 2 hours before the exam; consider having two shorter exams, if possible.

19. Preparing the Patient for the CBE Next the clinician should ask the patient if she needs assistance with undressing her upper body for the exam. If the answer is yes, then the clinician or a nurse may provide assistance as needed and under the direction of the patient. The clinician may also consider performing the exam with the patient’s shirt lifted for visualization; performing a modified exam through the patient’s clothing with plans to perform a thorough exam at the next patient visit or after patient trust becomes established.Next the clinician should ask the patient if she needs assistance with undressing her upper body for the exam. If the answer is yes, then the clinician or a nurse may provide assistance as needed and under the direction of the patient. The clinician may also consider performing the exam with the patient’s shirt lifted for visualization; performing a modified exam through the patient’s clothing with plans to perform a thorough exam at the next patient visit or after patient trust becomes established.

20. Visual Inspection of the Breasts The visual inspection of the breasts may be done while the patient is standing, seated in a wheelchair, or seated on the exam table, depending on her physical ability. If the patient has difficulty performing the four positions required for a complete exam, the clinician may offer assistance to help the patient hold her arms above her head; modify the hands-on-hip position as needed to achieve pectoral muscle contraction; use supportive devices, such as a walker or a chair, to assist the patient in leaning forward, if necessary.The visual inspection of the breasts may be done while the patient is standing, seated in a wheelchair, or seated on the exam table, depending on her physical ability. If the patient has difficulty performing the four positions required for a complete exam, the clinician may offer assistance to help the patient hold her arms above her head; modify the hands-on-hip position as needed to achieve pectoral muscle contraction; use supportive devices, such as a walker or a chair, to assist the patient in leaning forward, if necessary.

21. Positioning the Patient on the Exam Table An accessible exam table (one that can be lowered to at least 20 inches so the patient can be easily transferred from a wheelchair) is strongly recommended. If the patient needs assistance getting onto the table, the clinician can ask the patient for directions and provide skilled assistance as needed. The patient may prefer to bring her own attendant, or the clinic may provide assistance from trained personnel. Extra pillows or wedges should be available to aid in positioning the patient properly. For the lymph node and bimanual exam, the patient may be seated on the table with the side rails up or, if her balance is poor and she uses a wheelchair, she may remain seated in her chair.An accessible exam table (one that can be lowered to at least 20 inches so the patient can be easily transferred from a wheelchair) is strongly recommended. If the patient needs assistance getting onto the table, the clinician can ask the patient for directions and provide skilled assistance as needed. The patient may prefer to bring her own attendant, or the clinic may provide assistance from trained personnel. Extra pillows or wedges should be available to aid in positioning the patient properly. For the lymph node and bimanual exam, the patient may be seated on the table with the side rails up or, if her balance is poor and she uses a wheelchair, she may remain seated in her chair.

22. Breast Palpation If the patient has difficulty positioning her arms above her head for breast palpation, the clinician may ask permission to position the patient’s hand above her head; use nonexamining hand and/or pillows to stabilize the patient’s arm at a 90º angle; ask the patient’s caregiver or other attendant to help with stabilizing the arm, if such action is agreeable to the patient.If the patient has difficulty positioning her arms above her head for breast palpation, the clinician may ask permission to position the patient’s hand above her head; use nonexamining hand and/or pillows to stabilize the patient’s arm at a 90º angle; ask the patient’s caregiver or other attendant to help with stabilizing the arm, if such action is agreeable to the patient.

23. Completion of the Exam At the end of the exam, the clinician should ask the patient if she needs assistance to get off the exam table and/or to dress. Assistance can be provided as requested. The clinician should also ask the patient if she has any questions or concerns about the exam.At the end of the exam, the clinician should ask the patient if she needs assistance to get off the exam table and/or to dress. Assistance can be provided as requested. The clinician should also ask the patient if she has any questions or concerns about the exam.

24. Breast Self-Exam Not shown to have an effect on breast cancer mortality rate1 U.S. Preventive Services Task Force: Not enough evidenceto recommend for or against BSE2 ACS and others: Teach women the procedure and give them the option of using it3 As a “stand-alone” procedure, the breast self-exam has not been shown to be an effective screening tool. A Cochrane review of two large population-based trials conducted in Russia and Shanghai found that breast self-exam did not reduce breast cancer mortality, but did increase the number of diagnosed benign breast lesions.1 The Cochrane reviewers concluded that breast self-examination does not appear to reduce breast cancer deaths.1 The U.S. Preventive Services Task Force has also concluded that there is not enough evidence to recommend for or against breast self-exam.2 The American Cancer Society and other health organizations, however, continue to recommend that women be taught the procedure and offered the option of using it.3 Kosters JP, Gotzsche PC. Cochrane Database of Systematic Reviews. 2003;2: CD003373. 2. U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002. 3. Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44. As a “stand-alone” procedure, the breast self-exam has not been shown to be an effective screening tool. A Cochrane review of two large population-based trials conducted in Russia and Shanghai found that breast self-exam did not reduce breast cancer mortality, but did increase the number of diagnosed benign breast lesions.1 The Cochrane reviewers concluded that breast self-examination does not appear to reduce breast cancer deaths.1 The U.S. Preventive Services Task Force has also concluded that there is not enough evidence to recommend for or against breast self-exam.2 The American Cancer Society and other health organizations, however, continue to recommend that women be taught the procedure and offered the option of using it.3 Kosters JP, Gotzsche PC. Cochrane Database of Systematic Reviews. 2003;2: CD003373. 2. U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002. 3. Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44.

25. Breast Self-Exam Accommodations for Women with Disabilities Exam can be modified for women who have use of only one hand Thumbs, palms, or back of fingers can be used instead of finger pads to feel for lumps Exam can be broken into smaller parts for women who tire easily Women whose limited mobility precludes breast self-exams may opt for more frequent clinical breast exams Although the evidence for the effectiveness of breast self-exams is not strong, many women want the option of doing them. Discuss breast self-exams with your patients. If a woman with a disability chooses to do the exam, you can instruct her on how to do it most effectively, including modifications to accommodate any physical limitations she may have. For example, women who have the use of only one hand can be shown how to use that hand to examine both breasts. Women who have difficulty using or feeling with their finger pads can be instructed on how to use their thumbs or palms or even the back of their fingers to feel for lumps. Women who tire easily can be shown how to break the examination into smaller parts. They can also be advised to schedule the exam for a time during the day when their energy level is highest. A woman whose disability precludes her ability to examine her own breasts may wish to have more frequent clinical breast exams. Be sure to discuss this option with your patients. Some women with disabilities choose to have a husband, partner, or other person perform the breast self-exams for them. This option may also be discussed with your patients. Although the evidence for the effectiveness of breast self-exams is not strong, many women want the option of doing them. Discuss breast self-exams with your patients. If a woman with a disability chooses to do the exam, you can instruct her on how to do it most effectively, including modifications to accommodate any physical limitations she may have. For example, women who have the use of only one hand can be shown how to use that hand to examine both breasts. Women who have difficulty using or feeling with their finger pads can be instructed on how to use their thumbs or palms or even the back of their fingers to feel for lumps. Women who tire easily can be shown how to break the examination into smaller parts. They can also be advised to schedule the exam for a time during the day when their energy level is highest. A woman whose disability precludes her ability to examine her own breasts may wish to have more frequent clinical breast exams. Be sure to discuss this option with your patients. Some women with disabilities choose to have a husband, partner, or other person perform the breast self-exams for them. This option may also be discussed with your patients.

26. The Breast Health Access for Women with Disabilities (BHAWD) organization has a brochure on breast self-examination for women with physical or sensory limitations. It can be accessed through their Web site: bhawd.org. The Breast Health Access for Women with Disabilities (BHAWD) organization has a brochure on breast self-examination for women with physical or sensory limitations. It can be accessed through their Web site: bhawd.org.

27. We’ll now discuss special concerns that the diagnosis process raises for women with disabilities. We’ll now discuss special concerns that the diagnosis process raises for women with disabilities.

28. Percutaneous Diagnostic Biopsies Have largely replaced surgical biopsy as initial diagnostic biopsy procedure Are guided by stereotactic mammographic imaging, ultrasound, or MRI Are less invasive than surgical biopsy and often reduce need for further surgical procedures Improve planning for patient’s treatment Percutaneous biopsy has largely replaced surgical biopsy as the initial procedure of choice for diagnosing breast cancer. Percutaneous biopsies, which can be conducted under the guidance of stereotactic mammographic breast imaging, ultrasound guidance, or magnetic resonance imaging, are less invasive than surgical biopsies and have been shown to often reduce the need for further surgical procedures. Even when screening has revealed an obvious cancer, a biopsy may still be done to improve planning for the patient’s treatment.Percutaneous biopsy has largely replaced surgical biopsy as the initial procedure of choice for diagnosing breast cancer. Percutaneous biopsies, which can be conducted under the guidance of stereotactic mammographic breast imaging, ultrasound guidance, or magnetic resonance imaging, are less invasive than surgical biopsies and have been shown to often reduce the need for further surgical procedures. Even when screening has revealed an obvious cancer, a biopsy may still be done to improve planning for the patient’s treatment.

29. Biopsy Barriers A Woman Must be Able to… Remain still for 45–60 minutes, either sitting, prone, or supine Hyperextend arm Turn neck Get up onto the biopsy table Percutaneous biopsies present special challenges when performed on women with disabilities. Such biopsies may not be an option for women who are unable to lie or sit still for 45 to 60 minutes, who are unable to hyperextend their arm, who have difficulty turning their neck, or who are unable to get up onto the breast biopsy table. Percutaneous biopsies present special challenges when performed on women with disabilities. Such biopsies may not be an option for women who are unable to lie or sit still for 45 to 60 minutes, who are unable to hyperextend their arm, who have difficulty turning their neck, or who are unable to get up onto the breast biopsy table.

30. Biopsy Accommodations: Stereotactic Add-on Devices Several accommodations can be made to to help women with disabilities have a successful breast biopsy. Stereotactic mammographic and MRI imaging usually require the patient to lie prone during the biopsy procedure, but some stereotactic equipment has add-on devices that enable the patient to remain in an upright, seated position. Studies have shown that an add-on unit has an accuracy rate similar to that reported for dedicated prone biopsy tables.1 A woman in a wheelchair will need to be in a wheelchair with removable arms, however, to use these devices. Unfortunately, add-on digital devices were created at a time when medical centers were making the change from film to digital imaging. New stereotactic equipment uses prone biopsy tables. For a patient who must undergo the procedure in an upright position, you’ll need to call around to find a center that still has an add-on device. 1. Becker L, et al. AJR. 2001;177:1451-1457.Several accommodations can be made to to help women with disabilities have a successful breast biopsy. Stereotactic mammographic and MRI imaging usually require the patient to lie prone during the biopsy procedure, but some stereotactic equipment has add-on devices that enable the patient to remain in an upright, seated position. Studies have shown that an add-on unit has an accuracy rate similar to that reported for dedicated prone biopsy tables.1 A woman in a wheelchair will need to be in a wheelchair with removable arms, however, to use these devices. Unfortunately, add-on digital devices were created at a time when medical centers were making the change from film to digital imaging. New stereotactic equipment uses prone biopsy tables. For a patient who must undergo the procedure in an upright position, you’ll need to call around to find a center that still has an add-on device. 1. Becker L, et al. AJR. 2001;177:1451-1457.

31. Biopsy Accommodations: Ultrasound in Seated Position Ultrasound-guided biopsies can be conducted in an upright or semi-upright position, depending on where the lesion is located. So if your patient is able to sit upright for an extended time, an ultrasound-guided biopsy may be a good option. Not all lesions can be seen by ultrasound, however. Nor can all women with disabilities sit upright and still for the procedure. In these cases, the patient may need to go directly to surgery. Centers dedicated to breast care often have the most experience working with women with disabilities—and thus the most accessible equipment and facilities. You may want to start your search for biopsy accommodations there. Ultrasound-guided biopsies can be conducted in an upright or semi-upright position, depending on where the lesion is located. So if your patient is able to sit upright for an extended time, an ultrasound-guided biopsy may be a good option. Not all lesions can be seen by ultrasound, however. Nor can all women with disabilities sit upright and still for the procedure. In these cases, the patient may need to go directly to surgery. Centers dedicated to breast care often have the most experience working with women with disabilities—and thus the most accessible equipment and facilities. You may want to start your search for biopsy accommodations there.

32. Summary Using an accessible format, communicate the need for regular mammograms to your patients with disabilities Identify fully accessible mammography centers in your area. Alert them to a patient’s mobility or communication issues before the patient goes to the screening Adapt the clinical breast exam to meet the special needs of your patients with disabilities Teach your patients how to modify the breast self-exam to accommodate their particular disability Help ensure that accommodations are made for your patients with disabilities so they have successful breast biopsies In summary: Although breast cancer screening recommendations apply to all women, those with major mobility disabilities are less likely to undergo regular screening. Women with disabilities should be informed and counseled about the need for regular mammograms. All information should be presented in an accessible form. When counseling a woman about mammography, explain what she can expect during the procedure and discuss any concerns she may have. Identify fully accessible mammography centers in your area. Before your patient’s visit, alert the center’s staff to mobility or communications issues of hers that may require special attention. Learn how to adapt the clinical breast exam to meet the special needs of women with disabilities. Present women with disabilities with the option of using the breast self-exam. Teach them how to modify the exam to accommodate any physical limitations they may have. Although percutaneous breast biopsies present special challenges when performed on women with disabilities, accommodations can be made to ensure a successful biopsy.In summary: Although breast cancer screening recommendations apply to all women, those with major mobility disabilities are less likely to undergo regular screening. Women with disabilities should be informed and counseled about the need for regular mammograms. All information should be presented in an accessible form. When counseling a woman about mammography, explain what she can expect during the procedure and discuss any concerns she may have. Identify fully accessible mammography centers in your area. Before your patient’s visit, alert the center’s staff to mobility or communications issues of hers that may require special attention. Learn how to adapt the clinical breast exam to meet the special needs of women with disabilities. Present women with disabilities with the option of using the breast self-exam. Teach them how to modify the exam to accommodate any physical limitations they may have. Although percutaneous breast biopsies present special challenges when performed on women with disabilities, accommodations can be made to ensure a successful biopsy.

33. The following slides contain online and other breast cancer–related resources for healthcare professionals who are providing care to women with disabilities. The following slides contain online and other breast cancer–related resources for healthcare professionals who are providing care to women with disabilities.

34.

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