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educational programs

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

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educational programs

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  1. Women with Disabilities educational programs

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

  3. Overview Part 1:Incidence and Risk Part 2:Screening and Diagnosis Part 3:Treatment, Rehabilitation, and Ongoing Care www.womenwithdisabilities.org

  4. Incidence

  5. Breast Cancer in the United States:Incidence • 182,000 new cases diagnosed annually1 • One-third of all new cancers diagnosed in American women2 1. American Cancer Society. Cancer Reference Information. Revised: September 13, 2007. 2. Ahmedin J, et al. CA Cancer J Clin. 2007;57:43-66.

  6. Breast Cancer in the United States:Mortality • 24% since 19901 • Claims 40,000 women’s lives annually • Second-leading cause of cancer-related death in American women2 1. Ismail J, et al. J of Clin Oncology. 2007;25:TK-TK. 2. American Cancer Society. Cancer Reference Information. Revised: September 13, 2007.

  7. Women with disabilities have the same risk of breast cancer as women without disabilities. 1 in 8 lifetime risk1 1. American Cancer Society. Breast Cancer Facts & Figures 2007-2008.

  8. Women with disabilities are one-third more likely to die from their breast cancer than women without disabilities1 1. McCarthy EP, et al. Ann Intern Med. 2006;145:637-645.

  9. Why the Disparity? • After surgery for breast cancer, women with disabilities are less likely to receive:1 • Radiotherapy • Axillary lymph node dissection • They are also less likely to receive: • Screening mammograms2 Does lack of exercise play a role? 1. McCarthy EP, et al. Ann Intern Med. 2006;145:637-645. 2. Iezzoni LI, et al. Am J of Public Health. 2000;90:955-961.

  10. Coming to Terms

  11. What does disabilitymean?

  12. Americans with Disabilities Act A Person Has a Disability if He or She: • Has a physical or mental impairment that substantially limits one or more of the major life activities of such individual; • Has a record of such an impairment; or • Is regarded as having such an impairment1 1. Americans with Disabilities Act of 1990.

  13. U.S. Surgeon General’s “Call to Action to Improve the Health and Wellness of Persons with Disabilities” Disabilities Are… “…characteristics of the body, mind, or senses that, to a greater or lesser extent, affect a person’s ability to engage independently in some or all aspects of day-to-day life.” Disabilities Are Not Illnesses. “Just as health and illness exist along a continuum, so, too, does disability. Just as the same illnesses can vary in intensity from person to person, so, too, can the same condition lead to greater or lesser limitation in activity from one person to another.”1 1. Office of the Surgeon General. Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities. 2005.

  14. Disability Models Medical Model • Individual problem • Directly caused by disease Social Model • Does not reside in individual • Created by environmental barriers

  15. Words Matter Handicapped Disabled  Crippled Defective

  16. The Importance of Language

  17. Risk Factors

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

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

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

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

  22. The Modified Gail Model Risk Factors Used In Calculation:1 • Current age • Age at menarche • Age at first live birth or nulliparity • Number of first-degree relatives with breast cancer • Number of previous benign breast biopsies • Atypical hyperplasia in a previous breast biopsy • Race 1. National Comprehensive Cancer Network (NCCN). Risk factors used in the modified Gail Model; 2007.

  23. The Modified Gail Model 5-year Gail risk < 1.66% = low risk 5-year Gail risk > 1.66% = high risk NCI’s Breast Cancer Risk Assessment Tool: www.cancer.gov/bcrisktool

  24. Genetic Testing • May predict risk more accurately than family history alone1 • 5%–10% of women who develop breast cancer have BRCA gene mutations1 • Women with BRCA mutations havelifetime risk of1 • Up to 85% for breast cancer • Up to 60% for ovarian cancer • BRCA carriers at highest risk have family history of2 • Breast cancer diagnosis ≤ age 35 • Contralateral breast cancer • Myers MF, et al. Genetics in Medicine. 2006;8:361-370. • Begg CB, et al. JAMA. 2008;299:194-201.

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

  26. Tamoxifen and Raloxifene: AssessingRisks for Women with Disabilities • Increased risk of stroke and thromoboembolic events (women with limited mobility already at risk)1 • Increased risk of uterine cancer1 • Other risks:2 • Cataracts and other eye problems • Bladder problems • Vaginal problems 1. Vogel VG, et al., for the National Surgical Adjuvant Breast and Bowel Project (NSABP). JAMA. 2006;295:2727-2741. 2. National Cancer Institute. Reviewed May 13, 2002. Available at www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen.

  27. Managing Women with Disabilities on Tamoxifen and Raloxifene • Assess patient’s individual risk for thromoboembolism • Advise and assist patient with: • Quitting smoking • Lowering blood pressure • Maintaining a healthy weight • Exercising regularly • Follow patient closely

  28. Prophylactic Breast Surgery: Assessing Risks for Women with Disabilities • Reduces breast cancer risk by 90% in high-risk women1 • Most high-risk women report satisfaction with decision to have the surgery2 • Patient satisfaction is more variable regarding cosmetic results and body image2 Special concern for women with disabilities: How will the surgery affect my mobility and quality of life? 1. Hartmann L, et al. N Engl J Med. 1999;340:77-84. 2. Lostumbo L, et al. Cochrane Database of Systematic Reviews. 2004;4:CD002748.

  29. Managing Women with Disabilities Who Chose Prophylactic Surgery • Discuss with patient how surgery will affect her adaptive and assistive needs • Make sure patient has sufficient home care after surgery • Start physical therapy before surgery • Postsurgical physical therapy essential for restoring function and quality of life

  30. Modifiable Risk Factors • Being overweight • Women overweight at age 50:50% increase in risk1 • Not getting enough exercise • 1.25–2.5 hours of brisk walking: 18% decrease in risk2 • Consuming alcohol daily • Each 10 g of daily alcohol: 7.2% increase in risk3 1. Ahn J, et al. Arch Intern Med. 2007;167:2091-2102. 2. McTiernan A, et al. JAMA. 2003;290:1331-1336. 3.Chen WY, et al. Ann Intern Med. 2002;137:798-804.

  31. Women with disabilities often have more difficulty altering modifiable risk factors

  32. Distribution of Barriers to Improving Eating Habits (n=359)* * Participants were able to cite more than one barrier. Source: Hall L, Colantonio A, and Yoshida K. Int J of Rehabilitation Research. 2003;26:245-247.

  33. Barriers to Increasing Physical Activities • Lack of transportation • Lack of money • Lack of time • Inaccessible fitness centers • Healthcare and fitness professionals who are inexperienced with working with people with disabilities • Lack of social support • Fatigue and pain

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

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

  36. National Center on Physical Activity and Disability (NCPAD) www.ncpad.org

  37. Alcohol Use Among Women with Disabilities • Alcohol use is as prevalent among women with disabilities as among the general female population1 • Discuss alcohol use and its breast cancer risk with all patients • Patients at high risk of breast cancer must carefully weigh risks and benefits of moderate alcohol use 1. Li L, Ford JA. Applied Behavioral Sci Rev. 1996;4:99-109.

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

  39. Resources

  40. Breast Health Access for Women with Disabilities (BHAWD)Call: 512-204-4866TDD: 510-204-4574www.bhawd.org Center for Research on Women with Disabilities (CROWD)Baylor College of MedicineCall: 800-442-7693www.bcm.edu/crowd Health Promotion for Women with DisabilitiesVillanova University College of NursingCall: 610-519-6828www.nursing.villanova.edu/womenwithdisabilities Magee-Women’s Foundation“Strength & Courage Exercise DVD” (a compilation of exercises helpful to breast cancer patients)http://foundation.mwrif.org/

  41. National Breast and Cervical Cancer Early Detection ProgramCenters for Disease Control and PreventionCall: 1-800-CDC-INFOTTY: 1-888-232-6348www.cdc.gov/cancer/nbccedp National Center of Physical Activity and DisabilityCall: 1-800-900-8086TTY: 1-800-900-8086www.ncpad.org The National Women’s Health Information CenterCall: 1-800-994-9662TDD: 1-888-220-5446www.4women.gov/wwd Susan G. Komen for the Curewww.komen.org Women with DisabilitiesCenters for Disease Control and Preventionwww.cdc.gov/ncbddd/women

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