Battling breast cancer in older women: Where do we stand?

Battling Breast Cancer in Older Women: Where Do We Stand? Although age is the greatest risk factor for breast cancer, older women are not receiving the mammographic screenings they need.

B y MARGE DRUCAY

Bb R E A S T CANCER. More than 99% of the cases

-occur in women. It is the second leading cause of cancer mortality in all women over the age of 55.

In 1992, 180,000 new cases are expected to be diagnosed, with 43% of these in women over 65. An estimated 46,000 deaths are expected to occur this year) According to the General Accounting Office of the federal government, the past 20 years have seen no gains in prevention. 2 Many premenopausal women are terrified they will develop it, and there have been reports of "prophylactic" mastecto- mies. The risk of developing this disease within a lifetime has risen to 1 in 9, which reflects both the rising incidence and the burgeoning aging population. Physicians often misinterpret these statistics, by inaccurately representing individual risk, causing further a l a rm) The media has contributed to the escalating hysteria, often with sensa- tionalistic reporting and little research into the real issues. Breast cancer is the plague of the aging American woman.

Prevent ion and Detect ion Strategies

The American Cancer Society was instrumental in the implementation of a nationwide program intended to demonstrate the benefits of breast cancer detection to physicians and women. From 1986 through 1989 the Breas t C a n c e r D e t e c t i o n D e m o n s t r a t i o n P r o j e c t (BCDDP), involving 280,000 women in 29 locations, of- fered screening mammography and clinical breast examinations for a 5-year period. A study is underway with

MARGE DRUGAY, MS, RN,C, is an associate faculty member at Rush University in Chicago, where she is a doctoral student. 34/1/39395

high-risk premenopausal women using the drug tamox- ifen citrate in the hopes of preventing the development of breast cancer.

Mammography, or x-ray of the breast, in conjunction with clinical breast examination facilitates early diagnosis of cancer at a more treatable stage, thereby reducing the risk of untimely death. 4 In the first publication of findings from the BCDDP, results indicated that mammography and clinical breast examination together con- firmed cases not detected by either one alone but that the diagnostic role of mammography was greater. Mammog- raphy alone found 40% of all breast cancer cases, com- pared with 10% discovered by clinical examina t ion alone. 5 Despite American Cancer Society guidelines for annual screening of women over the age of 50--especially for those who are considered at higher risk--most women over the age of 50 do not undergo regular, routine screening mammography.

In one recent study, less than 47% of women over age 50 performed regular (monthly) self-examination of the breasts, another technique to detect abnormali t ies . 6 There is a direct relationship between increasing age and rising incidence of breast cancer; indeed, it has been said that the greatest risk factor for developing cancer is aging. An unreserved recommendation for periodic physical breast examination and mammographic screening for older women is supported in the literature. 5, 7, 8

E p i d e m i o l o g y , Resea r ch , a n d Pub l i c P o l i c y

There is no known cause of breast cancer and no means of preventing it. Recognized factors that increase risk are many (see box). Diet has been a prime target of those re- searching a cause, and the potential relationshi p between a high-fat diet and breast cancer has sparked controversy in lay and professional publications. 9-12 Proponents of the

240 Geriatric Nursing September/Oct0ber 1992

FACTORS THAT INCREASE RISK FOR BREAST CANCER

Age History of previous breast cancer

History of breast cancer in a first-degree female relative (mother, sister, grandmother)

Obesity, greater than 40% above normal weight Menarche before age 12

First pregnancy after age 30 Never pregnant

Late menopause after age 50

dietary theory stress that a high-fat diet, consumed by many American women, causes the production of excess estrogen, which in turn has been linked to breast cancer.

Indeed, the westernization of dietary habits in developing countries, which have long had a low-fat content, has been related to an increased incidence of breast, co- lon, and prostate cancers in those countries. This phe- nomena has been termed the "overnutr i t i0n of afflu- ence. ''12 Conflicting research findings have done nothing to clarify the di lemma for consumers. The dietary recommendations agreed on by several agencies, including the American Cancer Soci- ety, National Cancer Insti- tute, and the United States Department of Health and H u m a n Serv ices , among o the r s , a re shown in the " G u i d e l i n e s " b o x . A t present, however, there is no firm scientific evidence con- firming the relationship between diet and cancer.

Recent news reports noted that basic research underway in Japan has uncovered a possible chromosomal link to the development of breast cancer. Basic research in our own country has been deficient, according to many breast cancer advocacy groups. In 1989, $17 million was appro- priated for breast cancer research. The 1992 federal bud- get estimate is $30 million for basic research into the cause of this deadly disease. By way of contrast, the bud- get for basic AIDS research is $1.8 billion. In February of this year, 140 groups dedicated to breast cancer advocacy brought their concerns to Washington, D.C., in the hopes of stirring legislators to action to designate more dollars for research (see "Advocacy Groups" box). 13

D e t e c t i o n T e c h n i q u e s

~_ER1GAN ~ANCE_R 5~1EI¥ ~ GUII)E_L1NE~ ON DI~ET, NUTRIIION~ AND, C~NCER

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det 4. ~ t more htgh-b'~er foods. ~ ~s ~liolegra-m, cemals,

|egu.mes, vegetab/~, attd |nfat. 5. Cu~ dctvat on t~tCll ~ ~italte, 6. I ~ a ¢.G~n~pti~ Gt Gle,ohoIi© l ~ S , |f you drink at ~1}. Z Umit ¢omompli0n Ot surf-cured, smoked; afa~ngn3¢~

Because we do not know how to prevent breast cancer, secondary prevention, in the form of early detection and diagnosis, is the primary defense. Clinical breast examination and self-examination are dependent on the pres- ence of palpable abnormalities and so have inherent limitations related to technique and breast size. Thermog- raphy, or detection of areas of increased temperature, is considered an unscientific and unreliable tool for diagno-

sis of breast lesions, despite claims by its defenders) 4 UI- trasonography is also not a definitive modality for this diagnosis, but is used to differentiate between cystic and solid lesions. There may be a future role for magnetic res- onance imaging, but it is not now the diagnostic tool of choice. Mammography enables caregivers to detect early stage, nonpalpable lesions. For these reasons, the empha- sis for early detection efforts in older women should be primarily through mammographic screening.

S e c o n d a r y P r e v e n t i o n

Breast self-examination. Several studies have explored compl iance with r ecommenda t ions for breas t self- examination (BSE). Although women over 60 have been included in study samples, they have typically represented a small percentage of the total participants. In ad- dition, few published studies have focused on older women and BSE) 5"18

Not enough studies have assessed the proficiency of reported BSE or the effect of functional or tactile deficits, combined with possible sensory and memory impair- ments, in some older women. Stefanek and Wilcox 15

found that even with women who identified themselves as being at moderate or high risk (because of first-degree re la t ives with d iagnosed breast cancer) , BSE proficiency was poor despite frequent performance and con- fidence in their technique) 5

In a Vermont s tudy the average tumor size detected was 1.9 cm for those per- forming monthly BSE, ver- sus 2.47 cm for those per-

forming BSE less frequently, and 3.59 cm for those who never performed BS E) 9 Clearly those individuals per- forming BSE monthly had a distinct advantage in detect- ing their cancers at an earlier point. Mammography, however, detects tumors significantly smaller than 1.9 cm.

What of radiation from repeated mammograms causing breast cancer? It is estimated that one additional breast cancer per million women per year, with a 50% mortality rate, has been associated with mammography-

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The National Alilance of Breast Cancer Organizations 1180 Avenue of the Americas, 2nd floor

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Geriatric Nursing September/October 1992 241

related radiationfl ° Newer radiographic techniques use even less radiation exposure.

Because of limitations inherent in BSE and the impli- cation that the practice of BSE does not reduce mortality, the technique has not been universally advocated as a means of self-screening for breast cancer ) 6. 2t Older women in particular may not accept the practice readi- ly, 22 and may not exhibit proficiency or consistency for a number of reasons. Further research is needed to provide the data to determine an appropriate recommendation for the practice of BSE with older women. Until that time, the practice of monthly BSE as one modality should continue to be taught, reviewed, and encouraged for all women. It is another educational tool to help promote personal responsibility for health and well-being.

Clinical breast examination. Women who have an identified physician or primary health care provider have reported examinations to be more frequent than women who have no reliable source of health care. Studies are being conducted to determine the efficacy of this detection modality as well. As expected, women who have a regular source of health care and clinical breast examination as part of their routine care also have mammography recommended more frequently, particularly if they are younger. Nevertheless, as age increases, frequency of clinical breast examinations in conjunction with routine health care tends to decline.

Mammographic screening. In 1984, 11% of physicians recommended mammography; in 1989 that figure had risen to 37%--stii1 surprisingly low. 23 Studies have indicated that some physicians screen elderly women less frequently, regardless of family history of breast cancerfl 4 Younger women undergo m a m m o g r a p h y more frequently than do older women, are more knowledgeable and fearful about breast cancer and risk factors, and are more assertive about requesting the procedure. An older c l i e n t ' s l ack of u n d e r s t a n d i n g of r i sk f a c t o r s - - particularly that of increased incidence with increasing age- -and poor understanding of the potential value of mammography may lead to fewer older women being screened. 25

Mammographic screening is a term used when obtain- ing limited x-ray views, usually two, of both breasts in asymptomatic women. Minute cancers may be detected by this relatively pain-free procedure, and the rate of false-positive findings is approximately 2%. Predictors for compliance with screening have repeatedly been shown to be the physician atti tudes and practices toward mammography--specifically, a recommendation for the procedure.5-8, 25-27

Women who have not participated in screening efforts have identified that their physician had not recommended the procedure, and the women therefore felt it was unnecessary for them. Other reasons for nonparticipation with mammographic screening have been cited as lack of symptoms, inconvenience, cost, embarrassment, fear of radiation exposure, and fear of discovery of malignant disease.

Part of the reluctance of physicians in recommending mammography to their asymptomatic patients has been

the cost of the procedure, which many women were un- able or unwilling to bear. a, 24 Recent legislation has changed that factor.

As of January 1991 Medicare reimbursement was ex- tended to include mammographic screening for eligible women. Annual mammograms are covered for disabled women between 50 and 64; for other eligible woman over 65, biennial procedures are partially reimbursable. Pre- viously, mammography was reimbursable for diagnostic or treatment purposes only.

Arguments for this legislation became heated about the t ime of Nancy Reagan's mastectomy in the mid- 1980s. She was the third first lady to undergo some in- tervention for breast disease (Betty Ford had a mastectomy, and Rosalynn Carter underwent a biopsy), and the topic was a charged one. Hearings took place in late 1987, and Medicare coverage of mammography was signed into law in July 1988.

Barriers to S c r e e n i n g

Barriers to participation in mammographic screening include those that bar access to other health care services as well. Access to care includes more than entry to the facility that provides the procedure. Lack of transportation, medical insurance, a physician or health care provider, knowledge, literacy skills, or belief in the effectiveness of the procedure--all may inhibit an older woman from requesting or complying with this procedure.

Mammographic screening is not without some risk. There are those who are concerned that expanding mammographic screening will do one of two things. First, an increase in the rate of false-positive findings might occur, causing these women to require further diagnostic studies, including additional x-ray, biopsy, and possibly sur- gical procedures. This would produce a negative psychologic effect on the woman involved, as well as increasing health care costs. Second, an increase in the rate of false- negative findings would induce a false sense of security in some women and delay diagnosis and treatment until a later stage in the disease.

Both of these arguments appear logical, but there is in- sufficient evidence to indicate that either outcome will occur. At present, the benefits of early diagnosis and treatment for greater numbers of older women far outweigh the risks of misdiagnosis in a very small percentage (2%) of the procedures. There is a significant cost savings in the early treatment of the disease as well. The medical, nursing, socioeconomic, and psychologic costs of end- stage breast cancer care are staggering by comparison.

Underserved W o m e n

Minority women. Many factors influence a woman to seek (or not to seek) cancer screening. The Nat ional Health Interview Survey (NHIS) describes the differences in behaviors between race, ethnic, and socioeconomic strata. It has been documented that utilization of all cancer screening procedures increases with education and income levelfl 8 Conversely, those in minority or

242 Geriatric Nursing September/October 1992

economically disadvantaged populations may lack access to preventive services.

Breast cancer is the leading cause of cancer mortality in Afr ican-American women, and the second leading cause of cancer mortality for African-American women over 55. 29 Younger African-American women frequently have breast cancer detected at a later stage. Older women of all races frequently have a later stage of the disease diagnosed. Ensuing interventions and treatment therefore may be more extensive and more expensive, require longer recovery time, and are potentially more psycho- logically harmful than cancers detected and treated at an early stage.

Differences in cultural and social mores, as well as language and economic barriers, may prohibit some minority women from seeking mammography. Developing a cancer screening program for a specific cultural, racial, or ethnic group may provide certain challenges, but success- ful programs have been implemented) °, 3t Development of effective, culturally sensitive information is crucial to this effort. An American Cancer Society demonstration project currently underway in Illinois is specifically targeting African-American and Hispanic women, with the intent of exploring and removing barriers to mammo- g r a p h i c s c r e e n i n g ( p e r s o n a l c o m m u n i c a t i o n , J. Sauerzapf, April 2, 1992).

Being female, old, a minority,

and poor are criteria for not

having access to adequate cancer

prevention services.

Aging women/poor women. Jecker 32 writes effectively about issues of rationing health care based on age. In ad- dition to a "feminization of poverty," there is a feminization of aging occurring. More women survive to older age (over 85 years old) than do men, and this trend is expected to continue. Rationing of publicly funded health care is a passionately debated issue, and age-based rationing is one of the alternatives discussed.

With aging, women tend to require more publicly funded health care. In 1986 they constituted 71% of the population entitled to both Medicare and Medicaid funding. 32 If funding for health care will be rationed by age, women will suffer disproportionately because there are more of them. Breast cancer does not differentiate between independently wealthy and economically disadvantaged older women. Being female, old, a minority, and poor and uninsured are criteria for not having access to adequate cancer prevention services. 33

Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Insti- tute indicates that there is a greater likelihood that older women will have distant metastases at the time of diagnosis of breast cancer. If current estimates hold true, there will be approximately 1.4 million breast cancer pa-

tients and breast cancer survivors in the year 2030. 8 Sta- tistics of this magnitude require thoughtful, ethical, and equitable formulation of health care policy for aging women.

The forgotten women. If older women in general un- derutilize preventive services because of access barriers, then "forgotten" women fare even worse. These are the women abandoned in long-term custodial facilities, those who are chronically mentally ill, homeless, socially iso- lated, imprisoned, neglected, or abused. They are the women that families, communities, and society have scarce resources to support. They are women for whom preventive health care is a luxury; for such women a breast examination or mammography are virtually un- heard of.

In an unpublished review of the use of mammography in a retirement community, it was discovered that there had been no recommendations for mammography in 63% of the 72 women reviewed. This group represented a 25% random sampling of ambulatory women (aged 65 to 98) on the campus and was the second review within 1 year. These dismal results reflected a higher utilization than in the associated long-term care nursing facility (Drugay M. Unpublished findings). This finding is consistent with results reported on breast cancer detection methods in long-term care facilities. 34

Nursing Implications

Nurses are in an unparalleled position to assume a pro- active stance for efforts at early detection and diagnosis of breast cancer in older women. Treatment options have been well defined elsewhere and are not necessarily limited related-to age. s, 35, 36 Those who work with older women in all settings must heighten their awareness of the recommended modalities for cancer detection. Rou- tine breast self-examination is a simple technique that should be encouraged as one aspect of the overall context of health maintenance. Annual mammography should be stressed, and women should be encouraged to request the procedure if their physician fails to recommend it. The American Cancer Society has numerous leaflets and bro- chures about breast cancer issues that should be made available to these women.

Client education regarding risk factors, and the value of mammography to detect abnormalities at an early stage may be critical in altering or modifying health behaviors. Positive reinforcement and feedback, clarifica- tion of misconceptions and cancer myths, and nursing interventions sensitive to the age, ethnicity, and skills of the older woman provide a positive atmosphere in which learning may take place.

Identifying women who have never been screened and discussing this in the framework of patient advocacy may assist family members and physicians reluctant to burden the older patient with "unnecessary" testing. Given and Given 37 explore an agenda for cancer research for the elderly from a nursing perspective. This agenda details areas in need of nursing research and requires action n o w

if we are to improve outcomes for older women. We must promote early breast cancer detection efforts for aging

Geriatric Nursing September/October 1992 243

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244 G e r i a t r i c N u r s i n g September/October 1992

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Battling breast cancer in older women: Where do we stand?