Women
with
Disabilities
educational programs
Prevention, Diagnosis,
and Treatment of
Breast Cancer in
Women with Disabilities
Part 2: Screening and Diagnosis
Women with Disabilities Education Project
Overview
Part 1:
Incidence and Risk
Part 2:
Screening and Diagnosis
Part 3:
Treatment, Rehabilitation, and Ongoing Care
www.womenwithdisabilities.org
Screening
Most Common Screening Tests
 Mammography
 Clinical breast exam
 Breast self-exam
Mammography
7 Statistical Models:
Mammography reduces
the rate of death from
breast cancer by 7%–23%,
with a median of 15%.1
1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.
Mammography
Age
Interval
 Regular screening
lowers breast cancer
mortality by
 Optimal interval unknown
– 15%–20% in women
aged 40–49
– 25%–30% in women
aged 50–69
 Limited evidence for
effectiveness in women
aged 70+
 Reductions in mortality
have occurred at
intervals ranging from
12–33 months
 Many organizations
recommend annual
screenings for women
aged 40–49
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
Ultrasound?
Not a Good Stand-Alone Option
3 Studies of Women with
Hereditary Risk:1
 2 of 83 cancers detected solely
by annual ultrasonography
 2 additional cancers
detected through screenings
at 6-month intervals
Accessible Mammography Remains Best
Screening Option for All Women
1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.
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
1. Iezzoni LI, et al. Am J of Public Health. 2000;90:955-961.
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
Removing Informational Barriers
25% of women with
disabilities were not
told by their doctor to
get a mammogram
Helping Your Patient Prepare
 Explain what to expect
 Discuss any concerns
Breaking Down Barriers to
Mammography Screening
An Accessible Imaging
Center Should Have:
 Fully accessible equipment
 Staff trained to properly
assist women with
disabilities
 Systems in place for
successful positioning
during screening
 Systems in place for
successful communication during screening
www.WomenWithDisabilities.org
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
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.
Clinical Breast Exam (CBE) Protocol
1. Introduction to Exam:
Is client highly anxious, fearful or uncomfortable due to
cognitive impairments, prior history of sexual abuse, or other
reason? Is client likely to experience significant pain or
spasticity during the exam?
Yes
No
2. Preparing for Exam:
 Does client need assistance with undressing upper body?
 Does client refuse to remove or allow clothing to be removed?
Yes
No
3. Visual Inspection of the Breasts:
May be done standing, seated in wheelchair, or seated on exam
table – based on physical ability (balance, posture, endurance,
involuntary movement, and transfer)
4. Performing the 4 Positions:
 Does client have difficulty?
 Can the client assist?
Yes
No
5. Lymph Node Exam:
 Client seated on table with side rails up, or in wheelchair if has
poor balance
 Can be performed with shirt pulled above breasts and around
neck, or beneath loose clothing when visualization is possible
No
7. Breast Palpation:
Does client have difficulty positioning arms (due
to tremors, contractures, involuntary movement
or paralysis)?
Does client have difficulty raising arms?
 Ask permission to position hand
above head
 Use non-examining hand and/or pillows
to stabilize client’s arm at 90°angle
 If attendant/friend/ and/or family
member is available, he/she may assist
in stabilizing arm
 If client refuses all of above, perform
CBE with arms at sides
 Ask client for directions, provide assistance as needed
 Consider performing CBE with shirt lifting for visualization
 Consider performing modified CBE through clothing with plan
to perform thorough CBE at next visit or after client trust
becomes established
 Offer assistance to hold arms above head
 Modify hands on hip position as needed to achieve pectoral
muscle contraction
 Use support devices to assist client in leaning forward if
necessary (e.g., walker or chair)
 Offer the client the opportunity to undress in private. If client
chooses to undress in your presence, closely observe client
when undressing – arms are above head when shirt comes off,
and often the pectoral muscles are relaxed and tightened during
this process. Often the 4 positions can be observed without
intentional client cooperation if the client is anxious.
Yes
No
8. Completion of Exam:
Does client need assistance to get off table
or dress?
No
Yes
Offer assistance
6. Position on Exam Table:
 Does client need assistance?1
 Can client lie down?
 Determine if attendant/friend/and/or family member can be
present during exam
 Explain each step in simple terms, offer frequent reassurance
and praise
 Consider demonstrating breast exam on yourself (the
provider), if necessary, to assist client in understanding
procedure and purpose
 Consider recommending taking any prescribed anti-spasmotic,
analgesic or anti-anxiety medication 1-2 hours prior to exam or
as prescribed
Yes
 Ask client for directions, provide skilled assistance as needed.2
 Provide extra pillows or wedges for support as necessary
 Encourage client to lie on flat exam table
 Try having client sit on exam table then slowly recline back with
a good pillow support beneath the head
 Consider semi-reclined position with goal of greatest recline
as tolerated
 Consider performing exam in upright position
1. Recommend electrically controlled, high-low exam table with side rails
2. Client may prefer to bring own attendant/friend/ and/or family member, or provider has assistance from trained personnel.
Source: Breast Health Access for Women with Disabilities, January 2008.
Finally:
 Praise client’s efforts throughout the exam
(especially for women with cognitive intellectual
limitations)
 Discuss findings with client
 Describe follow-up schedule and plan to client
 Communicate with client’s primary care
physician if necessary and appropriate, and if
appropriate, her attendant/friend and/or family
member
Introducing the Patient to the CBE
1. Introduction to Exam:
Is client highly anxious, fearful or
uncomfortable due to cognitive impairments,
prior history of sexual abuse, or other reason?
Is client likely to experience significant pain or
spasticity during the exam?
Yes
Source: Breast Health Access for Women with Disabilities, January 2008.
 Determine if attendant/friend/and/or family
member can be present during exam
 Explain each step in simple terms, offer
frequent reassurance and praise
 Consider demonstrating breast exam on
yourself (the provider), if necessary, to
assist client in understanding procedure
and purpose
 Consider recommending taking any
prescribed anti-spasmotic, analgesic or
anti-anxiety medication 1-2 hours prior to
exam or as prescribed
Preparing the Patient for the CBE
2. Preparing for Exam:
 Does client need assistance with
undressing upper body?
 Does client refuse to remove or allow
clothing to be removed?
Yes
Source: Breast Health Access for Women with Disabilities, January 2008.
 Ask client for directions, provide
assistance as needed
 Consider performing CBE with shirt
lifting for visualization
 Consider performing modified CBE
through clothing with plan to perform
thorough CBE at next visit or after
client trust becomes established
Visual Inspection of the Breasts
3. Visual Inspection of the Breasts:
May be done standing, seated in wheelchair,
or seated on exam table – based on physical
ability (balance, posture, endurance,
involuntary movement, and transfer)
4. Performing the 4 Positions:
 Does client have difficulty?
 Can the client assist?
Yes
 Offer assistance to hold arms above head
 Modify hands on hip position as needed to
achieve pectoral muscle contraction
 Use support devices to assist client in
leaning forward if necessary (e.g., walker or
chair)
 Offer the client the opportunity to undress in
private. If client chooses to undress in your
presence, closely observe client when
undressing – arms are above head when
shirt comes off, and often the pectoral
muscles are relaxed and tightened during
this process. Often the 4 positions can be
observed without intentional client
cooperation if the client is anxious.
1.Recommend electrically controlled, high-low exam table with side rails
2.Client may prefer to bring own attendant/friend/ and/or family member, or provider has
assistance from trained personnel.
Source: Breast Health Access for Women with Disabilities, January 2008.
Positioning the Patient
on the Exam Table
5. Lymph Node Exam:
 Client seated on table with side rails
up, or in wheelchair if has poor
balance
 Can be performed with shirt pulled
above breasts and around neck, or
beneath loose clothing when
visualization is possible
6. Position on Exam Table:
 Does client need assistance?1
 Can client lie down?
Yes
Source: Breast Health Access for Women with Disabilities, January 2008.
 Ask client for directions, provide skilled
assistance as needed.2
 Provide extra pillows or wedges for support
as necessary
 Encourage client to lie on flat exam table
 Try having client sit on exam table then
slowly recline back with a good pillow
support beneath the head
 Consider semi-reclined position with goal of
greatest recline
as tolerated
 Consider performing exam in upright
position
Breast Palpation
7. Breast Palpation:
Does client have difficulty positioning arms (due
to tremors, contractures, involuntary movement
or paralysis)?
Does client have difficulty raising arms?
Yes
 Ask permission to position hand
above head
 Use non-examining hand and/or pillows
to stabilize client’s arm at 90°angle
 If attendant/friend/ and/or family member
is available, he/she may assist in
stabilizing arm
 If client refuses all of above, perform CBE
with arms at sides
Source: Breast Health Access for Women with Disabilities, January 2008.
Completion of the Exam
8. Completion of Exam:
Does client need assistance to get off table
or dress?
Yes
Offer assistance
Source: Breast Health Access for Women with Disabilities, January 2008.
Breast Self-Exam
 Not shown to have an effect on
breast cancer mortality rate1
 U.S. Preventive Services Task
Force: Not enough evidence
to recommend for or
against BSE2
 ACS and others: Teach women
the procedure and give them
the option of using it3
1.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.
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
Source: Breast Health Access for Women with Disabilities.
Breast Health
Access for Women
With Disabilities:
www.bhawd.org
Diagnosis
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
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
Biopsy Accommodations:
Stereotactic Add-on Devices
Digital Mammogram Unit
Stereotactic Biopsy Table
Biopsy Accommodations:
Ultrasound in Seated Position
Stretcher for supine
or semi-upright biopsy
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
Resources
Breast Health Access for Women with Disabilities (BHAWD)
Call: 512-204-4866
TDD: 510-204-4574
www.bhawd.org
Center for Research on Women with Disabilities (CROWD)
Baylor College of Medicine
Call: 800-442-7693
www.bcm.edu/crowd
Health Promotion for Women with Disabilities
Villanova University College of Nursing
Call: 610-519-6828
www.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/
National Breast and Cervical Cancer Early Detection Program
Centers for Disease Control and Prevention
Call: 1-800-CDC-INFO
TTY: 1-888-232-6348
www.cdc.gov/cancer/nbccedp
National Center of Physical Activity and Disability
Call: 1-800-900-8086
TTY: 1-800-900-8086
www.ncpad.org
The National Women’s Health Information Center
Call: 1-800-994-9662
TDD: 1-888-220-5446
www.4women.gov/wwd
Susan G. Komen for the Cure
www.cms.komen.org
Women with Disabilities
Centers for Disease Control and Prevention
www.cdc.gov/ncbddd/women
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