Breast Cancer Screening
Breast Cancer As A Health Issue
Breast cancer is a disease for which there is no foreseeable cure, and indications are that the incidence will remain high. The American Cancer Society estimates that more than 211,300 women were diagnosed with breast cancer in 2003, and almost 39,800 will die.
Although breast cancer remains a significant form of cancer mortality for women, in 1996 an overall decrease in mortality was reported. Because treatment is extremely effective with Stage I tumors, increases in mammography screening have influenced breast cancer mortality.
Early Screening Test In Breast Cancer
When discovered early, breast cancer victims may anticipate a 97% chance for complete cure. Prospective mortality-based studies have demonstrated the effectiveness of mammography screening, particularly in women 50-70 years of age, and therefore most organizations recommend periodic screening beginning at age 50.
Recommendation for Screening
Recently, mammography recommendations have been expanded to include women 40 to 49. Consequently, both the American Cancer Society and the National Cancer Institute now recommend screening beginning at age 40. Obviously, breast cancer screening by mammography does not magically become effective at age 40 or 50 or 60, and one mistake that fueled controversy was comparing one decade to another.
Comparing women aged 40 to 49 with women 50 and over creates artificial boundaries that cause much confusion. Now that the American Cancer Society and National Cancer Institute are in agreement, energy may be focused on other issues.
Breast Examination And Outcomes
The effectiveness of clinical breast examination is not as clear as that of mammography, although it is currently recommended. Some studies demonstrating a decrease in mortality for mammography have included clinical breast examination, but the independent effect of the latter has not been studied.
In addition, the efficacy of breast self-examination (BSE) has been documented although not in randomized, prospective mortality-based trials. To date, retrospective studies have found that BSE may detect an earlier stage of disease or smaller tumor size.
Reliability of Screening
Despite its apparent effectiveness, breast cancer screening is not used to its fullest advantage. While screening rates may approach 70% to 74%, rates are lower for minorities and women over 65. The rates for consistent mammography screening at recommended intervals are not good.
Rates for mammography in 2000 ranged from 57%-72%. Rates for clinical breast examination and mammography were higher, ranging between 37.3% and 69%. Recent data indicate that women may report BSE practice as frequently at seven to eight times a year but have low proficiency scores.
Potential of Breast Screening
It is obvious that breast cancer screening has the potential to reduce mortality and morbidity from this dreaded disease. Breast cancer screening rates, although increasing. are not optimal. Most problematic is the fact that women do not follow current recommendations for screening.
Minority rates for follow-up are dismal, and access to care is a real issue. This health-promoting detection activity is of primary importance to nurses in all areas of practice. Nurses are in an optimal position to increase all three screening methods (mammography, clinical breast examination, and BSE).
Interventions to promote mammography and teach BSE can be carried out during general health promotion or while women are being seen for other reasons. Clinical breast examination is a skill that should be learned by all nurse practitioners and conducted yearly on all women aged 20 and over.
Theoretical Assumptions About Mammography
Several important theoretical variables have been tested for relationships to breast cancer screening-in particular, mammography and BSE. The theory that has generated the most research is the health belief model.
The health belief model was initially conceptualized in the early 1950s to predict preventive behaviors such as influenza inoculations (Rosenstock, 1966). As originally formulated, the health belief model included the variable of perceived threat to health, which included the concepts of risk of contracting the disease (perceived susceptibility) and personal cost should the disease be contracted. (Perceived seriousness).
In addition, benefits: and barriers to taking a preventive action were predicted to influence the health behavior. In 1988, the concept of self-efficacy, or perceived confidence in carrying out a preventive behavior, was added to the health belief model.
Other theories that have been used to predict breast cancer screening have included Fishbein and Ajzen's (1975) theory of reasoned action, which postulates that two major concepts are related to breast cancer screening: (a) beliefs and evaluations of these beliefs and (b) social influence.
Social influence is also composed of two components: beliefs of significant others and the influence of significant others on the individual. Most recently, the transtheoretical model has been. tested with mammography use and found to predict behavior (Prochaska et al., 1994). This model defines the outcome in terms of stages of preparedness to engage in a health-promoting activity.
In addition to the factors involved in these models, descriptive research suggests that breast cancer screening is influenced by knowledge, previous health habits, particular demographic characteristics, and health care systems.
A number of studies spanning over a decade have used various models to predict mammography screening. In general, attitudinal variables such as perceived susceptibility, perceived benefits to screening, and perceived barriers to screening have been predictive of mammography.
Rakowski and co-workers (1992) found that perceived pros (benefits) and cons (barriers) varied across stages of mammography. The most consistent predictors of mammography use have been physician recommendations and barriers. The latter have included perceived lack of need, fear of results, fear of radiation, cost, pain, time, and inconvenience.
Recently, the trans-theoretical model has been used for predicting mammography by postulating that women move through a series of stages from precontemplation, or not thinking about mammography, to maintenance of mammography over time.
Descriptive studies to predict BSE have spanned the past 2 decades. Again, the variables of perceived susceptibility, benefits, and barriers have been significantly related to BSE. A less significant prediction of BSE compliance has been physician recommendation.
Instead, women who were taught personally and returned a demonstration have been found to comply at higher rates. A major problem with BSE research has been the measurement of outcomes. In many earlier studies women were asked how many times they examined their breasts, and this was used as the operational measure of compliance.
Later, self-report proficiency scales were widely used. Research has shown that there is often little correlation between reported frequency and proficiency, indicating that even if women practice BSE, they may not be doing it proficiently enough to detect lumps.
Actual measurement of BSE proficiency also has been problematic. The best studies have used trained observers to watch women either complete BSE or identify silicon lumps embedded in models. Subjective norms, as identified in the theory of reasoned action, have been predictive in some studies.
Most research has identified low to moderate correlations between attitudinal variables and BSE. Perceived confidence for completing self-examination has been one of the strongest predictors.
Intervention research for both mammography and BSE has built on the descriptive studies of earlier decades. Interventions have ranged from multistate community interventions to individual patient-oriented interventions.
Many of the individually focused interventions targeted perceptions of risk, benefits, and barriers, multistrategy interventions often targeted physician recommendation, which had been found to be an important predictor of mammography screening. Various ways of delivering messages have been tried, including the media, telephone delivery, tailored letters or postcards, and in-person counseling.
Access has been identified as a problem, as shown by the fact that persons in health maintenance organizations (HMOs) consistently have higher rates of mammography screening than do patients in private medical practice. Access-enhancing interventions have included the use of mobile vans, which provide casier access for women with transportation problems.
Costs of mammography for indigenous women continue to be a problem, although agencies such as the American Cancer Society and Little Red Door have helped to defray these costs. Social network interventions have been effective with minority groups.
Peer leaders can sometimes be important links for low-income, African American, or Hispanic women. Most interventions, especially those based on sound theory, have been successful in increasing mammography.
Interventions addressing BSE often focus on teaching women the correct skills for practice . Many of the interventions use educational strategies, with or without counseling, related to the theoretical constructs of perceived susceptibility, benefits, and barriers.
Many studies have used reminder systems or self-prompts to increase practice. Interventions have ranged from handing out pamphlets to one-to-one teaching sessions with return demonstrations.
Studies using models to identify lumps have been the most vigorous. Studies that include personal demonstrations, guided feedback, and both cognitive and personal instruction evidence the greatest increase in proficiency.
Descriptive and intervention studies based on similar theories of breast cancer screening have extended over the past 2 decades. The major difference in relation to promoting mammography is the addition of physician recommendation. Physician recommendation is important both because medical advice is related to mammography and because an order may be necessary to obtain a mammogram.
For BSE, personal teaching has been found to be a most important predictor. We now know enough about breast cancer screening to make certain recommendations for nursing practice. For both BSE and mammography, clinicians must take into account the individual's perceptions about their susceptibility to breast cancer.
If this perceived susceptibility is unrealistically low, efforts must be made to paint a more accurate picture. Perceived benefits and barriers to both mammography and BSE also should be addressed and individualized strategies developed.
For BSE teaching, the set of skills needed to complete this exam and observation of proficiency will be important. A major future direction related to mammography will be to increase interval compliance.
Breast cancer screening research has broad implications for increasing other health behaviors, such as colorectal or prostate screening. Preventive behaviors such as the use of skin protection and adherence to low-fat diets can also be targeted for intervention trials.
Finally, nurses must actively encourage public policy decisions that increase screening access for all people.
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