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Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities


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Title: Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities

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Prevention, Diagnosis, and Treatment of Breast
Cancer in Women with Disabilities
  • Part 3 Treatment, Rehabilitation, and Ongoing

Women with Disabilities Education Project
  • Part 1Incidence and Risk
  • Part 2Screening and Diagnosis
  • Part 3Treatment, Rehabilitation, and Ongoing
Treatment Options for Noninvasive Cancers1
  • LCIS
  • 1. Observation after diagnostic biopsy
  • 2. Tamoxifen to decrease the incidence of
    subsequent breast cancers
  • 3. Bilateral prophylactic total mastectomy,
    without axillary node dissection
  • 4. Clinical trials testing cancer prevention drugs
  • DCIS
  • 1. Breast-conserving surgery and radiation
    therapy with or without tamoxifen
  • 2. Total mastectomy with or without tamoxifen
  • 3. Breast-conserving surgery without radiation

1. National Cancer Institute. Available at
Treatment Options for Early Breast Cancer (Stages
I, II, IIIA, and Operable IIIC)1
  • Primary
  • Breast-conserving surgery lymph node dissection
    and radiation therapy
  • Modified radical mastectomy
  • Adjuvant
  • After surgery radiation therapy
  • Systemic chemotherapy
  • Hormone therapy (tamoxifen, aromatase inhibitors)
  • Trastuzumab (Herceptin) systemic chemotherapy

1. National Cancer Institute. Available at
Treatment Options for Stage IIIB, Inoperable
Stage IIIC, Stage IV, Recurrent, and Metastatic
Breast Cancer1
Stage IIIB and Inoperable Stage IIIC
Stage IV and Metastatic
  • Hormone therapy
  • Chemotherapy
  • Surgery with lymph node dissection and radiation
  • Targeted therapies (e.g., lapatinib, trastuzumab
    (Herceptin), bevacizumab (Avastin))
  • Clinical trials testing new drugs/treatments
  • Hormone therapy
  • Chemotherapy
  • Targeted therapies (e.g., lapatinib, trastuzumab
    (Herceptin), bevacizumab (Avastin))
  • Palliative radiation therapy and/or surgery
  • Clinical trials testing new drugs/treatments

1. National Cancer Institute. Available at
Disparities in Breast Cancer Treatment
Breast-Conserving Surgery Radiation Therapy
  • Women with Disabilities Were1
  • 20 less likely to receive breast-conserving
  • 19 less likely to receive lymph node dissection
  • 17 less likely to receive adjuvant radiation
  • 29 more likely to die from the breast cancer

1. McCarthy et al. Ann Intern Med.
Disparities in Breast Cancer Treatment
  • Chart Review1
  • Women with disabilities less likely to receive
    neoadjuvant chemotherapy compared to women
    without disabilities (13 of the time vs. 29 of
    the time), but
  • Difference was not statistically significant

1. Caban ME, et al. Cancer. 2002941391-1396.
Making the Treatment Decision
  • Avoid assumptions
  • Discuss medical and logistical pros and cons of
    each treatment option

Determining Medical Decision-Making Capacity
(Ability to Give Informed Consent)
  • So long as the patient appears to adequately
    understand and appreciate the personal
    significance of the following
  • That she has a general medical or mental
  • The nature and course of the disorder, and
  • The risks and benefits of the proposed
    intervention and of the alternative, including
    the alternative of no intervention and
  • So long as the patient makes a non-coerced
    choice that does not appear to be unduly
    influenced by a mental disorder, then the patient
    may be considered to possess capacity even if her
    choice appears to the physician to be

1. Moore RF. Medscape General Medicine. 19991(3).
Resources for Determining Ability to Give
Informed Consent
  • State medical associations
  • National Association of Developmental Disability
  • Assessment tools for women with limited verbal
  • Hopkins Competency Assessment Test
  • Competency Interview Schedule
  • MacArthur Competence Assessment Tool

Special Concerns Surgery
  • How will surgery affect the patients disability
    and quality of life?
  • What are the patients current assistive and
    adaptive needs, and how will surgery affect those

Overcoming Surgical Barriers
  • Anticipate and plan for any special needs that
    the patient might require during the surgery
  • Make sure patient will have assistance after the
  • Make sure patient has transportation to the
    surgery and to post-op medical appointments
  • Consider sending patient to a PT or OT
    consultation before surgery

Special Concerns Radiation Therapy
  • Is patient physically able to lie still and
    abduct arm for treatment?
  • Will patient have daily transportation to and
    from radiation therapy facility?
  • Will patient have necessary level of home care to
    address medical and daily living side effects of
    radiation therapy?

Overcoming Barriers to Radiation Therapy
  • Anticipate transportation and other access
    barriers make sure these issues are resolved
    before patient shows up for treatment
  • Consider shorter treatment course

Special Concerns Chemotherapy
Will patient have necessary level of home care to
address medical and daily living side effects of
Possible Side Effects
Special Concerns Chemotherapy
Side Effects Pose Potentially Debilitating
Consequences for Women with Disabilities
  • Fatigue May severely limit mobility for women
    with existing mobility limitations
  • Increase in Urine Output May cause significant
    problem for women with existing continence
  • Bone Loss Increases osteoporosis risk for women
    already at increased risk

Special Concerns Hormone Therapy
Will patient have necessary level of home care to
address medical and daily living side effects of
hormone therapy?
Possible Side Effects Tamoxifen/Raloxifene
Special Concerns Hormone Therapy
  • Aromatase Inhibitors
  • Increased risk of bone loss and fractures
  • Consider adjuvant use of bisphosphonates

Overcoming Barriers to Chemotherapy and Hormone
  • Ensure full patient participation in treatment
  • Tailor treatment based on side effect and risk
  • Identify and address patients needs before
    treatment begins
  • Increase home nurse visits, if needed
  • Monitor patients bone density and evaluate
    treatments to attenuate bone loss
  • Instruct patient on symptoms of thromboembolism

Support Patient During Treatment
  • Identify barriers to care
  • Identify resources to overcome those barriers
  • Prepare patient for possible side effects and
    their impact on her daily activities
  • Make sure she will have the proper assistance to
    deal with those side effects
  • Coordinate care with other specialists
  • Have a system in place that enables you and your
    patient to communicate easily throughout the
    treatment process
  • Ask patient if she would like to include a friend
    or family member in her care

Rehabilitation Strategies
  • Treat related diagnoses that increase the
  • Treat unrelated diagnoses that increase the
  • Manage pain
  • Improve fatigue
  • Increase strength and cardiovascular fitness
  • Prescribe adaptive equipment

Treat Related Diagnoses Lymphedema
  • Symptoms
  • Swelling, aching, tightness in arm
  • Hardening/thickening of skin
  • Restricted range of motion
  • May lead to cellulitis
  • 630 of survivors self-report lymphedema
  • Symptoms may develop up to 20 years after
    initial treatment2
  • National Cancer Institute. NCI Cancer Bulletin.
  • Petrek JA, et al. Cancer. 2001921368-1377.

Complete Decongestive Physiotherapy
  • Manual lymphatic massage
  • Inelastic compression bandaging
  • Remedial exercises
  • Meticulous skin care

Treat Related Diagnoses Rotator Cuff Tendinitis
  • Common disorder among breast cancer patients1
  • Results from weakness of the rotator cuff
  • Radiation therapy and chemotherapy contributeto
    the disorder
  • Associated with lymphedema2
  • Stubblefield MD, Custodio CM. Arch Phys Med
    Rehabil. 2006S96-S99.
  • Herrera JE, Stubblefield MD. Arch Phys Med
    Rehabil. 2004851939-1942.

Treating Rotator Cuff Tendinitis
  • Stretches and range-of-motion exercises to
    increase flexibility
  • Exercises to stabilize shoulder

Treat Related Diagnoses Overuse Injuries on
Unaffected Side
  • Women with disabilities are at increased risk of
    overuse injuries
  • Risk increases after cancer treatment

Treating Overuse Injuries
  • Early and aggressive physical therapy is
  • Patient should be evaluated for adaptive
    equipment and/or assistive devices

Treat Related Diagnoses Neck Pain
  • Second most common musculoskeletal condition
    among women
  • After breast cancer treatment, deconditioning
    increases risk

Treating Neck Pain
  • Restore range of motion
  • Maintain/improve upper body strength

Treat Unrelated Diagnoses That Increase the
To Avoid Diminished Function
  • Treat early
  • Treat aggressively

Manage Pain
  • Treatment goals
  • Ameliorate pain
  • Maintain optimal function
  • Closely follow patient for detrimental side
    effects of medication
  • Refer patient to PT and/or OT
  • Integrative treatments (e.g., acupuncture) may

Improve Fatigue
  • Possible Causes of Fatigue in Women
  • Inadequate sleep
  • Side effects from medications
  • Depression
  • Anemia
  • Thyroid illness
  • Poor nutrition
  • Deconditioning

Increase Cardiovascular Fitness
  • Exercise Improves1
  • Quality of life
  • Cardiorespiratory fitness
  • Physical functioning
  • Fatigue
  • Exercise May Improve2
  • Breast cancer survival
  • Greatest benefit Walking 35 hours per week at
    average pace (or equivalent)
  • McNeely ML, et al. CMAJ. 200617534-41.
  • Holmes MD, et al. JAMA. 20052932479-2486.

Increase Muscle Strength
  • Twice Weekly Strength Training
  • Improves quality of life1
  • Increases muscle mass2
  • Reduces body fat2
  • Reduces IGF-II levels2
  • Ohira T, et al. Cancer. 20061062076-2083.
  • Schmitz KH et al. Cancer Epidemiol Biomarkers
    Prev. 2005141672-1680.

National Center on Physical Activity and
Prescribe Appropriate Adaptive Equipment
  • The choice of equipment should involve patient,
    medical team, and PT/OT
  • An assessment should be made of womans needs at
    home and at work

The Alliance for Technology Access
Ongoing Care
Goals of Regular Follow-up Visits
  • Find local or distant recurrence of cancer
  • Find any new breast tumors that have developed
  • Find any treatment-related side effects (e.g,
    lymphedema, bone loss, cardiovascular problems)
  • Identify effects of the disease and its treatment
    on the patients disability and quality of life

Recommendations for Follow-up Care for Breast
  • Khatcheressian JL, et al. J Clin Oncology

Work Collaboratively
  • Ask questions
  • Anticipate problems
  • Create solutions
  • Have mechanism in place to alert you if the
    patient does not return for follow-up within
    recommended interval

Create a Teachable Moment
  • Provide information on healthy behaviors
  • Ascertain if patient needs help with depression
    or other mental health issue
  • If applicable, discuss the option of a genetics

  • Breast cancer treatment poses added practical
    issues for women with disabilities.
  • Present all the medical and logistical pros and
    cons of treatment options to your patients with
  • Know state laws regarding informed consent.
  • Discuss with your patients with disabilities how
    treatment may affect their adaptive and assistive
    needs. Help arrange support services to meet
    those needs.

Summary (continued)
  • Tailor each womans treatment to minimize its
    effect on worsening the patients existing
  • Refer the patient to physical and/or occupational
    therapy before her treatment starts.
  • During follow-up care, identify and address the
    effect that the cancer and its treatment has had
    on the womans disability.
  • Make sure the patients follow-up plan addresses
    how she will access and/or receive the care. Have
    a mechanism in place to alert your clinic or
    office if the patient does not return within the
    recommended interval.

  • Resources

Breast Health Access for Women with Disabilities
(BHAWD)Call 512-204-4866TDD Center for Research
on Women with Disabilities (CROWD)Baylor College
of MedicineCall
Health Promotion for Women with
DisabilitiesVillanova University College of
NursingCall 610-519-6828www.nursing.villanova.e
du/womenwithdisabilities Magee-Womens
FoundationStrength Courage Exercise DVD (a
compilation of exercises helpful to breast cancer

National Breast and Cervical Cancer Early
Detection ProgramCenters for Disease Control and
PreventionCall 1-800-CDC-INFOTTY National
Center of Physical Activity and DisabilityCall
The National Womens Health Information
CenterCall 1-800-994-9662TDD Susan G. Komen
for the Women with
DisabilitiesCenters for Disease Control and
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