‘ A BREAST HEALTHMODEE FORi‘bLDER WOMEN”?

Scholariy Project for the Degree of M S N :

MICHIGAN STATE UNIVERSITY
MADELYN JEAN ZEIGLER
' 1998 " '

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A BREAST HEALTH MODEL FOR OLDER WOMEN

BY
Madelyn Jean Zeigler

A Scholarly Project

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT
A BREAST HEALTH EDUCATION PROGRAM FOR OLDER WOMEN
BY
Madelyn Jean Zeigler

Breast cancer is a leading cause of death in elderly
women (American Cancer Society, 1988). Early diagnosis
leads to early intervention and can lead to longer survival
time. Educating women to understand and detect normal and
abnormal changes in their breasts and motivating them to
take action regarding self breast exam, clinical breast
exam, and mammography is a health promotion technique that
can lead to earlier breast cancer diagnosis, intervention,
and longer survival time. Health maintenance is primarily
the responsibility of the individual as health promotion is
primarily the responsibility of the health care
professional. The intent of this project is the development
of a model which can be implemented by an advance practice

nurse in the education of older women.

ACKNOWLEDGMENTS

A very special thank you to Caroline Gray, BSN, and
Pamela Bergman, BSN, for their help, support, and dedication
in implementing and promoting this project. I would also
like to thank my committee members Brigid Warren, Joan Wood,

and Patty Peek for their expertise in readying this project
for publication.

iii

TABLE

LIST OF FIGURES . . . . .
LIST OF TABLES . . . . .
INTRODUCTION . . . . . .
Background of the Problem

Statement of the Problem
Project Goal . . . .

Conceptual Definitions .

Conceptual Framework . .

Adaptation of The Health Belief

Review of Literature . .
Predictors of Taking

Social Groups Influence on Action
Education's Influence on Action .

Program Development . . . . . . . . . . . .

Background . . . . .

Actio

Selection and Arrangement of
Organization of Presenters .

Program Evaluation .

Implications for Advanced
care 0 O O O O O O O O 0

Summary . . . . . . . . .
LIST OF REFERENCES . . .
Appendix A . . .

Appendix B . . . . . . .
Appendix C . . . . . . .

Nursing

Model

OF CONTENTS

to the Project .

Eaterials :

Practice and Primary

Page

0
bu

\lUIub

14
17

18
19
20
22
23

. 31
. 34

LI ST OF FIGURES

Figure 1: Health Belief Model . . . . . . . . . .

Figure 2: Adaptation of The Health Belief Model by
Zeigler . . . . . . . . . . . . . . .

LIST OF TABLES

Page

Table 1: Ways of letting older adults know about
cancer prevention and early detection . . . . . 16

vi

INTRODUCTION

BackgmndeJhLEmblem
Cancer is an important public health problem in the

United States. Cancer of the breast is the most common
cancer in American women. It accounts for approximately
thirty percent of new cancer cases nationally (Landis,
Murray, Bolden, & Wingo, 1998; Nation Cancer Institute,
1998). Approximately 178,700 new cases of breast cancer are
expected in 1998 (American Cancer Society, 1998, p.8).

Being female puts all women at risk for breast cancer.
Gender and age are the two greatest risk factors for
developing breast cancer (Center for Disease Control, 1987).
Cancer of the breast is the second leading cause of cancer
deaths in women fifty five to seventy four years of age and
the third leading cause of malignancy related deaths in
women age seventy and older (Parker, Tong, Bolden, &
Windgo, 1997). Sixty seven percent of all new breast cancer
cases are detected in women greater than fifty years of age
(Ellerhorst-Ryan, & Goeldner, 1992), and 43% of all new
breast cancer cases occur in women sixty five years of age
or older (Fox, Siu, & Stein, 1994). At age sixty,
approximately 17 of every 1,000 women are expected to
develop breast cancer within five years (Grand Rapids
Clinical Oncology Program, 1998). The lifetime probability
of developing breast cancer is one in eight and is based on
maximum age interval of at least ninety five years (Feuer,
Lop-ming, & Boring, 1993; ACS 1998; Engelking, & Kalinowski,

1

1995). This means that a woman has a one in eight chance of
developing breast cancer if she lives to the age of ninety
five. The biggest risk occurs after the age of fifty.
Approximately two percent of the total risk occurs from
birth to age fifty, five percent from age fifty to seventy,
and four percent from age seventy to eighty five (Engleking
& Kalinowski).

In Michigan, breast cancer is the second leading site
of cancer for women. It accounts for approximately 33 t of
the cancer cases among Michigan women (Michigan Department
of Community Health, 1995). The reported number of breast
cancer cases for Antrim, Grand Traverse, Benzie, Kalkaska,
and Leelanau counties, the focus areas of this project, is
259 per 100,000 cases (Community Health Assessment, 1996).

The elderly population of Antrim, Benzie, Grand
Traverse, Kalkaska, and Leelanau counties is increasing.
The 1996 community health assessment for these counties has
estimated their population growth through the year two
thousand. The current population of these counties is:
Antrim (18,897); Benzie (12,016); Grand Traverse (67,290);
Kalkaska (14,038); and Leelanau (17,292) (0.8. Deptartment
of Commerce, p 256-270). Antrim and Benzie counties should
each have a 17% increase in population > 65years of age.
Leelanau county should have a 15% increase in population >
65 years of age, while Kalkaska should have an estimated 13%
increase in population of > 65 years of age. It is also
estimated that Grand Traverse county should have an
estimated 188% increase in population (Community Health

2

Assessment, 1996). The rise in the elderly population
increases the potential of breast cancer incidence for these
five counties; this in turn reflects a need for a community
breast health awareness program. All five counties have
listed health education, health promotion and screening
programs as targeted health goals for the future. However,
no specific health goals have been targeted for breast
education. The Community Health Assessment (1996) did
indicate that at least sixty percent of the women, fifty
years and older, in these counties received a clinical
breast exam and mammography within the preceding one to two
years. However, this still leaves 40% of the women fifty
years or older without proper screening. Currently there
are no educational programs that address this issue.
Statement_of_the_2roblem

There is an apparent lack of any educational breast
health awareness program for women sixty five years of age
and older for the five county area of Northwest lower
Michigan consisting of Antrim, Benzie, Grand Traverse,
Kalkaska, and Leelanau counties. Health education programs
for older women need to make them aware that breast cancer
screening should be a part of an expected physical or
gynecological exam. A breast health education program for
these women needs to identify proper screening practices,
breast changes relevant to age, and the effective
performance of self breast exam (SBE). It also needs to

address the social, cultural, financial, and patient

provider issues that may preclude elderly women from doing a
SBE or inhibit their seeking screening for breast cancer.
EzQi£§I_§Qa1

The goal of this scholarly project was to develop an
educational model on breast care which targets women age
sixty five and older in Antrim, Benzie, Kalkaska, Grand
Traverse, and Leelanau counties. By implementing the
educational model, the goal to motivate women to be active
participants in their breast health may be realized. The
objectives for this scholarly project include: 1) to utilize
the Health Belief Model to identify barriers and ways to
decrease these barriers, and thus increasing the motivation
of these women to become active participants in their breast
health, 2) to utilize adult learning techniques, 3) to
utilize established social groups as a vehicle to increase
the women's motivation and action, 4) to utilize oncology
nurses as program presenters, and 5) to establish an
evaluation plan.

WW

Breast: The part of the female anatomy that is located
between the second and sixth ribs between the sternal edge
and midaxillary line. It is made up of glandular tissue,
fibrous tissue, and fat (Bates, 1991).

Health: The actualization of inherent and acquired
human potential through goal-directed behavior, self-care,
and satisfying relationships with others while adjustments
are made as needed to maintain structural integrity and
harmony with relevant environments (Pender, 1996).

4

Educational_ugdel: An interpretative picture based on
specific theoretical presuppositions that infers teaching

objectives, teacher qualities, content selection, and
organizations. A basic scheme in which the system of
teaching can be understood (Casagrnde et al., 1998).
Qlder_flgmen: Persons of the female, ages 60-80,
(Younkin, & Davis, 1994).
Conceptuallzamemrk
The Health Belief Model (HBM) [Rosenstock, 1966] was

selected to guide this project.

 

 

 

Individual Perceptions Modifying Factors Likelihood of Action
Demographic variables (age,
sex, race, ethnicity, etc.) Perceived benefits of
Sociopsychologic variables preventive action
(personality, social class, peer minus
and reference-group pressure, Perceived barriers to
etc.) preventive action
Stmctural variables

 

 

(knowledge about the disease,
prior contact with the disease,

 

 

 

 

 

 

 

 

 

 

etc.)
Perceived susceptibility to 1
disease X Perceived threat of LIkClihOOd 0f taking
Perceived seriousness disease x recommended preventive
(severity) of disease X health action

 

 

 

 

 

 

 

Cues to action
Mass media campaigns
Advise from others
Reminder postcard from
physician or dentist
Illness of family member or
friend
Newspaper or magazine
article

 

 

 

Figure 1: Health Belief Model

The Health Belief Model (Rosenstock, 1966) reflects the
possible relationship between an individual perceptions,
modifying factors, and the likelihood of action. The HBM,
created by Rosenstock and associates (1966), relates
psychological theories of decision making to an individuals
decision about alternative health behaviors (Maiman, 8
Becker, 1974). It was formulated in an attempt to gain an
understanding of why individuals who are without illness
take action to avoid illness while others do not take any
action to avoid illness (Pender, 1996, p.35). This
framework suggests that an individual's beliefs about the
availability and the benefits of various courses of action
rather than the objective facts about the effectiveness of
action will determine the course the individual will take.
These beliefs are influenced by cultural beliefs, societal
norms, and social groups. Whether or not an individual will
act on their beliefs is determined by the perceived benefits
and perceived barriers to action as well as the cues to
action. If the negative aspects of taking action cause
severe enough conflicting motives the individual may not
proceed with action even though she perceives susceptibility
(Rosenstock, 1974; Becker, Drachman, Kirscht, 1974).

The following conceptual definitions are important in
order to understand the conceptual framework for this
project and are noted in the Health Belief Model (Figure 1).

Eerceiged_snsceptibility: The individual's awareness

of contracting a condition (Rosenstock, 1974).

Perceived_seyezity: Feelings concerning the serious of

contracting an illness or leaving it untreated. This
includes both medical/clinical consequences and social
consequences (Janz, & Becker, 1984).

2e:ceixed_henefits: The individual's belief that
taking a particular action against the defined illness will
reduce one's susceptibility or reduce ones severity, or both
(Rosenstock, 1974).

Perceiyed_bazzigrs; The potential negative aspects
that can result from taking action. This includes financial
burden, pain, inconvenience, embarrassment, emotional and
psychological stress (Rosentock, 1974).

gng§_tg_actign; Factors that serve as a trigger to
initiate action. These factors can be internal such as
perception of body image, or external, such as educational
programs, support groups, social groups or media
communication (Rosenstock, 1974).

Social_grgnps; A group of persons with whom an
individual maintains contact with and forms a type of social
bond which influences how a person thinks acts, and reacts
(Pender 1996).

Adantaticn_Qf_the_Health_Belief_Model_to_the_Brniect

A breast health program for older women, those over age
65, may be a direct cue to action for some women to initiate
the recommended health action. The cues to action increase
the individual's knowledge and awareness of the perceived
benefits of utilizing proper breast health initiatives,
thus, a larger benefits to barriers ratio is created which

7

propels the person to take action and perform such breast
health behaviors as SBE, CBE, and mammography. For other
women, the program will act as a modifying factor by
increasing their knowledge of normal and abnormal breast
changes. This knowledge may increase their perceived
susceptibility of risk, increase their perceived seriousness
and threat of getting breast cancer and lead to an increased
likelihood to take the recommended preventative health
action of routine SBE, CBE, and mammography.

Figure 2 provides a schematic representation of an

adaptation of the Health Belief Model incorporating these

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

components.
Individual Perceptions Modifying Factors Likelihood of Action
Demographic variables: Perceived benefits (early l
> 65yrs, female diagnosis, less cost, increased
Sociopsychologic variables : quality life, longer life)
peer and reference-group minus Perceived barriers
PW. (lad: d' education of provider
lflnwmndwuhmks umwmcumfimnmnkw,
knowledge about breast cancer minim], psychosocial,
disease, prior contact with the
disease, care provider
Perceived susceptibility knowledge. provider Imuent
to breast cancer I
Perceived seriousness I Perceived threat “f I mm “mm“
(severity) of breast cancer 7 breast “3“" I recommended preventive
health actro' n
SEE, CBE, Mammogram
(buuoaahs
Breast health education
Onmmudsxhhyums

 

 

 

Figure 2-Adaptation of The Health Belief Model by Zeigler (1998)

RexieLnLLiterature

Risk factors for breast cancer cannot be readily
impacted by change of habit, as the majority of risk factors
are inherent. Educational programs focusing on patient
education of risk factors, BBB, and appropriate screening
services provides secondary prevention practices which lead
to earlier diagnosis and intervention (Ellerhorst-Ryan, E
Goeldner, 1992). However, despite evidence that regular
breast cancer screening, including mammography, decreases
breast cancer mortality, women, ages 50 and older, do not
get effective screening. The lack of effective screening of
this age group can be related to the lack of education on
the part of the care provider as well as the individual
(Urban et al., 1995). Older women may be diagnosed at a
later stage of disease because they lack knowledge about the
signs of breast cancer, and the normal pathological changes
in their breasts. Many may hold different beliefs about
provider relationships as these women grew up in an era of
paternal medicine when one did not question the physician.
Also older women exhibit fewer prevention and detection
behaviors. They lack the knowledge regarding services
available to decrease barriers to access, and possess
inadequate knowledge regarding the need for cancer risk
prevention and screening (Fritch et al., 1997).

A needs assessment for the development of a health
promotion early cancer detection program by Fritch et al.
(1997) identified that older women are less likely to
participate in breast cancer screening. Cultural,

9

educational, social, and patient provider issues are
identified as barriers as to why older women are less likely
to obtain breast screening. Dislike for being probed,
language barriers, procrastination, gender of patient's
doctor, lack of knowledge of services, belief of ‘it won't
happen to me", fatalistic attitudes, fears of death,
isolation, institutionalization, modesty, embarrassment, “to
old to be at risk," fear of the diagnosis “cancer“ as well as
effects of treatment, surgery, and cost are all barriers
for not utilizing breast cancer screening services (Fritch
et al., 1997; Gray, 1985; Vanchon et al., 1991). The
elderly also attribute symptoms to "old age” or to an
already existing condition (List, 1992).

The most significant factor contributing to the
successful management of breast cancer is early detection;
it enables diagnosis of the disease before development of
nodal involvement (Ellerhorst-Ryan, & Goeldne, 1992). Many
tumors are found by women during breast self exam (BSE)
(Senie, Lessey, & Rosen, 1994). Research has shown that
women whose tumors were discovered during purposeful BSE
presented with significantly smaller tumors less node
involvement, and smaller lesions in the involved nodes
(Feldman, Carter, Nicastri, a Hosat, 1981). However, among
women over 75 years of age, a greater number of stage three
and four breast cancers are registered (Bellet, Alanso, &
Oeda, 1995). Once a person develops positive nodes,
survival is significantly affected. Approximately 58% of
women with positive nodes achieve a five year survival

10

compared to a 98% five year survival for those with stage
one disease (National Institute Health, 1988). Findings
such as these reinforce the efficacy of BSE and the need for
older women to become proficient in BSE and become aware of
and utilize screening guidelines for breast cancer.

Fox, Situ, & Stein (1994) found physician - patient
communication significantly influenced mammogram and CBE.
In a sample of 972 surveyed women, age greater than 50
years, and the majority being greater than 65 years of age,
they reported that the physician's style of communication
about mammograms and CBE significantly influenced the
women's self screening behaviors. Women who perceived their
physicians as showing some enthusiasm for mammography were
four and a half times more likely to have received a
mammogram the year before than those women who perceived
their physician as not being enthusiastic regarding
mammography. This same study also showed a decrease in
screening mammography and CBE in women greater than 75 years
of age. Also women who have a regular physician tend to
receive breast cancer screening (Fox et al., 1994 ).

Weinburger (1991) found that screening practices varied
with women's age and risk factors even though physicians
were aware of the American Cancer Society (AC8) guidelines.
In a study by the Indiana State Medical Association of
primary care physicians' self—reported practices of breast
cancer screening in older women, 86% of the physicians were
aware of ACS guidelines for mammography and 91% thought
these guidelines were reasonable. However, only 43% knew

11

that the ACS recommended annual screening mammography for
women seventy five years old and older. Regardless of their
knowledge base, the physicians varied their screening
practices of women with significant factors. Forty one
percent of all of the women, regardless of age, with no risk
factors were screened according to ACS guidelines.
Physicians reported using annual clinical breast exams
(CBE), or mammography less often in older women regardless
of the patient's risk factors.

Though screening mammography is the primary means of
reducing breast cancer mortality, the (CBE) and (SBE) are
complimentary methods for detection of tumors not visualized
by mammography (Senie, Lesser, Kinne, 5 Rosen, 1993). In a
longitudinal study conducted at Memorial Sloan-Kettering
Cancer Center of 729 patients diagnosed with breast cancer,
598 women self detected breast cancer by (SBE). One hundred
and one breast cancers were detected by (CBE) and 30 breast
cancers were detected by mammography. Of the patients whose
breasts cancers were detected by SBE, 371 were age 50 or
older with a mean age of 54.6 years. The mean age of those
women whose breast cancer was detected by mammography was
59.1 years, and the mean age of women diagnosed by CBE was
57.2 years. Ten year survival rates for these women were:
SBE: 336 without recurrence, 48 living with recurrent
disease; CBE: 70 without recurrence, 4 with recurrence;
mammography: 21 without recurrent disease, 4 with recurrent

disease (Sine et al., 1997).

12

WW

Utilizing the (HBM) as a predictor to taking action,
Murray, & McMillan (1993) in a random sample of 1,530 women
greater than sixteen years of age, N=757, found a positive
association between BSE, health motivation, and treatment
knowledge of breast cancer and a negative association
between cost and perceived benefits of treatment. Champion
(1987) in a convience sample of 585 women, age twelve
through seventy four, identified through stepwise multiple
regression the combined and independent effects of
susceptibility, seriousness, benefits, barriers, health
motivation, and control on frequency of SBE. A Pearsons
correlation coefficient, student t-test, and one way ANOVA
were used to identify the influence of demographic
variables, the method used to teach SBE, and knowledge.
Benefits and health motivation were significantly correlated
with SBE; however, the variance accounted for in the total
regression by these two variables was insignificant.
Barriers and knowledge accounted for 22% and 4%
respectively. Champion identified that knowledge of BSE
increased, the perceived benefits also increased but the
perceived barriers decreased. Results also indicated than
women taught SBE by personal contact engaged in SBE.

Gray (1990) in a study of women who belonged to a
county extension group indicated that women who perceived
BSE to be beneficial to decreasing the seriousness of the
disease had few barriers to performing BSE, and were highly
motivated to do so. As a group these women perceived BSE to

13

be beneficial in reducing seriousness of breast cancer
(F=48.63 with significance 5 0.0001); this suggested a
significant relationship between knowledge about breast
cancer and BSE practice.
W

A group is a system that has identifiable parts with
each part influencing all other parts. The group as a whole
influences each individual within the group and each
individual within the group influences the other individuals
within the group (Clark, 1987, pg.3). Groups become
important vehicles for learning and obtaining satisfaction.
The quality of people's lives often depends on their ability
to perform effectively in the groups in which they belong.
Groups that are effective work and strive to promote
behaviors that lead to effective functioning. Expression of
thoughts and feelings is encouraged. Trust, support,
safety, creativity, and constructive controversy is evident.
Group support and cohesiveness enhance learning and
acceptance of the individuals in the group (Clark, 1987).
Social groups contribute to health by creating a environment
that promotes health, decreases the likelihood of stressful
life events, provides feedback on individual action and
provides socially desirable consequences (Pender, 1996).

Gray (1990) suggested that group motivation may be a
factor in health matters as certain attitudes may be valued
by the group and therefore a member subscribes to that
particular attitude. Fitch et a1. (1997), in their needs
assessment program identified a variety of ways of letting

14

older adults know about cancer prevention and early
detection (Table 1). Fritch also recommended the use of
established group organizations as a vector for cancer
education, prevention, and detection programs.

Social support is a characteristic of networks that can
influence health outcomes of others in their social network
or group (Israel 8 Rounds, 1987). Individuals can influence
health outcomes of others in their social network by
offering various types of support such as information,
emotional support, and/or encouragement (House, & Hahn,
1985). These strong social ties and supportive
relationships found in group settings have proven to be
beneficial in influencing health related behaviors and
health outcomes of the people within the group (Tesson,
1997). Kang, Bloom, and Romeno, (1994) and Lloyd, Weiss,
Raibolt, and Pulley, (1994) have been more specific in
identifying that a woman's cancer screening behaviors are
influenced by social networks. A woman's interpersonal
network, such as an informal group, is an important source
of information about breast cancer screening and acts as a
informative source for services available (Marshall, Smith,
r. McKeon, 1995) . Groups can therefore be a “cues to action
to breast health, SBE, CBE, and mammography.

Nurses in a women's social network or group play an
important role in promoting health and offering health
information (Tessaro, 1997). By working within an
established formal or informal group and utilizing the
dynamics and cohesiveness of that group, a more pronounced

15

Table 1.

WW
AW

 

Organize sessions with speakers (in lay terms and in their
own language).

Hold a meeting with a cancer specialist including a question
and answer time.

Have videos available.
Use the local cancer society.

Have friends, survivors of cancer, tell their stories to
peer groups.

Share personal stories of high-profile people.

Use support groups.

Have drop-in sessions/clinics.

Create pamphlets (for some) in own language.

Use community venues (senior centers, seniors' days, etc.).
Write articles in seniors' newsletter.

Use celebrity spokespersons (i.e., sports person, community
leaders).

Set up displays in malls, shopping centers.

Work with other organizations to teach the isolated (i.e.,
Meals on Wheels, cable television.

Focus on seniors during cancer month.

Work with other organizations to distribute the cancer
message (i.e., banks, hospitals, pharmacies, telephone or
hydro companies in distributing bills).

Offer a social event along with the education.

Use peer teaching approach (older adult to older adult).

Promote positive messages and hope.

 

Fritch, et. al. (1997) Health promotion and early detection
of cancer in older adults: Needs assessment for program
development.

16

impact on healthy behaviors and screening practices can be
realized.
W

Generally, elderly women have inadequate knowledge
about breast cancer, detection, and treatment. Establishing
an education program to improve understanding about cancer
reduces fears, and promotes action to help elderly women
assume self-care activities (sites, 1995). A multistrategy
health education program implemented to increase mammography
use among women ages sixty and older, in retirement
communities of Philadelphia, identified that mammography
rates increased for this age group after the women attended
an educational program that identified knowledge deficits
related to screening practices. At the initiation of this
program 94% of the women involved, N=412, did not know that
risk of breast cancer increased with age. Women who
attended the educational presentation had a 75% to 86%
increase in obtaining follow up mammography. Those women
who did not attend the educational program showed a 22% to
41% increase in obtaining a follow up mammography (Rimer et
al., 1992). Walker, Lucal, & Crespo (1994) found similar
results regarding the implementation of a breast education
program as part of the West Virginia Rural Cancer Prevention
Project. Ansell, Lacey, Whitman, Chen, and Phillips (1994),
through a nurse-delivered intervention project to reduce
breast cancer, identified lack of knowledge about breast
cancer as a barrier preventing appropriate screening
measures to take place. A survey was completed by 450

17

participants prior to and after attending a 20 minute class
on breast cancer screening. Results identified a
significant increase in post presentation scores; i.e. 6.8
pre correct to 10.5 post correct out of 13 possible correct
answers. Follow up rates for mammography was approximately
90%.

W

This educational model is comprised of five phases: a)
back ground information, b) selection and arrangement of
program materials, (see Appendix A ), c) organization of
presenters, d) implementation of program, e) revisions of
the program.

The target population of this project is women sixty
five years of age and older, that reside in Northwest lower
Michigan, however, all women can benefit from this program
and will not be discriminated against. This program will be
presented by registered nurses who are currently employed at
Munson Medical Center and work in oncology. The program
length will be appropriate to the time constraints of
organized women's groups that are interested in
supplementing their regularly scheduled meetings. Program
length is anticipated to be 45minutes. The educational
model utilizes adult learning principles and teaching
strategies (Patient Education Department, Munson Medical
Center, 1998). These principles identify that adults learn
best when they are actively involved in the learning
process: Adults learn best when they feel their knowledge
and skills are valued and recognized; adults learn in

18

various styles, and learning is more effective when
reinforced by positive and satisfying experiences and when
it takes place in a non-threatening, comfortable
environment. Teaching strategies for the model include
visual, audio, and tactile strategies.

The program is designed to fit into the time
constraints of an already organized social group that wants
to supplement their regularly scheduled meeting. Program
length is approximately forty five minutes.

The objectives of the program are to assist individual
women in recognizing normal and abnormal breast changes, to
recognize risk factors of breast cancer, to recognize
barriers that prohibit them from carrying out breast cancer
screening practices, and to supply information on obtaining
mammography.

Background

In the spring of 1997 a member of the Women's Golf
Classic Committee approached an oncology nurse from Munson
Medical Center to develop a breast education program for
older women. The request was forwarded to the director of
the oncology service line, who approved the project. The
project was funded through a grant from the Women's golf
classic. The money provided for the purchase of breast
models, pamphlets, slide development, luncheon for potential
presenters, and miscellaneous items such as folders,

carrying cases, pencils, and wipes.

19

WWW

Information and material selection was based on
readability, availability, cost, correctness of information
and the integrity of the institution that published the
information. The program has been designed to fit into the
time constraints of an already organized social group that
wants to supplement their regularly scheduled meeting.
Program length is planned to be approximately forty-five
minutes. A variety of educational approaches, primarily
from currently available audio/visual and printed sources
were selected. The following paragraphs describe those
selected. The specific organization of the presentation and
use of the resources is presented in appendixes A and B.

The slide presentation is developed from the Trainer's
manual of the Native American Cancer Screening Training
Grant project. The information within the manual was
formatted from the American Medical Women's Association
Breast and Cervical Cancer Education Project for Primary
Care Physicians developed under a cooperative agreement the
Centers for Disease Control and Prevention (CDC).

The video, Instruction for Breast Self-Examination
(ACS, 1996) was chosen because it stresses the importance on
monthly BSE, it is easy to follow and features women in a
variety of ages, and the length, seven minutes, is
appropriate for the time constraints of this educational
model. It targets both audio and visual learners.

The literature on normal breast changes developed by
the Native American Cancer Screening Training Grant (1995)

20

was incorporated into the breast health model. Silicon
models of older breasts were purchased to provide hands on
experience to teach proper SBE technique and palpate
nodules.

The Primary Care and Cancer Breast Self-Examination
Guide (Bristol-Myers Squibb, 1995) was selected since it
included a take home guide on BSE. It also includes
information on breast anatomy and a step by step guide to
performing SBE using large print and a vocabulary that is
easy to read and understand. The colored photos provide
vivid techniques.

Understanding Breast Changes - A Health Guide for All
Women (National Cancer Institute, 1997), was also selected,
it provides another choice of a take home pamphlet on breast
physiology, mammography, how to follow up if a breast lump
is found, and a glossary that provides definitions of words
that may be difficult to understand.

A resource list including a written copy of available
resources in the five county target area regarding a variety
of women's health issues was also selected; it has a handout
on how to access services.

Commonly Asked Questions Regarding Breast Cancer
(Weber, 1997) was selected as a resource for the presenter;
it includes potential questions that may be asked and
provides an appropriate and concise answer. Application of
this puglication by health care providers should promote

uniformity of answers during the presentation.

21

The pre-test and post-test questions developed were
based upon ACS breast cancer screening guidelines and the
objectives for the educational model set forth by this
project's author. The pre-test is a method to understand
the level of knowledge of the program participants prior to
the program. The post-test is utilized to see if the
objectives of the program were met, and understood by the
participants.

A program evaluation was developed as a tool to be used
by the participants to supply subjective feedback
information regarding the structure, design, and information
of the program and data regarding the presenter's knowledge
and presentation of the program. This information will be
utilized to improve the quality of the program and insure
that the information presented is targeted to the audiences
needs.

WW

It is anticipated that presenters for implementation of
the model will be volunteers solicited from registered
nurses who currently work in the oncology service line at
Munson Medical Center. The presenters can utilize their
volunteering as points towards obtaining a higher position
on the clinical ladder at Munson. This provides a source of
incentive which will hopefully increase the number of
oncology nurses willing to participate. A sign up sheet to
gather names of interested nurses will be posted on the
oncology floor two weeks prior to the preparation of these
oncology nurses. The newly developed educational model,

22

Breast Health for Older Women, will serve as the method of
education for these nurses. The participating nurses will
also be asked to provide constructive criticism of the
project as a means for evaluating the program. The
presenters are responsible for getting technical equipment
and program material to and from the speaking location.
Wanna

The program evaluation consists of pre-test, post-test
questions relating to the objectives presented. An
evaluation tool of general questions regarding the length of
the program, delivery of the program, program content, and
the ability of the program to motivate women will also
utilized (Appendix B).

..."...e . ,...-.( :..-. -_-..- ...‘

The role of Educator as an advanced practice nurse
(APN) defines the essence of nursing and delineates the APN
role from other health care providers. Nurses impact health
care through the knowledge they extend to others whether it
be in the role of clinician, assessor, counselor, advocate
or researcher. Promoting health through education empowers
individuals to be in control of their health and well being
and to make well informed health care decisions.

The Breast Health Education Model (BHEM) provides the
APN with an educational tool to instruct and empower women
to take an active role in their health care. Implementation
of the BHEM should promote active participation in women in
identifying and understanding the benefits of maintaining
proper breast health. This model will also assist these

23

women in identifying their own individual barriers that may
prohibit them from obtaining appropriate screening and help
them overcome their individual barriers through self
understanding and empowerment. Through the utilization of
this model the APN can promote lifestyle changes that will
impact the women's values regarding health maintenance and
health promotion. As a resource clinician, the APN has the
capability to promote breast health through community
education programs, in both the public and private sector.
The APN can be an expert resource person for the general
community and for individuals who desire information about
breast health.

As a clinician, the APN will be able to utilize this
breast education model program, or segments of this model,
as an assessment tool with her female population. The model
can identify physical, emotional, cultural and psychosocial
issues that prevent her patients from implementing standard
breast health procedures. After a thorough assessment, the
APN can utilize the BHEM to establish and implement a health
plan which utilizes appropriate resources to obtain breast
cancer screening, follow up, and an evaluation of both the
components health plan.

As a research tool the APN can use the BHEM to identify
barriers significant to this female population. If a
significant barrier is identified the APN's success or lack
of success can be evaluated. The relationships between cues
to action and outcomes also lends itself to research.
Identifying whether breast cancer screening, mammography

24

and/or CBE has increased among the target population will
help identify if this program is an effective tool in
promoting breast cancer screening among these women sixty
five years old or older. If the educational model is
successful in promoting breast cancer screening among women
these women in the designated five county area could be
successful if implemented in another geographical area.
Research of this type focuses on determinants that will
impact patient education, health maintenance and health
promotion. The role of the APN as educator, clinician,
counselor are also important determinants of breast health.

In the role of counselor the APN needs to be able to
identify factors that influence patient health behaviors.
The APN counsels the patient to make an informed decision
regarding her breast health after identifying and working
through potential barriers that would prohibit the woman
from partaking in a breast cancer screening program. The
BHEM can prepare the APN to be proficient in this area by
identifying cultural, psycho-social, financial, emotional,
factors that would inhibit a women from seeking out and
obtaining appropriate breast cancer screening.

Education of nurses and nursing students about breast
cancer can be accomplished through the use of this
educational program. It can prepare these nurses to be
proficient in identifying risk factors for breast cancer,
become familiar with performing CBE, and discuss breast
health issues with their patients. The use of this program
as an educational tool to teach other advanced practice

25

nurses can increase their ability as clinicians, assessors,
and educators in the area of breast health and breast cancer
screening.

Summazx

Development of educational programs aimed at increasing
elderly women's knowledge regarding breast health need to
focus on identifying barriers that inhibit the use of BSE,
CBE, and mammography. Once identified, the nurse needs to
identify and implement strategies that will decrease the
barriers and increase compliance in the use of
breast cancer screening methods. Financial and
accessibility barriers may be easy to identify and easily
remedied through utilization of free federal mammography
screening programs, local charitable organizations, and
local American Cancer Society agencies. Personal and
cultural barriers may be more difficult to identify and
alter. The APN needs to be aware and sensitive of such
personal concerns and attempt to educate and motivate these
women to explore and clarify their value system.

By achieving reduction in barriers that preclude
elderly women from implementing and obtaining SBE, CBE, and
mammography there is a potential to increase earlier breast
cancer diagnosis, increase survival time, and decrease the

number of breast cancer deaths in elderly women.

26

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Michigan Dept. of Community Health (1995). Cancer
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Munson Medical Center Patient Education Department
(1995).
Unpublished manuscript.

Murray, M., McMillian, C. (1993). Health beliefs locus
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Parker, S.T., Tong, T., Bolden, S., Wingo, P.A. (1997).
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Multistrategy Health Education Program to Increase
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Bancrt51_101(4). 359-380-

Rosenstock, I. M. (1966). Why People use Health
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Rosenstock, I.M. (1974). Historical Origins of the
Health Belief Model. Personal Health Behavior. Heelth

Education_monogramsl 1-7.

Senei, R.T., Lesser, M., Kinne, D.W., Rosen, P.P.
(1993). Methods of Tumor Detection Influences Disease Free
Survival of Women with Breast Carcinoma.

Sitzes, C. R. (1995). A Community-Based Breast Cancer
Education and Screening Program for Elderly Women.

Geriatric_Nursins+_16(4). 151- -154-

Tessarro, I. (1997L The Natural Helping Role of
Nurses in Promoting Health Behaviors in Communities.

Adxanced_2ractice_Nurse_Quarterl¥1_z(4), 73-78.

Urban, N., Taplin, s.H., Taylor, V.M., Peacock, K.s.,
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D.E., Mahloch, J., & Majer, K. (1995). Community
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Age 50-75. 2rexentatixe_uedicinel_211 477-484-

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29

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;H‘ g .. O ‘ \; 0.. ‘0 ,;.OO , .. . ;o o .'

14- 16.
Weber, E. (1997). Questions and Answers About Breast

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Weinberger, M., Saunders, A.F., Samsa, G.P., Bearon,
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30

APPENDICES

APPENDIX A
A Breast Health Education Model [or Older women
BY

HADELYN J. ZEIGLER 1998

This model describes a breast health education program
targeting women 65 years of age and older. It's objectives
include the following:

To provide breast health education for women greater 65
years, but not exclude younger women.

To increase self-awareness of breast cancer risks in
older women.

To increase awareness of screening guidelines for women
greater than 65 years in order in encourage self-
advocacy.

To increase awareness of the importance of BSE.

To demonstrate correct technique for BSE utilizing
breast models.

To increase awareness of community resources relating
to breast health.

Breast Health for the Elderly Women

Program Outline

I.

II.

Set Up

Allow yourself enough time to set up the slide
projector, monitor and VCR. The time needed will be
individual depending on ones audio - visual setup
capabilities. Approximately 15-20 minutes should be
allowed. This is not a part of the allotted
presentation time (i.e. be prepared to start on time!).

Introduction (3 minutes)

Hello, my name is, (give your name) and I am a cancer
nurse. I work at ( give place of work, how long you
have worked as a nurse and how long as a cancer nurse).
The program I will presenting to you today is about
breast health. Breast health is an important part of

31

III.

every women's life. Knowing your breasts and knowing
what is normal for you is the first step in breast
health. Knowing how and when to perform self-breast
examination (SBE) should be as routine as putting on a
brassiere. Doing a self-breast examination takes less
than 15 minutes a month and it should become every
women's habit.

The purpose of presentation is to make everyone in this
room aware of reasons why some women do not perform
SBE, seek a clinical breast exam (CBE), or have a
mammogram and make available to you avenues to
resources to obtain screening services. This
presentation will also offer hands on experience, using
silicon breast model, to palpate breast nodules, as
well as review how to perform a SBE. If you identify a
reason for not obtaining or doing a SBE, CBE, or
mammogram and you want to discuss further please feel
free to talk with me after this presentation. Also
feel free to ask questions throughout this
presentation. As you walked in you were given a brief
list of questions. Please answer the questions as they
are important in helping identify if the program meets
your needs. All information is confidential as no
names are required.

Pre-Test (3 minutes) see Appendix B

Enlarge and make copies for the presentation for easier
reading.

Have women fill out upon entering the room.
Slide Program 1-14 (5 minutes) - See Appendix B

Normal breast: Changes of time in the breast. (3
minutes)

The breast reacts to hormones during a woman's lifetime
affecting day to day change, month to month change, and
long term change.

Puberty: Estrogne production begins and affects the
growth of the glandular tissue.

Fat in the breasts increases and fibrous tissue becomes
more elastic. Complete development of the breasst
occurs after ovulation begins with the effect of
progesterone (Refer to page on the breast gland).

Henstrual Cycle: Changes in size and firmness of the
breasts occur due to hormone balance. Breasts become
large before menstruation due to fluid retention and
growth of duct glands. All areas of the breast are not
affected to the same degree; thus certain areas are
more tender than others.

32

Pregnancy: During pregnancy breast changes become more
extreme due to swelling and growth of mammary glands
and ducts.

Henopause: Breasts change during menopause because of
the loss of mammary glands. The breast is replaced
largely with fat.

Practice with models. (15 minutes)

Audience will have the opportunity to demonstrate
proper SBE technique and/or utilize models to palpate
nodules located in the model.

VII. Questions and answers (5 minutes)
Refer to “Commonly Asked Questions Regarding Breast
Cancer.”
These are meant to be a resource guide for the
presenters.

VIII. Handouts (2 minutes)
Refer to “Women's Health Resources.”

Post Test (3 minutes) See Appendix B; Questionnaire B
Enlarge and make copies for the presentation for easier
reading.

Have women fill out at the end of the program.

x. Evaluation (3 minutes) See Appendix B; Program
Evaluation
Enlarge and make copies for the presentation for easier
reading.
Have women fill out at the end of the program.

33

I.

II.

III.

IV.

VI.

VII.

APPENDIX B
Slide 1: BREAST HEALTH FOR THE OLDER WOMAN

Slide 2: Risk Factors for Breast Cancer
A. Two Major Risk Factors
0 Gender
0 Age
B. Other Risk Factors
Family History of Breast Cancer
0 Parity/Nulliparity
0 First Delivery after age 25-30
0 Atypical Hyperplasia on Breast Biopsy

Source National Cancer Society

Slide 3: Factors that Increase Risk

A. Simply being a woman and getting older puts you at
risk for developing breast cancer. The older you
are, the greater your chance of getting breast
cancer.

B. Breast Cancer Incidence Rate, per 100,000:
0 Women ages 40 to 49 - 161
0 Women ages 50 and over 8 347

Source: Center for Disease Control

Slide 4: Risk of Developing Breast Cancer
A. By age 25: one in 19,608

B. By age 30: one in 2525

C. By age 35: one in 622

D. By age 40: one in 217

E. By age 45: one in 93

F. By age 50: one in 50

G. By age 55: one in 33

Source: National Cancer Society

Slide 5: The woman most likely to get breast cancer
is:
A. Elderly - in her 80's
Unfortunately, this population of women is the
least likely to be screened for breast cancer.
Source: Center for Disease Control

Slide 6: One in Nine

A. One in nine women living to age 85 will be
diagnosed with breast cancer during her lifetime.

B. If a woman lives beyond 85 years of age, her risk
increases to one in eight.

Source: CDC

Slide 7: Every Woman is at Risk

This is a powerful fact and often convinces patients of
the importance of screening.

Source: CDC

34

VIII. Slide 8: Protect your Breast Health

IX.

XI.

XII.

A. Get a breast exam from your health care provider
at the time of your regular physical exam.

B. Get a mammogram as often as your health care
provider recommends. Ask when to schedule your
next mammogram.

C. Check your breasts each month. Your health care
provider can show you how.

These three exams can help you and your health
care provider learn what is normal for your
breasts and what may be signs of problems.

Source: CDC

Slide 9: Detection - Why early detection?

A. Survival rate of breast cancer diagnosed and
treated at Stage 0 (in situ cancer) approaches

100%.

B. Stage 1 disease has a 5 year survival a rate of
85-95% (dependent on the size of the primary
tumor).

Source: CDC

Slide 10: Clinical Breast Exam (CBE)
(a breast exam by your health care provider)
A. Detects 15% of cancers not found by mammography.

B. Misses 40% of cancers that can be diagnosed by
mammograms.

C. 45% of breast cancers detected are found using
both modalities

- CBE is generally the most available method of
breast cancer screening.
0 Relatively few women are proficient and/or

comfortable with BSE, and mammography is
restricted by age, economics and availability.

Source 8 CDC

Slide 11: What is a Mammogram?
A. Safe, low-dose x-ray picture of the breast

B. Two kinds:
0 Screening
. Diagnostic

Source: CDC

Slide 12: Mammogram Results

A. Learning the results of your mammogram is very
important.
B. Chances are your mammogram will be normal

35

C. Do not assume it is normal just because you have
not received the results.

D. If you have not received your screening results
within 10 days, ask your health care provider or
call the mammography facility.

Source : CDC

XIII. Slide 13: Remember...You are in Charge of your Breast

XIV.

XV.

Health

A. Schedule screening mammograms as often as your
health care provider recommends (yearly age 50 and
older).

B. Always find out the results of your mammogram.

C. Follow your health care provider's recommendations
for follow up.

D. Schedule diagnostic mammography, if needed, as
soon as possible.

Source: CDC

Slide 14. Remember..

A. Have a clinical breast exam as part of your
regular physical exam.

B. Do monthly Self Breast Exams.

C. Call your health care provider if you notice:
0 a lump or thickening of the breast
0 a discharge from the nipple
0 skin changes in the breast

Source: CDC

Slide 15. Remember.. You are in charge of your Breast

Health
Source: CDC

36

Questionnaire A

AGE

 

larital Status: single married_____ divorced_____ widow

 

 

Education: (fill in highest grade completed):
1) Elem. (Grade)___ 2) Jr._High (grade)___ 3) High School (Grade)___
4) College (Grade)___ 5) Graduate School___ 6) Post Graduate ___

Income Level (check one): 0-19,999___ 20,000-39,00Q___ 40,000-59,999___
60,000-79,999___ 80,000-99,999___ greater than 100,000___

Breast Cancer History: Is there a history of BREAST CANCER in any of
the following members of your family or yourself (please circle)
Self Mother Grandmother Sister Daughter Aunt

Has a doctor ever told you that you had a lump in your breast, or
breasts?
Appendix C If Yes, was the tumor cancerous? Yes No

 

Do you examine your breasts regularly for lumps or other changes?
Yes No Don't Know

How often do you examine your breasts for lumps?

 

 

1. How frequently should a women over 50 have a mammogram?
Yearly every 5 years every 3 years

2. How frequently should a woman do self breast exam?
Every 6 months monthly not necessary

3. Is Breast Self Exam necessary when you have annual mammogram?
Yes No

4. Can you list one risk factor for developing breast cancer?
Age weight smoker

5. Can you give one reason why you or someone may not do a self-breast

exam?
Don't know how it's not important too busy

37

10.

Questionnaire B

every other month

How frequently should a woman over 50 have a mammogram?
6 years yearly 2 years
Is Breast self exam necessary when you have an annual mammogram?
Yes No
How often should a woman do Breast Self Exam?
Same time each month never
Give a reason why you would not have a mammogram or clinical breast
exam.
Find on provided resource list who to contact about obtaining a
mammogram.
As a result of this session can you perform a self-breast exam?

2!; N9

Evaluation

Based on this program I plan to do 1) SBE, 2) have regular CBE, 3)

have a mammogram yearly (circle all that apply)
The presentation lasted the right amount of time?
The program was well organized?

The information was important to me?

The information was what I expected?

I would recommend this program to a friend.

The speaker was clear and understandable?

The speaker was knowledgeable about the subject?
The speaker encouraged participation?

Comments

YO.

YO.

YO.

Yes

YO.

YO-

Yes

ID!

No

No

NO

NO

No

No

No

NO

 

 

38

Women’s Health Resources
Women’s Health Network

The women’s health Network is an informational system designed to educate and
inform community members about women’s health concerns.

A lending library provides books, pamphlets, videos, and a computer database for
women seeking information on health care topics. The library is located on the ground
floor of Munson Medical Center’s Pavilion.
Library Hours

Monday - Wednesday - Friday 8am - 4pm

Tuesday - Thursday 1 lam - 8pm

A registered nurse is available to assist in the research process as well as answer questions
about women’s health issues.

Focus on Women is a community lecture series presenting topics related to women’s
health and well-being. For information regarding upcoming lectures and more information
call 616 - 935-6678 or 1-800-376-11135.

Support Groups:

Breast Cancer Support Group: Peer led for women who have received a diagnosis of
breast cancer.

General Support Group: For individual and their families who have received a cancer
diagnosis, facilitated by an Oncology Clinical Nurse Specialist

Individual Support Services: One -on-one services with an Oncology Clinical Nurse
Specialist or Medical Social Worker.

For more information about cancer support services: (616) 936-6578.
Internet: http://www.nabco.org (breast cancer resource list)
More Information
Ifyou have limited income, no health insurance, or if your health insurance doesn’t pay
for mammograms, call 1-800-922- MAMM to see if there is a federally-funded program
near you that offers free breast exams and mammograms.
The American Cancer Society, Michigan Division, l-800-ACS-2345.
National Cancer Institute Cancer Information Service, 1-800-422-6237.

39

Q:

A:

Q:
A:

A:

Appendix C

COHHOELY ASKED QUESTIONS REGARDING BREAST CANCER

Should I be concerned about hormone replacement therapy in
relationship to breast cancer.

This decision is highly individualised between a patient and her
doctor. There are also many books published on the subject.

What is the Medicare reimbursement for mammograms?

If a patient has met their deductible for the year, the 203 portion
that she should owe for a mammogram will be approximately 821.76.
Medicare will reimburse for one mammogram to be performed every two
years. The total cost for a mammogram is $108.70.

Do I need a mammogram if I don't have any symptoms?
Mammography may detect breast cancer up to two years before you or
your doctor can feel a lump.

If there is no history of breast cancer in my family, do I need to
worry about getting it?

80‘ of women who develop breast cancer have no family history of the
disease.

I have had one normal mammogram, do I need another?
Once is not enoughl. A mammogram can detect breast cancer when it is
in its earliest, most treatable stages, but only if done regularly.

Are mammograms painful?
A mammogram is simply an x-ray of your breast. Although the
procedure may cause discomfort, it is very quick.

Do I still need a mammogram even if my doctor doesn't say I do?

Don't wait! The American Cancer Society recommends that once you
turn 40, you should have a mammogram every 1 to 2 years. Starting at
age 50 you should have a mmmmogram every year. Examine your breasts
monthly and make sure your doctor gives you a breast examination once
a year.

If a mammogram does find something, isn't it too late?
Over 90% of women with breast cancer survive if the cancer is found
and treated early, before it has spread beyond the breast.

Can getting a mammogram expose me to unsafe levels of radiation?

The radiation exposure from mammography equipment is very low,
similar to being in the sum for two hours. It is far more dangerous
to allow breast cancer to go undetected and untreated than to be
exposed to very low doses of radiation.

Who is at risk to develop breast cancer?

Every woman is at risk for breast cancer. Breast cancer is the most
common cancer in America and one in nine women will develop breast
cancer in her lifetime. The two most significant risk factors for
breast cancer are being female and getting older.

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What does the American Cancer Society recommend for early detection
of breast cancer?

Have regular mammograms: screening mammographies should begin by age
40. Have one every year or two to age 49, and every year after age
50. See your doctor for regular breast exams: at least every three
years between the ages of 20 and so and every year after 60.

Practice monthly breast self-exam: ask your doctor, nurse, or
mammography technician to teach you the proper method. The local
office of the American Cancer Society can give you a how-to-do
diagram as well.

How can I tell if I should be concerned about a lump in my breast?
All lumps should be checked by a doctor. Most are not serious, but
only the doctor can tell you this. Sometimes a biopsy is needed to
be certain.

Will I lose my breast?

Since 1990, the Mational Cancer Institute (MCI) has recommended that
women with early-stage breast cancer be treated with breast-
conserving treatment instead of mastectomy (surgery to remove the
breast). Breast-conserving treatment is defined as lumpectomy
(removal of the breast lump) or partial mastectomy followed by
radiation therapy. anpectomy removes only the small piece of the
breast that contains the cancer, leaving a small scar and most of
the breast intact.

Can breast cancer be cured?

95t of woman diagnosed with early-stage breast cancer are alive at
five years, the usual milestone doctors use to tell if a treatment
has worked. For women with advanced-stage cancer, a cure is possible
in a significant number, and the cancer can be controlled in most
cases. However, there is always the possibility of recurrence, even
20 years later. For this reason, all survivors should see their
doctors for regular check ups and mammograms.

Is the incidence of breast cancer increasing?

From 1982 to 1987, the incidence rates for breast cancer rose by
about 4‘ per year, but they have leveled off since. Most of the
earlier increase is believed to be due to the wider use of screening
mammography, which allows cancer to be detected at earlier stages.

What causes breast cancer?

Mo one knows for sure. And there probably isn't just one single
cause. Changes in breast genes may be the most important. The
hormone estrogen, which is produced normally by women's ovaries, is
thought to play a large role by making the breast cancer grow faster.

What about the breast cancer gene?

A test for the gene BRCAI is available commercially for women at high
risk and is offered to women through their doctors. But its
significance is controversial. The gene is thought to play a role in
breast cancer primarily in women under age 35, about 5‘ of the total
with cancer, who are affected by hereditary or familial breast
cancers.

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Can breast cancer be prevented?

There is no known way to prevent breast cancer, and 70. of women who
get the disease have no known ‘risk factors.’ Early detection and
prompt treatment are the best way to treat breast cancer successful

Is a family history of breast cancer important?
Yes. A women whose mother, sister, daughter, or grandmother had
breast cancer has an increased risk of developing the disease.

How often should I have a mammogram?

The American Cancer Society recommends that after age 50 all women
get a mammogram and a clinical breast exam done by a doctor yearly.
For women aged 40 to 45 a mammogram and clinical breast exam should
be done at least once every year or two. Women under age 30 should
talk with their doctor about how often a mammogram should be
performed.

Will a blood transfusion be needed during breast surgery?

Generally not for the less extensive surgeries used today to treat
breast cancer. However, in breast reconstruction, the Wflap'
reconstruction techniques are complex and could require the use of a
blood transfusion during surgery, so women might plan to donate blood
beforehand for this purpose (Weber, 1977).

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