Myths and negative stereotypes of the elderly, particularly of women, continue to exist. Nowhere is this more apparent than in the area of health care related to preventive screening, education, and counseling for breast, uterine, and cervical cancer. Many elderly women have even come to believe existing misconceptions regarding their need for preventive screening based on the prevailing attitude of, "Why bother at your age?"
Nurses have a major responsibility to use the nursing process to assess, plan, implement, and evaluate preventive health screening programs specifically targeted to the needs of elderly women. In so doing, we assume a major role in negating the stereotypes of aging as a declining and degenerative process. We are instead promoting optimum wellness and active participation in health care for elderly women who have had an all too infrequent role.
In an attempt to provide a wellnessoriented, humanistic, and accessible health screening service, we proposed a free breast, uterine, and cervical cancer screening clinic targeted to elderly women in the community. We incorporated the criteria adopted by the National Conference on Preventive Medicine:
1) The procedure was appropriate to health goals of the relevant population.
2) For purposes of screening, the disease or condition has an asymptomatic period during which detection and treatment can substantially reduce morbidity or mortality or both.
3) The procedure is relatively easy to administer.
4) The procedure is available to the population at reasonable cost.
5) Resources are generally available for follow-up diagnostic and therapeutic interventions if required.1 Cancer is a disease that occurs primarily in the older segment of the population. Approximately 50% of all cancers occur in persons 65 years of age and older.2 Therefore, to establish an effective screening program, we must identify all high-risk groups.
Cancer of the vulva, often preceded by pruritis or leukoplakia, is quite uncommon in women under the age of 65. Cancer of the vagina accounts for less than 1% of the cancers of the female reproductive tract. However, it constitutes the greatest risk for the elderly woman who experiences bleeding, watery discharge, and the presence of a lesion.3
According to the Vital Statistics of the U.S. in 1975, uterine cancer was the fourth leading cause of death due to cancer in the 55 to 74 age group. In women over 75, uterine cancer still ranks as the fifth most common cause of death among women who develop cancer. Cancer of the uterine cervix is most prevalent in those women over 40 (with highest incidence from ages 40 to 49) who have had several pregnancies and/ or regular sexual intercourse beginning at an early age with several partners. Its earliest warning signs are irregular bleeding or vaginal discharge.3
The Papanicolaou cytologic smear is 95% accurate for cancer of the cervix and 75% to 80% accurate for cancer of the endometrium.4 This easily applied, economical, and effective tool, in combination with education regarding the recognition and reporting of symptoms, is responsible for a decrease in incidence of invasive cancer and has resulted in a significant reduction in mortality.
Certain risk factors are specific for the development of endometrial cancer. These include age, late menopause, history of estrogen replacement therapy during or after menopause, obesity, diabetes, infertility, and fewer pregnancies.5 The warning sign of endometrial cancer is abnormal vaginal bleeding. This symptom is present in 79% of women who develop this pathology. The American Cancer Society recommends a pelvic examination annually after age 40. However, endometrial cancer may not be evident in the uterus upon palpation. Therefore, all symptomatic women should be referred for endometrial biopsy, even if they have a negative Papanicolaou smear.
Ovarian cancer usually occurs in women between the ages of 55 and 64. 7 This cancer is often asymptomatic in its early stage. A bimanual examination remains the most important diagnostic tool for ovarian disease.3 A normalsized ovary in a post-menopausal woman would indicate the need for a thorough gynecologic evaluation.
Breast cancer is the most common form of cancer among women in this country. Seventy-five percent of all breast cancers are detected in women over age 50.8
Effective treatment of all of these cancers depends on early diagnosis. Yet, early detection efforts for older women have been minimal. This is why we chose to develop a combined breast, uterine, and cervical cancer screening clinic.
It is very important to analyze the motivating factors that prompt elders to participate in a cancer detection clinic. Stromborg and Bourque-Nord discussed patient motivation and satisfaction with a cancer detection clinic.9 They noted that early detection is one of the most promising ways to control cancer, and that people are normally anxious about the physical examination. They then investigated what specific factors were strong enough to overcome this anxiety. The majority of their sample of 198 were women (66.8%) between the ages of 30 and 60 (75.7%).
By means of a self-report checklist questionnaire, clients were asked to check the three most important reasons for attending the clinic. Reasons cited most frequently were belief in preventive checkups (62.1%), the clinic's physical proximity to respondent's environment (47%), and the subject having a friend or relative with cancer (40.5%). Others reported such reasons as having a personal problem, seeing articles in the media, reasonable cost, and feeling that a recent physical examination had not been thorough. Although these findings are not applicable to all populations, they were an important basis for our clinic, which we called "For Women Only."
Nearly 20% of the Lawrence, Massachusetts community is elderly. The seniors have received a number of health services through the Greater Lawrence Home Health and Nursing Services Agency's Elder Health Program. This agency combined efforts with the Lawrence Healthworks (a family life resource center that provides family planning and screening services) and the University of Lowell, graduate nurse practitioner instructor/author to develop this free clinic. The local community hospital provided payment for and development of the Papanicolaou slides.
The clinic's focus was on two aspects of preventive health - breast, uterine, and cervical cancer detection, and education and counseling. This clinic was unique because of its target population - elderly women only.
Convenience is of utmost importance in motivating people to use health services. Therefore, we conducted our clinic on a mobile health van, provided by Healthworks. It was equipped with two examining rooms and was set up adjacent to the Lawrence Senior Center.
Twenty-three women, with a mean age of 68.7 years and a range of 62 to 76, participated in the clinic. The clinic began with a group education program that reviewed breast self-examination (BSE) with a film and demonstration. Equipment and supplies, including breast models and a breast cancer quiz, were furnished by the Massachusetts Division of the American Cancer Society. Each client then had individual BSE instruction review and examination. Keeping in mind that the psychological fear of breast cancer can far outweigh the logical component of BSE simplicity, we emphasized the value of preventing the progression of disease by specifically referring to the 85% cure rate with early detection of breast cancer.
The private, one-to-one session with the nurse practitioner student/RN was important in strengthening patient confidence and competence with the skill and, hence, in encouraging its continued use. A complete breast physical assessment reinforced the participant's negative findings and introduced her to the idiosyncratic nature of her own breasts. Participants evaluated the provision of emotional support positively when they were asked to complete a written evaluation.
Following the breast cancer screening, we assisted clients onto the mobile health van. A nurse practitioner student, with preceptor supervision, conducted interviews to briefly review personal, family, medical, gynecologic and obstetric histories. The short, focused history was essential in identifying risk factors for breast, uterine, and cervical cancer. In addition, it afforded the nurse an opportunity to identify learning needs and to provide education and counseling about the value of preventive health practices.
The physical examination included measurement of blood pressure and weight. Pelvic examination included assessment of external genitalia; vaginal and cervical examination with Pap smears (endocervix, cervical, and vaginal pool); bimanual examination of the cervix, uterus, and adnexa; and rectovaginal examination. No matter what her age, the client undergoing a pelvic exam must be relaxed. Since many of the women being examined had never had a pelvic exam, we tried to provide the support, reassurance, and comfort they needed.
Given the invasive nature of this aspect of the physical examination, one must ask what prompted these elderly women to participate in the clinic. It is interesting to note that each of the women was under the care of a primary physician. Stromborg and BourqueNord found that a significantly higher percentage of respondents saw the nurse practitioner (1) as a caring individual, (2) who explained the procedures of the examination.9 Additionally, the Senior Center members' direct and continued contact with the coordinator of the Elder Health Program undoubtedly provided an immeasurable impetus for their involvement in this first-time effort.
The student nurse practitioner who examined the client stressed the need for follow-up of abnormal findings. The coordinator of the Elder Health Program reinforced this during the exit interview. Clients were referred to primary physicians and gynecologic clinics for breast, uterine, and cervical abnormalities. These included four referrals for follow-up of abnormal Pap pathology, three referrals for abnormal pelvic examination findings, and five referrals for breast masses.
Appropriate education and scheduling of necessary follow-up appointments, as well as telephone and written communcation, helped assure adequate follow-up. We utilized the American Cancer Society Uterine, Cervical, and Breast Clinical Records for follow-up and documentation of findings.
We evaluated the clinic goals for assessment, early detection, and patient education regarding breast, uterine, and cervical cancer in three ways. We conducted exit interviews with participants; clients completed a written evaluation following breast self-examination and physical assessment; and the health providers held a formal team meeting. Clients had participated actively and all seemed satisfied.
The evaluation phase is a critical component of the nursing process. A decided limitation of any one-time screening clinic is the assurance of adequate follow-up and continuity of care. This is especially true given the fragmented nature of a clinic designed to detect a specific disease or condition.
Emphasis on preventive rather than episodic health practices, especially for the elderly population, is not sufficiently fostered by the health care system today. Medicare reimbursement, with its acute care focus and Part B deductible, discourages the elderly from seeking preventive care. Lack of transportation may be a further impediment to services offered. Few recognize the need for accessible resources. A cost-effective and relevant cancer screening clinic for elderly women based on a nursing model is one form of nurse-managed and client-centered health care that may positively influence future health behaviors.
Further investigation is needed to identify factors that motivate elderly women to engage in health-protecting behavior. Such research would help establish a climate that would encourage the elderly to take an active role in their health care. In addition, the gerontological nurse practitioner who conducts the necessary assessment, education, and counseling and referral not only fosters positive health practices, but demonstrates a key role for other nurse practitioners in preventive health care.
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- 2. Patterns of Care for Elderly Cancer Patients. Bethesda, MD, U.S. Department of Health, Education, and Welfare, National Institutes of Health, Guide Supplement for Grants and Contracts, 1982.
- 3. Rossman I: Clinical Geriatrics. Philadelphia, J. B. Lippincott Company, 1979.
- 4. Goroll AH, May LA, Mulley AG: Primary Care Medicine. Philadelphia, J. B. Lippincott Company, 1981.
- 5. Breast Self- Examination Pap Screening Program. Boston, American Cancer Society, Massachusetts Division, 1983.
- 6. Martin L: Health Care of Women. Philadelphia, J.B. Lippincott Company, 1978.
- 7. Facts on Ovarian Cancer. New York, American Cancer Society, 1980.
- 8. Facts on Breast Cancer. New York, American Cancer Society, 1980.
- 9. Stromborg MF, Bourque-Nord S: A cancer detection clinic: patient motivation and satisfaction. Nurs Pract 1979; 4:10-11,51.