"We may grow old in body, but we need never grow old in mind and spirit. . . . Old age is the consummation of life, rich in blessings. "
- Marcus Tullius Cicero
One of the greatest health problems facing women in this country today is breast cancer. About 1 in 9 will develop this disease at some time during her life. One of the major risk factors is being over the age of 50 years. Approximately 45% of all cases of breast cancer occur in women over age 65.' The majority of women residing in long-term care facilities are over the age of 65 and therefore are at high risk for the development of breast cancer. In addition, residents of Long Island, New York, are even more at risk: breast cancer rates are 30% higher than the national average in Nassau County and 10% higher in Suffolk County. Despite comprehensive research concerning the increased risk of breast cancer on Long Island, a rationale for these statistics has not been established.
The American Cancer Society recommends the monthly practice of breast self-examination (BSE) and yearly mammographies for women over the age of 50. Both of these methods should be continued after the age of 65. It is reasonable to expect that thorough, organized examinations for breast cancer or yearly mammographies would be a part of the services offered in long-term care facilities because a majority of the women residents are over the age of 65.
A descriptive study on breast cancer detection among women in long-term care facilities was undertaken because no research has been reported on this topic. Facilities chosen for this study were located on Long Island, an area that has the greatest national incidence of breast cancer.
REVIEW OF THE LITERATURE
Breast cancer is a major threat to elderly women because the incidence increases with age.2·3 A study done by Alien et al determined that 23% of the 1 ,795 patients studied with breast cancer between the ages of 15 and 94 years were over the age of 65, and 6.4% were over the age of 75.2 A study done by Robie noted that approximately 45% of new breast cancer cases were detected in women over the age of 65 .4
Years of life, even in patients of advanced age, are lost due to breast cancer.5 The life expectancy of the average 70-year-old woman is 15 years, and several years are contemplated for the average 85-year-old woman.2 Adkins, quoted in an article by Rybolt et al, reviewed 60 patients over the age of 75 and found that not one 78-yearold with breast cancer survived for even half of the life expectancy of 9.2 years.5 Most (71.4%) of the patients died of the breast cancer.
Amsterdam et al studied 100 Israeli women over 70 years of age who had breast cancer and found that surgery and irradiation could achieve a survival rate among these women almost equal to that of younger populations.6 In a retrospective study reported by Herbsman et al of 780 breast cancer patients treated surgically, 138 patients were over the age of 70. The rate of survival among the elderly group was comparable to that of the younger patients "irrespective of race, type of surgery, histology, or tumor size."7
Early detection offers the best hope of cure and decreased mortality. According to studies done by Eddy1 and Stewart8, continued screening will reduce mortality in women with breast cancer by about one third.
Robie points out that "physicians perform fewer breast examinations on women over age 65 than in the younger age group, and only 16% of mammograms are done in women over the age of 60."4 Rybolt and Waterbury determined that only 49% of physicians ordered mammographies on asymptomatic women, and only 1 1 % complied with American Cancer Society guidelines. Breast cancer detection methods were found to be frequently underused for older patients.5
Effective screening involves the use of thorough, organized examinations and mammographies.5 Breast cancer screening hi the elderly can generate early detection of more cases, better cost-effectiveness, and a better cure and salvage rate.3
No literature appears concerning breast cancer detection in long-term care facilities. The New York State Health Code mandates that each resident admitted to a long-term care facility, and periodically throughout the year, be seen by a physician. However, a breast cancer detection examination is not indicated as a routine part of these visits.
The purpose of this study was to determine the extent of the use of breast cancer detection methods among residents in long-term care facilities.
The sample consisted of 79 longterm care facilities located in Nassau and Suffolk counties of Long Island. The sample included nursing homes and health related facilities (Table 1).
The two researchers conducted telephone interviews with the director or the associate director of nursing service in each facility. The reason for the survey was explained prior to obtaining the information. Consent was granted when individuals responded to the interview questions. Two predetermined, openended questions were used: Are routine mammographies done? Are any established routine tests for breast cancer detection used in your facility?
Six of the 79 facilities surveyed reported having some type of breast cancer detection procedures in place. An additional two facilities have physicians on staff who routinely order yearly mammographies on residents under their care. One facility reported doing yearly mammographies on highrisk individuals, but these risks were not identified (Table 2).
Thus, approximately 10% of the 79 long-term care facilities surveyed offered some type of breast cancer detection services to their residents. Based on the discussions conducted during data collection, and the personal experience of one of the authors, a systematic breast cancer detection examination does not appear to be a part of routine physical examinations.
Although this survey focused on the routine use of breast cancer detection methods, data concerning Pap smears were also generated. Information indicated that a parallel existed between the routine detection for both types of cancer. Pap smears were not usually done on a routine basis but rather on a symptomatic basis. Because increasing age is not a risk factor for cervical cancer, the need for routine Pap smears in institutionalized women was not a topic for this article.
TYPE AND LOCATION OF LONG-TERMCARE FACILITIES*
BREASTCANCER DETECTION METHODS USED*
A review of the literature supports the importance of breast cancer detection for women over the age of 65. This study has demonstrated that only 10% of the long-term care facilities surveyed provided some type of breast cancer detection for their residents.
Based on the results of this study, although limited to one geographic area, it appears that physicians and others charged with the care of the institutionalized population over age 65 would benefit from education regarding the importance of providing routine breast cancer detection services. Yearly mammographies are recommended, and it might be beneficial to teach the staff providing the physical care how to do appropriate breast examinations. Some of the directors voiced concern over the cost of this service; however, many third party payers will underwrite this expense. Those caring for the elderly should be encouraged to use this procedure.
The responses from the various interviews conducted generally indicated surprise, ie, "we never thought about it," "it's a good idea," and several mentioned that they were looking into it. Additional comments heard during the data collection included "who cares," "too old," and "residents have multiple medical problems that have higher priorities." It is interesting to speculate whether these attitudes apply to only institutionalized women or to all women over the age of 65. Many elderly women feel it is not necessary to do BSE or to ask their physicians for mammographies.
As life expectancy continues to increase, we can anticipate a greater number of women affected by breast cancer. Early detection will ensure the older population of a greater life expectancy and quality of life.
Change begins when the need for the change has been identified. The use of breast cancer detection methods in long-term care facilities has been ignored, and society appears to be uninformed concerning this issue. Therefore, these researchers are pursuing ways to increase society's awareness concerning the issue of breast cancer detection among institutionalized women. The following strategies will be used: contact with selected political figures concerned with the issue of breast cancer detection; communication of the study results to participating agencies and various health-care practitioners; and presentation of inservice programs to selected personnel in longterm care facilities.
Recommendations for Further Study
A replication of this study in other geographical areas is recommended for further study. An exploratory study among physicians is needed to determine the need for breast cancer detection for long-term care residents. The feasibility of the use of mammographies should be explored in long-term care facilities, as well as the development of guidelines for breast cancer detection in women over 75 years of age.
- 1. Eddy D. Cancer Screening Test: Do elderly women need them? Nursing '88. 1988; 1 8(9): 11 3.
- 2. Alien C, Cox EB, Mantón KG, Cohen HJ. Breast cancer in the elderly. Current patterns ofcuK.JAmGeriatrSoc. 1986; 34:637-642.
- 3. Holmes FF, Heame H. Cancer stage-to-age relationship: Implications for cancer screening in the elderly. J Am Geriatr Soc. 1981; 29:55-57.
- 4. Robie PW. Cancer screening in the elderly. J AmGeriatrSoc. 1989; 37:888-893.
- 5. Rybott AH, Waterbury L. Breast cancer in older women: Trends in diagnosis. Geriatrics. 1989; 44<6): 69-70,75-77,80-82.
- 6. Amsterdam E, Birkenfeld S, Gilad A, Krispin M. Surgery for carcinoma of the breast in women over 70 years of age. J Surg Oncol. 1987:35:180-183.
- 7. Herbsman H, Feldman J, Seldera J, Garenor B, Alfonsa A. Survival following breast cancer surgery in the elderly. Cancer. 1981; 47:2358-2363.
- 8. Stewart JA, Foster R. Breast cancer and aging. SemOnco!. 1989; 16(1):41-50.
TYPE AND LOCATION OF LONG-TERMCARE FACILITIES*
BREASTCANCER DETECTION METHODS USED*