Disease Preveniton and Health Promotion Screening: Breast Cancer
Submitted by Maria C. Hatter, RN, BSN
Hye Jeong Robbibaro, RN, BSN
The American Cancer Society (ACS) defines cancer as a disease that causes cells in the body to change and grow at an uncontrolled rate (ACS, 2015). This accelerated cell growth rate usually creates a lump or mass, which is called a tumor (ACS, 2015). The location of the body in which the tumor grows delineates the cancer classification. Although breast cancer is referred to as a single disease, there are up to 21 cell subtypes and at least four different molecular subtypes resulting in varied biological presentations, responses to treatment, outcomes, and risk factors (ACS, 2015). In simpler terms, breast cancer is classified in the following two ways: invasive cancer or as carcinoma in situ (CIS), which is non-invasive and the earliest form of breast cancer (ACS, 2015). Breast cancer usually begins in the glandular tissue for milk production when the abnormal cells have broken through the walls of the gland or ducts (ACS, 2015). The growth of these cells become invasive by spreading into the surrounding tissue and other areas of the body (ACS, 2015). As the aforementioned information indicates, health screening and early cancer detection are pivotal to accomplishing the Healthy People 2020’s goal of reducing the number of new cancer cases, illness, disability, and deaths caused by cancer (healthypeople.gov, 2016).
Worldwide in both developed and underdeveloped nations, breast cancer is the leading form of cancer in women (WHO, 2016). According to the ACS, breast cancer is the second leading cause of cancer death in women and the leading cause of premature mortality for females (ACS, 2015). Additionally, the National Cancer Institute (NCI) states that a woman living in the United States (U.S.) has a one in eight risk of developing invasive breast cancer in her lifetime (NCI, 2012). Current estimates for breast cancer in the U.S. are as follows: 61,000 new cases of CIS will be diagnosed, 246,660 new cases of invasive cancer will be diagnosed in women, and that an estimated 40,450 women will succumb to death (NCI, 2012; ACS, 2015). Middle-aged to older women are the largest population at risk for the development of breast cancer (NCI, 2012). Many non-modifiable risk factors exist such as: sex (females have a higher risk than males), increased age, race, family history, genetic alterations, personal history of breast cancer, breast density, reproductive history, and radiation therapy (NCI, 2012). However, several modifiable risk factors may decrease the risk of breast cancer such as: limited use of hormonal birth control, tobacco use, alcohol use, diet, physical activity, obesity, and weight gain (ACS, 2015). Interestingly, research has shown that night shift work may increase breast cancer risk by 40 percent (ACS, 2015). Finally, the ACS and Centers for Disease Control have identified a growing racial disparity among black women, who have a higher incidence for the development of breast cancer before age 45 and have a greater overall breast cancer mortality (ACS, 2015).
Review of Literature
Ong and Mandl’s (2015) research provides supportive evidence that initiating mammography screenings after the age of 50 may reduce unnecessary medical expenditure due to false-positive mammograms. The study indicated that the primary concern of breast cancer is the overall cost which is secondary to services affiliated with the diagnosis and treatment (Ong & Mandl, 2015). Campbell and Ramsey (2009) estimate that the lifetime per-patient cost to treat breast cancer range from 20,000 dollars to 100,000 dollars resulting in 88.7 billion dollars’ worth of total national medical costs in 2011 (ACS, 2015). Ideally, general screening guidelines should be tailored to suite the individual. Clinicians and patients should strive to establish a trusting relationship that would create the opportunity for an informed, proactive approach to healthcare.
Per the United States Preventive Services Task Force (USPSTF), mammography, clinician breast exam, and breast self-exam are the accepted screening tools for breast cancer detection (AHRQ, 2014). Currently, the Agency for Healthcare Research and Quality (AHRQ) recognizes the following new screening tools for detection of breast cancer: digital mammography and magnetic resonance imaging (MRI) (Campbell & Ramsey, 2009). However, availability, access to equipment, cost, and lack of research conducted using these tools for detection of breast cancer inhibit the determination of validity of these tools (Campbell & Ramsey. 2009). The only proven effective breast cancer screening method is mammography (WHO, 2016). Thus, the AHRQ and USPSTF (2014) validate that film mammography is the standard for detecting breast cancer. Film mammography has a sensitivity of 77 to 95 percent and a specificity of 94 to 97 percent (USPSTF, 2016). The negative inputs of using film mammography is exposure to radiation which increases risk for the patient, dense breast tissue may lead to false positives or over-diagnoses, increased anxiety, and additional unnecessary testing or increased medical expenses such as biopsies (Ong & Mandl, 2015). No consensus has been reached by the ACS, NCI, USPTF and AHRQ with respect to the ideal age to begin screening for breast cancer or how often the screening should be performed. The guidelines range from 40 to 50 years of age as the starting point for initiating film mammography. Breast tissue density in females under the age of 50 years old leads to many false-positive mammography results thus increasing medical costs and negative psycho-emotional experiences for the patient (Ong & Mandl, 2015). However, the one aspect that all of these agencies agree upon is greatest risk factor for the development of breast cancer is increased age (ACS, 2015; AHRQ, 2014; NCI, 2012). The frequency of film mammography, which differs by one to two years, is the major variation among the agency recommendations. The USPTF recommendation for women ages 50 to74 years of age is a screening mammography ordered every two years (AHRQ, 2014; USPSTF, 2016). The ACS recommends 40 years of age as the threshold to begin screening mammography (ACS, 2015). The USPTF and WHO agree with this recommendation of starting mammography screening at age 40 for females at high risk (AHRQ, 2014; USPSTF, 2016; WHO, 2016).
Health care providers (HCPs) have the important role of serving as educators and advocates for vulnerable breast cancer populations. In order to diminish the mortality of breast cancer-related deaths, patient instruction concerning the modifiable risk factors and mammography screening practices as prevention strategies is essential. Finally, HCPs must be knowledgeable concerning current screening practices and the importance of early detection measures. In order to decrease overall healthcare costs and enhance outcomes, both patient and provider should work together to stay up-to-date concerning preventative practices to decrease breast cancer mortality among the population.
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