Older women's breast screening behaviors: what nurses need to know

MedSurg Nursing, April, 2007 by Mary Elaine Koren, Judith E. Hertz

The population of adults age 65 and older is expected to double in size in the next 50 years (U.S. Census Bureau, 2004). The majority of this aging population is women, and breast cancer is a major health concern for older women. The incidence of breast cancer ranks highest among all female cancers (Jemel et al., 2005), and both the incidence and death rate for breast cancer increase as women age (Ries et al., 2005).

Little is known about the breast screening behaviors of breast self-examination (BSE), mammograms, and clinical breast examination (CBE) in women age 65 and older (Bruening et al., 2006; Yarbrough 2004). Furthermore, studies of breast screening behaviors often group ages 65-95 together despite the 30-year age span (Stamler, Lafreniere, Thomas, & Out, 2002; Tittle, Chiarelli, McGough, McGee, & McMillan, 2002). Differences in breast screening behaviors among three age groups of women age 65 and older are discussed. Also, implications from the study's findings are addressed.

Review of Literature

Questions have been raised regarding the impact of BSE and mammography on mortality. One often cited, large, randomized study found little relationship between BSE and breast cancer mortality (Thomas et al., 2002). After a systematic review of studies, Olsen and Gotzsche (2001) concluded that mammography leads to increased numbers of unnecessary mastectomies and has little impact on breast cancer survival for women age 50 and older. These reports obscure the inherent merit of BSE: it is noninvasive, involves no radiation exposure, raises women's awareness of their anatomy, and promotes self-control (Elmore, Armstrong, Lehman, & Fletcher, 2005). Furthermore, mounting scientific evidence from multiple clinical trials continues to support annual mammogram screening for women age 40 and older (American Cancer Society [ACS], 2005; Elmore et al., 2005). Although controversy surrounds the efficacy of BSE and mammography, organizations such as the American Society of Clinical Oncology (Smith et al., 1999) and the Susan G. Komen Breast Foundation (2005) continue to recommend screening with monthly BSE and routine mammograms.

Another issue is establishing the best method for assessing women's BSE proficiency. In a meta-analysis of 20 research studies, Ku (2001) measured BSE behavior by self-reported frequency only. Another study used an observational instrument to measure breast examination proficiency of health care providers (Coleman et al., 2003). Several observational instruments are available to assess proficiency of patients' BSE performance on breast models (Reis, Trockel, King, & Remmert, 2004; Wood, Duffy, Morris, & Carnes, 2002). However, the models present problems because they are stiff and less pliable than human tissue. Ideally, BSE proficiency should be evaluated while women are performing BSE on their own breasts. However, no identified study investigated how accurately or proficiently women performed BSE on themselves.

For many years, gerontologists recognized differences among the young-old (65-74 years), old (75-84 years), and old-old (85 years and older) (Atchley, 2000). In a recent comprehensive evaluation of breast screening research, women over age 65 were evaluated as a homogeneous group or age was completely ignored (Bruening et al., 2006). Some studies on BSE frequency and proficiency categorized women by age but the specific age groupings varied. For example, a survey by Stamler and colleagues (2002) compared Canadian women above and below age 50, and found that participants age 50 and older practiced BSE less frequently than their younger counterparts. Akrigg (2001) evaluated both frequency and proficiency of BSE in a pilot study of 34 Asian women age 31-77. The author categorized the women by decade of life but found no significant differences in BSE among the age groups.

Various age categories also were used to investigate frequency of mammography screening among older women. Lauver, Kane, Bodden, McNeel, and Smith (1999) sampled 119 women age 51-80, while Tang, Solomon, and McCracken (2000) sampled Chinese-American women age 60-102. In both studies, mammography adherence decreased as age increased. Similarly, CBE research grouped women age 65 and older into one age category (George, 2000; Tang et al., 2000) and found fewer older women participate in CBE screening than younger women.

Older women are less likely to participate in mammography screening (Sharp, Michielutte, Spangler, Cunningham, & Freimanis, 2005) or mammography along with CBE than women age 65 and younger (Rawl, Champion, Usha, & Foster, 2000). Some of the barriers to mammography screening reported by older women include lack of health care provider referral, lack of transportation to a facility, concern about pain, lack of friends who have routine mammography, nonenrollment in a health maintenance organization (Levy-Storms, Bastani, & Reuben, 2004), and burdens of care giving to others (Messina et al., 2004).

In summary, little research is available on the breast screening behaviors of women age 65 and older, and some results are inconsistent. Studies that included women over age 65 often grouped them together without distinction of age. The grouping of women age 65 and older into one age category is problematic and limits understanding. Women age 65 may have different needs than 95-year-old women. They are a generation apart in age. None of the reviewed studies evaluated the accuracy of women performing BSE on their own breasts.