educational programs Women with Disabilities
Prevention, Diagnosis, and Treatment of  Breast Cancer in  Women with Disabilities Part 3: Treatment, Rehabilitation, and ...
Overview <ul><li>Part 1: Incidence and Risk </li></ul><ul><li>Part 2: Screening and Diagnosis </li></ul><ul><li>Part 3: Tr...
Treatment
Treatment Options for  Noninvasive Cancers 1 <ul><li>LCIS </li></ul><ul><li>1. Observation after diagnostic biopsy </li></...
Treatment Options for Early Breast Cancer (Stages I, II, IIIA, and Operable IIIC) 1 <ul><li>Primary: </li></ul><ul><li>Bre...
Treatment Options for Stage IIIB, Inoperable Stage IIIC, Stage IV, Recurrent, and Metastatic Breast Cancer 1 <ul><li>Hormo...
Disparities in Breast Cancer Treatment:   Breast-Conserving Surgery + Radiation Therapy <ul><li>Women with Disabilities We...
Disparities in Breast Cancer Treatment:  Chemotherapy <ul><li>Chart Review: 1 </li></ul><ul><li>Women with disabilities le...
Making the Treatment Decision <ul><li>Avoid assumptions </li></ul><ul><li>Discuss medical  and  logistical pros and cons o...
Determining Medical Decision-Making Capacity (Ability to Give Informed Consent) <ul><li>“ So long as the patient appears t...
Resources for Determining Ability to Give Informed Consent <ul><li>State medical associations  </li></ul><ul><li>National ...
Special Concerns:   Surgery <ul><li>How will surgery affect the patient’s disability and quality of life? </li></ul><ul><l...
Overcoming Surgical Barriers <ul><li>Anticipate and plan for any special needs that the patient might require during the s...
Special Concerns:  Radiation Therapy <ul><li>Is patient physically able to lie still and abduct arm for treatment? </li></...
Overcoming Barriers to  Radiation Therapy <ul><li>Anticipate transportation and other access barriers; make sure these iss...
Special Concerns:  Chemotherapy Possible Side Effects Will patient have necessary level of home care to address medical an...
Special Concerns:  Chemotherapy <ul><li>Fatigue:  May severely limit mobility for women with existing mobility limitations...
Special Concerns:   Hormone Therapy  Possible Side Effects: Tamoxifen/Raloxifene Will patient have necessary level of home...
Special Concerns:   Hormone Therapy <ul><li>Aromatase Inhibitors: </li></ul><ul><li>Increased risk of bone loss and fractu...
Overcoming Barriers to Chemotherapy and Hormone Therapy <ul><li>Ensure full patient participation  in treatment decisions ...
Support Patient During Treatment <ul><li>Identify barriers to care </li></ul><ul><li>Identify resources to overcome those ...
Rehabilitation
Rehabilitation Strategies <ul><li>Treat related diagnoses that increase the disability </li></ul><ul><li>Treat unrelated d...
Treat Related Diagnoses:  Lymphedema <ul><li>Symptoms </li></ul><ul><ul><li>Swelling, aching, tightness in arm </li></ul><...
Complete Decongestive Physiotherapy <ul><li>Manual lymphatic massage </li></ul><ul><li>Inelastic compression bandaging </l...
Treat Related Diagnoses:   Rotator Cuff Tendinitis <ul><li>Common disorder among breast cancer patients 1 </li></ul><ul><l...
Treating Rotator Cuff Tendinitis <ul><li>Stretches and range-of-motion exercises to increase flexibility </li></ul><ul><li...
Treat Related Diagnoses:   Overuse Injuries on  Unaffected Side <ul><li>Women with disabilities are at increased risk of  ...
Treating Overuse Injuries <ul><li>Early and aggressive physical therapy is essential </li></ul><ul><li>Patient should be e...
Treat Related Diagnoses:  Neck Pain <ul><li>Second most common musculoskeletal condition among women </li></ul><ul><li>Aft...
Treating Neck Pain <ul><li>Restore range of motion </li></ul><ul><li>Maintain/improve upper body strength </li></ul>
Treat Unrelated Diagnoses That Increase the Disability <ul><li>Treat early </li></ul><ul><li>Treat aggressively </li></ul>...
Manage Pain <ul><li>Treatment goals </li></ul><ul><ul><li>Ameliorate pain </li></ul></ul><ul><ul><li>Maintain optimal func...
Improve Fatigue <ul><li>Possible Causes of Fatigue in Women: </li></ul><ul><li>Inadequate sleep </li></ul><ul><li>Side eff...
Increase Cardiovascular Fitness <ul><li>Exercise Improves: 1 </li></ul><ul><li>Quality of life </li></ul><ul><li>Cardiores...
Increase Muscle Strength <ul><li>Twice Weekly Strength Training: </li></ul><ul><li>Improves quality of life 1 </li></ul><u...
www.ncpad.org National Center on Physical Activity and Disability
Prescribe Appropriate  Adaptive Equipment <ul><li>The choice of equipment should involve patient, medical team, and PT/OT ...
Ongoing Care
Goals of Regular Follow-up Visits <ul><li>Find local or distant recurrence of cancer </li></ul><ul><li>Find any new breast...
Recommendations for Follow-up Care for Breast Cancer 1 <ul><li>Khatcheressian JL, et al.  J Clin Oncology  2006;24:5091-50...
Work Collaboratively <ul><li>Ask questions </li></ul><ul><li>Anticipate problems </li></ul><ul><li>Create solutions </li><...
Create a “Teachable Moment” <ul><li>Provide information on healthy behaviors </li></ul><ul><li>Ascertain if patient needs ...
Summary <ul><li>Breast cancer treatment poses added practical issues for women with disabilities. </li></ul><ul><li>Presen...
Summary  (continued) <ul><li>Tailor each woman’s treatment to minimize its effect on worsening the patient’s existing disa...
<ul><li>Resources </li></ul>
Breast Health Access for Women with Disabilities (BHAWD) Call: 512-204-4866 TDD: 510-204-4574 www. bhawd .org   Center for...
National Breast and Cervical Cancer Early Detection Program Centers for Disease Control and Prevention Call:  1-800-CDC-IN...
References <ul><li>Ahmedin J, Siegel R, Ward E, Murray T, Xu J, and Thun MJ. Cancer statistics, 2007.  CA Cancer J Clin.  ...
<ul><li>Breast Health Access for Women with Disabilities (BHAWD).  Breast health and beyond: a provider’s guide to the exa...
<ul><li>Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of biolateral prophylactic mastectomy in women with a family his...
<ul><li>Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the Breast Canc...
<ul><li>Moore RF. A guide to the assessment and care of the patient whose medical decision-making capacity is in question....
<ul><li>Nosek MA, Howland CA. Breast and cervical cancer screening among women with physical disabilities.  Arch Phys Med ...
<ul><li>Shapiro CL, Manola J, Leboff M. Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in ...
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  1. 1. educational programs Women with Disabilities
  2. 2. Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities Part 3: Treatment, Rehabilitation, and Ongoing Care Women with Disabilities Education Project
  3. 3. Overview <ul><li>Part 1: Incidence and Risk </li></ul><ul><li>Part 2: Screening and Diagnosis </li></ul><ul><li>Part 3: Treatment, Rehabilitation, and Ongoing Care </li></ul>www.womenwithdisabilities.org
  4. 4. Treatment
  5. 5. Treatment Options for Noninvasive Cancers 1 <ul><li>LCIS </li></ul><ul><li>1. Observation after diagnostic biopsy </li></ul><ul><li>2. Tamoxifen to decrease the incidence of subsequent breast cancers </li></ul><ul><li>3. Bilateral prophylactic total mastectomy, without axillary node dissection </li></ul><ul><li>4. Clinical trials testing cancer prevention drugs </li></ul><ul><li>DCIS </li></ul><ul><li>1. Breast-conserving surgery and radiation therapy with or without tamoxifen </li></ul><ul><li>2. Total mastectomy with or without tamoxifen </li></ul><ul><li>3. Breast-conserving surgery without radiation </li></ul>1. National Cancer Institute. Available at www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page5.
  6. 6. Treatment Options for Early Breast Cancer (Stages I, II, IIIA, and Operable IIIC) 1 <ul><li>Primary: </li></ul><ul><li>Breast-conserving surgery + lymph node dissection and radiation therapy </li></ul><ul><li>Modified radical mastectomy </li></ul><ul><li>Adjuvant: </li></ul><ul><li>After surgery: radiation therapy </li></ul><ul><li>Systemic chemotherapy </li></ul><ul><li>Hormone therapy (tamoxifen, aromatase inhibitors) </li></ul><ul><li>Trastuzumab (Herceptin) + systemic chemotherapy </li></ul>1. National Cancer Institute. Available at www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page5.
  7. 7. Treatment Options for Stage IIIB, Inoperable Stage IIIC, Stage IV, Recurrent, and Metastatic Breast Cancer 1 <ul><li>Hormone therapy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Surgery with lymph node dissection and radiation therapy </li></ul><ul><li>Targeted therapies (e.g., lapatinib, trastuzumab (Herceptin), bevacizumab (Avastin)) </li></ul><ul><li>Clinical trials testing new drugs/treatments </li></ul><ul><li>Hormone therapy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Targeted therapies (e.g., lapatinib, trastuzumab (Herceptin), bevacizumab (Avastin)) </li></ul><ul><li>Palliative radiation therapy and/or surgery </li></ul><ul><li>Clinical trials testing new drugs/treatments </li></ul>1. National Cancer Institute. Available at www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page5. Stage IIIB and Inoperable Stage IIIC Stage IV and Metastatic
  8. 8. Disparities in Breast Cancer Treatment: Breast-Conserving Surgery + Radiation Therapy <ul><li>Women with Disabilities Were: 1 </li></ul><ul><li>20% less likely to receive breast-conserving surgery </li></ul><ul><li>19% less likely to receive lymph node dissection </li></ul><ul><li>17% less likely to receive adjuvant radiation therapy </li></ul><ul><li>29% more likely to die from the breast cancer </li></ul>1. McCarthy et al. Ann Intern Med. 2006;145:637-645.
  9. 9. Disparities in Breast Cancer Treatment: Chemotherapy <ul><li>Chart Review: 1 </li></ul><ul><li>Women with disabilities less likely to receive neoadjuvant chemotherapy compared to women without disabilities (13% of the time vs. 29% of the time), but </li></ul><ul><li>Difference was not statistically significant </li></ul>1. Caban ME, et al. Cancer . 2002;94:1391-1396.
  10. 10. Making the Treatment Decision <ul><li>Avoid assumptions </li></ul><ul><li>Discuss medical and logistical pros and cons of each treatment option </li></ul>
  11. 11. Determining Medical Decision-Making Capacity (Ability to Give Informed Consent) <ul><li>“ So long as the patient appears to adequately understand and appreciate the personal significance of the following: </li></ul><ul><ul><li>That she has a general medical or mental disorder, </li></ul></ul><ul><ul><li>The nature and course of the disorder, and </li></ul></ul><ul><ul><li>The risks and benefits of the proposed intervention and of the alternative, including the alternative of no intervention; and </li></ul></ul><ul><li>So long as the patient makes a non-coerced choice that does not appear to be unduly influenced by a mental disorder, then the patient may be considered to possess capacity even if her choice appears to the physician to be unreasonable.” 1 </li></ul>1. Moore RF. Medscape General Medicine . 1999;1(3).
  12. 12. Resources for Determining Ability to Give Informed Consent <ul><li>State medical associations </li></ul><ul><li>National Association of Developmental Disability Councils: www.nacdd.org </li></ul><ul><li>Assessment tools for women with limited verbal skills: </li></ul><ul><ul><li>Hopkins Competency Assessment Test </li></ul></ul><ul><ul><li>Competency Interview Schedule </li></ul></ul><ul><ul><li>MacArthur Competence Assessment Tool </li></ul></ul>
  13. 13. Special Concerns: Surgery <ul><li>How will surgery affect the patient’s disability and quality of life? </li></ul><ul><li>What are the patient’s current assistive and adaptive needs, and how will surgery affect those needs? </li></ul>
  14. 14. Overcoming Surgical Barriers <ul><li>Anticipate and plan for any special needs that the patient might require during the surgery itself </li></ul><ul><li>Make sure patient will have assistance after the operation </li></ul><ul><li>Make sure patient has transportation to the surgery and to post-op medical appointments </li></ul><ul><li>Consider sending patient to a PT or OT consultation before surgery </li></ul>
  15. 15. Special Concerns: Radiation Therapy <ul><li>Is patient physically able to lie still and abduct arm for treatment? </li></ul><ul><li>Will patient have daily transportation to and from radiation therapy facility? </li></ul><ul><li>Will patient have necessary level of home care to address medical and daily living side effects of radiation therapy? </li></ul>
  16. 16. Overcoming Barriers to Radiation Therapy <ul><li>Anticipate transportation and other access barriers; make sure these issues are resolved before patient shows up for treatment </li></ul><ul><li>Consider shorter treatment course </li></ul>
  17. 17. Special Concerns: Chemotherapy Possible Side Effects Will patient have necessary level of home care to address medical and daily living side effects of chemotherapy? Fatigue Sexual dysfunction Heart failure Weight gain Fatigue Neuropathy Mucositis Cognitive impairment Alopecia Bone loss Myelosuppression/Infection Premature menopause Vomiting Heart failure Nausea Long-Term Short-Term
  18. 18. Special Concerns: Chemotherapy <ul><li>Fatigue: May severely limit mobility for women with existing mobility limitations </li></ul><ul><li>Increase in Urine Output: May cause significant problem for women with existing continence problem </li></ul><ul><li>Bone Loss: Increases osteoporosis risk for women already at increased risk </li></ul>Side Effects Pose Potentially Debilitating Consequences for Women with Disabilities:
  19. 19. Special Concerns: Hormone Therapy Possible Side Effects: Tamoxifen/Raloxifene Will patient have necessary level of home care to address medical and daily living side effects of hormone therapy? Increased risk of thromboembolism Headaches Loss of appetite/weight gain Skin rash Vaginal dryness or itching Irregular menstrual periods Vaginal spotting Nausea and vomiting
  20. 20. Special Concerns: Hormone Therapy <ul><li>Aromatase Inhibitors: </li></ul><ul><li>Increased risk of bone loss and fractures </li></ul><ul><li>Consider adjuvant use of bisphosphonates </li></ul>
  21. 21. Overcoming Barriers to Chemotherapy and Hormone Therapy <ul><li>Ensure full patient participation in treatment decisions </li></ul><ul><li>Tailor treatment based on side effect and risk profile </li></ul><ul><li>Identify and address patient’s needs before treatment begins </li></ul><ul><li>Increase home nurse visits, if needed </li></ul><ul><li>Monitor patient’s bone density and evaluate treatments to attenuate bone loss </li></ul><ul><li>Instruct patient on symptoms of thromboembolism </li></ul>
  22. 22. Support Patient During Treatment <ul><li>Identify barriers to care </li></ul><ul><li>Identify resources to overcome those barriers </li></ul><ul><li>Prepare patient for possible side effects and their impact on her daily activities </li></ul><ul><li>Make sure she will have the proper assistance to deal with those side effects </li></ul><ul><li>Coordinate care with other specialists </li></ul><ul><li>Have a system in place that enables you and your patient to communicate easily throughout the treatment process </li></ul><ul><li>Ask patient if she would like to include a friend or family member in her care </li></ul>
  23. 23. Rehabilitation
  24. 24. Rehabilitation Strategies <ul><li>Treat related diagnoses that increase the disability </li></ul><ul><li>Treat unrelated diagnoses that increase the disability </li></ul><ul><li>Manage pain </li></ul><ul><li>Improve fatigue </li></ul><ul><li>Increase strength and cardiovascular fitness </li></ul><ul><li>Prescribe adaptive equipment </li></ul>
  25. 25. Treat Related Diagnoses: Lymphedema <ul><li>Symptoms </li></ul><ul><ul><li>Swelling, aching, tightness in arm </li></ul></ul><ul><ul><li>Hardening/thickening of skin </li></ul></ul><ul><ul><li>Restricted range of motion </li></ul></ul><ul><li>May lead to cellulitis </li></ul><ul><li>6%–30% of survivors self-report lymphedema symptoms 1 </li></ul><ul><li>Symptoms may develop up to 20 years after initial treatment 2 </li></ul><ul><li>National Cancer Institute. NCI Cancer Bulletin . 2007;4:5-6. </li></ul><ul><li>Petrek JA, et al. Cancer. 2001;92:1368-1377. </li></ul>
  26. 26. Complete Decongestive Physiotherapy <ul><li>Manual lymphatic massage </li></ul><ul><li>Inelastic compression bandaging </li></ul><ul><li>Remedial exercises </li></ul><ul><li>Meticulous skin care </li></ul>
  27. 27. Treat Related Diagnoses: Rotator Cuff Tendinitis <ul><li>Common disorder among breast cancer patients 1 </li></ul><ul><li>Results from weakness of the rotator cuff musculature </li></ul><ul><li>Radiation therapy and chemotherapy contribute to the disorder </li></ul><ul><li>Associated with lymphedema 2 </li></ul><ul><li>Stubblefield MD, Custodio CM. Arch Phys Med Rehabil . 2006;S96-S99. </li></ul><ul><li>Herrera JE, Stubblefield MD. Arch Phys Med Rehabil . 2004:85:1939-1942. </li></ul>
  28. 28. Treating Rotator Cuff Tendinitis <ul><li>Stretches and range-of-motion exercises to increase flexibility </li></ul><ul><li>Exercises to stabilize shoulder </li></ul>
  29. 29. Treat Related Diagnoses: Overuse Injuries on Unaffected Side <ul><li>Women with disabilities are at increased risk of overuse injuries </li></ul><ul><li>Risk increases after cancer treatment </li></ul>
  30. 30. Treating Overuse Injuries <ul><li>Early and aggressive physical therapy is essential </li></ul><ul><li>Patient should be evaluated for adaptive equipment and/or assistive devices </li></ul>
  31. 31. Treat Related Diagnoses: Neck Pain <ul><li>Second most common musculoskeletal condition among women </li></ul><ul><li>After breast cancer treatment, deconditioning increases risk </li></ul>
  32. 32. Treating Neck Pain <ul><li>Restore range of motion </li></ul><ul><li>Maintain/improve upper body strength </li></ul>
  33. 33. Treat Unrelated Diagnoses That Increase the Disability <ul><li>Treat early </li></ul><ul><li>Treat aggressively </li></ul>To Avoid Diminished Function:
  34. 34. Manage Pain <ul><li>Treatment goals </li></ul><ul><ul><li>Ameliorate pain </li></ul></ul><ul><ul><li>Maintain optimal function </li></ul></ul><ul><li>Closely follow patient for detrimental side effects of medication </li></ul><ul><li>Refer patient to PT and/or OT </li></ul><ul><li>Integrative treatments (e.g., acupuncture) may help </li></ul>
  35. 35. Improve Fatigue <ul><li>Possible Causes of Fatigue in Women: </li></ul><ul><li>Inadequate sleep </li></ul><ul><li>Side effects from medications </li></ul><ul><li>Depression </li></ul><ul><li>Anemia </li></ul><ul><li>Thyroid illness </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Deconditioning </li></ul>
  36. 36. Increase Cardiovascular Fitness <ul><li>Exercise Improves: 1 </li></ul><ul><li>Quality of life </li></ul><ul><li>Cardiorespiratory fitness </li></ul><ul><li>Physical functioning </li></ul><ul><li>Fatigue </li></ul><ul><li>Exercise May Improve: 2 </li></ul><ul><li>Breast cancer survival </li></ul><ul><li>Greatest benefit: Walking 3–5 hours per week at average pace (or equivalent) </li></ul><ul><li>McNeely ML, et al. CMAJ. 2006:175:34-41. </li></ul><ul><li>Holmes MD, et al. JAMA. 2005;293:2479-2486. </li></ul>
  37. 37. Increase Muscle Strength <ul><li>Twice Weekly Strength Training: </li></ul><ul><li>Improves quality of life 1 </li></ul><ul><li>Increases muscle mass 2 </li></ul><ul><li>Reduces body fat 2 </li></ul><ul><li>Reduces IGF-II levels 2 </li></ul><ul><li>Ohira T, et al. Cancer . 2006;106:2076-2083. </li></ul><ul><li>Schmitz KH et al. Cancer Epidemiol Biomarkers Prev . 2005;14:1672-1680. </li></ul>
  38. 38. www.ncpad.org National Center on Physical Activity and Disability
  39. 39. Prescribe Appropriate Adaptive Equipment <ul><li>The choice of equipment should involve patient, medical team, and PT/OT </li></ul><ul><li>An assessment should be made of woman’s needs at home and at work </li></ul>www.ataccess.org The Alliance for Technology Access
  40. 40. Ongoing Care
  41. 41. Goals of Regular Follow-up Visits <ul><li>Find local or distant recurrence of cancer </li></ul><ul><li>Find any new breast tumors that have developed </li></ul><ul><li>Find any treatment-related side effects (e.g, lymphedema, bone loss, cardiovascular problems) </li></ul><ul><li>Identify effects of the disease and its treatment on the patient’s disability and quality of life </li></ul>
  42. 42. Recommendations for Follow-up Care for Breast Cancer 1 <ul><li>Khatcheressian JL, et al. J Clin Oncology 2006;24:5091-5097. </li></ul><ul><li>Tell your doctor if there is a history of cancer in your family. The following risk factors may indicate that breast cancer could run in the family: </li></ul><ul><ul><li>Ashkenazi Jewish heritage </li></ul></ul><ul><ul><li>Personal or family history of ovarian cancer </li></ul></ul><ul><ul><li>Any first-degree relative (mother, sister, daughter) diagnosed with breast cancer before age 50 </li></ul></ul><ul><ul><li>Two or more first-degree or second-degree relatives (grandparent, aunt, uncle) diagnosed with breast cancer </li></ul></ul><ul><ul><li>Personal or family history of breast cancer in both breasts </li></ul></ul><ul><ul><li>History of breast cancer in male relative </li></ul></ul>Genetic Counseling Referral About a year after diagnosis, you may continue to visit your oncologist or transfer your care to a primary care doctor. Women receiving hormone therapy should talk with their oncologist about how often to schedule follow-up visits for re-evaluation of their treatment. Coordination of Care Continue to visit a gynecologist regularly. Women taking tamoxifen should report any vaginal bleeding to their doctor. Pelvic Examination Perform a breast self-examination every month. This procedure is not a substitute for a mammogram. Breast Self-Examination Schedule a mammogram one year after your first mammogram that led to diagnosis, but no earlier than six months after radiation therapy. Obtain a mammogram every six to 12 months thereafter. Post-Treatment Mammography Visit your doctor every three to six months for the first three years after the first treatment, every six to 12 months for years four and five and every year thereafter Medical History and Physical Examination Recommendation Follow-up Care Test
  43. 43. Work Collaboratively <ul><li>Ask questions </li></ul><ul><li>Anticipate problems </li></ul><ul><li>Create solutions </li></ul><ul><li>Have mechanism in place to alert you if the patient does not return for follow-up within recommended interval </li></ul>
  44. 44. Create a “Teachable Moment” <ul><li>Provide information on healthy behaviors </li></ul><ul><li>Ascertain if patient needs help with depression or other mental health issue </li></ul><ul><li>If applicable, discuss the option of a genetics referral </li></ul>
  45. 45. Summary <ul><li>Breast cancer treatment poses added practical issues for women with disabilities. </li></ul><ul><li>Present all the medical and logistical pros and cons of treatment options to your patients with disabilities. </li></ul><ul><li>Know state laws regarding informed consent. </li></ul><ul><li>Discuss with your patients with disabilities how treatment may affect their adaptive and assistive needs. Help arrange support services to meet those needs. </li></ul>
  46. 46. Summary (continued) <ul><li>Tailor each woman’s treatment to minimize its effect on worsening the patient’s existing disability. </li></ul><ul><li>Refer the patient to physical and/or occupational therapy before her treatment starts. </li></ul><ul><li>During follow-up care, identify and address the effect that the cancer and its treatment has had on the woman’s disability. </li></ul><ul><li>Make sure the patient’s follow-up plan addresses how she will access and/or receive the care. Have a mechanism in place to alert your clinic or office if the patient does not return within the recommended interval. </li></ul>
  47. 47. <ul><li>Resources </li></ul>
  48. 48. Breast Health Access for Women with Disabilities (BHAWD) Call: 512-204-4866 TDD: 510-204-4574 www. bhawd .org Center for Research on Women with Disabilities (CROWD) Baylor College of Medicine Call: 800-442-7693 www.bcm.edu/crowd Health Promotion for Women with Disabilities Villanova University College of Nursing Call: 610-519-6828 www.nursing.villanova.edu/womenwithdisabilities Magee-Women’s Foundation “Strength & Courage Exercise DVD” (a compilation of exercises helpful to breast cancer patients) http://foundation.mwrif.org/
  49. 49. National Breast and Cervical Cancer Early Detection Program Centers for Disease Control and Prevention Call: 1-800-CDC-INFO TTY: 1-888-232-6348 www.cdc.gov/cancer/nbccedp National Center of Physical Activity and Disability Call: 1-800-900-8086 TTY: 1-800-900-8086 www.ncpad.org The National Women’s Health Information Center Call: 1-800-994-9662 TDD: 1-888-220-5446 www.4women.gov/wwd Susan G. Komen for the Cure www.cms.komen.org Women with Disabilities Centers for Disease Control and Prevention www. cdc . gov / ncbddd /women
  50. 50. References <ul><li>Ahmedin J, Siegel R, Ward E, Murray T, Xu J, and Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43-66. </li></ul><ul><li>Ahn J, Schatzkin A, Lacey JV, et al. Adiposity, adult weight change, and postmenopausal breast cancer risk. Arch Intern Med. 2007;167:2091-2102. </li></ul><ul><li>American Cancer Society. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89. </li></ul><ul><li>American Cancer Society. American Cancer Society issues recommendation on MRI for breast cancer screening. March 28, 2007. Available online. </li></ul><ul><li>American Cancer Society. Breast Cancer Facts & Figures 2007-2008. Atlanta: American Cancer Society, Inc.; 2007. </li></ul><ul><li>American Cancer Society. Detailed guide: breast cancer: what are the key statistics for breast cancer? Cancer Reference Information. Revised: September 13, 2007. </li></ul><ul><li>Americans with Disabilities Act of 1990. Public Law 101-336. U.S. Statutes at Large 104 (1990), codified at U.S. Code 42,§12101. Available at www.ada.gov/pubs/ada.htm#Anchor-Sec-47857 . </li></ul><ul><li>Becker L, Taves, D, McCurdy L, et al. Stereotactic core biopsy of breast microcalcifications: comparison of film versus digital mammography, both using an add-on unit. AJR. 2001;177:1451-1457. </li></ul><ul><li>Begg CB, Haile RW, Borg A, et al. Variation of breast cancer risk among BRCA 1/2 carriers. JAMA. 2008;299:194-201. </li></ul><ul><li>Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Eng J Med. 2005;353:1784-1792. </li></ul>
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