Breast cancer and the uptake of mammography screening services by women with intellectual disabilities

Disability and mammography screening: intangible barriers to participation

PURPOSE

The aim of this study was to investigate intangible or non-physical barriers to participation of women with disability in mammography screening.

METHOD

 Women with disability were recruited via specific advocacy and support organisations in New South Wales, Australia. Interviews were conducted which focused on issues relating to participants' experience with breast screening services.

RESULTS

 A total of 75 women with varying degrees of disability agreed to participate. Three key intangible barriers were identified related to the women's expectations to be informed, to be involved and to be treated with respect. Details of the content, type, timing of appropriately presented information as well as who should provide it were emphasised. Barriers to active involvement to manage their disability and take control over their experience were identified. The women also indicated the specific treatment they received from screening staff which negatively impacted on their experience.

CONCLUSIONS

 This study has provided important and clinically significant detail of intangible barriers to participation in screening mammography experienced by women with physical disability. These study outcomes suggest ways in which the satisfaction with the mammogram experience can be increased for these women and contribute to increased participation in mammography screening.

The role of community nurses and residential staff in supporting women with intellectual disability to access breast screening services

BACKGROUND

Women with intellectual disability (ID) are surviving to the age group at greatest risk of developing breast cancer (50-69 years). These women are more likely to experience a greater number of risk factors placing them at an advanced threat of developing breast cancer. However, as a result of cognitive deficits and communication difficulties these women are dependent upon staff to support them to attend the breast screening clinics.

AIM

The aim of this paper was to examine how community nurses and residential staff support women with ID to access breast screening services.

METHODOLOGY

Six focus groups were held with community nurses and residential staff who work in the field of ID in one region of the UK. The focus groups were tape recorded and the transcriptions were subjected to a thematic content analysis.

FINDINGS

Although many of the participants recognised the risk factors and signs/symptoms of breast cancer, there was still a deficit of knowledge. Both positive and negative experiences of women with ID attending for breast screening were reported; however, greater discussion focused on the latter. The participants identified 'a lack of health educational material' and also negative 'emotions, attitudes and physical barriers' as inhibiting factors for attendance.

DISCUSSION

This paper highlights the need for developing a health promotion programme for women with ID focusing on breast awareness and information on screening, and also healthier lifestyles. Breast awareness via visual checks was identified for women with ID who refused to attend the breast clinics; however, issues of informed 'consent' and 'vulnerability' were raised for staff and also family carers having to undertake these checks. Development of user-friendly health educational literature using 'pictures, symbols, signs' and simplified words should be accessible to all ID staff, healthcare staff, and also women with ID.

The P15 - a multinational assessment battery for collecting data on health indicators relevant to adults with intellectual disabilities

BACKGROUND

Health disparities between adults with intellectual disabilities (ID) and the general population have been well documented but, to date, no dedicated assessment battery for measuring health disparity has been available. This paper reports on the development and testing of a multinational assessment battery for collecting data on a range of health indicators relevant to adults with ID.

METHODS

An assessment battery (the P15) was developed following piloting, and administered to samples of adults with ID, in 14 EU countries. Samples were neither random, nor representative of the countries from which they were drawn. However, within the local health administration areas selected in each country, efforts were made to ensure samples were broadly representative of the typical living circumstances, ages and ability levels of the administrative population of adults with ID. The total sample comprised 1269 adults with ID, of whom 49% were female. The mean age was 41 years (range 19 to 90).

RESULTS

Overall, feasibility, internal consistency and face validity of the P15 was acceptable.

CONCLUSIONS

With some refinement the P15 could be useful for collecting data on health indicators known to be particularly important for adults with ID. It is useable in a range of countries and has the potential to highlight health inequity for adults with ID at a national or local level. Larger scale epidemiological studies are needed to exploit the potential of the P15 to address health inequity in this group.

Predictors of mammography use in older women with disability: the patients' perspectives

To determine the factors associated with mammography use among Medicare beneficiaries and reasons for nonuse. Cohort of 4610 community-dwelling Medicare beneficiaries ≥ 65 years included in the 2004-2005 Medicare Current Beneficiary Survey. Regression models evaluated the association of disability with mammography use. Reasons for underuse are described. Women with disability were more likely than women with no disability to report lower mammography use (unadjusted, moderate disability OR = 0.76; 95% CI = 0.64, 0.91; severe disability OR = 0.46; 95% CI = 0.40, 0.54). Lower use was significant for women with severe disability (adjusted, OR = 0.67; 95% CI = 0.54, 0.83) and women with fair-poor self-rated health, no HMO enrollment and ≥ 3 comorbidities. No physician recommendation, no need, dislike/pain during the test and forget it were reasons for underutilization. Mammography use decreases with increasing level of disability. Common reasons for underutilization are no physician recommendation, no need, dislike/pain during the test and forgot it. Screening guidelines should be used to target women with disabilities who can benefit from mammography.

Nursing perspectives on cancer screening in adults with intellectual and other developmental disabilities

Health care disparities have been documented in cancer screenings of adults with intellectual and other developmental disabilities. Developmental disabilities nurses were surveyed to better understand and improve this deficiency. Two thirds of respondents believed that adults with intellectual and developmental disabilities received fewer cancer screenings compared with the general population. The most frequently cited barriers to cancer screenings were as follows: patient need for sedation, unsuccessful attempts at screening, and failure of the primary care clinician to order cancer screening tests. Nurses observed that health care providers frequently did not tailor cancer screening recommendations to individuals' family histories, life expectancies, or their disability-specific cancer risks. The authors suggest interventions to improve cancer screening centered around education and training, accessibility, financing-insurance, modification of procedures, and patient tracking.

Health disparities between women with and without disabilities: a review of the research

As part of a women's health center project, we reviewed 16 years of research to examine health disparities between women with and without disabilities. We reviewed MEDLINE-indexed articles between 1990 and 2005 with data on women with and without physical, sensory, intellectual, developmental, or psychiatric disabilities. Our review found few articles examining health disparities in chronic disease, cancer, mental health and substance abuse, preventive screening, health-promoting behaviors, and health services utilization. Results reflect apparent health disparities between women with and without disabilities. Challenges for the field exist in standardizing disability definitions and determining a future course for health disparity research and policy.

Breast and cervical cancer screening practices among disabled women aged 40-75: does quality of the experience matter?

BACKGROUND

Women with disabilities (WWD) face significant barriers accessing healthcare, which may affect rates of routine preventive services. We examined the relationship between disability status and routine breast and cervical cancer screening among middle-aged and older unmarried women and the differences in reported quality of the screening experience.

METHODS

Data were from a 2003-2005 cross-sectional survey of 630 unmarried women in Rhode Island, 40-75 years of age, stratified by marital status (previously vs. never married) and partner gender (women who partner with men exclusively [WPM] vs. women who partner with women exclusively or with both women and men [WPW]).

RESULTS

WWD were more likely than those without a disability to be older, have a high school education or less, have household incomes <$30,000, be unemployed, and identify as nonwhite. In addition, WWD were less likely to report having the mammogram or Pap test procedure explained and more likely to report that the procedures were difficult to perform. After adjustment for important demographic characteristics, we found no differences in cancer screening behaviors by disability status. However, the quality of the cancer screening experience was consistently and significantly associated with likelihood of routine cancer screening.

CONCLUSIONS

Higher quality of cancer screening experience was significantly associated with likelihood of having routine breast and cervical cancer screening. Further studies should explore factors that affect quality of the screening experience, including facility characteristics and interactions with medical staff.

Linked data: opportunities and challenges in disability research

BACKGROUND

Disability research data often exist in the form of individual records located within discrete registers that may extend across sensitive political boundaries.

METHOD

This paper discusses the opportunities and challenges associated with using linked health and administrative data for disability research, with examples from research projects conducted both in Australia and overseas.

RESULTS

Linked data offer distinct value in providing a comprehensive profile for a range of health issues, such as morbidity, mortality, assessing health care costs and/or quality of service provision.

CONCLUSIONS

While the use of record linkage in health research is not a novel concept, recent advances in technology and electronic data management plus improved data linkage protocols have markedly increased the feasibility and opportunity for successfully utilising data linkage for the purposes of research, while at the same time protecting the privacy of the individual. An awareness and appropriate management of the associated challenges is required to maximise the outcomes of disability research using linked data.

Early stage breast cancer treatments for younger Medicare beneficiaries with different disabilities

OBJECTIVE

To explore how underlying disability affects treatments and outcomes of disabled women with breast cancer.

DATA SOURCES

Surveillance, Epidemiology, and End Results program data, linked with Medicare files and Social Security Administration disability group.

STUDY DESIGN

Ninety thousand two hundred and forty-three incident cases of early-stage breast cancer under age 65; adjusted relative risks and hazards ratios examined treatments and survival, respectively, for women in four disability groups compared with nondisabled women.

PRINCIPAL FINDINGS

Demographic characteristics, treatments, and survival varied among four disability groups. Compared with nondisabled women, those with mental disorders and neurological conditions had significantly lower adjusted rates of breast conserving surgery and radiation therapy. Survival outcomes also varied by disability type.

CONCLUSIONS

Compared with nondisabled women, certain subgroups of women with disabilities are especially likely to experience disparities in care for breast cancer.

Primary care for women with intellectual disabilities

Women with intellectual disabilities (ID) need thoughtful, well-coordinated care from primary care physicians. They are particularly susceptible to experiencing disparities in care because of varied participation in shared decision making. This review of the current literature comments on the quantity and quality of existing studies regarding several key women's health issues: menstrual disorders, cervical and breast cancer screening, contraception, and osteoporosis. A review of the current thinking regarding ethical and legal issues in medical decision making for these women is also provided. We found that there are several high-quality studies recommending early and frequent screening for osteoporosis, which is more common in women with ID. Smaller and fewer studies comment specifically on techniques for accomplishing the gynecological examination in women with ID, although the cervical cancer screening recommendation should be individualized for these patients. Consensus data on the management of menstrual problems and contraception in women with ID is provided. There are some data on breast cancer incidence but few articles on methods to improve screening rates in women with ID.

Screening tests for adults with intellectual disabilities

Adults with intellectual disabilities need thoughtful, well-coordinated primary care from family physicians. However, evidence-based screening recommendations are lacking. We examined screening recommendations for common preventable conditions using the US Preventative Service Task Force guidelines. We also reviewed the literature about the prevalence of these conditions in adults with intellectual disabilities. Obesity, osteoporosis, and smoking are more prevalent in adults with intellectual disabilities, and enhanced screening for these conditions is recommended. Abnormal Papanicolaou smears and cervical cancer are less common in adults with intellectual disabilities and screening recommendations should be individualized. We also discussed strategies to make screening procedures less stressful for these patients.

Developing health indicators for people with intellectual disabilities. The method of the Pomona project

AIM

Recently, attention has focused on the health inequalities experienced by people with intellectual disabilities (ID) when compared with the general population. To inform policies aimed at equalizing health opportunities, comparable evidence is needed about the aspects of their health that may be amenable to intervention.

METHOD

Applying the framework of the European Community Health Indicators (ECHI) for the general population, the Pomona group developed a set of health indicators reflecting aspects of the health of people with ID: socio-demographic data, health status, health determinants and health systems.

RESULTS

This paper documents the procedures that partners carried out in 13 European countries. The process comprised a search for evidence in published literature; consultation with advocates, family members and health professionals; and analyses of national and international databases. Indicators were selected if they were appraised as important, useful, measurable and if resulting data would enable comparisons between the health of people with ID and that of the general population.

CONCLUSION

The thus developed indicator set that is aligned with ECHI will permit investigators to compare key aspects of health of people with ID with those of people in the general population within Europe. The final set of 18 indicators will be applied in the Pomona 2 project (2005-08) to gather information about the health of samples of adults in 14 participating European countries.

The profile and incidence of cancer in Down syndrome

BACKGROUND

Down syndrome is one of the commonest causes of intellectual disability. As life expectancy improves with early and more intensive surgical and medical treatments, people with the disorder are more likely to exhibit classic morbidity and mortality patterns and be diagnosed with diseases such as cancer.

METHODS

A profile of cancer cases among people with Down syndrome has been compiled, based on the analysis of a linked data set that included information from the Disability Services Commission of Western Australian and the State Cancer Registry.

RESULTS AND CONCLUSIONS

Although the total age- and sex-standardized incidence ratios (SIRs) for people with Down syndrome were similar to that for the general population, SIRs for leukaemia were significantly higher while the incidence of certain other types of cancers was reduced. Overall, there was a lower incidence of solid tumours in Down syndrome, possibly reflecting the age profile of the study cohort.

Cancer incidence of persons with down syndrome in Finland: A population-based study

Individuals with Down syndrome (DS) have a predisposition to leukaemia and testicular cancer, but data on the incidence of cancers are yet sparse. A cohort of 3,581 persons with DS was identified from a National Registry of Finnish persons with intellectual disability collected between 1978 and 1986 and followed-up for cancer incidence until 2002. Standardised incidence ratios (SIRs) were defined as ratios of observed number of cancer cases to those expected from the national cancer incidence rates, by age and sex. The overall cancer risk was equal to that of the general population, but a significantly high risk of leukaemia (SIR 10.5, CI 95% 6.6-15.8) and testicular cancer (SIR4.8, CI 95% 1.8-10.4) was found.

Women with cerebral palsy and breast cancer screening by mammography

Women with cerebral palsy and breast cancer screening by mammography. We emphasize the need to identify specific barriers to participation in breast cancer screening by mammography experienced by women with cerebral palsy (CP). Mammography screening has been found to reduce mortality rates by 30%, but women with disabilities such as CP underuse this important preventive medicine facility, potentially leading to delay in diagnosis of breast cancer and a less favorable prognosis. Because equity in health care is compromised through underutilization by these women, barriers to participation and successful outcomes must be investigated. Barriers such as appropriate information, transport, and assistance prevent women with CP from getting to the facility. Once there, communication difficulties, physical limitations, psychologic barriers, and staff attitudes become barriers to a successful outcome. Education for health personnel as well as adaptation of the mammographic technique to suit the physical limitations of women with CP are critical to increasing participation and ensuring successful outcomes. Importantly, there is a need to identify women for whom having a mammogram is not an option and for whom alternative breast screening methods should be provided.

The incidence of cancer in people with intellectual disabilities

OBJECTIVE

During the last 50 years there have been significant improvements in life expectancy among people with intellectual disability (ID), and so their incidence of age-associated diseases, such as cancer, is rising. The aim of this study was to compare the rate of cancer in people with ID with that found in the general population.

METHODS

Information on 9409 individuals registered with the Disability Services Commission of Western Australia was linked to the State Cancer Registry, with 200 cases of cancer detected over 156,729 person-years. Standardised incidence ratios (SIRs) and 95% confidence intervals were calculated for both sexes separately by 5-year age groups for the period 1982-2001. The same procedures were adopted in the estimation of SIRs for specific types of cancers.

RESULTS

The age-standardised incidence of all cancers in people with ID was not significantly different from the general population. However, males with ID were observed to have a significantly increased risk of leukaemia, brain and stomach cancers, and a reduced risk of prostate cancer, while leukaemia, corpus uteri and colorectal cancers were significantly higher in females.

CONCLUSIONS

Health practitioners need to be aware that with improvements in life expectancy the incidence of cancer in people with ID is likely to rise. More proactive health promotion campaigns may be needed for people with ID, who are likely to be poor users of screening services and whose symptoms may not be reported until they are in more advanced, less treatable stages of disease.

Women with disabilities: general practitioners and breast cancer screening

BACKGROUND

Because they undergo breast cancer screening (BCS) relatively infrequently, women with physical or mental impairments may be at higher risk of late-stage breast cancer than women without impairments. A panel of 600 general practitioners (GPs) in Provence (southeastern France) provided information from which barriers potentially associated with BCS practices for women with disabilities were evaluated.

METHODS

In 2002, a telephone questionnaire collected data about GPs' personal and professional characteristics and their attitudes and practices regarding patients with disabilities. Analysis in 2003 used simple and multiple logistic regressions.

RESULTS

More than a quarter of the GPs reported apparently inadequate BCS practices for people with disabilities. Feelings of discomfort when treating people with disabilities, lack of assistance, and communication difficulties were inversely associated with BCS for women with mental and physical impairments. General practitioners' information-seeking strategies were associated with BCS for women with mental impairments, and nursing home work experience was inversely associated with BCS for women with physical impairments.

CONCLUSIONS

Appropriate training sessions should be made available to improve primary health care quality and prevention practices and to reduce GPs' misperceptions of people with disabilities.