Women

with
Disabilities
educational programs

Prevention, Diagnosis,
and Treatment of
Breast Cancer in
Women with Disabilities
Part 2: Screening and Diagnosis
Women with Disabilities Education Project

Overview
Part 1:
Incidence and Risk

Part 2:
Screening and Diagnosis

Part 3:
Treatment, Rehabilitation, and Ongoing Care

www.womenwithdisabilities.org

Screening

Most Common Screening Tests

Mammography
Clinical breast exam
Breast self-exam

Mammography

7 Statistical Models:
Mammography reduces
the rate of death from
breast cancer by 7%23%,
with a median of 15%.1

1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.

Mammography
Age

Interval

Regular screening
lowers breast cancer
mortality by

Optimal interval unknown

15%20% in women
aged 4049
25%30% in women
aged 5069

Limited evidence for

effectiveness in women
aged 70+

Reductions in mortality
have occurred at
intervals ranging from
1233 months
Many organizations
recommend annual
screenings for women
aged 4049

Magnetic Resonance Imaging

and Ultrasound
MRI
Annual MRI screening recommended for women
with genetic mutations for breast cancer or with
other factors that put them at very high risk

Ultrasound
Effectiveness not yet demonstrated
Used primarily to
Evaluate breast abnormalities identified through
CBE or mammography
Guide breast biopsies and FNA

Ultrasound?
Not a Good Stand-Alone Option
3 Studies of Women with
Hereditary Risk:1
2 of 83 cancers detected solely by
annual ultrasonography
2 additional cancers
detected through screenings
at 6-month intervals

Accessible Mammography Remains Best

Screening Option for All Women
1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.

Mammography Disparities
Of Women Aged 50 Years
63.5% with no mobility problems
vs.
51.5% with moderate mobility problems
and
43.3% with major mobility problems
Had mammogram within previous 2 years1

1. Iezzoni LI, et al. Am J of Public Health. 2000;90:955-961.

Reasons for Screening Disparities

1. Inadequate access to facilities and equipment
2. Lack of accessible transportation
3. Difficulty positioning for exams
4. Inability to remain still for exams
5. Lack of provider knowledge and sensitivity about
serving women with disabilities
6. Financial restraints, including a lack of adequate
health insurance
7. Lack of patient knowledge of breast cancer risk and
the need for screening
8. Patient unawareness of free screening programs

Removing Informational Barriers

25% of women with

disabilities were not

told by their doctor to
get a mammogram

Helping Your Patient Prepare

Explain what to expect

Discuss any concerns

Breaking Down Barriers to

Mammography Screening
An Accessible Imaging
Center Should Have:
Fully accessible equipment
Staff trained to properly
assist women with
disabilities
Systems in place for
successful positioning
during screening
Systems in place for
successful communication during screening

www.WomenWithDisabilities.org

Clinical Breast Examination

May identify 4.5%10.7% of breast cancers that
mammography misses1
Clinician proficiency impacts effectiveness1
Recommendations vary:
American Cancer Society2
Every 3 years for average-risk women in 20s and 30s
Annually for women aged 40

U.S. Preventive Services Task Force3

No recommendation/Not enough evidence

1. McDonald S, Saslow D, Alciati MH. CA Cancer J Clin. 2004;54:345-361.

2. Smith, RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44.
3. U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002.

Clinical Breast Exam (CBE) Protocol

1. Introduction to Exam:
Is client highly anxious, fearful or uncomfortable due to
cognitive impairments, prior history of sexual abuse, or other
reason? Is client likely to experience significant pain or
spasticity during the exam?

Yes
Yes

No
No
2. Preparing for Exam:
Does client need assistance with undressing upper body?
Does client refuse to remove or allow clothing to be removed?

Yes
Yes

No
No
3. Visual Inspection of the Breasts:
May be done standing, seated in wheelchair, or seated on exam
table based on physical ability (balance, posture, endurance,
involuntary movement, and transfer)

4. Performing the 4 Positions:

Does client have difficulty?
Can the client assist?

Yes
Yes

No
No
5. Lymph Node Exam:
Client seated on table with side rails up, or in wheelchair if has poor
balance
Can be performed with shirt pulled above breasts and around neck,
or beneath loose clothing when visualization is possible

6. Position on Exam Table:

Does client need assistance?1
Can client lie down?

No
No

Yes
Yes

Determine if attendant/friend/and/or family member can be

present during exam
Explain each step in simple terms, offer frequent reassurance
and praise
Consider demonstrating breast exam on yourself (the provider),
if necessary, to assist client in understanding procedure and
purpose
Consider recommending taking any prescribed anti-spasmotic,
analgesic or anti-anxiety medication 1-2 hours prior to exam or
as prescribed

7. Breast Palpation:
Does client have difficulty positioning arms (due
to tremors, contractures, involuntary movement
or paralysis)?
Does client have difficulty raising arms?

Ask permission to position hand

above head
Use non-examining hand and/or pillows
to stabilize clients arm at 90angle
If attendant/friend/ and/or family member
is available, he/she may assist in
stabilizing arm
If client refuses all of above, perform
CBE with arms at sides

Ask client for directions, provide assistance as needed

Consider performing CBE with shirt lifting for visualization
Consider performing modified CBE through clothing with plan to
perform thorough CBE at next visit or after client trust becomes
established
Offer assistance to hold arms above head
Modify hands on hip position as needed to achieve pectoral
muscle contraction
Use support devices to assist client in leaning forward if
necessary (e.g., walker or chair)
Offer the client the opportunity to undress in private. If client
chooses to undress in your presence, closely observe client
when undressing arms are above head when shirt comes off,
and often the pectoral muscles are relaxed and tightened during
this process. Often the 4 positions can be observed without
intentional client cooperation if the client is anxious.

Yes
Yes

No

8. Completion of Exam:
Does client need assistance to get off table
or dress?

No

Yes
Yes
Offer assistance

Ask client for directions, provide skilled assistance as needed. 2

Provide extra pillows or wedges for support as necessary
Encourage client to lie on flat exam table
Try having client sit on exam table then slowly recline back with a
good pillow support beneath the head
Consider semi-reclined position with goal of greatest recline
as tolerated
Consider performing exam in upright position

1.
1. Recommend
Recommend electrically
electrically controlled,
controlled, high-low
high-low exam
exam table
table with
with side
side rails
rails
2.
2. Client
Client may
may prefer
prefer to
to bring
bring own
own attendant/friend/
attendant/friend/ and/or
and/or family
family member,
member, or
or provider
provider has
has assistance
assistance from
from trained
trained personnel.
personnel.

Source: Breast Health Access for Women with Disabilities, January 2008.

Finally:
Praise clients efforts throughout the exam
(especially for women with cognitive intellectual
limitations)
Discuss findings with client
Describe follow-up schedule and plan to client
Communicate with clients primary care physician
if necessary and appropriate, and if appropriate,
her attendant/friend and/or family member

Introducing the Patient to the CBE

1. Introduction to Exam:
Is client highly anxious, fearful or
uncomfortable due to cognitive impairments,
prior history of sexual abuse, or other
reason? Is client likely to experience
significant pain or spasticity during the exam?

Yes

Source: Breast Health Access for Women with Disabilities, January 2008.

Determine if attendant/friend/and/or family

member can be present during exam
Explain each step in simple terms, offer
frequent reassurance and praise
Consider demonstrating breast exam on
yourself (the provider), if necessary, to
assist client in understanding procedure
and purpose
Consider recommending taking any
prescribed anti-spasmotic, analgesic or
anti-anxiety medication 1-2 hours prior to
exam or as prescribed

Preparing the Patient for the CBE

2. Preparing for Exam:
Does client need assistance with
undressing upper body?
Does client refuse to remove or allow
clothing to be removed?

Yes

Source: Breast Health Access for Women with Disabilities, January 2008.

Ask client for directions, provide

assistance as needed
Consider performing CBE with shirt
lifting for visualization
Consider performing modified CBE
through clothing with plan to perform
thorough CBE at next visit or after
client trust becomes established

Visual Inspection of the Breasts

3. Visual Inspection of the Breasts:
May be done standing, seated in wheelchair,
or seated on exam table based on physical
ability (balance, posture, endurance,
involuntary movement, and transfer)

4. Performing the 4 Positions:

Does client have difficulty?
Can the client assist?

Yes

Offer assistance to hold arms above head

Modify hands on hip position as needed to
achieve pectoral muscle contraction
Use support devices to assist client in
leaning forward if necessary (e.g., walker or
chair)
Offer the client the opportunity to undress in
private. If client chooses to undress in your
presence, closely observe client when
undressing arms are above head when
shirt comes off, and often the pectoral
muscles are relaxed and tightened during
this process. Often the 4 positions can be
observed without intentional client
cooperation if the client is anxious.

1.Recommend
1.Recommend electrically
electrically controlled,
controlled, high-low
high-low exam table
table with
with side
side rails
rails
2.Client
2.Client may prefer to bring own attendant/friend/ and/or family member, or provider has
assistance
assistance from
from trained personnel.
Source: Breast Health Access for Women with Disabilities, January 2008.

Positioning the Patient

on the Exam Table
5. Lymph Node Exam:
Client seated on table with side rails
up, or in wheelchair if has poor
balance
Can be performed with shirt pulled
above breasts and around neck, or
beneath loose clothing when
visualization is possible

6. Position on Exam Table:

Does client need assistance?1
Can client lie down?

Yes

Source: Breast Health Access for Women with Disabilities, January 2008.

Ask client for directions, provide skilled

assistance as needed.2
Provide extra pillows or wedges for support
as necessary
Encourage client to lie on flat exam table
Try having client sit on exam table then
slowly recline back with a good pillow
support beneath the head
Consider semi-reclined position with goal of
greatest recline
as tolerated
Consider performing exam in upright
position

Breast Palpation
7. Breast Palpation:
Does client have difficulty positioning arms (due
to tremors, contractures, involuntary movement
or paralysis)?
Does client have difficulty raising arms?
Yes

Ask permission to position hand

above head
Use non-examining hand and/or pillows
to stabilize clients arm at 90angle
If attendant/friend/ and/or family member
is available, he/she may assist in
stabilizing arm
If client refuses all of above, perform
CBE with arms at sides

Source: Breast Health Access for Women with Disabilities, January 2008.

Completion of the Exam

8. Completion of Exam:
Does client need assistance to get off table
or dress?

Yes

Offer assistance

Source: Breast Health Access for Women with Disabilities, January 2008.

Breast Self-Exam
Not shown to have an effect on
breast cancer mortality rate1
U.S. Preventive Services Task
Force: Not enough evidence
to recommend for or
against BSE2
ACS and others: Teach women
the procedure and give them
the option of using it3

1.Kosters JP, Gotzsche PC. Cochrane Database of Systematic Reviews. 2003;2:CD003373.

2.U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations
and Rationale. 2002.
3.Smith RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44.

Breast Self-Exam Accommodations

for Women with Disabilities
Exam can be modified for women who have use
of only one hand
Thumbs, palms, or back of fingers can be used
instead of finger pads to feel for lumps
Exam can be broken into smaller parts for
women who tire easily
Women whose limited mobility precludes breast
self-exams may opt for more frequent clinical
breast exams
Source: Breast Health Access for Women with Disabilities.

Breast Health
Access for Women
With Disabilities:

www.bhawd.org

Diagnosis

Percutaneous Diagnostic Biopsies

Have largely replaced surgical biopsy as initial
diagnostic biopsy procedure
Are guided by stereotactic mammographic
imaging, ultrasound, or MRI
Are less invasive than surgical biopsy and often
reduce need for further surgical procedures
Improve planning for patients treatment

Biopsy Barriers
A Woman Must be Able to
Remain still for 4560
minutes, either sitting,
prone, or supine
Hyperextend arm
Turn neck
Get up onto the biopsy table

Biopsy Accommodations:
Stereotactic Add-on Devices

Digital Mammogram Unit

Stereotactic Biopsy Table

Biopsy Accommodations:
Ultrasound in Seated Position

Stretcher for supine

or semi-upright biopsy

Summary
Using an accessible format, communicate the need for
regular mammograms to your patients with disabilities
Identify fully accessible mammography centers in your
area. Alert them to a patients mobility or communication
issues before the patient goes to the screening
Adapt the clinical breast exam to meet the special needs
of your patients with disabilities
Teach your patients how to modify the breast self-exam to
accommodate their particular disability
Help ensure that accommodations are made for your
patients with disabilities so they have successful breast
biopsies

Resources

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-Womens Foundation
Strength & Courage Exercise DVD (a compilation of exercises
helpful to breast cancer patients)
http://foundation.mwrif.org/

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 Womens 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

References
Ahmedin J, Siegel R, Ward E, Murray T, Xu J, and Thun MJ. Cancer statistics, 2007. CA Cancer J Clin.
2007;57:43-66.
Ahn J, Schatzkin A, Lacey JV, et al. Adiposity, adult weight change, and postmenopausal breast cancer risk.
Arch Intern Med. 2007;167:2091-2102.
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.
American Cancer Society. American Cancer Society issues recommendation on MRI for breast cancer
screening. March 28, 2007. Available online.
American Cancer Society. Breast Cancer Facts & Figures 2007-2008. Atlanta: American Cancer Society, Inc.;
2007.
American Cancer Society. Detailed guide: breast cancer: what are the key statistics for breast cancer? Cancer
Reference Information. Revised: September 13, 2007.
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.
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.
Begg CB, Haile RW, Borg A, et al. Variation of breast cancer risk among BRCA 1/2 carriers. JAMA.
2008;299:194-201.
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.

Breast Health Access for Women with Disabilities (BHAWD). Breast health and beyond: a providers guide to
the examination and screening of women with disabilities, 2nd ed. January 2008.
Caban ME, Nosek MA, Graves D, Esteva FJ,McNeese M. Breast carcinoma treatment received by women with
disabilities compared with women without disabilities. Cancer. 2002;94:1391-1396.
Chen WY, Colditz GA, Rosner B, et al. Use of postmenopausal hormones, alcohol, and risk for invasive breast
cancer. Ann Intern Med. 2002;137:798-804.
Collaborative Group on Hormonal Factors in Breast Cancer. Alcohol, tobacco and breast cancercollaborative
reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and
95,067 women without the disease. Brit J of Cancer. 2002;87:1234-1245.
CROWD, Baylor College of Medicine. Health behaviorsweight management; 2007. Available at
www.bcm.edu/crowd/?pmid=1430.
Elmore JG, Fletcher SW. The risk of cancer risk prediction: what is my risk of getting breast cancer? J of the
NCI. 2006;98:1673-1675.
Finch A, Beiner M, Lubinski J, et al. Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and
peritoneal cancers in women with a BRCA1 or BRCA2 mutation. JAMA. 2006;296:185-192.
Fisher B, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-1241.
Hall L, Colantonio A, Yoshida K. Barriers to nutrition as a health promotion practice for women with disabilities.
Int J of Rehabilitation Research. 2003;26:245-247.

Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of biolateral prophylactic mastectomy in women with a
family history of breast cancer. N Engl J Med. 1999;340:77-84.
Herrera JE, Stubblefield MD. Rotator cuff tendonitis in lymphedema: a retrospective case series. Arch Phys
Med Rehabil. 2004:85:1939-1942.
Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer
diagnosis. JAMA. 2005;293:2479-2486.
Hughes RB. Achieving effective health promotion for women with disabilities. Family & Community Health.
2006;29:44S-51S.
Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the
U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:344-346.
Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and use of screening and preventive
services. Am J of Public Health. 2000;90:955-961.
Irwig L, Houssami N, van Vliet C. New technologies in screening for breast cancer: a systematic review of their
accuracy. Brit J Cancer. 2004;90:2118-2122.
Ismail J, Chen BE, Anderson WF, Rosenberg PS. Breast cancer mortality trends in the United States according
to estrogen receptor status and age at diagnosis. J of Clin Oncology. 2007;25:TK-TK.
Kaplan C, Richman S. Informed consent and the mentally challenged patient. Contemporary Ob/Gyn.
2006;51:63-72.
Kauff ND, Domcheck SM, Friebel TM, et al. Risk-reducing salpingo-oophorectomy for the prevention of BRCA1and BRCA2-associated breast and gynecologic cancer: a multicenter, prospective study. J Clin Oncology.
2008:26:1331-13337.

Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the Breast
Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. J Clin Oncology. 2006;24:5091-5097.
Kosters JP, Gotzsche PC. Review: regular self-examination or clinical examination for early detection of breast
cancer. Cochrane Database of Systematic Reviews. 2003;2:CD003373.
Li L, Ford JA. Triple threat: alcohol abuse by women with disabilities. Applied Behavioral Sci Rev.
1996;4:99-109.
Lostumbo L, Carbine N, Wallace J, Ezzo J. Prophylactic mastectomy for the prevention of breast cancer.
Cochrane Database of Systematic Reviews. 2004;4:CD002748.
McCarthy EP, Ngo LH, Roetzheim RG, et al. Disparities in breast cancer treatment and survival for women with
disabilities. Ann Intern Med. 2006;145:637-645.
McDonald S, Saslow D, Alciati MH. Performance and reporting of clinical breast examination: a review of the
literature. CA Cancer J Clin. 2004;54:345-361.
McNeely JL, Campbell KL, Rowe BH, Klassen TP,Mackey JR, Courneya KS. Effects of exercise on breast
ancer patients and survivors: a systematic review and meta-analysis. CMAJ. 2006:175-34-41.
McTiernan A, Kooperberg C, White E, et al. Recreational physical activity and the risk of breast cancer in
postmenopausal women. JAMA. 2003;290:1331-1336.
Meijers-Heijboer H, van Geel B, van Putten WL, et al. Breast cancer after prophylactic bilateral mastectomy in
women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2001;345:159-164.
Mele N, Archer J, Pusch BD. Access to breast cancer screening services for women with disabilities. JOGNN.
2005;34:453-464.

Moore RF. A guide to the assessment and care of the patient whose medical decision-making capacity is in
question. Medscape General Medicine. 1999;1:(3). Available at www.medscape.com/viewarticle/408024_1.
Myers MF, Change M-H, Jorgensen C, et al. Genetic testing for susceptibility to breast and ovarian cancer:
evaluating the impact of a direct-to-consumer marketing campaign on physicians knowledge and practices.
Genetics in Medicine. 2006;8:361-370.
National Cancer Institute. Breast cancer (PDQ): treatment. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional.
National Cancer Institute. Ductal carcinoma in situ. Breast cancer (PDQ): treatment. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page5.
National Cancer Institute. Estimating breast cancer risk: questions and answers. Updated September 5, 2006.
Available at www.cancer.gov/Templates/doc.aspx?viewid=ac1e8937-d95b-4458-a78a-1fe33dbfcbdc.
National Cancer Institute. Lymphedema after cancer: how serious is it? NCI Cancer Bulletin. 2007;4:5-6.
National Cancer Institute. Tamoxifen: questions and answers. Reviewed May 13, 2002. Available at
www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Breast
Cancer Screening and Diagnosis Guidelines. V.1.2007. Risk factors used in the modified Gail Model; 2007.
National Survey of Women with Physical Disabilities. Recent research findings: findings on reproductive health
and access to health care. Center for Research on Women with Disabilities, Baylor College of Medicine; 1996.
Available at www.bcm.edu/crowd/finding4.html.

Nosek MA, Howland CA. Breast and cervical cancer screening among women with physical disabilities. Arch
Phys Med Rehabil. 1997:78 (12 Suppl 5):S39-44.
Nosek MA, Hughes RB, Petersen NJ, et al. Secondary conditions in a community-based sample of women with
physical disabilities over a 1-year period. Arch Phys Med Rehabil. 2006;87:320-327.
Office of the Surgeon General. Surgeon Generals Call to Action to Improve the Health and Wellness of Persons
with Disabilities. Rockville, MD: Public Health Service; 2005.
Ohira T, Schmitz KH, Ahmed RL, Yee D. Effects of weight training on quality of life in recent breast cancer
survivors: the weight training for breast cancer survivors (WTBS) study. Cancer. 2006;106:2076-2083.
Paskett ED, Naughton MJ, McCoy TP, Case LD, Abbott JM. The epidemiology of arm and hand swelling in
premenopausal breast cancer survivors. Cancer Epidemiology Biomarkers & Prevention. 2007;16:775-782.
Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema in a cohort of breast carcinoma survivors 20 years
after diagnosis. Cancer. 2001;92:1368-1377.
Poulos AE, Balandin S, Llewellyn G, Dew AH. Women with cerebral palsy and breast cancer screening by
mammography. Arch Phys Med Rehabil. 2006;87:304-307.
Randolph WM, Goodwin JS, Mahnken JD, Freeman JL. Regular mammography use is associated with
elimination of age-related disparities in size and stage of breast cancer at diagnosis. Ann Intern Med.
2002;137:783-790.
Robson M, Offit K. Clinical practice: management of an inherited predisposition to breast cancer. N Engl J Med.
2007;357:154-162.
Schmitz KH, Ahmed RL, Hannan PJ, Yee D. Safety and efficacy of weight training in recent breast cancer
survivors to alter body composition, insulin, and insulin-like growth factor axis proteins. Cancer Epidemiol
Biomarkers Prev. 2005;14:1672-1680.

Shapiro CL, Manola J, Leboff M. Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss
in women with early-stage breast cancer. J of Clin Oncology. 2001;14:3306-3311.
Smeltzer S. Preventive health screening for breast and cervical cancer and osteoporosis in women with
physical disabilities. Family & Community Health. 2006;29:35S-43S.
Smith, RA, Cokkinides V, Eyre HJ. American Cancer Society Guidelines for the Early Detection of Cancer,
2005. CA Cancer J Clin. 2005;55:31-44.
Smith RA, Cokkinides V, Eyre HJ. Cancer Screening in the United States, 2007: a review of current guidelines,
practices, and prospects. CA Cancer J Clin. 2007;57:90-104.
Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil.
2006;S96-S99.
U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. Washington, DC: U.S. Public
Health Services; 2000.
U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and
ovarian cancer susceptibility. September 2006. Available at
www.ahrq.gov/clinic/uspstf/uspsbrgen.htm#summary.
U.S. Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale.
Rockville, MD: Agency for Healthcare Research and Quality; 2002.
Vogel VG, Costantino JP, et al., for the National Surgical Adjuvant Breast and Bowel Project (NSABP). Effects
of tamoxifen vs. raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the
NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial. JAMA. 2006;295:2727-2741.