Breast Cancer Screening

Article first published online: 4 AUG 2010

Position
The Association of Women's Health, Obstetric and Neonatal Nurses
(AWHONN) strongly encourages all women to take an active role in
monitoring their own breast health. Women need easy access to
evidence-based information upon which to base decisions about their
health care. Nurses and other health care providers should discuss the
benefits, limitations, and potential harms of breast self-examinations,
clinical breast examinations, screening mammography and other
breast care services with women. Women should work with their health
care providers to carefully evaluate their risks for developing breast
cancer. After a thorough risk assessment, women can further
collaborate with their health care providers to develop an
individualized plan for breast cancer screening.
AWHONN supports access for women to screening mammography and
other health care services, based on an assessment for breast cancer
risk.
Background
After skin cancer, breast cancer is the second most common cancer
diagnosed in women. It is the second leading cause of cancer death
after lung cancer (American Cancer Society [ACS], 2009d). A woman's
lifetime risk of being diagnosed with invasive breast cancer is one in
eight. Currently there are more than 2.5 million breast cancer survivors
in the United States (ACS, 2009c). Breast cancer can also occur in
males, but their lifetime risk is one in 1,000 (ACS, 2010).
Screening mammography is used to evaluate women for breast cancer
in absence of signs or symptoms of the disease. Due to its ability to
potentially detect lesions before they are palpable, mammography is a
key component of a comprehensive breast cancer surveillance plan.
Early detection may improve a woman's chance of surviving breast
cancer. No woman should experience a delay in diagnosis because she
has not been effectively counseled about her personal risk factors,
screening options, risks, benefits and limitations of screening or
because she does not have access to quality breast care services.
Screening Recommendations & Risk Assessment
Experts agree that women age 50 and over should have routine
screening mammography. For women under age 50, recommendations
vary regarding the need for and frequency of screening mammography.
In general, the younger a woman is, the more dense her breast tissue,

making it more difficult to read her mammogram. AWHONN supports

research and the development of new and more effective screening
modalities for younger women, especially those at high risk. AWHONN
also supports the development of decision tools for use by providers
and patients when considering breast screening. These tools help to
promote a patient's involvement and incorporate her values in her
decision making.
Risk assessment for breast cancer includes age; hormonal factors such
as early age at menarche, late age of menopause, late age at first
pregnancy, nulliparity, and use of hormonal therapies; familial factors
including family history of breast cancer and genetic test results for
BRCA mutations; and personal factors such as personal history of
breast cancer, findings from earlier breast biopsies, and past exposure
to chest irradiation. Other associated risk factors include post
menopausal obesity, lack of exercise, and alcohol use (ACS, 2009e).
Women under the age of 50 who are identified as being high risk for
breast cancer may need earlier or more frequent screening than their
lower risk counterparts. Further, since 20% of breast cancers are now
detected in women under the age of 50 (the vast majority are in their
40s), breast cancer risk assessment is crucial when making decisions
about screening for individual women (ACS, 2009a).
Recommended intervals for screening mammography for women
without risk factors are generally based on age:
Age 2540:

Breast screening recommendations based on risk assessment

Age 4049:

Screening mammography recommendations vary

Annually if indicated by risk assessment

Age 50 plus:
Yearly or biennial screening mammography
Jump to
Nurse's Role
Breast cancer screening and prevention is complex and challenging.
While mammography is considered the best screening method
available for identifying breast abnormalities in low risk women age 50
and greater, some 10% of breast abnormalities in older women and
25% in younger women go undetected by mammogram (American
College of Radiology, 2010). Therefore, it is important for nurses and
other health care providers to make individualized breast cancer
screening plans with women based on their age, health status, breast
cancer risk assessment, and personal values.
Nurses working in women's health need ready access to evidencebased information and should be able to translate scientific evidence
into their own clinical practice. Nurses working with women must be
able to effectively educate women about normal breast anatomy,
abnormalities, breast cancer risk factors, and the benefits, limitations,

and risks of breast screening techniques. By providing this information,

nurses support women in making informed decisions about the
screening methods best suited to their individual situations.
Since most AWHONN nurses are women, and because breast cancer is
a major health threat to women, nurses should consider volunteering
for breast cancer clinical trials. They may also encourage their
patients, when appropriate, to do the same.

Health Policy Considerations

Lack of access to health care corresponds with less timely cancer
screening and cancer diagnosis at more advanced stages (ACS,
2009b). For a variety of reasons, a growing number of Americans do
not have access to health care services associated with breast cancer
screening and treatment.
Rural challenges. People living in rural areas of the country face
a number of barriers related to accessing health care. They may
experience limited access to health care services, especially specialists
in mammography services and limited geographic access to new
technologies for breast screening (Gosschalk & Carozza, 2003).
Lack of insurance. Those without health insurance may delay or
even forgo regular visits to a health care provider. A study from the
American Cancer Society suggested that a lack of health insurance is
associated with more advanced stage at diagnosis for a number of
cancers, including breast (Halpern et al., 2008).
Health disparities. White women are diagnosed with breast
cancer at higher rates than any other race/ethnicity in the United
States. However, Black women have more advanced tumors at
diagnosis and are more likely to die from breast cancer than White
women. Several research studies indicate that the disparity in death
rates may be due to differences in specific risk factors, differences in
the biology of cancer in Black women, breast cancer screening rates,
and access to health care services (Amend, Hicks, & Ambrosone,
2006).
Women with disabilities. Women with physical and
developmental disabilities face a number of barriers to accessing
health care services. According to the Centers for Disease Control and
Prevention (CDC), disabled women are less likely to have regular
mammogram screenings (2010).
Language barriers. In the United States rates of breast cancer
screening are lower among women who do not speak English (Jacobs,
Karavolos, Rathouz, Ferris, & Powell, 2005). Language differences
between providers and patients may compromise informed decision

making and adherence to treatment regimens (Institute of Medicine,

2002).
Limited health literacy. Women who lack basic health literacy
skills may have difficulty obtaining, processing, and understanding
cancer-related information. As a result, these women may not
recognize the symptoms of breast cancer or have the skills to make
appropriate breast cancer screening and prevention decisions (Davis,
Williams, Marin, Parker, & Glass, 2002).
Access to affordable and acceptable health care services is a basic
human right (AWHONN, 2008). Therefore, AWHONN strongly supports
policy initiatives that increase women's access to mammography and
other breast cancer screening and prevention services, including
cancer risk assessment programs and genetic counseling and testing
when indicated. Until a prevention method applicable to all women or a
cure for breast cancer is found, early detection will remain extremely
important. AWHONN especially supports programs that work to
eliminate the barriers noted above.