Prevention, Diagnosis, and Treatment of Breast Cancer in Women with Disabilities

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Prevention, Diagnosis, and Treatment of Breast
Cancer in Women with Disabilities

• Part 3 Treatment, Rehabilitation, and Ongoing
  Care

Women with Disabilities Education Project
3
Overview

• Part 1Incidence and Risk
• Part 2Screening and Diagnosis
• Part 3Treatment, Rehabilitation, and Ongoing
  Care

www.womenwithdisabilities.org
4
Treatment
5
Treatment Options for Noninvasive Cancers1

• LCIS
• 1. Observation after diagnostic biopsy
• 2. Tamoxifen to decrease the incidence of
  subsequent breast cancers
• 3. Bilateral prophylactic total mastectomy,
  without axillary node dissection
• 4. Clinical trials testing cancer prevention drugs

• DCIS
• 1. Breast-conserving surgery and radiation
  therapy with or without tamoxifen
• 2. Total mastectomy with or without tamoxifen
• 3. Breast-conserving surgery without radiation

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
6
Treatment Options for Early Breast Cancer (Stages
I, II, IIIA, and Operable IIIC)1

• Primary
• Breast-conserving surgery lymph node dissection
  and radiation therapy
• Modified radical mastectomy
• Adjuvant
• After surgery radiation therapy
• Systemic chemotherapy
• Hormone therapy (tamoxifen, aromatase inhibitors)
• Trastuzumab (Herceptin) systemic chemotherapy

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
7
Treatment Options for Stage IIIB, Inoperable
Stage IIIC, Stage IV, Recurrent, and Metastatic
Breast Cancer1
Stage IIIB and Inoperable Stage IIIC
Stage IV and Metastatic

• Hormone therapy
• Chemotherapy
• Surgery with lymph node dissection and radiation
  therapy
• Targeted therapies (e.g., lapatinib, trastuzumab
  (Herceptin), bevacizumab (Avastin))
• Clinical trials testing new drugs/treatments

• Hormone therapy
• Chemotherapy
• Targeted therapies (e.g., lapatinib, trastuzumab
  (Herceptin), bevacizumab (Avastin))
• Palliative radiation therapy and/or surgery
• Clinical trials testing new drugs/treatments

1. National Cancer Institute. Available at
www.cancer.gov/cancertopics/pdq/treatment/breast/H
ealthProfessional/page5.
8
Disparities in Breast Cancer Treatment
Breast-Conserving Surgery Radiation Therapy

• Women with Disabilities Were1
• 20 less likely to receive breast-conserving
  surgery
• 19 less likely to receive lymph node dissection
• 17 less likely to receive adjuvant radiation
  therapy
• 29 more likely to die from the breast cancer

1. McCarthy et al. Ann Intern Med.
2006145637-645.
9
Disparities in Breast Cancer Treatment
Chemotherapy

• Chart Review1
• Women with disabilities less likely to receive
  neoadjuvant chemotherapy compared to women
  without disabilities (13 of the time vs. 29 of
  the time), but
• Difference was not statistically significant

1. Caban ME, et al. Cancer. 2002941391-1396.
10
Making the Treatment Decision

• Avoid assumptions
• Discuss medical and logistical pros and cons of
  each treatment option

11
Determining Medical Decision-Making Capacity
(Ability to Give Informed Consent)

• So long as the patient appears to adequately
  understand and appreciate the personal
  significance of the following
• That she has a general medical or mental
  disorder,
• The nature and course of the disorder, and
• The risks and benefits of the proposed
  intervention and of the alternative, including
  the alternative of no intervention and
• 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

1. Moore RF. Medscape General Medicine. 19991(3).
12
Resources for Determining Ability to Give
Informed Consent

• State medical associations
• National Association of Developmental Disability
  Councils www.nacdd.org
• Assessment tools for women with limited verbal
  skills
• Hopkins Competency Assessment Test
• Competency Interview Schedule
• MacArthur Competence Assessment Tool

13
Special Concerns Surgery

• How will surgery affect the patients disability
  and quality of life?
• What are the patients current assistive and
  adaptive needs, and how will surgery affect those
  needs?

14
Overcoming Surgical Barriers

• Anticipate and plan for any special needs that
  the patient might require during the surgery
  itself
• Make sure patient will have assistance after the
  operation
• Make sure patient has transportation to the
  surgery and to post-op medical appointments
• Consider sending patient to a PT or OT
  consultation before surgery

15
Special Concerns Radiation Therapy

• Is patient physically able to lie still and
  abduct arm for treatment?
• Will patient have daily transportation to and
  from radiation therapy facility?
• Will patient have necessary level of home care to
  address medical and daily living side effects of
  radiation therapy?

16
Overcoming Barriers to Radiation Therapy

• Anticipate transportation and other access
  barriers make sure these issues are resolved
  before patient shows up for treatment
• Consider shorter treatment course

17
Special Concerns Chemotherapy
Will patient have necessary level of home care to
address medical and daily living side effects of
chemotherapy?
Possible Side Effects
18
Special Concerns Chemotherapy
Side Effects Pose Potentially Debilitating
Consequences for Women with Disabilities

• Fatigue May severely limit mobility for women
  with existing mobility limitations
• Increase in Urine Output May cause significant
  problem for women with existing continence
  problem
• Bone Loss Increases osteoporosis risk for women
  already at increased risk

19
Special Concerns Hormone Therapy
Will patient have necessary level of home care to
address medical and daily living side effects of
hormone therapy?
Possible Side Effects Tamoxifen/Raloxifene
20
Special Concerns Hormone Therapy

• Aromatase Inhibitors
• Increased risk of bone loss and fractures
• Consider adjuvant use of bisphosphonates

21
Overcoming Barriers to Chemotherapy and Hormone
Therapy

• Ensure full patient participation in treatment
  decisions
• Tailor treatment based on side effect and risk
  profile
• Identify and address patients needs before
  treatment begins
• Increase home nurse visits, if needed
• Monitor patients bone density and evaluate
  treatments to attenuate bone loss
• Instruct patient on symptoms of thromboembolism

22
Support Patient During Treatment

• Identify barriers to care
• Identify resources to overcome those barriers
• Prepare patient for possible side effects and
  their impact on her daily activities
• Make sure she will have the proper assistance to
  deal with those side effects
• Coordinate care with other specialists
• Have a system in place that enables you and your
  patient to communicate easily throughout the
  treatment process
• Ask patient if she would like to include a friend
  or family member in her care

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Rehabilitation
24
Rehabilitation Strategies

• Treat related diagnoses that increase the
  disability
• Treat unrelated diagnoses that increase the
  disability
• Manage pain
• Improve fatigue
• Increase strength and cardiovascular fitness
• Prescribe adaptive equipment

25
Treat Related Diagnoses Lymphedema

• Symptoms
• Swelling, aching, tightness in arm
• Hardening/thickening of skin
• Restricted range of motion
• May lead to cellulitis
• 630 of survivors self-report lymphedema
  symptoms1
• Symptoms may develop up to 20 years after
  initial treatment2

• National Cancer Institute. NCI Cancer Bulletin.
  200745-6.
• Petrek JA, et al. Cancer. 2001921368-1377.

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Complete Decongestive Physiotherapy

• Manual lymphatic massage
• Inelastic compression bandaging
• Remedial exercises
• Meticulous skin care

27
Treat Related Diagnoses Rotator Cuff Tendinitis

• Common disorder among breast cancer patients1
• Results from weakness of the rotator cuff
  musculature
• Radiation therapy and chemotherapy contributeto
  the disorder
• Associated with lymphedema2

• Stubblefield MD, Custodio CM. Arch Phys Med
  Rehabil. 2006S96-S99.
• Herrera JE, Stubblefield MD. Arch Phys Med
  Rehabil. 2004851939-1942.

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Treating Rotator Cuff Tendinitis

• Stretches and range-of-motion exercises to
  increase flexibility
• Exercises to stabilize shoulder

29
Treat Related Diagnoses Overuse Injuries on
Unaffected Side

• Women with disabilities are at increased risk of
  overuse injuries
• Risk increases after cancer treatment

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Treating Overuse Injuries

• Early and aggressive physical therapy is
  essential
• Patient should be evaluated for adaptive
  equipment and/or assistive devices

31
Treat Related Diagnoses Neck Pain

• Second most common musculoskeletal condition
  among women
• After breast cancer treatment, deconditioning
  increases risk

32
Treating Neck Pain

• Restore range of motion
• Maintain/improve upper body strength

33
Treat Unrelated Diagnoses That Increase the
Disability
To Avoid Diminished Function

• Treat early
• Treat aggressively

34
Manage Pain

• Treatment goals
• Ameliorate pain
• Maintain optimal function
• Closely follow patient for detrimental side
  effects of medication
• Refer patient to PT and/or OT
• Integrative treatments (e.g., acupuncture) may
  help

35
Improve Fatigue

• Possible Causes of Fatigue in Women

• Inadequate sleep
• Side effects from medications
• Depression
• Anemia
• Thyroid illness
• Poor nutrition
• Deconditioning

36
Increase Cardiovascular Fitness

• Exercise Improves1
• Quality of life
• Cardiorespiratory fitness
• Physical functioning
• Fatigue

• Exercise May Improve2
• Breast cancer survival
• Greatest benefit Walking 35 hours per week at
  average pace (or equivalent)

• McNeely ML, et al. CMAJ. 200617534-41.
• Holmes MD, et al. JAMA. 20052932479-2486.

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Increase Muscle Strength

• Twice Weekly Strength Training
• Improves quality of life1
• Increases muscle mass2
• Reduces body fat2
• Reduces IGF-II levels2

• Ohira T, et al. Cancer. 20061062076-2083.
• Schmitz KH et al. Cancer Epidemiol Biomarkers
  Prev. 2005141672-1680.

38
National Center on Physical Activity and
Disability
www.ncpad.org
39
Prescribe Appropriate Adaptive Equipment

• The choice of equipment should involve patient,
  medical team, and PT/OT
• An assessment should be made of womans needs at
  home and at work

The Alliance for Technology Access
www.ataccess.org
40
Ongoing Care
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Goals of Regular Follow-up Visits

• Find local or distant recurrence of cancer
• Find any new breast tumors that have developed
• Find any treatment-related side effects (e.g,
  lymphedema, bone loss, cardiovascular problems)
• Identify effects of the disease and its treatment
  on the patients disability and quality of life

42
Recommendations for Follow-up Care for Breast
Cancer1

• Khatcheressian JL, et al. J Clin Oncology
  2006245091-5097.

43
Work Collaboratively

• Ask questions
• Anticipate problems
• Create solutions
• Have mechanism in place to alert you if the
  patient does not return for follow-up within
  recommended interval

44
Create a Teachable Moment

• Provide information on healthy behaviors
• Ascertain if patient needs help with depression
  or other mental health issue
• If applicable, discuss the option of a genetics
  referral

45
Summary

• Breast cancer treatment poses added practical
  issues for women with disabilities.
• Present all the medical and logistical pros and
  cons of treatment options to your patients with
  disabilities.
• Know state laws regarding informed consent.
• Discuss with your patients with disabilities how
  treatment may affect their adaptive and assistive
  needs. Help arrange support services to meet
  those needs.

46
Summary (continued)

• Tailor each womans treatment to minimize its
  effect on worsening the patients existing
  disability.
• Refer the patient to physical and/or occupational
  therapy before her treatment starts.
• During follow-up care, identify and address the
  effect that the cancer and its treatment has had
  on the womans disability.
• Make sure the patients 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.

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• Resources

48
Breast Health Access for Women with Disabilities
(BHAWD)Call 512-204-4866TDD
510-204-4574www.bhawd.org Center for Research
on Women with Disabilities (CROWD)Baylor College
of MedicineCall 800-442-7693www.bcm.edu/crowd
Health Promotion for Women with
DisabilitiesVillanova University College of
NursingCall 610-519-6828www.nursing.villanova.e
du/womenwithdisabilities Magee-Womens
FoundationStrength Courage Exercise DVD (a
compilation of exercises helpful to breast cancer
patients)http//foundation.mwrif.org/

49
National Breast and Cervical Cancer Early
Detection ProgramCenters for Disease Control and
PreventionCall 1-800-CDC-INFOTTY
1-888-232-6348www.cdc.gov/cancer/nbccedp National
Center of Physical Activity and DisabilityCall
1-800-900-8086TTY 1-800-900-8086www.ncpad.org
The National Womens Health Information
CenterCall 1-800-994-9662TDD
1-888-220-5446www.4women.gov/wwd Susan G. Komen
for the Curewww.cms.komen.org Women with
DisabilitiesCenters for Disease Control and
Preventionwww.cdc.gov/ncbddd/women
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References

• Ahmedin J, Siegel R, Ward E, Murray T, Xu J, and
  Thun MJ. Cancer statistics, 2007. CA Cancer J
  Clin. 20075743-66.
• Ahn J, Schatzkin A, Lacey JV, et al. Adiposity,
  adult weight change, and postmenopausal breast
  cancer risk. Arch Intern Med. 20071672091-2102.
• American Cancer Society. American Cancer Society
  guidelines for breast screening with MRI as an
  adjunct to mammography. CA Cancer J Clin.
  20075775-89.
• 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.htmAnchor-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. 20011771451-1457.
• Begg CB, Haile RW, Borg A, et al. Variation of
  breast cancer risk among BRCA 1/2 carriers. JAMA.
  2008299194-201.
• Berry DA, Cronin KA, Plevritis SK, et al. Effect
  of screening and adjuvant therapy on mortality
  from breast cancer. N Eng J Med.
  20053531784-1792.

51

• 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. 2002941391-1396.
• Chen WY, Colditz GA, Rosner B, et al. Use of
  postmenopausal hormones, alcohol, and risk for
  invasive breast cancer. Ann Intern Med.
  2002137798-804.
• 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.
  2002871234-1245.
• CROWD, Baylor College of Medicine. Health
  behaviorsweight management 2007. Available at
  www.bcm.edu/crowd/?pmid1430.
• Elmore JG, Fletcher SW. The risk of cancer risk
  prediction what is my risk of getting breast
  cancer? J of the NCI. 2006981673-1675.
• 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.
  2006296185-192.
• 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. 20023471233-1241.
• Hall L, Colantonio A, Yoshida K. Barriers to
  nutrition as a health promotion practice for
  women with disabilities. Int J of Rehabilitation
  Research. 200326245-247.

52

• 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. 199934077-84.
• Herrera JE, Stubblefield MD. Rotator cuff
  tendonitis in lymphedema a retrospective case
  series. Arch Phys Med Rehabil. 2004851939-1942.
• Holmes MD, Chen WY, Feskanich D, Kroenke CH,
  Colditz GA. Physical activity and survival after
  breast cancer diagnosis. JAMA. 20052932479-2486.
  
• Hughes RB. Achieving effective health promotion
  for women with disabilities. Family Community
  Health. 20062944S-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. 2002137344-346.
• Iezzoni LI, McCarthy EP, Davis RB, Siebens H.
  Mobility impairments and use of screening and
  preventive services. Am J of Public Health.
  200090955-961.
• Irwig L, Houssami N, van Vliet C. New
  technologies in screening for breast cancer a
  systematic review of their accuracy. Brit J
  Cancer. 2004902118-2122.
• 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.
  200725TK-TK.
• Kaplan C, Richman S. Informed consent and the
  mentally challenged patient. Contemporary Ob/Gyn.
  20065163-72.
• Kauff ND, Domcheck SM, Friebel TM, et al.
  Risk-reducing salpingo-oophorectomy for the
  prevention of BRCA1- and BRCA2-associated breast
  and gynecologic cancer a multicenter,
  prospective study. J Clin Oncology.
  2008261331-13337.

53

• 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. 2006245091-5097.
• Kosters JP, Gotzsche PC. Review regular
  self-examination or clinical examination for
  early detection of breast cancer. Cochrane
  Database of Systematic Reviews. 20032CD003373.
• Li L, Ford JA. Triple threat alcohol abuse by
  women with disabilities. Applied Behavioral Sci
  Rev. 1996499-109.
• Lostumbo L, Carbine N, Wallace J, Ezzo J.
  Prophylactic mastectomy for the prevention of
  breast cancer. Cochrane Database of Systematic
  Reviews. 20044CD002748.
• McCarthy EP, Ngo LH, Roetzheim RG, et al.
  Disparities in breast cancer treatment and
  survival for women with disabilities. Ann Intern
  Med. 2006145637-645.
• McDonald S, Saslow D, Alciati MH. Performance and
  reporting of clinical breast examination a
  review of the literature. CA Cancer J Clin.
  200454345-361.
• 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. 2006175-34-41.
• McTiernan A, Kooperberg C, White E, et al.
  Recreational physical activity and the risk of
  breast cancer in postmenopausal women. JAMA.
  20032901331-1336.
• 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. 2001345159-164.
• Mele N, Archer J, Pusch BD. Access to breast
  cancer screening services for women with
  disabilities. JOGNN. 200534453-464.

54

• Moore RF. A guide to the assessment and care of
  the patient whose medical decision-making
  capacity is in question. Medscape General
  Medicine. 19991(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. 20068361-370.
• National Cancer Institute. Breast cancer (PDQ)
  treatment. Available at www.cancer.gov/cancertopic
  s/pdq/treatment/breast/healthprofessional.
• National Cancer Institute. Ductal carcinoma in
  situ. Breast cancer (PDQ) treatment. Available
  at www.cancer.gov/cancertopics/pdq/treatment/breas
  t/HealthProfessional/page5.
• National Cancer Institute. Estimating breast
  cancer risk questions and answers. Updated
  September 5, 2006. Available at
  www.cancer.gov/Templates/doc.aspx?viewidac1e8937-
  d95b-4458-a78a-1fe33dbfcbdc.
• National Cancer Institute. Lymphedema after
  cancer how serious is it? NCI Cancer Bulletin.
  200745-6.
• National Cancer Institute. Tamoxifen questions
  and answers. Reviewed May 13, 2002. Available at
  www.cancer.gov/cancertopics/factsheet/Therapy/tamo
  xifen.
• 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.

55

• Nosek MA, Howland CA. Breast and cervical cancer
  screening among women with physical disabilities.
  Arch Phys Med Rehabil. 199778 (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. 200687320-327.
• 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.
  20061062076-2083.
• 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. 200716775-782.
• Petrek JA, Senie RT, Peters M, Rosen PP.
  Lymphedema in a cohort of breast carcinoma
  survivors 20 years after diagnosis. Cancer.
  2001921368-1377.
• Poulos AE, Balandin S, Llewellyn G, Dew AH. Women
  with cerebral palsy and breast cancer screening
  by mammography. Arch Phys Med Rehabil.
  200687304-307.
• 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. 2002137783-790.
• Robson M, Offit K. Clinical practice management
  of an inherited predisposition to breast cancer.
  N Engl J Med. 2007357154-162.
• 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.
  2005141672-1680.

56

• 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. 2001143306-3311.
• Smeltzer S. Preventive health screening for
  breast and cervical cancer and osteoporosis in
  women with physical disabilities. Family
  Community Health. 20062935S-43S.
• Smith, RA, Cokkinides V, Eyre HJ. American Cancer
  Society Guidelines for the Early Detection of
  Cancer, 2005. CA Cancer J Clin. 20055531-44.
• 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. 20075790-104.
• Stubblefield MD, Custodio CM. Upper-extremity
  pain disorders in breast cancer. Arch Phys Med
  Rehabil. 2006S96-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/usps
  brgen.htmsummary.
• 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.
  20062952727-2741.