L E T T E R S

On "Ba t t l i ng Breas t C a n c e r "

A recent study at the University of Michigan indicates that angry women live longer, so perhaps I should be g ra te fu l to Marge Drugay for ex tending my l i f e - - because this article ["Battl ing Breast Cancer in Older Women: Where Do We S tand?" GERIATRIC NURSING 1992;13:240-4] made me angry. The author has perpet- uated the same patronizing attitude toward women as the medical establishment and the American Cancer Society. This is the same system that has abused women across the life span, doing unnecessary hysterectomies, conducting major studies on heart disease that include men only, de- laying a major study of dietary links with breast cancer, in part because "women couldn't be trusted to follow a low-fat diet ," and promoting silicone breast implants without adequate testing. Frankly, I expected better from a nurse.

For too long breast cancer was considered a personal tragedy. Now, at long last, the media are beginning to re- port the facts. Describing this in terms such as "escalat- ing hysteria" and "sensationalistic reporting" trivializes the seriousness of the problem. Seeking ways to reduce concern does nothing to reduce the risk, the incidence, the suffering and death caused by breast cancer. What needs to be addressed are the grim facts, including these:

1. Breast cancer is a national epidemic; this year it will kill 46,000 American women. Breast cancer ki l ls one Amer ican woman every I2 minutes .

2. Breas t cancer will s t r ike 180,000 A m e r i c a n women this year, 81,000 of them women over 65. Twenty-five percent of those women will be dead in 5 years; 50% will be dead in 10 years.

3. More than 70% of women diagnosed with breast cancer have none of the known risk factors in their background.

4. There is no cure for breast cancer; it is a chronic disease, l

5. There is no known way of preventing breast cancer because we do not know the cause. Most of the re- search has been devoted to new drugs and other therapies, not to finding the cause.

6. Despite two decades of "the war on cancer," mor- tality rates have not improved; they have increased for women over 65, pa r t i cu l a r l y in Af r i can - American women.

7. Treatments for breast cancer (summarized by Dr. Susan Love as "slash, burn, and poison") are harsh, making the t reatment almost worse than the disease.

8. Mammography is not prevention, and it misses 20% of breast cancers. In addition, not all mam- mograms are reliable or even safe. Only a third of all mammography units in the United States are accredited by the American College of Radiolo- gists, and there are no federal regulatory standards for this science. (To find out whether a particular facility is accredited, call 1-800°ACS-2345.)

9. Funding for mammography is inadequate. The av- erage cost for a mammogram is $110, and the ACS guidelines suggest an annual mammogram for women over age 65. Medicare reimburses $55 for a biennial mammogram. What 's wrong with this picture?

10. Concerns regarding radiation from repeated mam- mograms causing breast cancer are not "overreac- t i re ." Ionizing radiation is a known carcinogen, yet it is used for detection and for t reatment of breast cancer. Though the experts say the radia-

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noninvasive test, analogous to the PSA blood test for prostate cancer.

11. Older women are subject to the double whammy of ageism and sexism when they deal with the med- ical establishment. As Drugay points out, this is particularly true with breast cancer: Physicians screen elderly women less often, and, as a study of 22,899 cancer patients in New Mexico showed, the percentage of people receiving potentially "cura- tive" treatments declines with age. 2 Overall, 92% of people agod 54 or under received potentially curative t reatments for localized cancers. Tha t percentage declined to 80% for those aged 65 to 74, 72% for those aged 75 to 84, and 62% for those aged 85 or older. Thus older cancer patients are less likely to be treated appropriately unless they are sufficiently informed and motivated to take charge of their own treatment. Physicians need to learn to individualize t reatment and not worry about age per se.

12. Breast cancer is a disease of denial and fear; it is the ultimate betrayal of a woman's body. For the breast, symbol of nurturing and femininity, to be diseased and perhaps mutilated understandably gives rise to a host of emotions, including anger, grief, and terror. A recent letter to "Dear Abby" said: "I do not want that breast removed. To know that I may wake up and find that I am only part of a woman scares me to death . . . . Death is better than surgery . . . . Sign me 'DEATH ROW WOM- AN. ' " Nurses can help women deal with these emotions through listening, understanding, and education. I would have liked to see more specifics on this aspect of care in Drugay's article. What are the "cancer myths"2 I submit that one of them is: "Five cancer-free years constitutes a cure." There are many others, too numerous to mention here.

13. Scant attention is being focused on the environ- mental link with breast cancer and other cancers, even though the NCI revealed that the most fre- quently mentioned causes of cancer were environ- mental pollutants, job-related exposures to carcin- ogens, and chemicals or additives. One study in Hartford, Conn., showed a possible link between

294 Geriatric Nursing November/December 1992

pesticides and breast cancer. Why aren ' t more such studies underway? There are plenty of tissue specimens avai lable f rom the 500,000 annual breast biopsies.

14. Many physicians are not well informed on the lat- est diagnostic and t reatment advances in breast cancer, and there is wide geographic variation in treatment approaches, ranging from radical mas- t ec tomy to lumpec tomy with radiat ion. Ma n y women with node-negative breast cancer are sub- jected to unnecessary toxic chemotherapy because their physician does not use a "breast cancer risk profile"--a battery of tests to help separate those who need chemotherapy to prevent recurrence from those who do not. 3 Thus second opinions be- come even more critical to the woman with breast cancer.

So, in answer to the question in the title of the article--- "Where do we s t and?"mi f "we" refers to older women with breast cancer, we stand on the losing side of the bat- tle. This disease is killing us in greater numbers than ever: the mortality rates among older women have risen from 88.4 per 100,000 in 1973 to 93.0 per 100,000 in 1988--an increase of 5.2%. And no one knows why.

If " w e " refers to nurses, however, we stand on the threshold of an opportunity to turn the tide and help older women win the battle against breast cancer. Nurses can' help in two ways:

1. Empowering patients by teaching them the truth about breast cancer, the benefits of early detection th rough m a m m o g r a p h y and breas t se l f -exam- ination (BSE), the treatment alternatives, and the importance of second opinions.

2. Becoming politically active on this issue and on all women's health issues, demanding legislation to establish federal mammography s tandards and increased funding for research into better detection m e t h o d s ( n o n i n v a s i v e m e t h o d s such as the PSA blood test for prostate cancer) and finding the cause(s) of breast cancer so that it can be prevented.

As a longtime supporter of nurses and nursing, I be- lieve that nurses can seize this opportunity and play a key role in improving our odds in the battle against breast cancer. Since most nurses are women and all are aging, victory in this battle will benefit all of us. The members of Breast Cancer Action invite all nurses to add their voices and their votes to ours.

N A N C Y EVANS Breast Cancer Action, San Francisco

REFERENCES

1. Love SM. Dr. Susan Love's breast book. Reading, Massachusetts: Addison- Wesley, 1991.

2. AARP Bulletin, June 1992, pp. 1-14. 3. Cancer News, Summer 1992, pp. 12-13.

R e p l y

I am somewhat perplexed at the hostile tone of Ms. Evans' letter, since the intent of my article was to educate

gerontological nurses about breast cancer detection for women over 65.

I concur that some of the media have begun to report "facts." However, both electronic and print media have contributed to rising alarm and hysteria by reporting in- formation that has not been substantiated (such as the Canadian study on radiation from mammography) and by neglecting to correct misinformation. The media have also used instances of the most dramatic or unusual cases, leading many women to believe these cases are the norm. I have spoken with women who are now afraid to have a mammogram: they are afraid to discover any abnormal- ity because of "hor ror stories" they have seen on TV. They were re luc tant b e fo r e - -n o w they are terrified. Responsible information about breast cancer is more often found in the back pages of the newspaper, or on radio or TV at 7 on Sunday morningmnot exactly prime- time.

I believe that the article supported the data that breast cancer is a serious problem for older women and that the only prevention we have at present is early detection. Ms. Evans appears disapproving of mammography as a de- tection modality, but it is the most effective means we have at the present time. Current mammographic tech- nique utilizes low-dose radiation exposure and is safer than ever before. We are exposed to more radiation on an average cross country flight than we are from mammog- rapby. The American College of Radiology has stringent guidelines for m a m m o g r a p h y and col laborated with H C F A to develop rules for Medicare reimbursement. Yes, there are false-negative results, but they represent a small percentage of the total number of mammographic studies. There are problems with mammography, but they are being addressed because women demand it.

I fully support the need for more funding and research into the cause and noninvasive detection of breast cancer. I also believe that all women must educate themselves about early detection and t reatment of breast cancer. Since mammography does detect early stage, smaller

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