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BMJ No 7115 Volume 315 Papers Saturday 25 October 1997
Breast examinations in older women: questionnaire survey of attitudes of patients and doctorsEugene Haigney, Rosemary Morgan, Debra King, Branwell Spencer Breast examination is important in older women, in whom the incidence of breast cancer is higher.(1) It is, however, an intimate examination, and older patients and doctors may be deterred for several reasons. The attitudes of older women to this procedure have not previously been established. Both this and the attitudes of doctors may determine whether the procedure remains part of the routine physical examination.
Subjects, methods, and resultsThe study was approved by the Wirral district's ethics committee. One hundred elderly (mean (range) age 83 (71-94) years) female inpatients (abbreviated mental test score 8/10 or more) were interviewed by a doctor not involved in their medical care. All patients were fully recovered from their acute illness. A questionnaire (available from us) was administered and the responses recorded. The case notes of the same 100 patients were audited by using a standardised proforma. One hundred hospital doctors working in two h Review of 100 case notes showed only 11 of the patients had had a
breast examination documented (two of which yielded abnormal results).
Of 10 patients with a history of bone pain, only one had a breast
examination, while four with weight loss had no breast examination
documented. Liver function tests gave abnormal results in 15 women,
only two of whom had a breast examination. There were five patients
with a history of breast cancer, none of whom had a breast examination
documented.
None of the patients said they would be offended if they were
asked to undergo a breast examination. Fifty four patients felt neutral
about it, 32 would be pleased to be asked, 10 would be reluctant about
being examined, two would be upset, and two would be embarassed. Most
patients (86) thought a breast examination was important and would give
permission for this examination. Most (88) also had not had mammography
or a breast examination previously. A few patients (12) said that they
would always want a chaperone, while 18 wanted a chaperone only when a
male doctor was examining. Most (70) were not concerned whether a
chaperone was present or not. Only a few patients (13) thought a breast
examination would worry them, while 45 thought it would reassure them.
None of the patients had refused to undergo a breast examination. Some
(25) would prefer a female doctor to examine them, but most (70) had no
preference.
Of the hospital doctors interviewed, only five said that they would
routinely do a breast examination on every woman over the age of 50
years, though 43 thought breast examinations should be a routine part
of the physical examination. Some doctors (15) felt uncomfortable in
performing breast examinations, and 34 (all men) would insist on a
chaperone. Only 12 would be deterred because of the possibility of
being accused of assault. Most hospital doctors (56) did not think
women were offended by breast examinations. A small number of doctors
(11) did not feel confident in detecting breast lumps because of
inadequate The treatment women of all ages should be getting for breast
cancer has been outlined.(2) About 40% of women with breast
cancer are aged over 70.(3) Giving women of 70 or over
"adequate" treatment can enable them to reach a five year survival
rate similar to that for younger women.(4)
Few women in this study had had a breast examination or undergone
mammography. As most of our patients regarded a breast examination as
important and would give permission, omission must be due to failure by
medical staff to do this examination. Few doctors would routinely do a
breast examination on women over the age of 50, although over half
thought it should be done as part of the physical examination. Most
doctors thought women were not offended so omission is not because of
fear of offending patients. There are probably multifactorial reasons
why doctors do not routinely perform breast examinations: some feel
uncomfortable, a few lack confidence, and some are deterred by claims
of assault. Requirement of a chaperone may make examination difficult
as nursing staff may not be available. It may not be a priority in the
assessment of an acute medical emergency and subsequently overlooked.
Some doctors may also have misconceptions that breast cancer in elderly
women is less aggressive than in younger women and that older women
cannot endure aggressive treatment.
This study suggests that older female patients have a positive attitude
towards breast examinations which is not reflected by the attitudes and
practice of hospital doctors. There needs to be a change in attitudes
and training so that older women do not miss out on diagnosis and
treatment.
Department of Medicine for the Elderly, Royal Liverpool
University Hospitals,
Correspondence to: Dr Morgan
Funding: No external funding.
(Accepted 3 September 1997)
References
1 Ries L A B, Hankey B F, Edwards B K, eds.
Cancer statistics review, 1983-1987. Bethesda, MD:
National Cancer Institute, 1989. (NIH Publication No 90-2789.)
2 Sheldon T, Melville A, Sharp F. The management of primary
breast cancer. Effective Health Care Bull
1996;2(6):1-16.
3 Adami H, Malker B, Holmberg L, Persson I, Stone B. The
relation between survival and age at diagnosis in breast cancer.
N Engl J Med 1986;315:559-63.
4 Amsterdam E, Birkenfield S, Chlad A, Krispin M. Surgery for
carcinoma of the breast in women over 70 years of age. J Surg
Oncol 1987;180:183.
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