MODULE 1. Interprofessional working in early detection of breast cancer
8. Midwives’ role in early breast cancer detection in Estonia
This text introduces you the incidence of breast cancer and the work of the screening programme in Estonia, reflecting the specificities of the country. You can also learn about the role and duties of midwives in relation to breast cancer detection.
In this module you have learned about the roles and duties that different health professionals have in early breast cancer detection. Try to think about three common midwifery duties related to breast cancer detection. Now read the text and check if your guesses are right.
In this module you have learned about the roles and duties that different health professionals have in early breast cancer detection. Try to think about three common midwifery duties related to breast cancer detection. Now read the text and check if your guesses are right.
Content of this material
- Breast cancer statistics in Estonia
- Treatment trends
- Prevention and screening programmes
- Midwives’ role and duties regarding breast cancer detection
- Crisis counsellors and breast centres
Current statistics
Cancer statistics has been available since 1968 in Estonia. In the years 1968-2014, cancer morbidity both in men and women doubled. Morbidity rates of breast cancer and prostate cancer are constantly increasing. The 5-year survival rate is 75% (Vähihaigestumus Eestis, 2014, Vähi sõeluuringute register, 2017).
Breast cancer (BC) is a leading cause of cancer deaths among women in Estonia. Although the BC incidence in Estonia is lower than in Western-European countries, an upward trend has been evident for more than 20 years, and it is likely to be associated with the same determinants as suggested for other European countries. The increasing impact of reproductive risk factors, but also other factors that may be more amenable to intervention such as obesity and low physical activity, are probably related to the gradual adoption of the western lifestyle (Baburin et al 2014, Innos et al 2013, Kallak & Padrik, 2013).
In Estonia, about 600 women are diagnosed with breast cancer each year. The morbidity rate increases with aging population, almost 80% of all breast cancers are diagnosed in women over 50. In 2014 breast and skin cancers were most common types of cancer among women (Vähihaigestumus Eestis 2014, Ulp et al 2010).
Breast cancer (BC) is a leading cause of cancer deaths among women in Estonia. Although the BC incidence in Estonia is lower than in Western-European countries, an upward trend has been evident for more than 20 years, and it is likely to be associated with the same determinants as suggested for other European countries. The increasing impact of reproductive risk factors, but also other factors that may be more amenable to intervention such as obesity and low physical activity, are probably related to the gradual adoption of the western lifestyle (Baburin et al 2014, Innos et al 2013, Kallak & Padrik, 2013).
In Estonia, about 600 women are diagnosed with breast cancer each year. The morbidity rate increases with aging population, almost 80% of all breast cancers are diagnosed in women over 50. In 2014 breast and skin cancers were most common types of cancer among women (Vähihaigestumus Eestis 2014, Ulp et al 2010).
Updated statistics
Since January 2015 a new national health register has been developed – the Cancer Screening Register (CSR), including the data collected in the screening programmes of breast cancer and cervical cancer. The CSR is a digital register obtaining data from the National Health System which cooperates with national inventories (e.g. the Population Register, the Death Causes Register, the Cancer Register and the Health Insurance Fund). The CSR helps to divide resources, develop health policy and research activities (Vähi sõeluuringute register 2017).
Treatment trends
Thanks to increasing diagnostic accuracy the rate of benign tumour operations is decreasing. Family doctors, gynaecologists and midwives have an important role in cancer diagnosis. It is recommended that the patient with complaints is referred to initial examination (e.g. to mammography and/or ultrasound examination) by a designated specialist. It used to be a common way to send patients with any complaints initially to the mammalogist who however referred the patient to initial radiographic examination. That kind of way was a waste of patient money and time, prolonging the waiting lists for patients. According to the current tactics the patient is first referred to initial radiographic examination and then returns to the specialist/consultant. Treatment methods are being developed in several ways. The most radical breast cancer surgery is being replaced by more sustainable methods. The biggest qualitative change in oncological breast surgery was in 2000 when the Sentinel Node Biopsy (SNB) was started. The first SNB in Estonia was performed on June 17 in 2004. Nowadays it is part of daily work. Today, breast cancer treatment is multimodal and multidisciplinary.
Different specialists are working for one goal – to increase patients’ quality of life (Padrik et al 2007, Lehtsaar 2012).
Publicity
The public campaign of early breast cancer detection “Do not be late” is continued, aiming to raise public awareness that early detected breast cancer is curable and to encourage women to take part in the screening programmes. A pink ribbon is used all over the world as a symbol to remember it (Project “Ära jää hiljaks”).
BS related information currently visible for the public in Estonia is mainly addressed to women of screening age (50-62 years) and may create a false perception in older women. Results have shown that 20% of women reported that they had received no information on BC during the past 12 months, clearly indicating the need for making these messages more visible and reaching all women. Educational messages to the general population should be aimed at increasing the awareness of BC symptoms, assisting women in symptom recognition, and encouraging earlier presentation, with special emphasis on reaching older women (Innos et al 2013).
BS related information currently visible for the public in Estonia is mainly addressed to women of screening age (50-62 years) and may create a false perception in older women. Results have shown that 20% of women reported that they had received no information on BC during the past 12 months, clearly indicating the need for making these messages more visible and reaching all women. Educational messages to the general population should be aimed at increasing the awareness of BC symptoms, assisting women in symptom recognition, and encouraging earlier presentation, with special emphasis on reaching older women (Innos et al 2013).
Prevention and screening programmes
There are huge benefits with early detection of breast cancer. The mortality rate decreases and the treatment outcome is better. The majority of countries have organized screening programmes for decades. In Estonia the breast cancer screening programme was started in 2003 and it is nation-wide. The early breast cancer detection programmes are managed by the Health Insurance Fund, the Institute for Health Development and the Ministry of Social Affairs (Eesti Vähiliit 2015).
Women with health insurance and aged between 50 to 62 years are involved in the screening free of charge. They are sent an invitation by e-mail or by post. A digital invitation is visible in the digital health information system (www.digilugu.ee). Denominative invitation is sent based on the year of birth, because it is not possible to examine all women at a time. There are no restrictions regarding residence – so women can go to the most appropriate medical office.
Women with health insurance and aged between 50 to 62 years are involved in the screening free of charge. They are sent an invitation by e-mail or by post. A digital invitation is visible in the digital health information system (www.digilugu.ee). Denominative invitation is sent based on the year of birth, because it is not possible to examine all women at a time. There are no restrictions regarding residence – so women can go to the most appropriate medical office.
An innovative mobile mammography trailer started work in 2008. The visit of Mammobus has grown substantially over recent years and exceeds the attendance of the stationary cabinets (Ulp et al 2010).
Screening programme improvements
Since February 2017 all family doctors get information about the women on their patient list who have been invited for screening. This measure should increase the rate of participation in screening. Family doctors have an opportunity to inform women more specifically and remind them that prevention is important. This work can also be performed by family nurses and midwives working in primary care (Eesti Haigekassa 2017).
Results have shown that the use of mammography was particularly low among women aged 65 and over, 66% of them had never had a mammogram. While screening is currently available only to women aged 50 to 62 years in Estonia the referral of older women to prophylactic mammography should be more widely used by gynaecologists and /or family doctors. The future aim of the screening programme could be to expand the target group in the coming years for both younger and older age groups, women between the ages of 45-69 and beyond, from 40 to 75 years. In addition, it is important to find extra funding for the inclusion of uninsured women in screening (6-8%) (Innos et al 2013, Ulp et al 2010).
Results have shown that the use of mammography was particularly low among women aged 65 and over, 66% of them had never had a mammogram. While screening is currently available only to women aged 50 to 62 years in Estonia the referral of older women to prophylactic mammography should be more widely used by gynaecologists and /or family doctors. The future aim of the screening programme could be to expand the target group in the coming years for both younger and older age groups, women between the ages of 45-69 and beyond, from 40 to 75 years. In addition, it is important to find extra funding for the inclusion of uninsured women in screening (6-8%) (Innos et al 2013, Ulp et al 2010).
Is there anything which associates breast cancer and midwives? In Estonia we can see it!
Pillars for midwifery practice in Estonia (in terms of early detection of breast cancer)
On the basis of the Estonian Midwives Association and the Midwifery Development Plan for 2017-2021, midwives are reproductive health professionals who provide support and guidance to women throughout their life cycle, not only during the childbearing years but also during menopause. Midwives are well-positioned in their daily practice to provide health education, encourage healthy behaviours and ease the access to primary and secondary prevention. This includes regular screening for early detection of breast cancer. Such activities fit within the essential competencies identified by the International Confederation of Midwives. Midwives have significant responsibilities in terms of early detection of several breast conditions. On the basis of the guidelines for antenatal care, breast examination carried out by the midwife, is strongly recommended. During antenatal care the main purpose is to evaluate breast condition and the physiological status for breastfeeding.
Since the antenatal period women are advised and taught to use breast self-examination methods. It is found in a number of studies that in early diagnosis of breast cancer, the BSE is of great importance and approximately 90% of the women with breast cancer have felt a mass in their breasts while taking a shower and/or performing the BSE. Some clinical findings and risks for breast cancer can be detected during pregnancy and/or lactation. Diagnosis may be difficult in women who are pregnant or lactating. Women presenting with a breast lump during pregnancy should be referred to a breast specialist team and further tests should be conducted (RCOG Guidelines, Pregnancy and breast cancer 2011)
The midwife is a recognized health professional who carries out health visits to women at all ages. Within the health visit women are informed about the protection against breast cancer and early diagnosis in order to raise their awareness of breast cancer.
Since the antenatal period women are advised and taught to use breast self-examination methods. It is found in a number of studies that in early diagnosis of breast cancer, the BSE is of great importance and approximately 90% of the women with breast cancer have felt a mass in their breasts while taking a shower and/or performing the BSE. Some clinical findings and risks for breast cancer can be detected during pregnancy and/or lactation. Diagnosis may be difficult in women who are pregnant or lactating. Women presenting with a breast lump during pregnancy should be referred to a breast specialist team and further tests should be conducted (RCOG Guidelines, Pregnancy and breast cancer 2011)
The midwife is a recognized health professional who carries out health visits to women at all ages. Within the health visit women are informed about the protection against breast cancer and early diagnosis in order to raise their awareness of breast cancer.
Purpose
Midwifery is aimed to enhance women’s breast cancer awareness by several activities: Support confidence to check breasts. This will be apparent in the data reported by women in relation to their engagement in these self-care behaviours at specific time frames. It is very important to motivate women to check their breasts and to seek help when changes are noticed. Health beliefs play an important role in an individual’s interest in health protection behaviour which leads to increased screening practices (Oluwatosin 2012).
Midwives professional standards
The Professional Standard is a document which describes the work as well as the skills, knowledge and attitudes as competency requirements. According to the Standard the midwife is a health specialist who offers health services. Health promotion, health education and reproductive health are one part of work. The midwife organizes midwifery activities in cooperation with colleagues, doctors, patients and other team members. One cannot underestimate the role of the midwife in women’s life as midwives are the first health professionals to have contact with women during postnatal home visits (Ämmaemandate kutsestandard 2015).
Midwives play a fundamental role in guiding women towards the early diagnosis programmes and informing about the protection against breast cancer and early diagnosis those women who are at a greater risk (Oluwatosin 2012).
Midwives play a fundamental role in guiding women towards the early diagnosis programmes and informing about the protection against breast cancer and early diagnosis those women who are at a greater risk (Oluwatosin 2012).
Midwife’s rights
The midwife has a right to conduct independent appointments, without the doctor being involved. The midwife has usually more time for the woman and therefore a better opportunity to discuss more in details than a doctor whose appointment time is more limited. The midwife has a right to refer the patient to the mammalogist or for initial examination.
Midwife-woman bond
Bonding between the woman and the midwife usually starts when the first pregnancy is planned. After that more frequent visits are made to the midwife, involving the development of a trusting relationship. It is very common that the communication is maintained even if no more pregnancies are planned. The atmosphere is more friendly and relaxed during the independent appointment of the midwife, encouraging the patient to talk more openly about the main problem but also about the relationship or body image problems (Demirelöz et al 2010).
Feminine side
Beautiful breasts are a symbol of femininity. Be they bigger or smaller, they influence the attraction for the opposite sex. They are and have been one part of the erotic nature game. They represent sexuality, motherliness, because the noblest reason is to feed the rising generation. Beautiful and feminine breasts have been throughout history one of the most common expositions. They play a substantial role in marketing and commercial side. For example, even jeans are sold with bared women breasts. Although the woman's nature is to tempt and to be desired, they want to be loved and love themselves just the way they feel – unique – as nature created them! (Rasmann et al 2015)
Transformation of self-image
Unfortunately the faith can be tough - breaking all illusions at one moment – diagnosis of malignant breast tumour. At one moment the femininity is replaced by fear, darkness and battle for life. Women faced with chemotherapy, radiation therapy - some struggle, but some lose faith… If a woman loses one part of her body, she may totally lose her femininity. In relation to radical surgery, there are always some doubts – is everything going to be all right. Women need support in their life, support when they are pregnant, planning pregnancy or choosing a birth control method (Rasmann et al 2015).
(Pregnancy) crisis counsellor = midwife = women counsellor
Crisis counsellors, who are frequently midwives with special education, work in the bigger women´s clinics in Estonia. Their field of work is wide, including patients with some horrible experience in the past, fear or anxiety, problems with body-image, relationship problems, exposure to death etc. The best way to understand women is being a woman herself.
Breast centres
There are two breast centres in the capital city of Estonia, employing among other professionals also midwives, aimed to provide women objective and up-to-date information on breast health and an easy access to consultation. In the capital of Estonia the breast centre was created in 2012, employing 3 doctors and 4 midwives.
Results have shown that women in any age group need to be examined more widely. To visit the centre one needs a referral letter from the midwife or the family doctor. After the first consultation the patient is referred to the breast specialist’s appointment. If the problems with breasts are more cosmetic as asymmetry, there is a possibility to solve the problem with explaining the physiology and to offer psychosocial support. Midwives as well as doctors are dealing with breast cancer prevention, talking about connections between breast health and healthy lifestyle. The midwife is informing about and teaching the self-examination technique, because only the self-examination that is correctly performed by women is beneficial (Oluwatosin 2012).
If the woman has complaints, the first health professional to turn to is a gynaecologist or midwife. The midwife gives advice and orders the needed examinations. If the midwife identifies a more urgent problem, the doctor and multidisciplinary team will be involved to handle the case. Patients commonly need primary consultation and the midwife as a health professional is in a suitable position to do that. The psychological aspect is very important, especially when the examinations are over and there are already some answers (Lehtsaar 2012).
The time interval between the patient first noticing a symptom and first consulting a doctor is often referred to as patient delay. Studies in European countries have shown that between 17-20% of patients with BC symptoms delay their presentation for three months or more. In Estonia, the median patient delay was 16 days, 32% of the patients having a medical appointment within one week of initial symptom discovery (Innos et al 2013).
Results have shown that women in any age group need to be examined more widely. To visit the centre one needs a referral letter from the midwife or the family doctor. After the first consultation the patient is referred to the breast specialist’s appointment. If the problems with breasts are more cosmetic as asymmetry, there is a possibility to solve the problem with explaining the physiology and to offer psychosocial support. Midwives as well as doctors are dealing with breast cancer prevention, talking about connections between breast health and healthy lifestyle. The midwife is informing about and teaching the self-examination technique, because only the self-examination that is correctly performed by women is beneficial (Oluwatosin 2012).
If the woman has complaints, the first health professional to turn to is a gynaecologist or midwife. The midwife gives advice and orders the needed examinations. If the midwife identifies a more urgent problem, the doctor and multidisciplinary team will be involved to handle the case. Patients commonly need primary consultation and the midwife as a health professional is in a suitable position to do that. The psychological aspect is very important, especially when the examinations are over and there are already some answers (Lehtsaar 2012).
The time interval between the patient first noticing a symptom and first consulting a doctor is often referred to as patient delay. Studies in European countries have shown that between 17-20% of patients with BC symptoms delay their presentation for three months or more. In Estonia, the median patient delay was 16 days, 32% of the patients having a medical appointment within one week of initial symptom discovery (Innos et al 2013).
Conclusion
Midwives help women to participate in the breast cancer screening programmes as well as to apply breast self- examinations, refer women to breast sonography, mammography and to the mammalogist. This is the way how midwives we are able to improve protective health behaviours through health education and support.
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References
- Baburin, A., Aareleid, T., Padrik, P., Valvere, V.,Innos, K. (2014). Time trens in population-based cancer survival in Estonia: Analysis by age and stage. Acta Oncologica; 53:226-234.
- Demirelöz, M., Ceber, E., Özentürk, G. (2010). Midwives Roles in Women’s improvement protective behaviour against breast cancer whether they have a family history of Cancer or Not. Asian Pacific Journal of Cancer Prevention, 11:1037-1043.
- Eesti Haigekassa 2017 https://www.haigekassa.ee/et/uudised/mida-saab-teha-rinnavahi-oigeaegseks-avastamiseks?highlight=s%C3%B5eluuringud
- Eesti Vähiliit www.cancer.ee
- Kallak, K., Padrik, P. (2013). Tõenduspõhine rinnavähi kiiritusravi. Eesti Arst 92 (10):575-580.
- Kutsestandard Ämmaemand, tase 7 http://www.kutsekoda.ee/et/kutseregister/kutsestandardid/10470095/pdf/ammaemand-tase-7.6.et.pdf
- Lehtsaar,J. (2012) Rinnavähk-diagnoosimisest ravini Kliinikumis. Kliinikumi Leht, 142 (4).
- Oluwatosin, A. (2012). Primary health care nurses’ knowledge practice and client teaching of early detection measures of breast cancer in Ibadan. BioMedCentral Nursing 11:22
- Padrik, P., Eelma, E., Lehtsaar, J.(2007). Rinnavähi ravi arengusuunad. Eesti Arst; 86 (11) :819-822
- Projekt “Ära jää hiljaks” http://cancer.ee/projekt-ara-jaa-hiljaks/
- Rasmann, K., Riener, M.(2015). Rindade ilu ja valu. http://www.tursekeskuse.ee/uudised/rindade-ilu-ja-valu/
- RCOG Guidelines, Pregnancy and breast cancer, 2011 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_12.pdf
- Ulp, S., Kuusemäe, K., Talk, M., Raudsepp, T.(2010). 10 aastat rinnavähi sõeluuringut Eestis: samm-sammult püstitatud eesmärkide poole. Eesti Arst; 89 (7-8):493-501
- Vähihaigestumus Eestis 2014 http://www.tai.ee/tegevused/registrid/vahiregister
- Vähi sõeluuringute register 2017 http://www.tai.ee/et/tegevused/registrid/vahi-soeluuringute-register