What nurses need to know

Older women’s breast screening behaviors: what nurses need to know

Mary Elaine Koren

The population of adults age 65 and older is expected to double in size in the next 50 years (U.S. Census Bureau, 2004). The majority of this aging population is women, and breast cancer is a major health concern for older women. The incidence of breast cancer ranks highest among all female cancers (Jemel et al., 2005), and both the incidence and death rate for breast cancer increase as women age (Ries et al., 2005).

Little is known about the breast screening behaviors of breast self-examination (BSE), mammograms, and clinical breast examination (CBE) in women age 65 and older (Bruening et al., 2006; Yarbrough 2004). Furthermore, studies of breast screening behaviors often group ages 65-95 together despite the 30-year age span (Stamler, Lafreniere, Thomas, & Out, 2002; Tittle, Chiarelli, McGough, McGee, & McMillan, 2002). Differences in breast screening behaviors among three age groups of women age 65 and older are discussed. Also, implications from the study’s findings are addressed.

Review of Literature

Questions have been raised regarding the impact of BSE and mammography on mortality. One often cited, large, randomized study found little relationship between BSE and breast cancer mortality (Thomas et al., 2002). After a systematic review of studies, Olsen and Gotzsche (2001) concluded that mammography leads to increased numbers of unnecessary mastectomies and has little impact on breast cancer survival for women age 50 and older. These reports obscure the inherent merit of BSE: it is noninvasive, involves no radiation exposure, raises women’s awareness of their anatomy, and promotes self-control (Elmore, Armstrong, Lehman, & Fletcher, 2005). Furthermore, mounting scientific evidence from multiple clinical trials continues to support annual mammogram screening for women age 40 and older (American Cancer Society [ACS], 2005; Elmore et al., 2005). Although controversy surrounds the efficacy of BSE and mammography, organizations such as the American Society of Clinical Oncology (Smith et al., 1999) and the Susan G. Komen Breast Foundation (2005) continue to recommend screening with monthly BSE and routine mammograms.

Another issue is establishing the best method for assessing women’s BSE proficiency. In a meta-analysis of 20 research studies, Ku (2001) measured BSE behavior by self-reported frequency only. Another study used an observational instrument to measure breast examination proficiency of health care providers (Coleman et al., 2003). Several observational instruments are available to assess proficiency of patients’ BSE performance on breast models (Reis, Trockel, King, & Remmert, 2004; Wood, Duffy, Morris, & Carnes, 2002). However, the models present problems because they are stiff and less pliable than human tissue. Ideally, BSE proficiency should be evaluated while women are performing BSE on their own breasts. However, no identified study investigated how accurately or proficiently women performed BSE on themselves.

For many years, gerontologists recognized differences among the young-old (65-74 years), old (75-84 years), and old-old (85 years and older) (Atchley, 2000). In a recent comprehensive evaluation of breast screening research, women over age 65 were evaluated as a homogeneous group or age was completely ignored (Bruening et al., 2006). Some studies on BSE frequency and proficiency categorized women by age but the specific age groupings varied. For example, a survey by Stamler and colleagues (2002) compared Canadian women above and below age 50, and found that participants age 50 and older practiced BSE less frequently than their younger counterparts. Akrigg (2001) evaluated both frequency and proficiency of BSE in a pilot study of 34 Asian women age 31-77. The author categorized the women by decade of life but found no significant differences in BSE among the age groups.

Various age categories also were used to investigate frequency of mammography screening among older women. Lauver, Kane, Bodden, McNeel, and Smith (1999) sampled 119 women age 51-80, while Tang, Solomon, and McCracken (2000) sampled Chinese-American women age 60-102. In both studies, mammography adherence decreased as age increased. Similarly, CBE research grouped women age 65 and older into one age category (George, 2000; Tang et al., 2000) and found fewer older women participate in CBE screening than younger women.

Older women are less likely to participate in mammography screening (Sharp, Michielutte, Spangler, Cunningham, & Freimanis, 2005) or mammography along with CBE than women age 65 and younger (Rawl, Champion, Usha, & Foster, 2000). Some of the barriers to mammography screening reported by older women include lack of health care provider referral, lack of transportation to a facility, concern about pain, lack of friends who have routine mammography, nonenrollment in a health maintenance organization (Levy-Storms, Bastani, & Reuben, 2004), and burdens of care giving to others (Messina et al., 2004).

In summary, little research is available on the breast screening behaviors of women age 65 and older, and some results are inconsistent. Studies that included women over age 65 often grouped them together without distinction of age. The grouping of women age 65 and older into one age category is problematic and limits understanding. Women age 65 may have different needs than 95-year-old women. They are a generation apart in age. None of the reviewed studies evaluated the accuracy of women performing BSE on their own breasts.


This descriptive study was designed to explore the practice of BSE, and participation in mammography and CBE among three age groups of older women. Three research questions were addressed. Do three age groups of older women (ages 65-74, 75-84, and 85-95):

1. Differ in the reported frequency of performing BSE?

2. Differ in their self-reported and observed proficiency in performing BSE?

3. Report differences in participation in mammography and CBE during the past year?

Sample and setting. The first author recruited a convenience sample of 200 women from 19 community-based sites for elders in one midwestern suburban county. Sites included senior housing units, some of which served as blood pressure screening sites for the county health nursing department; a blood pressure screening clinic at the health department; senior dining centers; and senior centers managed by the park district. Eligible participants were female, age 65 or older, and able to complete the questionnaire. The first author also evaluated participants in the observational part of the study to determine the adequacy of participants’ upper-extremity motor and sensory function to perform BSE. Participation rates at the sites were 30%-35%. All participants were Caucasian.

Measures. One self-report survey was used to gather data. Demographic data of age, level of education, and income were collected. Frequency of BSE was assessed with one question asking women how many times they examined their breasts in the past year; responses ranged from “once a month or more” to “not at all.” Two questions assessed self-reported participation in mammography and CBE during the past year; responses were “yes” or “no.”

Proficiency of BSE, both self-reported and observed, was evaluated with an investigator-developed checklist of 10 behaviors. Content validity of the checklist was based on an exhaustive review of the literature, ACS recommendations, and experts in the field. Final revisions were made after a pilot test with five women age 65 and older. One point was assigned to each reported or correctly completed behavior. The total proficiency score was the sum of the 10 items, with higher scores indicating higher levels of proficiency. Although the checklist included palpation and inspection behaviors, the emphasis was on palpation. In this study, Cronbach’s alpha for self-reported proficiency was 0.91 and for observed proficiency was 0.53.

Procedures. After institutional review board approval was obtained from a university-based hospital, the investigator visited each community site, discussed data collection with the site’s director, and obtained the director’s approval. During subject recruitment, each potential participant received an information sheet detailing the purpose of the study. Individuals who elected to participate in the study gave informed written consent before completing the data collection form. The investigator remained on site to answer questions until all women completed the survey, at which time the participants handed completed surveys to the investigator.

To obtain a subsample of women for BSE observation, all participants were invited to participate in the observational proficiency exam. Because few agreed to be observed, recruitment was stopped after 10 women from each age group were recruited. Individual appointments were made at a mutually agreeable time for BSE performance in the privacy of the participant’s home. After obtaining a separate written informed consent, the investigator completed the proficiency checklist while observing the woman perform BSE and provided feedback on BSE technique.

Data analysis. The Statistical Package for the Social Sciences (SPSS, Version 3.1) was used to analyze data. Descriptive statistics were used to group data, while Chi-square and one-way analysis of variance (ANOVA) were used to test differences among age groups.


The 200 participants were categorized into three age groups: ages 65-74 (n=77; 38.5%), 75-84 (n=78; 39%), and 85-95 (n=45; 22.5%). The three age groups of women differed significantly by educational attainment, [chi squire] (2, N=200) = 19.82, p<0.005, but not by income. Almost one-half of the 85-95 year-olds had post-high school education (46%), compared to 17% of the 65-74 year-olds and 35% of the 75-84 year-olds. The majority (n=160, 80%) reported an annual income of $20,000 or less.

The frequencies and percentages of women reporting the breast screening behaviors of BSE, mammogram, and CBE during the previous year are identified in Table 1. Only the proportion of women receiving mammogram was statistically significant; 22.2% of the 85-95 year-olds reported having a mammogram during the previous year, compared with 49.3% of 65-74 year-olds and 38.5% of 75-84 year-olds. Although not statistically significant, results in Table 1 indicate that the number of women performing BSE and receiving a CBE also declined with age.

Likewise, although not statistically significant (F (2, 199) = 2.24, p=0.11), self-rated proficiency scores declined with age; 65-74 year-olds had a mean score of 5.43; for 75-84 year-olds it was 4.95, and 3.95 for 85-95 year-olds. While self-reported and observed proficiency scores were correlated significantly (Spearman R=0.475, p<0.01), the mean self-reported scores for all women were higher (M=6.38) than the mean observed scores (M=3.71).

Observed proficiency scores also were not significantly different among the age groups, F (2,29)=1.47, p=0.247. However, when observing proficiency, the investigator noted varying palpation techniques among the three age groups. The proficiency checklist included three palpation behaviors: (a) use flat fingers, (b) press firmly, and (c) make small finger movements. The 85-95 year-old group performed these behaviors least often, and the 65-74 year-old group performed them most frequently. Regarding the use of small finger movements alone, only two women in the 75-84 year-old group and one woman from each of the other age categories incorporated this procedure into the BSE. Finally, two women palpated both breasts simultaneously and reported having been taught that method.


In this study, the proportion of 85-95 year-old women reporting at least monthly practice of BSE was less than that of younger age groups. Only one-third or less of the participants reported performing monthly BSE; this frequency decreased with age but was not statistically significant. The results of this study are similar to previous research in finding a decrease in the frequency of BSE with advancing age (Stamler et al., 2002).

No other study examined the observed proficiency scores of older women performing BSE. The self-reported and observed proficiency scores were correlated significantly even though the observed mean score was lower than the self-reported mean score. Self-reported proficiency is an indicator of actual skill performance, although not an exact predictor. This suggests that the proficiency tool was indeed measuring the same BSE behaviors whether self-reported or observed.

In the present study, 39% of all participants had a mammogram in the past year. As age increased, the proportion of women reporting participation in mammography screening decreased significantly. Similar to other studies, women over age 65 were less likely to participate in mammography by itself (Sharp et al., 2005), or mammography in combination with CBE, than women under age 65 (Rawl et al., 2000).

Over half the women (58%) in this study reported an annual CBE at a higher rate than a mammogram. Perhaps participants in this study obtained more CBEs because their health care providers performed CBE during a normal office visit but did not recommend a mammogram. Older women are more likely to have a mammogram if suggested by a health professional (Champion et al., 2003; Resnick, 2003).

Why were there so few statistically significant differences among the age groups of older women? Perhaps the research questions were not sensitive enough to measure the differences. The sample also was not representative of the population because it was an ethnically homogeneous convenience sample. For example, this sample of old-old women was more highly educated than the national population (Gist & Hetzel, 2004). Akrigg (2001) also found no differences by age group. Therefore, it is possible that breast screening behaviors really are similar among these different age groups of older women. However, age largely has been ignored in most studies (Bruening et al., 2006).

Clinical Implications

Because of breast cancer’s increasing incidence and mortality rates, breast screening becomes more important for women as they age (ACS, 2005). Women and their health care providers must make a decision regarding which breast screening behaviors are advantageous based on the woman’s state of health and her values and personal preferences (Walter & Covinsky, 2001). Personal preferences and the balance of benefit and harm should be discussed with each woman (Smith et al., 2003; Yarbrough, 2004). Nurses also should discuss possible barriers to breast screening, such as lack of transportation, perceived pain with the exam, inadequate health insurance, and lack of friends who are screened routinely (Levy-Storms et al., 2004). The primary reason women are screened is because of a health care provider’s recommendation (Champion et al., 2003; Resnick, 2003). Therefore nurses carry a responsibility to provide information and encouragement for older women to participate in breast screening activities of BSE, mammography, and CBE (Marshall, 2004).

Ideally, nurses should teach BSE techniques and breast awareness to older women and then evaluate their learning with a return demonstration. While self-reported proficiency was related to observed proficiency, it was not a perfect predictor. Observation is important to ensure appropriate skill performance. An optimal time is during the CBE when the nurse can observe the woman’s SBE performance and provide immediate feedback.

BSE techniques need to be tailored to specific needs of stratified age groups (Stamler, Thomas, & Lafreniere, 2000). In this study, although findings were not significant statistically, the investigator’s observations revealed that the oldest group of women performed three discrete palpation behaviors less frequently than the younger age groups. Also, two women in this study examined both breasts simultaneously and had apparently misunderstood what they were taught. Teaching may need to be repeated and provided in more than one form, such as verbal instruction and written instruction with pictures. Furthermore, if older women have joint changes due to arthritis, they should be encouraged to use a general palpation technique which covers the entire breast (Resnick, 2003). Older women also may need a system of reminders in order to practice monthly BSE (Wood et al., 2002).

It is difficult to enumerate the essential steps to perform a proficient breast exam. Perhaps it is more important to emphasize the woman’s familiarity with her own body, especially among older women. The best way to become familiar with the breast is through a general palpation technique (Resnick, 2003). Building on this idea, Bailey (2000) and McCready, Littlewood, and Jenkinson (2005) recommended teaching breast awareness to women regardless of their age. Breast awareness is more than just BSE; it involves a “woman knowing how her breasts look and feel normally, so that she will be able to detect any change which might be unusual” (Bailey, 2000, p. 1). A woman knows her own body better than anyone else. It is important to build on this concept and encourage women to know their own breasts.

These principles for modifying teaching and evaluation of older women also might apply to other health screening behaviors. For example, women with impaired vision may have difficulty recognizing skin changes while screening skin for cancer. Women with joint impairments may have difficulty with other psychomotor skills, such as fecal occult blood testing. Likewise, because of discrepancies between self-reports and observations of proficiency, nurses need to evaluate learning with return demonstrations any time older adults are taught psychomotor skills.

Recommendations and Conclusions

Future research should seek larger, more representative samples of older women grouped according to each decade of life, and use both self-reported and observational reports of BSE proficiency. In addition, the Cronbach’s alpha of the observational proficiency tool should be reassessed and inter-rater reliability evaluated. BSE research should continue to focus on how women execute the procedure on their own breasts, not on a breast model.

This study adds to the understanding of breast screening behaviors of older women in three age groups, an area of study virtually ignored. Screening is critical because older women are at high risk for breast cancer. However, screening techniques may need to be altered for older women due to changes of aging.

Acknowledgments: The authors appreciate the thoughtful review of this manuscript by Patricia Fox, PhD, RN, FAAN, and Clare Andres, MA.

Note: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.


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Mary Elaine Koren, PhD, RN, is Assistant Professor of Nursing, Northern Illinois University School of Nursing, DeKalb, IL.

Judith E. Hertz, PhD, RN, is Associate Professor of Nursing, Northern Illinois University School of Nursing, DeKalb, IL.

Table 1.

Self-Reported Breast Screening Behaviors During the

Previous Year Among Three Age Groups of Older Women (N = 200)

Breast Screening Behavior Age 65-74 Age 75-84 Age 85-95

(n = 77) (n = 78) (n = 45)

n (%) (1) n (%) n (%)

Frequency of BSE During Previous Year

Monthly or more often 25 (32:5%) 25 (32.1%) 12 (26.7%)

Less than monthly 33 (42.9%) 32 (41.0%) 15 (33.3%)

Not at all 19 (24.7%) 21 (26.9%) 18 (40.0%)

Mammogram (2)

Yes 38 (49.3%) 30 (38.5%) 10 (22.2%)

No 39 (50.6%) 48 (61.5%) 35 (77.8%)


Yes 49 (63.6%) 43 (55.1%) 24 (53.3%)

No 28 (36.4%) 35 (44.9%) 21 (46.7%)

(1) Percentages are based on number in each age

group, not the total sample

(2) [chi square] (2, N = 200) = 8.80, p = 0.012

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