Related to Breast Cancer Stage

Breast Self-Examination and Medical Examination Related to Breast Cancer Stage RUBY T. SENIE, RN, MA, PAUL PETER ROSEN, MD, MARTIN L. LESSER, PHD, AND DAVID W. KINNE, MD Abstract: The frequency and type of breast examinations reported by 1,21 primary breast cancer patients was studied in relation to local stage of disease. No significant relationship was found between the reported frequency of breast self-examination (BSE) and stage of disease; however, annual medical examination was significantly associated with small tumor size (P <.01) and absence of axillary lymph node metastases (P <.001). Regardless of the frequency of any method of examination, the majority (0 per cent) of tumors were first detected by the patients. Among those who detected their lesion, a greater frequency of medical examination was associated with an earlier pathological stage of disease (P <.001). Patients who were examined more frequently by a physician appeared to be more sensitive to clincially significant breast abnormalities. These findings underscore the importance of examiner skill in the successful use of palpation to detect breast cancer. Instruction in BSE by a health professional during periodic examinations may provide the optimal opportunity for improved proficiency in self-examination. (Am J Public Health 191; 71:53-0.) Until a method of prevention is readily available, diagnosis and treatment of breast carcinoma at an early stage provide the greatest opportunity for long-term survival. Poorer prognosis has been repeatedly associated with increasing stage of disease. 1 2 During the past few years it has been reported that more patients have presented with smaller tumors.3 Factors which may have contributed to this trend include: the establishment of breast cancer screening centers; more frequent inclusion of breast evaluation by physicians during routine physical examinations; and greater patient awareness of breast diseases through publicity by the media. Breast self-examination (BSE) has been encouraged by some clinicians as a valuable aid in early detection especially among those considered at increased risk.4 Others have questioned the ability of patients to detect small tumors in view of the difficulties physicians have experienced when evaluating large breasts or those composed of dense tissue.5 The purpose of this study is to describe the regularity of breast examinations reported by breast cancer patients. We have chosen especially to explore the relationships of physician evaluation and patient self-examination to local stage of disease. From the Memorial Sloan Kettering Cancer Center. Address reprint requests to Dr. Paul Peter Rosen, Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021. Ms. Senie, formerly a research associate with the Department of Pathology, is currently a doctoral student in epidemiology at Yale University. Dr. Lesser is with the Biostatistics Laboratory, and Dr. Kinne is Chief of the Breast Service, Department of Surgery. This paper, submitted to the Journal September, 190, was revised and accepted for publication January 13, 191. Editor's Note: See also related editorial, p. 572, this issue. Methods and Materials Interviews were conducted with 1,21 breast cancer patients consecutively admitted at Memorial Sloan-Kettering Cancer Center between October 197 and June 197, 97 per cent of the women with primary carcinoma admitted during the 22-month period. The frequency of breast selfexamination (BSE), physician examination, mammography and method of detection were among the items investigated as part of a general study of pathologic and epidemiologic aspects of breast cancer.7 Pathological review conducted by one of the authors provided data pertaining to the extent of axillary nodal involvement. The gross size of the primary tumor was measured at the time of diagnosis at Memorial Hospital and has been excluded for those patients referred for treatment after diagnosis elsewhere. The statistical significance of associations was tested using methods of chi square applied to contingency tables. The y (gamma) statistic was computed to assess the strength of association between ordinal variables or between an ordinal and dichotomous variable. Analysis of variance was used to determine the significance of differences between means for the variables tumor size and age at diagnosis. Mantel-Haenszel techniques were applied to stratified data. Results The Study Population At diagnosis the 1,21 women ranged in age from 21 to 95 years with a mean of 5 (SD = 12). A greater percentage were age 0 or older (39 per cent) than under 45 years (19 per AJPH June 191, Vol. 71, No. 53

SENIE, ET AL. TABLE 1-The Frequency of Self Examination in Relation to Selected Variables (0 Patients) (4 Patients) (37 Patients) Monthly Occasionally Never Age Group at N % N % N % Diagnosis' <45 years 91 39 90 39 51 22 45-150 30 200 40 155 0+ 109 23 19 41 2 3 Menstrual Status2 Pre 1 3 121 37 27 Peri 2 30 107 40 79 30 Post 151 24 20 42 211 34 Education Level3 <High Schobl 5 24 120 44 5 32 HS or Vocational 123 27 194 42 14 32 College or higher 12 34 4 3 147 30 Family History4 Present 1 34 139 3 115 30 Absent 219 2 349 42 23 32 Prior Benign Breast Disease Biopsy Proven5 40 75 54 25 Clinical Only 9 33 119 41 7 2 None 1 24 294 41 24 Hypertension History 0 22 12 44 12 34 No History 270 32 32 3 252 30 Marital Status Never Married 25 25 43 43 34 32 Currently Married 255 32 30 39 224 29 Previously Married 70 21 139 42 120 3 'P<.001, y =.19 2p <.005, y =.5 3P <.04, y = -.0 4P <.02 SP <.001 p <.003 'P <.02, y = -.15 cent). Using previously described criteria for menstrual status,9 27 per cent were pre-, 22 per cent peri-, and 51 per cent postmenopausal. The racial distribution was 91 per cent White, 7 per cent Black, and 2 per cent Hispanic or Oriental. More women were Jewish (42 per cent) than Catholic (3 per cent), or Protestant (1 per cent), other or no religious preference ( per cent). Among the 23 per cent of the population who were foreign born, the majority (9 per cent) were from Europe. Approximately 3 per cent of the women had completed high school (some with vocational training) and 40 per cent indicated college or graduate school education. Most patients were or had been married (92 per cent) and a majority gave a history of at least one full pregnancy (79 per cent). A familial history of breast carcinoma in one or more relatives was reported by 32 per cent of the women. Prior surgically treated benign disease was indicated by per cent and an additional 24 per cent gave a history of having had a clinically diagnosed benign condition. Medical care was reported by 30 per cent for hypertension, 19 per cent for thyroid disorders, and 7 per cent for diabetes. More than 43 per cent indicated use of steroid hormones at some point following puberty for one of the following: contraception, relief of menstrual or menopausal symptoms, prevention of miscarriage or lactation. 54 Relative weight categories (under, optimum, and over) were computed using the Metropolitan Life Insurance Table of Desirable Weights for Women. The full range of weight for small through large frame was considered optimum for each height. The optimum range varied from 10 (±+14) pounds for women 4'" to 15 (±+ 1) pounds for those 5' 1'. Invasive carcinomas were detected in 91 per cent of the patients; infiltrating duct carcinoma was the mnost frequent histologic type (9 per cent). Eleven per cent of the tumors were larger than 4 cm while 40 per cent were less than 2 cm. Axillary lymph node metastases were identified in 41 per cent of the 1,10 women who had an axillary dissection and internal mammary lymph nodes contained carcinoma in 30 per cent of the 10 cases treated by extended radical mastectomy. More than 52 per cent of the tumors were located in the upper outer quadrant of the breast. The left breast was affected in 5 per cent of the cases. Mean tumor size among the 1,011 measured lesions was 2. cm. Previous treatment for contralateral breast carcinoma was reported by 2 patients (7 per cent) and 102 ( per cent) were diagnosed with simultaneous bilateral disease. Self-Examination Patients were asked if they practiced BSE. Those who gave an affirmative response were questioned further con- AJPH June 191, Vol. 71, No.

BREAST EXAMINATION AND CANCER STAGE TABLE 2-Medical Examination with Breast Evaluation In Past 10 Years In Relation to Selected Factors Age Groups' <45 45-0+ Menstrual Status2 Pre Peri Post Education Level3 <High School HS or Vocational College or higher Family History4 History No History Prior Benign5 Breast Disease Biopsy Proven Clinical Only None Prior Breast4 Cancer History No History Thyroid Disease History No History Hypertension5 History No History Marital Status7 Never Married Currently Married Previously Married Religion5 Jewish Protestant Catholic Other Hormone Usage5 Ever Never Relative Weight Under Optimum Over Frequency of Breast Self Examination5 Monthly Occasionally Never N 155 327 244 222 12 322 125 21 340 250 47 12 213 1 2 4 147 579 15 541 53 515 15 342 1 23 32 34 70 474 12 20 2 (72 Patients) (2 Patients) (13 Patients) Yearly Less Frequent Never 7 5 51 52 4 54 70 5 57 75 73 49 75 5 50 4 52 4 7 54 4 9 53 1 4 50 74 47 N 5 142 152 4 202 94 142 11 105 247 47 4 241 3 2 127 225 32 205 115 133 57 137 25 133 219 3 19 120 77 144 1 25 2 32 2 25 33 24 27 30 22 22 21 30 29 29 27 2 2 29 37 25 32 2 33 22 30 N 19 3 3 20 20 9 51 0 27 30 10 14 11 3 1 14 124 55 3 5 5 37 23 7 11 32 10 9 70 13 5 9 7 1 19 13 13 3 5 1 4 12 13 15 10 7 12 15 1 15 9 1 4 11 1 'P <.001, y =.24 2p <.001, y =.2 3P <.001, y = -. 4P <.01 5P <.001 p <.03 7P <.001, y =.1 Bp <.003 ceming the frequency and regularity of BSE during the three years prior to entry into the study. Three frequency groups were established: at least monthly, occasional (every two or three months), and never, with reported frequencies of 29 per cent, 40 per cent, and 29 per cent respectively. No attempt was made to evaluate the technique or skill of the patients who gave a history of breast self-examination. AJPH June 191, Vol. 71, No. Selected variables were analyzed for the three frequency groups of self-examination (Table 1). A pattern of decreasing frequency of BSE with increasing age at diagnosis was observed. The mean age at diagnosis of women who reported monthly BSE was 53 years (SD = 12), five years younger than those who never performed self-examination, with a mean for occasional practicers of 5 years (SD = 12). 55

SENIE, ET AL. TABLE 3-Frequency of Medical Examination Related to Tumor Size and Axillary Nodal Status' Tumor Size2 Nodal Status2 Examination Frequency < 2 cm. 2 cm Negative Positive N % N % N % N % Yearly 332 51 323 49 450 3 22 37 Less Frequent 133 40 197 0 193 57 14 43 Never 27 21 99 79 5 44 71 5 1Includes 1,011 measured tumors and 100 microscopic lesions; 1,10 with axillary lymph node evaluations. 2p <.001 (y =.32, tumor size, -y =.21, nodal status). 3No significant difference from this resuft was found when patients with axillary metastases were subclassified by number of involved nodes (1-3 vs. 4 or more). Analysis of variance of the mean age of the patients in the three groups indicated statistically significant differences (P <.001). Monthly BSE was reported more frequently by patients with the following factors: presently married, higher education level, premenopausal status, family history of breast cancer, prior benign breast disease (either clinically diagnosed or surgically treated), and more frequent medical examination of the breasts. No significant association was found between the frequency of BSE and the following: religion, hormone usage, and relative weight. Mean tumor sizes were compared by analysis of variance. No significant differences from the overall mean of 2. cm (SD = 1.7) were observed in relation to the frequency of BSE. After stratifying the data by family history of breast cancer, history of benign breast disease, education level, and relative weight, no significant association between tumor size and frequency of self-examination was identified. No correlation was detected between the presence of axillary lymph nodes metastases and regularity of BSE within the total population nor within the stratified categories. Medical Examination of Breasts Yearly examinations were reported by 0 per cent, while 29 per cent were seen less often, and 11 per cent had not had an examination by a physician during the ten years prior to diagnosis. The frequency of medical examination in relation to selected variables is displayed in Table 2. The mean age of those who had not seen a physician during the ten years prior to diagnosis was 2 years (SD = 13), eight years more than those reporting annual or more frequent checks. Patients with intermediate examination schedules had a mean age of 57 years (SD + 12). Analysis of variance of age at diagnosis for the three frequency groups indicated significant differences (P <.001) between the means. Older women, although less likely to have annual breast examinations, reported frequent blood pressure and cardiac evaluations. There was no association between a history of hypertension and the frequency of physicians' evaluation of the breasts. Tumor size and axillary lymph node status at the time of diagnosis were significantly correlated with the frequency of medical examination (Table 3). A more favorable stage of disease was associated with more frequent physician examination. Among those who had yearly medical examinations, the mean size was 2.3 cm (SD = 1.4), significantly smaller than the 3.4 cm (SD = 2.2) mean tumor size of those who had not been examined within ten years of diagnosis (P <.001). Those with infrequent medical evaluations were noted to have an intermediate mean size of 2. cm (SD = 1.). Relationship of BSE and Medical Examination Frequency As noted above, a significant association was observed between the frequency of BSE and medical examination of TABLE 4-Size of Tumor in Relation to the Frequency of Examinations* Breast Examination < 2 cm 2 2 cm Totals BSE/Medical N % N % (a) Monthly/yearly 122 53 107 47 229 (b) Occasionally or never/yearly 210 49 21 51 42 (c) Monthly/less frequently or never 29 55 5 4 (d) Occasionally or never/ less frequently or never 1 241 5 372 Total Table P <.001 (a) vs (b) NS, Odds Ratio 1.2 (c) vs (d) NS, Odds Ratio 1.0 (a) vs (c) P <.005, Odds Ratio 2.2 (b) vs (d) P <.001, Odds Ratio 1. (a + b) vs (c + d) P <.001,y =., Odds Ratio 1.9 'Includes 1,011 measured tumors and 100 microscopic lesions. 5 AJPH June 191, Vol. 71, No.

TABLE 5-Axillary Nodal Status in Relation to Frequency of Examinations* Nodal Status BREAST EXAMINATION AND CANCER STAGE Breast Examinations Negative Positive Totals N % N % (a) Monthly/yearly 1 7 3 33 254 (b) Occasionally or never/yearly 20 1 39 45 (c) Monthly/less frequently 4 53 41 47 7 (d) Occasionally or never/ less frequently or never 203 53 47 Total Table P <.003 (a) vs (b) NS, Odds Ratio 1.3 (c) vs (d) NS, Odds Ratio 1.0 (a) vs (c) P <.03, Odds Ratio 1. (b) vs (d) P <.03, Odds Ratio 1.4 (a + b) vs (c + d) P <.001, y =.21, Odds Ratio 1.5 *Includes 1,10 patients with axillary lymph node evaluations. the breasts. To investigate this further, patients were grouped with regard to both types of examination. Four subsets were established: a) Monthly BSE/yearly medical b) Occasional or never BSE/yearly medical c) Monthly BSE/less frequent or no medical d) Occasional or never BSE/less frequent or no medical The relationships of these four patterns of examination with tumor size and nodal status are presented in Tables 4 and 5. Although the differences in overall distribution in each table were significant, further analysis revealed that subsets (a) and (b) did not differ appreciably from each other. Subsets (c) and (d) presented similar relationships. By comparing subset (a) with (c) the influence of the frequency of medical examination among the 3 reporting monthly BSE was evaluated. Women reporting annual medical examinations were found to have a significantly higher proportion of tumors less than 2 cm than those with less frequent or no medical evaluations (P <.005). The odds ratio of 2.2 confirms the strength of the association. A similar although less significant finding (P <.03) was observed in relation to the proportion of patients with no axillary nodal metastases. Comparison of combined subsets (a + b) and (c + d) revealed significant differences with respect to tumor size and nodal status; the odds ratios of 1.9 and 1.5 indicate the association with frequency of medical examination. The combined subsets were stratified by menstrual status (Table ) and analyzed by the Mantel Haenszel technique. Controlling for menopausal group, a significant association was noted when tumor size was analyzed by the examination frequency subsets. The analysis of nodal status by examination frequency also revealed a significantly different pattern among the stratified subsets. Method of Detection Among the 957 patients who were asked how the tumor TABLE -Tumor Size and Axillary Nodal Status in Relation to Examination Schedule Stratified by Menstrual Status Tumor Size Nodal Status Menstrual Status < 2cm 2cm Negative Positive Premenopausal(1,2) N % N % N % N % (a + b) 93 50 92 50 151 9 (c + d) 2 32 0 50 50 51 50 Perimenopausal(3,4) (a + b) 7 49 0 51 97 55 7 45 (c + d) 34 51 5 39 4 45 54 Postmenopausal(5,) (a + b) 11 52 151 4 203 4 115 3 (c + d) 9 15 5 10 57 123 43 (Tumor Size, Nodal Status) 'p <.01, -y =.37, Odds Ratio 2.2 2p <.01, -y =.39, Odds Ratio 2.3 3NS, y =.19, Odds Ratio 1.5 4NS, y =.1, Odds Ratio 1.4 5P <.001, y =.34, Odds Ratio 2.0 NS, y =.15, Odds Ratio 1.4 AJPH June 191, Vol. 71, No. 57

SENIE, ET AL. TABLE 7-Method of Detection in Relation to Tumor Size and Axillary Nodal Status' Tumor Size2 Nodal Status3 Detected by < 2cm 2 2cm Negative Positive N % N % N % N % Patient 2 3 429 2 407 55 33 45 Physician 75 53 41 104 73 3 27 Mammography 37 2 1 37 4 7 1 ' Includes 70 with measurable tumors and 929 with axillary lymph node evaluations among the 957 patients with known method of detection. 2Tumor Size Total Table P <.0001 Patient vs Physician P <.0001 3Nodal Status Total Table P <.0001 Patient vs Physician P <.001 was first detected,* a majority reported self-detection (0 per cent). Symptoms described by a small proportion included: pain or injury ( per cent); nipple discharge (3 per cent); or change is size or shape of the breast (1 per cent). The frequency of self-detection did not differ significantly by histologic type in the group of cases with invasive duct, lobular, or medullary lesions. Among the 42 patients with a history of previously diagnosed benign or malignant breast disease, the proportion of tumors self-detected was smaller than among those without prior breast conditions (74 per cent and 4 per cent respectively, P <.001). The method of detection was analyzed to separate the contribution of physician examination and mammography (Table 7). In 15 per cent of the cases, the lesion was initially found during a routine breast examination by a physician and in 5 per cent by mammography. Measured tumor size and the frequency of axillary lymph node metastases differed significantly by method of detection (P <.0001). After exclusion of patients with lesions detected by mammography, significant differences were noted in stage of disease between physician and patient detected cases. This observation is further supported by the finding of a significant difference (P <.01) in mean tumor size between tumors detected by physician palpation (2.1 cm SD = 1.4) and by the patient (2.7 cm SD = 1.7). Among the women who detected their carcinoma, size distribution was not significantly related to the frequency of BSE. However, a significantly greater proportion of lesions smaller than 2 cm was observed when women who detected their own carcinoma reported annual medical examinations. Relative weight was significantly associated with tumor size among those reporting self detection (P <.001). Women who were 20 or more pounds over their optimum range were more likely to have lesions of 2 cm or larger (2 per cent) than were those patients at ideal weight or less than 20 pounds in excess (5 per cent). Among those detected during a routine medical examination, weight was not a significant factor. *This question was added to the study four months after the first patients were accessioned. 5 Discussion Some clinicians consider emphasis on routine monthly self examination unduly frightening while others have recommended the practice and have provided careful instruction in BSE especially for those considered at high risk. Two recently published studiesl'0 1 described an association between more frequent BSE and less advanced stages of breast carcinoma. This observation was not confirmed in a study by Smith, et al,12 or by the data we have reported. We found no significant differences in mean tumor size or axillary lymph node status in relation to the frequency of breast self examination. Conceivably, this lack of agreement could be the result of differences in study design. In one report, interviews were conducted by several investigators using patients from seven institutions.'0 There was a 71 per cent participation rate. Those who refused interview tended to be older and more often widowed. These two factors were observed to be significantly related to frequency of BSE in our study and may have been a source of bias. Another study contained data recorded by an unspecified number of physicians prior to treatmentll as part of their clinical evaluation. Certainly, lack of uniform data ascertainment would be a serious concern. In addition, information was available for only 73 per cent of potential cases. We have minimized these types of selection bias in the present study. Personal interviews were conducted primarily by one nurse with 97 per cent of all consecutively diagnosed and treated breast cancer patients in one institution during a 22-month period. Demographic data such as age at diagnosis, menstrual status, and education level have been found to be significantly related to the frequency of health care practices. These may be reflected in geographic and institutional differences between populations studied. Therefore, an appreciation of the distribution of these variables among different populations is necessary before one can compare them with respect to methods of breast examination. By separating the frequency of BSE into three categories (monthly, occasionally, and less frequent or never), we were able to evaluate tumor size and nodal status in relation AJPH June 191, Vol. 71, No.

BREAST EXAMINATION AND CANCER STAGE to these patterns. Other reports have not considered the frequency of self examinationl' or have joined those with a monthly pattern and those performing BSE occasionally.12 Foster, et al,11 who categorized their patients into the same three frequency groups as in our study, observed a positive effect of BSE when patients were analyzed by clinical stage. Those in Stages 0, I and II were compared to patients clinically staged in III or IV. Although measured tumor size was found to differ significantly when women who reported ever performing BSE were compared to those who never practiced self-examination, the presence of pathologically determined axillary metastases did not show a significant associaton to BSE practice. Our findings agree with those of other studies in which decreasing frequency of BSE was associated with increasing age."1 A positive relationship between higher education levels and greater regularity of health care practices has also been noted."' 13 However, Greenwald, et al,10 using multivariate analysis did not detect any interaction between factors which we found significantly related to frequency of BSE and medical examination including: menstrual status, marital status, age, and education level. As in several other reviews,1012 we did not assess the skill of women reporting monthly or occasional BSE. Howe has reported that the abilities of women claiming to perform BSE varied considerably with only a small proportion competent enough to detect lumps in a simulated model.'4 The majority of the present study population may also have lacked skill and this would have obscured the beneficial effects for those who practiced BSE proficiently. Other possibly confounding factors that could not be controlled and may have affected our results include the degree of honesty and recall ability of those interviewed. Thiessen found that breast size and tissue characteristics could substantially limit the effectiveness of self exami- nation. These features, difficult to quantify for accurate comparisons, were not evaluated for the patients in this study. However, the significant relationship that we observed between relative body weight and tumor size among those reporting self detection suggests that breast size has an effect on tumor detection by patients. Our data indicate that BSE as currently practiced by the women in this study should not substitute for evaluation by a physician. We believe this is primarily the result of differences in the skill of the examiners. It is possible that careful instruction and routine practice would sufficiently improve BSE proficiency to enable a woman to be as effective in examining her own breasts as a trained professional. Although we found that monthly BSE practiced by our study population did not provide a diagnostic advantage over examination by physicians, comparing BSE frequency among women who sought annual medical examinations suggests some positive effects of BSE in this group. No similar influence was detected when BSE frequency was analyzed in women who did not seek annual medical examinations. It is reasonable to speculate that the observed benefit among those reporting annual physician evaluation and monthly BSE results from the interest of the individual women in their health care practices and the influence of breast examination procedures practiced by their physicians. Others have observed that the greatest degree of efficiency and compliance on a monthly basis has been achieved following personal instruction by a physician or a nurse. 15- Our data should not be taken to imply that routine medical examination of the breasts need necessarily be performed by a physician. Several authors have noted that, within a screening situation, nurse clinicians can be highly successful in identifying significant, palpable lesions.'' 19 Hall, et al,20 were able to demonstrate that training with standardized models improved the ability of a group of nonprofessional volunteers to detect breast lumps. There is evidence to suggest that careful instruction in the performance of BSE with periodic breast examination by a skilled professional other than a physician may provide an important contribution to the clinical diagnosis of breast cancer. 21, 22 REFERENCES 1. Berg JW, Robbins GF: Factors influencing short and long term survival of breast cancer patients. Surg. Gynecol Obstet 19;122:11-1 2. Say CC, Donegan WL: Invasive carcinoma of the breast: prognostic significance of tumor size and axillary nodes. Cancer 1974;34:4-471. 3. Fox MS: On the diagnosis and treatment of breast cancer. JAMA 1979;241:49-494. 4. Haagensen CD: Diseases of the Breast, 2nd Ed. Philadelphia: W.B. Saunders, 1971:-9. 5. Moore F: Breast self-examination. N Eng J Med 197;299:304-305.. Thiessen EV: Breast self-examination in proper prospective. Cancer 1971;2:1537-1545. 7. Senie RT, Rosen PP, Lesser ML, et al: Epidemiology of breast carcinoma II: Factors related to the predominance of left sided disease. Cancer 190;4:1-1%.. Goodman LA, Kruskal WH: Measures of association for cross classification. J AM Stat Assoc 1954;49:732-74. 9. Rosen PP, Senie RT, et al: Epidemiology of breast carcinoma: Age, menstrual status, and exogenous hormone usage in patients with lobular carcinoma in situ. Surgery 1979;5:219-224. 10. Greenwald P, Nasca PC, Lawrence CE, et al: Estimated effect of breast self-examination and routine physician examination on breast cancer mortality. N Eng J Med 197;299:271-273. 11. Foster RS, Lang SP, Costanza MC, et al: Breast self-examination practices and breast cancer stage. N Eng J Med 197;299:25-270. 12. Smith EM, Francis AM, Polissar L: The effect of breast selfexam practices and physician examinations in extent of disease at diagnosis. Prev Med 190;9:409-4. 13. Moss AJ, Wilder MH: Use of selected medical procedures associated with preventive care, United States, 1973. Vital and health statistics: Series 10, Data from the National Health Survey; No. 110 (DHEW pub. No. (HRA) 77-153, 1977, Washington, D.C. 14. Howe H: Breast self-examination proficiency: the basic element of BSE efficacy. Public Health Rep. March, April issue 191. 15. McCusker J, Morrow GR: Factors related to the use of cancer early detection techniques. Prev Med 190;9:3-397. 1. Rose MR: Survey reveals women's attitudes to breast selfexamination. NZ Nursing J 197;71:24-2.. Strax P: Strategy (motivation) for detection of early breast cancer. Cancer 190;4:92-929. 1. Moskowitz M: Clinical examination of the breasts by nonphysicians. A viable screening option? Cancer 1979;44:1-4. AJPH June 191, Vol. 71, No. 59

SENIE, ET AL. 19. George WD, Sellwood RA, Asbury D, Hartley G: Role of nonmedical staff in screening for breast cancer. Br Med J 190;2: 147-149. 20. Hall DC, Adams CK, Stein GH, et al: Improved detection of human breast lesions following experimental training. Cancer 190;4:40-414. 21. Gastrin G: Programme to encourage self-examination for breast cancer. Br Med J 190;2:193. 22. Mahoney U, Bird BL, Cooke GM: Annual clinical examination. N Eng J Med 1979;301:5-. ACKNOWLEDGMENT This study was supported by Contract NO1-CB3997, Breast Cancer Task Force, National Cancer Institute. I Forum Scheduled on Hospital's Role in Care for Elderly I A "Forum on Health Care for the Elderly: The Hospital's Role" will be held in Chicago, June 1 1-12, 191, hosted by the Hospital Research and Educational Trust (the Trust) and the American Hospital Association (AHA) under the sponsorship of the Administration on Aging of the US Department of Health and Human Services. The invitational forum, organized by the AHA/Trust Office on Aging and Long-Term Care, will bring together hospital and health care leaders to address the issues facing hospitals as a result of demographic trends, the changing nature of the hospital patient, and the resulting changing role of the hospital. Sessions will address the characteristics of the elderly patient, reorientation of the hospital's internal resources, reorientation of the hospital's relationship to other health care providers, manpower implications, and the consequences for financing of health care. An advisory panel was appointed to commission and to review papers from leading authorities for each of the sessions. The AHA and the Trust jointly established the Office on Aging and Long-Term Care to identify and foster effective responses from hospitals to the health needs of the growing elderly population. The Office is working toward a number of objectives including: establishing an information clearinghouse; publishing and disseminating information; conducting conferences and demonstration and research projects; and establishing liaisons with public policy and aging groups to encourage joint efforts promoting the effective care for the elderly. For further information about the June 11-12 forum, contact the AHA/Trust Office on Aging and Long-Term Care, the Hospital Research and Educational Trust, 40 North Lake Shore Drive, Chicago, IL 01 1; phone 2/20-20. 0 AJPH June 191, Vol. 71, No.