Periodic Well-Woman Visit: Individualized Contraceptive Care

Periodic Well-Woman Visit

The basic components of the periodic well-woman visit for asymptomatic patients aged 19 and older include a history, physical examination, selected laboratory tests, and counseling (Table 1).1,2 Recognizing that it is not possible for busy clinicians to cover all of the items recommended by professional association guidelines in today’s managed care environment, participants in a multidisciplinary panel of experts focused on items they consider essential. They also suggested a number of time-saving tips for screening and assessment techniques to help provide the most appropriate care for each patient within the shortest possible time (Sidebar A).

TABLE 1. Basic Components of the Periodic Well-Woman Visit: Asymptomatic Patients Aged 19 or Older1,2 SIDEBAR A. Time-Saving Tips for the Periodic Well-Woman Visit: Ages 19 and Older
History:

  • Personal, family, sexual, medical, smoking, abuse/neglect

Physical Exam:

  • Height, weight, blood pressure, neck, breasts, abdomen, pelvic, and skin*
  • Aged 40 or older: add oral cavity, axillae

Laboratory Tests:

  • As appropriate: cervical cytology, screening for sexually transmitted infections
  • Aged 19–39: thyroid-stimulating hormone screening*; for aged 50 or older, screen every 5 y
  • Aged 40 or older: add mammography
  • Aged 45 or older: add lipid profile assessment (every 5 y), colon cancer screening, fasting glucose testing (every 3 y)
  • Aged 65 or older: add bone density screening (every 2 y in absence of new risk factors)

Counseling:

  • Reproductive-age women: discuss contraceptive options, including emergency contraception; teach breast self-examination†

*For individuals at increased risk.
†Not recommended by the USPSTF or the Canadian Task Force; considered optional by the American Cancer Society.
Adapted from: Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 292. American College of Obstetricians and Gynecologists. Obstet Gynecol 2003;102:1117-24.

History:

  • Self-administered history completed in waiting room; health care provider reads, makes written and oral comments on any positive findings, and inquires about any incomplete responses

Physical:

  • Staff member records height, weight, blood pressure, reviews allergies, medications, and primary care provider at check-in
  • Clinician encourages patient to identify priorities and issues that are important to her at this visit, and together they select those that can be covered in the amount of time available

Laboratory Tests:

  • Post or provide patient handout explaining new guidelines for Pap smear screening; pelvic examination not required to initiate hormonal contraception ®

Counseling:

  • Provide handouts/wall charts describing contraceptive options; refer to Web site for breast self-examination instruction, if requested by patient
  • If not all counseling issues are completed during the visit: 1) schedule return visit; 2) schedule telephone appointment; 3) refer to hotline or Web site for specific issues; 4) offer reading/printed material; 5) refer to another source of care (e.g., clinic, health counselor, abuse treatment center)

 

Patient History

Key elements that should be covered in the patient’s personal, sexual, medical, and family history include the reason for the visit, her menstrual history, whether pain or bleeding is present during or after intercourse, any other medical conditions, smoking and abuse history, the family medical history, her sexual orientation, and whether she is currently sexually active. Women who are sexually active and at risk for pregnancy should be questioned about the use of birth control and measures to prevent STIs, and whether or not they may be pregnant.

Time-Saving Tip

Many clinicians save a considerable amount of time by having the patient complete a self-administered questionnaire in the waiting room. The health care provider is obligated to read this history, make written and oral comments on any positive findings, and inquire about any incomplete responses. Also available is a patient interview software that gathers complete present illness and past histories, translates the information into clinical terminology, and organizes the positives and negatives for each organ system.3

The following text relates to components of the periodic well-woman visit only. Additional assessments are appropriate in response to positives elicited during the history or examination, and during problem-related visits.

Physical Examination

The American College of Obstetricians and Gynecologists (ACOG) recommends that the physical examination performed as part of the periodic well-woman visit include measurement of height, weight, blood pressure, examination of the neck (adenopathy, thyroid), breasts, abdomen, and skin, if the woman is at increased risk of skin cancer as the result of increased recreational or occupational exposure to sunlight; family or personal history of skin cancer; or clinical evidence of precursor lesions.1,2 The panel of experts also thinks that listening to the heart and lungs should be an option for selected patients, such as smokers or those with a history of mitral valve prolapse. Calculation of the patient’s body mass index (BMI) can help determine whether or not she is overweight, and her waist-to-hip ratio can provide an indication of cardiovascular risk. A number of BMI and waist-to-hip ratio calculators are available on the Internet, such as the one at Aetna’sSM InteliHealth (www.intelihealth.com) under “interactive tools.”4 For reimbursement purposes, the new Health Care Financing Administration (HCFA) documentation guidelines state that a general multi-system exam should include findings for at least 8 of 12 organ systems: constitutional (e.g., vital signs, general appearance); eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; hematologic/lymphatic/immunologic.5

Time-Saving Tips

Table 2. Components of the Pelvic Examination: Asymptomatic Women*
Component Comment
Vaginal speculum Recommended for all sexually active women under age 25; necessary only for older women undergoing screening for lower genital tract cancer or STIs.
Bimanual USPSTF states that there is insufficient evidence to recommend for or against bimanual pelvic examination in asymptomatic women at increased risk of developing ovarian cancer.7
Rectal USPSTF strongly recommends screening of women 50 years of age and older for colorectal cancer.9 Experts recommend digital rectal exam for women aged 50 or older as part of pelvic exam.
*Not required to initiate or renew a prescription for hormonal contraception.6

 

Have a staff member record the patient’s height, weight, and blood pressure, review allergies and medi-cations, and verify the patient’s primary care provider before escorting the patient to an examining room. The abuse history can be taken in advance if it is conducted in a private space and the questions are asked orally by a nurse or person trained to conduct such interviews.

The clinician should encourage the patient to identify the priorities and issues that are important to her, and together they should select those that can be covered in the amount of time available at this visit. Other, less urgent issues can be addressed during a scheduled return visit, by phone or e-mail consultation, printed materials, or the patient can be referred to a hotline or Internet website for specific issues, suggestions, or printed materials.

Pelvic Examination

Components of the pelvic examination for an asymptomatic woman are listed in Table 2. However, experts emphasize that a pelvic examination is not required in order to prescribe hormonal contraception.6 Visual inspection of the external genitalia, vaginal speculum examination, and screening for sexually transmitted infections are recommended for all sexually active women under the age of 25 years, but are necessary only for older women who are undergoing screening for lower genital tract cancer or STIs. Although a routine bimanual pelvic exam is included in the ACOG recommendations for women aged 19 years and older and for teens aged 13 to 18 years of age when indicated by the medical history,1,2 some experts question the need. The US Preventive Services Task Force (USPSTF) concluded that there is insufficient evidence to recom-mend for or against bimanual pelvic examination in asymptomatic women at increased risk of developing ovarian cancer.7 In addition, the American Academy of Family Physicians (AAFP) does not recommend the use of ultrasound of the pelvis or serum tumor markers in women without a family history of multiple relatives affected by ovarian cancer.8 For this latter group, the AAFP concludes there is insufficient evidence to recommend for or against routine screening.

 

Experts emphasize that a pelvic examination is not required in order to prescribe hormonal contraception.6

The USPSTF recommends that clinicians screen men and women 50 years of age or older for colorectal cancer.9 Therefore, some experts suggest that digital rectal examination and fecal occult blood screening be included in the periodic health examination of women 50 years of age or older as part of the pelvic examination. For anyone aged 40 or older with a family history of early colorectal cancer, the AAFP recommends a fecal occult blood test annually, sigmoidoscopy, and barium enema or colonoscopy.8 Although ACOG does recommend colon cancer screening in women aged 40 or older; it does not specifically recommend rectal examinations in this age group.1,2

Laboratory Tests

Cervical Cytology Screening

SIDEBAR B. The Papanicolaou (Pap) Smear: The Most Effective Cancer Screening Test Ever Devised10,13
  • Cervical cancer was the leading cause of cancer death in US women as recently as the 1930s.13
  • Since the introduction of the Pap test in 1943, death from cervical cancer among US women has been reduced by more than 70 percent.10
  • Because the conventional Pap test is associated with a high false-negative rate, liquid-based, thin-layer preparation techniques have been developed to increase the sensitivity of Pap tests in detecting abnormalities.10 Most health insurance programs currently cover liquid-based thin-layer techniques. In the absence of cost concerns, the liquid-based approaches to cervical cytology appear preferable to conventional slide-based Pap tests.

Since 1943 when the Papanicolaou (Pap) smear was introduced, the incidence of invasive cervical cancer in US women has decreased significantly.10 (Sidebar B). This decrease has been attributed, at least in part, to organized

early detection programs. The routine of an annual visit to the clinician for a Pap smear has been widely accepted by women of all ages since the 1960s, when initiating and continuing hormonal contraception (i.e., oral contraceptives) became linked to obtaining a Pap smear.11 Today, both the American Cancer Society (ACS) and the new ACOG guidelines (see Table 3) recommend that cervical cancer screening begin approximately three years after a woman’s first sexual intercourse or by age 21, whichever comes first.12,13 Unlike ACS, which states that women younger than 30 can be tested every two years if a liquid-based method is used, ACOG thinks that there are very limited data to support this approach and recommends annual cervical cancer screening up to age 30.12,13

 

Although not all women will require annual Pap smears, the ACOG guidelines emphasize the importance of annual gynecologic examinations, even if cervical cytology is not performed.

 

A Major Change in the ACOG Guidelines for Women Aged 30 or Older

The new ACOG guidelines recognize that screening frequency can be individualized beginning at the age of 30 years in a woman known to have a negative history and several recent cervical cytology tests (Table 3).13 When cervical cytology alone is used, women who have negative results on three consecutive annual tests can be rescreened every two to three years.13 When both cervical cytology and the Food and Drug Administration (FDA)-approved test for high-risk human papillomavirus (HPV) types are used, women with a negative result on both tests should be rescreened no more often than every three years. If only one test is negative, more frequent screening is needed. Although not all women will require annual Pap smears, the ACOG guidelines emphasize the importance of annual gynecologic examinations, even if cervical cytology is not performed.

TABLE 3. Screening Recommendations for Cervical Cancer*13
First screen: Approximately 3 years after first sexual intercourse or by age 21, whichever comes first.
Women up to age 30:
Annual cervical cytology screening.
Women age 30 or older: Two acceptable screening options.

  1. Cervical cytology alone
    If negative results on 3 consecutive annual tests, rescreen with cervical cytology alone every 2–3 years.
  2. Cervical cytology + FDA- approved test for high-risk types of HPV
    If negative results on both tests, rescreen with combined tests every 3 years.
    If only one test is negative, more frequent screening is needed.
Exceptions:
More frequent screening may be required for higher-risk women who are infected with HIV, are immunosuppressed, were exposed to DES (diethylstilbestrol) in utero, have had previous abnormal Pap tests, or were previously diagnosed with cervical cancer.
Hysterectomy with removal of cervix: If for benign reasons, with no history of abnormal or cancerous cell growth, routine cytology testing may be discontinued.

If a history of abnormal cell growth (classified as CIN 2 or 3), screen annually until 3 consecutive, negative, vaginal cytology tests; then routine screening may be discontinued.

When to discontinue screening: ACS – non-high-risk women at age 70; USPSTF – by age 65; ACOG notes that due to limited studies of older women, it is difficult to set an across-the-board upper age limit for cervical cancer screening.
*Regardless of the frequency of cervical cancer screening, annual gynecologic examinations, including pelvic examinations, are still recommended

There is good evidence to support less frequent Pap smears for women aged 30 years or older. Data from eight cervical cancer screening programs with more than 1.8 million women showed that there was little difference in the incidence of cervical cancer with screening every year compared with every three years.14 However, there was significantly less protection against cervical cancer when the screening interval was extended to once every 5 or 10 years (Figure 1).

More recently, an analysis of cervical cancer screening results for 31,728 US women aged 30 to 64 years who had three or more consecutive negative tests found that the prevalence of biopsy-proven cervical intraepithelial neoplasia of grade 2 was 0.028 percent and that of grade 3 neoplasia was 0.019 percent; none of the women had invasive cancer.15 Compared with annual creening, Pap testing performed once three years after the last negative test in these women was associated with an excess risk of cervical cancer of approximately 3 in 100,000. An observation made by the authors is that, for a woman aged 30 years or older, the risk of cervical cancer associated with less frequent Pap testing (every three years) is low and roughly the same as the risk of breast cancer among men aged 45 to 64 years.15

 

An observation made by the authors is that, for a woman aged 30 years or older, the risk of cervical cancer associated with less frequent Pap testing (every three years) is low and roughly the same as the risk of breast cancer among men aged 45 to 64 years.

 

Will Women Accept Less Frequent Pap Test Screening?

Providers of women’s health care will be challenged to convince women that less frequent Pap smears will not significantly increase their risk of cervical cancer. Results of eight focus group interviews of women from urban practices, a university health center, and a rural family practice residence identified a number of barriers to risk-based cervical cancer screening (Sidebar C).11 As the result of years of promotion by the lay press and various organizations of the annual Pap smear as a key component of women’s health care, the women surveyed believe that annual screening is necessary and reduces cervical cancer mortality. Their reluctance to consider risk-based cervical cancer screening is based on a lack of knowledge about risk factors for cervical cancer, its natural history, and the effectiveness of annual versus triennial screening. Moreover, some women are suspicious that the recommendations for less frequent Pap smear screening were driven by organized medicine and the insurance industry, not by science. Women’s reluctance to change their beliefs was colored by experiences with the health care system, such as impersonal providers and staff, poor communication, limited access, and bad experiences during a particular visit. Clearly, educational efforts by clinicians and their staff will be important in changing women’s attitudes toward annual Pap testing. Some experts expect that clinicians may continue to offer annual cervical cytology for all patients having periodic well-woman visits until insurance companies restrict reimbursement for this service.

SIDEBAR C. Barriers to Risk-Based Cervical Cancer Screening11
  • Women strongly believe that annual (or even more frequent) screening is important.
  • Women perceive annual screening to be successful in reducing cervical cancer mortality.
  • Annual visit to a clinician for a Pap smear appears to be a firmly entrenched paradigm.
  • Reluctance of women to consider risk-based cervical cancer screening is based on lack of knowledge about.
    – risk factors for cervical cancer
    – its natural history
    – effectiveness of annual vs triennial screening, and
    – suspicion that changes in recommendations are motivated by economic factors, not by science
SIDEBAR D. Screening Recommendations for Sexually Transmitted Infections1,2,7,13,16
  • Routine screening for chlamydial infection strongly recommended for all sexually active women aged 25 years or younger13,16 and other asymptomatic women at increased risk for infection.8,13,16
  • Routine screening for chlamydial infection is recommended for all pregnant women aged 25 years or younger and others at increased risk for infection.16
  • Routine screening for gonorrheal infection is recommended for all sexually active adolescents1,2 and other asymptomatic women at high risk for infection.* 1,2,7

*”High risk” is defined as history of multiple sexual partners or a sexual partner with multiple contacts, sexual contact with individuals with culture-proven STI, history of repeated episodes of STIs, or attendance at clinics for STIs.13

Screening for Sexually Transmitted Infections

The new ACOG recommendations, a recent update by the US Preventive Services Task Force, and the revised AAFP policy recommendations for periodic health examinations recommend routine screening of all sexually active women aged 25 years or younger (regardless of marital status) for chlamydial infection and of other asymptomatic women at increased risk of infection (i.e., a history of multiple sexual partners or a sexual partner with multiple contacts, sexual contact with individuals with culture-proven STI, a history of repeated episodes of STIs, or attendance at clinics for STIs).1,2,8,16 AAFP also recommends screening of high-risk individuals for chlamydial infection beginning at the age of 18 years.8 Routine screening for chlamydial infection is recommended by the USPSTF for all pregnant women aged 25 years or younger and others at increased risk for infection, because there is fair evidence that screening and treatment improve pregnancy outcomes.16 However, the task force makes no recommendation for or against screening of asymptomatic, low-risk pregnant women aged 26 years or older because the benefits are small. Routine screening of sexually active adolescents for gonorrheal infection is recommended in the new ACOG guidelines, and both ACOG and the USPSTF recommend such screening for other asymptomatic women at high risk for infection.1,2,7

Regarding screening for human immunodeficiency virus (HIV), ACOG recommends testing in patients who are at high risk, defined as having any of the following:

  • Seeking treatment for STIs
  • Drug use by injection
  • History of prostitution
  • Past or present sexual partner who is HIV positive or bisexual or injects drugs
  • Long-term residence or birth in an area with high prevalence of HIV infection
  • History of transfusion from 1978 to 1985
  • Invasive cervical cancer1,2

Such testing should be offered to all women seeking evaluation prior to conception.

Counseling

In addition to contraceptive counseling, which will be discussed in detail in the next section, health care providers have traditionally taught or reviewed techniques for breast self-examination (BSE).

Breast Self-Examination

In 2001, the Canadian Task Force on Preventive Health Care concluded that there was good evidence that BSE causes harm and in a 2002 update, the USPSTF concluded that the evidence was insufficient to recommend for or against teaching or performing routine BSE.17,18 The American Cancer Society’s updated guidelines issued in 2003 make BSE optional.19 Further support for these changes was provided by a subsequent Cochrane Review and a meta-analysis.20,21 The Cochrane experts’ review of data from two large (nearly 400,000 women) population-based studies from Russia and Shanghai that compared BSE with no intervention found no statistically significant differences in breast cancer mortality.20 Almost twice as many biopsies with benign results were performed in the BSE group compared with the no BSE group. The reviewers concluded that “…the data do not suggest a beneficial effect of screening by breast self-examination whereas there is evidence for harms. At present, breast self-examination cannot be recommended.”

A meta-analysis of the 20 observational studies and three clinical trials that reported on breast cancer death rates or rates of advanced breast cancer according to BSE practice found no difference in death rate in studies on women who detected their cancer during an examination, and none of the trials of BSE training showed lower mortality in the BSE group.21 Compared with no self-examination, more women practicing BSE sought medical advice and underwent biopsies. The conclusion of this meta-analysis, like that of the Cochrane Review, was that regular BSE is not an effective method of reducing breast cancer mortality.

The experts think that it is no longer necessary to teach BSE during the periodic well-woman visit. Rather, they agree with the suggestion that women should be encouraged to pay attention to symptoms or changes in their breasts.22 Nevertheless, if a woman requests it, a staff member should be available to provide instruction in BSE, or the patient can be directed toward resources that instruct women in BSE such as the American Cancer Society or breastcancer.org.23,24

Time-Saving Tip

It is no longer necessary to teach BSE.

SIDEBAR E. Web Sites Dealing with Specific Issues
Smoking

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Washington, DC: US Dept of Health and Human Services; June 2000. Public Health Service publication no. 000032. Available at http://www.surgeongeneral.gov/tobacco. Accessed March 27, 2003.

Campaign for Tobacco Free Kids: http://www.tobaccofreekids.org

American Legacy Foundation: http://women.americanlegacy.org

CDC smoking and tobacco research database: http://www.cdc.gov/tobacco/search

Drug Issues

National Institute on Drug Abuse: http://www.nida.nih.gov

Center for Counseling and Health Resources: http://www.aplaceofhope.com

Weight Management

World Health Organization. Report of a WHO Consultation on Obesity, 3-5 June 1997, Geneva, WHO/NUT/NCD/98.1. http://www.who.int

CDC module on screening for overweight children and adolescents: http://www.cdc.gov/nccdphp/dnpa/growthcharts/training
/modules/module3/text/intro.htm

Health and Safety Topics

CDC health and safety topics: http://www.cdc.gov/az.do#top

Mental Health Issues

CDC mental health work group: http://www.cdc.gov/mentalhealth

National Institute of Mental Health: http://www.nimh.nih.gov

American Psychiatric Association: http://www.psych.org

American Psychological Association: http://www.apa.org

American Psychiatric Nurses Association: http://www.apna.org

Violence

The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings: http://endabuse.org/programs/healthcare/files/Consensus.pdf

Other Counseling Issues

If other counseling cannot be completed given the time constraints of a periodic well-woman visit, the multi-disciplinary panel of experts who met in November 2003 suggests the following options:

  • Schedule a return visit.
  • Schedule a telephone appointment.
  • Use e-mail exchange between patient and provider.
  • Refer to hotline or Web site for specific issues (Sidebar E).
  • Offer reading lists or printed material.
  • Refer to another source of care (e.g., clinic, health counselor, abuse treatment center).

References

  1.  

    Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 292. American College of Obstetricians and Gynecologists. Obstet Gynecol 2003;102:1117-24.

  2. Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 292. Washington, DC: American College of Obstetricians and Gynecologists; November 2003.
  3. Instant Medical History.TM Columbia, SC: Primetime Software. Information available at http://www.MedicalHistory.com.
  4. AetnaSM InteliHealth. Interactive Tools. Calculate your body mass index. Available at http://www.intelihealth.com. Accessed February 13, 2004.
  5. Edsall RL, Moore KJ. Exam documentation: charting within the guidelines. Available at http://www.aafp.org. Accessed November 20, 2003.
  6. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception. Current practice vs evidence. JAMA 2001;285:2232-9.
  7. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd edition. Baltimore, MD: Williams & Wilkins, 1996.
  8. American Academy of Family Physicians. Summary of Recommendations for Periodic Health Examinations. Rev. 5.4, August 2003. Available at http://www.aafp.org.
  9. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic Updates. Colorectal Cancer – Screening. July 2002. Available at http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed February 13, 2004.
  10. Association of Reproductive Health Professionals. Advances in Cervical Cancer Prevention. ARHP Clinical Proceedings. Washington, DC: ARHP; 2003.
  11. Smith M, French L, Barry HC. Periodic Abstinence from Pap (PAP) smear study: Women’s perceptions of Pap smear screening. Ann Fam Med 2003;1:203-8.
  12. American Cancer Society. Cancer Facts & Figures 2003. Atlanta, GA: ACS; 2003.
  13. American College of Obstetricians and Gynecologists. Cervical Cytology Screening. ACOG Practice Bulletin No. 45. Washington, DC: ACOG; 2003.
  14. Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. IARC Working Group on evaluation of cervical cancer screening programmes. Brit Med J (Clin Res Ed) 1986;293:659-64.
  15. Sawaya GF, McConnell KJ, Kulasingam SL, et al. Risk of cervical cancer associated with extending the interval between cervical-cancer screenings. N Engl J Med 2003;349:1501-9.
  16. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic Updates. Screening. Chlamydial Infection. 2001. Available at http://www.ahrq.gov/clinic/uspstf/uspschlm.htm. Accessed November 20, 2003.
  17. Baxter N. Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer? Can Med Assoc J 2001;164:1837-46.
  18. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic Updates. Breast Cancer – Screening. 2002. Available at http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm. Accessed November 20, 2003.
  19. Role of breast self-examination. Changes in guidelines. American Cancer Society, May 15, 2003. Available at http://www.cancer.org. Accessed February 13, 2004.
  20. Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
  21. Hackshaw AK, Paul EA. Breast self-examination and death from breast cancer: a meta-analysis. Br J Cancer 2003;88:1047-53.
  22. Green BB, Taplin SH. Breast cancer screening controversies. J Am Board Fam Pract 2003;16:233-41.
  23. American Cancer Society. How to perform a breast self-examination. Available at http://www.cancer.org. Accessed February 13, 2004.
  24. Breast Self Exam. Available at http://www.breastcancer.org. Accessed February 13, 2004.