Breast cancer screening tests

Document Sample
Breast cancer screening tests Powered By Docstoc
					early detection programs for
       breast cancer
             Dr Marilys Corbex
  WHO Eastern Mediterranean Regional Office
Estimated cancer incidences in the EM region
                           Relative incidence of breast and cervical
                                   cancers in the EM region

                                           Incidence (crude rates per 100 000) of breast and cervix cancer in the EMR
                     50
                     45
                                                                                                      BREAST
                     40
new cases/100 000




                     35                                                                               CERVIX

                     30
                     25
                     20
                     15
                     10
                      5
                      0
                                                                           AE
                                                               q




                                                                                                            n
                                                  ia




                                                                t




                                                                                                            a
                                                       Ku r
                                                               it




                                                                                                 iA n
                                                                                    o




                                                                                                         an
                                                            an




                                                                                                  Tu n
                                                             yp
                                           in




                                                                                               gh isia
                                 an




                                                                                                           ti
                          n




                                                                                                           n




                                                                                                          ia
                                                                                                           a
                                                              a



                                                           Ira




                                                                                                        Ira
                                                                                                        by
                                                           wa




                                                                                   c




                                                                                                          a
                                                                                                          e




                                                                                                       ou
                                                   r
                       no




                                                                                                        ta
                                                           at




                                                                                                        bi
                                          a
                                                Sy




                                                                                                       al
                                                                                oc




                                                                                            Sa Sud
                                                                          U
                                                          rd




                                                                                        m




                                                                                                      m
                                                        Eg
                                  t




                                                                                                     Li
                                       hr
                              kis




                                                                                                    ra
                                                                                                     is
                                                        Q




                                                                                                      n




                                                                                                    m
                                                                                                   jib
                      ba




                                                                                                   O
                                                                                       Ye
                                                       Jo




                                                                               or




                                                                                                 an
                                      Ba




                                                                                                So
                           Pa




                                                                                                 D
                    Le




                                                                              M




                                                                                              ud
                                                                                             Af
Effect of early detection



         From the early 70ies to the late
         90ies treatments have only
         improved slightly survival in U.S.
         The main improvement come from
         early detection.
     Early detection programs
1. Who to target ?
2. With which tools (screening tests) ?
3. Which kind of organization ?
4. Why to monitor the program ? (quality
   control).
Who to target ?
                      1. Who to target ?
Age is the major risk factor of Breast cancer.
 Target population has to be defined according to age pyramid and age specific incidence of
the country, taking into account available resources.

                                                              500
 Age Range         Risk of BC
                                                                             Egypt 1999-2001
                                                              400
     30 to 39      1 in 227                                                  Jordan 1996-2001

                                      incidence per 100 000
                              x 3.4
                                                              300
     40 to 49      1 in 67                                                   US SEER 1999-2001

                                                              200
     50 to 59      1 in 36
                                                              100
     60 to 69      1 in 26
                                                               0
(US-SEER estimates)                                                 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74     75+

                                                                                                        age
                                                                                                                 derived from MECC monography 2006 data


                                        Figure: Age Specific incidence Rates for breast cancer
                                        from Tanta population registry, Amman population
                                        registry and US SEER
       High risk groups ?
                  factors                    RR

Nb of 1st degree relatives with BC
                         1 vs none            2
                         2 vs none           3-5
First child             age >30 vs <20       2-3

Breast feeding          none vs 4 children   2.5

Menarche                <11 vs >15           1.5

Number of child         none vs 3            1.5
Which tools ?
 Breast cancer screening tests

• Breast self examination (BSE)
• Clinical breast examination (CBE)
• Mammography
• Ultrasonography
• Electrical impedance imaging
• Magnetic resonance imaging
• Positron emission tomography (PET)
• Scinti-mammography
• Digital mammography
            Screening tests

•   Sensitivity: The proportion of all those
    with disease that the test correctly
    identifies as positive.

•   Specificity: The proportion of all those
    without disease (normal) that the test
    correctly identifies as negative.
                           Mammography
Sensitivity
• From 53% to 92% in western countries*
• Low in pre-menopausal women (from
  44% to 76 % in women <50*)
Specificity
• From 82% to 98% in western countries*


Mammography requires quality control
Continuous Training and Monitoring,
Double reading




   *IARC handbook of cancer prevention
              Breast Self Examination
Sensitivity                         Specificity
low* (<17%)                                low*


Randomized trials of BSE:

The Russian federation / WHO study
(Semiglazov et al. 2003)
193 000 women aged 40 to 64 (begun in 1985)
 More BC death in the BSE group than the
control group

The Shangai study (Thomas et al. 2002)
267 040 women aged 31 to 66 (begun in 1990)
 No difference in mortality between BSE and
control group
     *IARC handbook of cancer prevention
BSE: a deceiving screening tool
• No effect on mortality by breast cancer
• High programmatic cost (training, reinforcement, management of
  false positive).
• For women: time consuming (training), adverse psychological
  effects.
• Potential harmful effect (delayed presentation).


 However “Breast awareness” cannot be overemphasized.
  Women do not have to worry about BSE procedure but have to be
  breast aware and ready to report anything suspicious to a
  practitioner.
       Clinical Breast Examination
Sensitivity (western countries)
• From 40% to 70%* # in western countries
Specificity
• From 85% to 95%* in western countries


Advantages
Low cost technique
Performable by non medical staff

       Efficiency for screening is under evaluation (No RT results to date)

       Duffy et Al. BHGI 2006: Modelisations suggest that the benefit of CBE is
       a little more than half of the benefit of Mammography

*IARC handbook of cancer prevention, #BHGI guidelines
Which kind of program ?
   Adapt program
    to resources

If resources are low, choose carefully:
• The target population (cost effectiveness)
• The method for early detection (cheap)
• But also the organisation of the program
       Early detection methods
• Screening aim at identifying the disease before
  symptoms appears by applying a test to the population
  at risk.
  The effective application of the tests to the right
  population is critical.

• Clinical downstaging: aims at identifying the disease
  through its very first symptoms.
  Clinical downstaging programs relies on education of
  health care providers and women as well as on efficient
  referral and diagnosis procedures.
2. Clinical downstaging
        2. Education of population at risk (poster,
        pamphlet, presentation, medias, special
        events…)

    opportunistic CBE

        1. Education of Heath staff (training sessions)

    3.Improved referral




        4. Rapid diagnostic and treatment
     Clinical downstaging in Sarawak




             photo Sarawak


SARAWAK
              Sarawak development
Population (2000) = 2.07 million
HDI = 0.805
(Egypt=0.702; Lybia=0.799)
Experience of downstaging in Sarawak,
               Malaysia
                                                       Percentage of patients presented at late stage
                                                    for NPC, breast and cervix in DRO, SGH (1991-1999)
                                300                                                                                        100


                                                                                                                           90

                                250                                                                      N breast
                                                                                                                           80
                                                                                                         N NPC
                                                                                                         N cervix
                                                                                                         % late breast     70
                                200
                                                                                                         % late NPC




                                                                                                                                 percentage of late stage
           number of patients




                                                                                                         % late cervix     60


                                150                                                                                        50


                                                                                                                           40

                                100
                                                                                                                           30


                                                                                                                           20
                                50

                                                                                                                           10


                                 0                                                                                         0
                                      1991   1992        1993     1994     1995    1996     1997     1998           1999
                                                                          years



 Percentage of late stage presentation for breast cancer was reduced
  by half over 4 years.
                            Method
Training Programme – 2 days
Students:    health staff from 18 district hospitals of Sarawak
               77 male/female nurses team from rural clinics (PHC)
Teachers:      1 coordinator, 1 clinical-oncologist, (1 ENT doctor),
               1 gynecologist and 6 female and male nurses



                   district
                                          urban population
                  hospitals

training
  team
                   PHC
                                             rural population
                  centers
             Reasons for success
                 in Sarawak
1. Increased awareness about cancer in the public & the
   health professionals.
2. Increased interaction between the health professionals
   and population (above all, in remote area)
3. Better organization: Improved referral (referral by
   nurses)
4. low cost : 10 000 $ (Poster, pamphlet, teaching material
   + travels of the training team, no salary cost)
          Organization of programs
1. Write the plan, assess the tools needed (HR, posters, etc)
2. Obtain good statistics of the “before situation”
3. Pilot study in a small region/population (possibly comparing
   different approaches)
4. Ensure a disciplined action
5. Obtain good statistic of the “after situation”. Ensure a fair
   evaluation.
7. Monitoring

      Planning              Action                Evaluation
Why to monitor the program ?
  So many opportunities to go wrong…
• Reach more the women are lower risk (young) than the women at
  high risk (old)
• Screen too much some groups  saturate screening facilities
• Create anxiety  saturate screening facilities with benign breast
  problems
• Low quality of screening tests (Mxm, CBE). False negative and false
  positive
• Poor follow up of positive women
• Poor access to treatment facilities  diagnostic without treatment !
• Neglect the acceptance of the program (“Philippines effect”) in
  women and men screening without diagnostic !

 ALL THESE NEED TO BE MONITORED
                   The Philippine study
Outcome of screening by clinical examination of the breast in a trial in the Philippines.
                           Pisani et al. Int J Cancer. 2006

  Objective: to assess whether mass screening by CBE is feasible in an urban
  population of a low-income country, and its efficacy in reducing BC mortality.

  Results:
  151,168 women were interviewed and offered CBE, 92% accepted.
  • 2.5 % (3479) were detected positive for a lump and referred for diagnosis.
  • Of these only 35% completed diagnostic follow-up, whereas 42.4% actively
  refused further investigation even with home visits, and 22.5% were not traced.
  • This behaviour was not due to logisitic or economic barriers.
  • In U.S. receipt of an abnormal mammography result is associated with
  considerable psychiatric morbidity.


  Conclusions: in this relatively well-educated population, cultural and logistic
  barriers to seeking diagnosis and treatment persist and need to be addressed
  before any screening programme is introduced.
                The Fakous
       clinical downstaging project
1- downstaging program                  targeted group

 - education of PHC                     all PHC staff
        2 days workshop

 - education of the population
         door to door visits           women 35-65
         women meetings (CBE)          women 35-65
         “men” awareness               all population

2- barriers study                       BC cases

 - socio / psycho / economic barriers
 to early diagnosis and treatment
 (“sociological questionnaire”)
       The Fakous project
                             Downstaging ?
                 Reached                       Unreached
                 women                         women


Barrier study: Effect of the program on barriers (risk factors)

Barrier study:     « risk factors » of late presentation


                 early BC                        late BC
 Problems for early detection programs
           in the EM region
• Lack of knowledge about the socio-cultural barriers existing in the
  population. These may need behavioural interventions.
• Information and programs reach better the women at lower risk
  (young).
• Misconception in the medical community (high risk groups, target
  population, risk factors, etc)
• “technomania” (digital mammography…)
• Barriers inherent to the health system.
• Proper structures for diagnosis and treatment (available, affordable)
• No evaluation of cost and benefit of fighting breast cancer against
  competing health needs
• Lack of 1/ planning, 2/ organisation, 3/ monitoring, quality control
          Planification and quality control


Suba et al. Cervical cancer
prevention for all the world’s
women: genuine promise resides in
skilled quality management rather
than novel screening approaches.
In press 2007




• Careful planning: if you fail to plan, you plan to fail
• Importance of quality management:
     • political and sociological obstacle to performance measurement
     • Program leaders and staff need to be sensitized to quality and evaluation
    Literature for Breast cancer
                                                ARTICLES


                • Anderson et al. 2006. Breast cancer in limited-resource countries: an
                  overview of the Breast Health Global Initiative 2005 guidelines.
                • Pisani et al. 2006. Outcome of screening by clinical examination of the
                  breast in a trial in the Philippines.
                • Miller AB. 2005. Screening for breast cancer -is there an alternative to
                  mammography?
                • Semiglazov et al. 2003. Results of a prospective randomized investigation
                  [Russia (St.Petersburg)/WHO] to evaluate the significance of self-
                  examination for the early detection of breast cancer
                • Anderson et al. 2003. Overview of breast health care guidelines for
                  countries with limited resources.
                • Hackshaw & Paul. 2003. Breast self-examination and death from breast
Breast cancer
                  cancer: a meta-analysis.
   in Latin
  America
                • Etzioni et al. 2003. The case for early detection.
 Raising        • Thomas et al. 2002. Randomized trial of breast self-examination in
awareness         Shanghai: final results.
  of the
 options        • Mittra et al. 2000. Is clinical breast examination an acceptable alternative
                  to mammographic screening?
PAHO pub
                • Pinotti et al. 1993. Breast cancer control programme in developing
                  countries.
‫شـكـرا‬
Thank You

				
DOCUMENT INFO