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Promoting early symptomatic presentation in older women with breast cancer in the NHS breast screening programme
LJL Forbes, L Atkins, S Sellars, J Patnick, L Tucker, AJ Ramirez
Breast Cancer Research , 2010, DOI: 10.1186/bcr2660
Abstract: We randomised 867 women attending their final round of screening to receive the PEP Intervention or usual care, measuring breast cancer awareness at baseline and 1 year. We systematically reviewed the evidence of effectiveness of interventions to promote cancer awareness and early presentation.At 1 year, the intervention increased the proportion breast cancer aware compared with usual care (24% vs. 4%; odds ratio = 15.2, 95% CI = 4.8 to 47.8). The systematic review found one randomised trial of a one-to-one intervention that showed a much smaller effect on breast cancer awareness.The PEP Intervention is more effective than any other intervention to promote breast cancer awareness. It will now be offered to all women attending for a final mammogram in three NHS breast screening services, to assess costs and feasibility and to measure its effect on breast cancer awareness in routine clinical practice. If implemented across the whole Programme, the PEP Intervention has the potential to reduce avoidable deaths from delayed symptomatic presentation in older women.
Promoting early breast cancer presentation in women after their final routine breast screening mammogram
A Ramirez
Breast Cancer Research , 2006, DOI: 10.1186/bcr1430
Abstract: The ultimate aim of the intervention is to reduce the proportion of older women with breast cancer who delay their presentation, and thereby save lives.
Involving users in the design of a randomised controlled trial of an intervention to promote early presentation in breast cancer: qualitative study
Lindsay JL Forbes, Carol Nicholls, Louise Linsell, Jenny Graham, Charlotte Tompkins, Amanda J Ramirez
BMC Medical Research Methodology , 2010, DOI: 10.1186/1471-2288-10-110
Abstract: Qualitative study involving 69 women participating in 7 focus groups and 17 in-depth interviews. 15 women had a previous diagnosis of breast cancer and 54 did not.The women held strong views and had a good understanding of the rationale of the design of clinical trials. The women recognised that in a very large trial with long-term follow-up it was necessary to incorporate design features to make the trial feasible and efficient. Most strikingly, they supported the idea of opt-out consent and identifying women with breast cancer using routine datasets.This model of user involvement engaged women well with the design challenges of the trial and led to improvements to the protocol. The study strengthens the case for user involvement, in particular through focus groups and in-depth interviews, in the design of trials.It is widely accepted that involving service users in the design of research makes for more relevant research questions, higher levels of participation, better study design, and better interpretation of findings [1]. The Department of Health Research Governance Framework recommends that "relevant service users..... should be involved wherever possible in the design, conduct, analysis and reporting of research" [2]. However, triallists rarely report whether users have been involved in the research and where they have, what happened as a result [3], which makes it difficult to judge how useful the user involvement was.We have designed a randomised controlled trial to evaluate the policy of offering a complex low-risk intervention to promote early symptomatic presentation of breast cancer in older women, and thereby improve survival. The intervention, known as the Promoting Early Presentation (PEP) Intervention, consists of a 10-minute interaction with a health professional supported by a booklet. It is designed to provide older women with information about the symptoms and risk of developing breast cancer, and the motivation, confidence and skills to present
Is it feasible to train diagnostic radiographers to deliver a psycho-educational intervention to promote early presentation of breast cancer amongst older women? A pilot study
C Burgess, P Whelehan, L Omar, L Tucker, L Kedge, A Ramirez
Breast Cancer Research , 2008, DOI: 10.1186/bcr2017
Abstract: A 10-minute structured interview has been developed and tested, which aims to improve older women's knowledge about breast symptoms and personal risk, and to increase confidence to detect a breast change. The intervention is quality assured against competency ratings on the content and style of the interview.Includes didactic teaching, communication skills training, experiential learning using role-play with actors and feedback on videotaped interviews. Skills are rehearsed in a clinic setting with mentoring from trained radiographers.Feasibility of training in the NHSBSP was tested with four radiographers working in the South East and South West London breast screening services. Competence and confidence to deliver the interview were assessed before and after training.All four radiographers completed the training programme. Three of the four radiographers were assessed as competent and all increased their confidence to deliver the intervention.It is feasible to train diagnostic radiographers to reliably deliver an intervention to promote early presentation of breast cancer, and thereby potentially save lives.
Temporal trends in breast cancer presentation in the third world
Stanley NC Anyanwu
Journal of Experimental & Clinical Cancer Research , 2008, DOI: 10.1186/1756-9966-27-17
Abstract: A prospective study initiated in 1985 for all breast cancer patients attending 4 hospitals located in the Eastern Nigeria heartland where the author practiced. On attendance to hospital detailed epidemiological data including social habits were collected from patients.Reports from our first series [1987–97] showed some improvement in terms of earlier presentation compared to a historical control of earlier reports from the sub-region. Reports from the present study showed that this improvement has not been maintained probably as a result of diversion of public health campaign finances to HIV/AIDS. However there is an increasing mean age of presentation due to a higher representation of above 70 years age group and a significant reduction in parity. Alcohol intake and smoking have remained at low levels among the patients.There is need to take another look at cancer public health campaign mechanisms in the face of competing demands from HIV. Public control measures should include among others teaching of Breast Self Examination [BSE] to patients, Clinical Breast Examination [CBE] to health workers and opportunistic CBE to all patients. Strenuous efforts should be made to break the vicious cycle of late presentation, poor treatment outcome and reluctance of patients to present to health facilities because of poor outcome.Breast cancer is now the most common female malignancy world-wide with up to a million cases annually[1,2]. Areas of greatest incidence have been N. America and Europe with black Africa considered an area of low incidence[2]. Studies from Nigeria indicate breast cancer has recently overtaken cervical cancer as the commonest female malignancy in areas of Western and Eastern Nigeria[3]. In other parts of the world racial incidence rates have changed due from migration and adoption of 'Western' life-style [4-6]. General worldwide mortality rates have decreased as a result of earlier detection, more favourable stage distribution and improved management[7]
Delays in presentation and treatment of breast cancer in Enugu, Nigeria
E.R Ezeome
Nigerian Journal of Clinical Practice , 2010,
Abstract: To assess the delays and define the causes of delay in presentation and treatment of breast cancer patients inEnugu,Nigeria. Across-sectional survey of breast cancer patients using a semi structured questionnaire. SurgicalOncology unit,University ofNigeriaTeachingHospitalEnugu, (UNTH-E),Nigeria. 164 consecutively presenting breast cancer patients seen between June 1999 andMay 2005. Most of the patients (82.3%) reported for initial evaluation at a modern health facility while 17.5% reported first toAlternative practitioners. Forty six patients (26.4%) presented within a month of noticing the symptoms while 72 (45.3%) delayed more than 3 months. In contrast, 18 (17%) were seen at the site of definitive treatment within one month of seeking help at the initial hospital while 73.4% had a delay of more than 3months after the initial hospital contact. Institutional or physician induced delayswere present in 46.2% of the caseswhile patient related delayswere present in 79.2% of cases.Only use of alternative practitioners for initial treatmentwas significantly related to delays ofmore than threemonths before presentation (p= 0.017). For breast cancer prevention programs in Nigeria to succeed, they must in addition to breast awareness and screening programs, address the institutional bottlenecks, the dearth of knowledge among primary care physicians and improve referrals fromalternative practitioners and prayer houses.
Ruptured gallbladder as the first presentation of breast cancer
M Jones, J Mathew, KE Abdullah, T McCulloch, KL Cheung
World Journal of Surgical Oncology , 2009, DOI: 10.1186/1477-7819-7-50
Abstract: Here we present a case of an elderly lady with acute abdomen with evidence of possible perforation of gall bladder on CT scan. Histopathology of the cholecystectomy specimen revealed invasive lobular breast cancer.Her metastatic breast cancer with right sided primary discovered subsequent to her presentation with acute abdomen is managed successfully with Anastrozole.We present a rare case of gall bladder perforation from metastatic breast cancer.Lobular carcinomas of the breast have higher prevalence of spread to gastrointestinal tract compared to their ductal counterparts [1]. Although breast cancer metastasis to the gall bladder has previously been reported [2-4], metastasis leading to perforation is very rare. We present this rare case of metastatic breast cancer presenting for the first time as ruptured gallbladder.An 84-year-old lady was admitted to hospital with a 12-hour history of severe, central abdominal pain and vomiting. Her abdomen was generally tender and reduced breath sounds were noted at the right lung base. Oxygen saturations were 94% on air and all other basic observations were normal. Liver function tests were also normal.A CT scan demonstrated free air and fluid within the peritoneum, air within the intra-hepatic bile ducts and gallbladder, and a right-sided pleural effusion [Fig 1]. CT scan did not show any obvious evidence of matastatic disease. It was concluded that the gallbladder had perforated and patient was prepared for emergency laparotomy.She underwent laparotomy, and was found to have a gangrenous, perforated gallbladder containing multiple small gallstones. Cholecystectomy was performed following an attempt of intra-operative cholangiogram which was unsuccessful due to difficulty in cannulating the cystic duct.Histologically, the lesion appeared to be a metastatic adenocarcinoma [Fig 2]. The gallbladder showed haemorrhagic infarction of the wall, probably caused by an obstructing metastatic carcinoma near the cystic duct. The tumour
The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation  [PDF]
Ketan Sharma,Ainhoa Costas,Ruth Damuse,Jean Hamiltong-Pierre,Jordan Pyda,Cecilia T. Ong,Lawrence N. Shulman,John G. Meara
Journal of Oncology , 2013, DOI: 10.1155/2013/206367
Abstract: Background. In Haiti, breast cancer patients present at such advanced stages that even modern therapies offer modest survival benefit. Identifying the personal, sociocultural, and economic barriers-to-care delaying patient presentation is crucial to controlling disease. Methods. Patients presenting to the H?pital Bon Sauveur in Cange were prospectively accrued. Delay was defined as 12 weeks or longer from initial sign/symptom discovery to presentation, as durations greater than this cutoff correlate with reduced survival. A matched case-control analysis with multivariate logistic regression was used to identify factors predicting delay. Results. Of patients accrued, 90 (73%) reported symptom-presentation duration and formed the basis of this study: 52 patients presented within 12 weeks of symptoms, while 38 patients waited longer than 12 weeks. On logistic regression, lower education status (OR = 5.6, ), failure to initially recognize mass as important (OR = 13.0, ), and fear of treatment cost (OR = 8.3, ) were shown to independently predict delayed patient presentation. Conclusion. To reduce stage at presentation, future interventions must educate patients on the recognition of initial breast cancer signs and symptoms and address cost concerns by providing care free of charge and/or advertising that existing care is already free. 1. Introduction Breast cancer remains the most common cancer and most common cause of cancer-related death amongt women worldwide [1]. While incidence rates have historically been higher in the developed world, recent evidence suggests an alarming increase in both incidence and mortality in low-income developing countries (LIDCs) [2]. Coupled with stable-to-declining age-standardized mortality rates in developed countries [3], an increasing number of preventable breast cancer deaths will continue to shift to LIDCs worldwide. Within LIDCs, the problem is further exacerbated as relative survival rates (approximated as the complement of the mortality-to-incidence ratio [4]) are lower due to both advanced stage at presentation and inaccessibility of potentially curative therapy [2, 5]. For example, in one study of sub-Saharan Africa, 90% of breast cancer patients presented with stage III or IV disease, a median tumor size of 10?cm, and palpable nodal metastasis [6]. These patterns of disease can be so advanced that even optimal western therapy may offer minimal survival benefit. This is distinctly different than in the developed world, where the majority of women present with early-stage disease, and more than 80% survive at least
Pattern of Presentation and Survival of Breast Cancer in a Teaching Hospital in North Western Nigeria
Terfa S. Kene,Vincent I. Odigie,Lazarus MD. Yusufu,Bidemi O. Yusuf
Oman Medical Journal , 2010,
Abstract: Objectives: Developing countries are experiencing demographic and epidemiologic transition and the prevalence of non-communicable diseases especially cancers which is on the increase. Breast cancer is the most common and lethal malignancy in developing countries with varying presentation. This study aims to determine the pattern of presentation and survival of breast cancer patients in North Western Nigeria.Methods:A five-year retrospective review of breast cancer records from 2001-2005 was conducted. Relevant information was retrieved and analyzed using statistical package for social science software. Manchester stage III and IV were classified as advance disease. Survival analysis was carried out with survival defined as the time between the date of commencement of treatment and the date of last follow-up or death.Results: Most of the patients were in the 4th and 5th decades 58 (57.4%) with a mean age of 44.5±13 years. Majority of the patients were females 99 (96.1%). One of the four males had invasive lobular carcinoma while the others presented with invasiveductal carcinoma 3 (75.0%). Most of the patients were premenopausal 62 (62.6%) and were presented late with advanced breast cancer disease 64 (62.1%). The left breast was more affected 64 (62.1%), and the upper outer quadrant was mostly involved 48 (60.7%), followed by the areola, 43(41.7%) either singly or in combination. Invasive ductal carcinoma was detected in 85 (82.5%) cases and was the predominant histological finding. Survival rate beyond 30 months was observed in 24.5% of cases and 100% for advanced and early breast cancer respectively, (p=0.0001). The overall survival rate beyond 36 months was 70.4% and postmenopausal patients (70.6%) had better survival beyond 36 months than premenopausal (68.5%) patients (p=0.05).Conclusion: The overall survival rate was low and patients with early breast cancer had better survival than those with advanced disease. Majority of the patients were young premenopausal women with advanced breast cancer.
Mammography and beyond: developing technologies for the early detection of breast cancer
Eugenio Paci
Breast Cancer Research , 2002, DOI: 10.1186/bcr429
Abstract: Following a short presentation of the history of mammography, the theory of efficacy evaluation through randomized clinical trials (all referenced) and the more recent evaluations of screening programmes that are ongoing in several countries are critically re-examined. The second chapter discusses new developments in breast imaging and in related technologies; a table presents the current status of imaging technologies for a large number of devices, few of which are currently of interest with regard to early detection. Most of the technologies discussed pertain to clinical diagnosis, and are unlikely to surpass mammography in the field of early detection in the near future.A chapter entitled Technologies in development: genetic and tumor markers reports on the progress that has been made in this important field, but it states that "... the ability to predict who will develop breast cancer is modest at best." We are still in the realm of basic research, and application of these technologies in screening is far from reaching routine daily practice. However, the authors emphasize the opportunity to improve predictive oncology in the early stages of breast cancer. Furthermore, with private companies developing genetic tests, and the fact that "The tests are not subject to FDA [Food and Drug Administration] regulation and thus clinical validity and utility did not have to be documented before entry into the market", there is a need for a new policy and for genetic counselling for women who request testing.The following chapter on the development and regulation of new technologies (which is referred to only within the context of the USA) is original to the best of my knowledge, at least for a European audience. The narrative of the initiatives and collaborations that have been active between government agencies, private industries and associations, and the examples of funding mechanisms for medical technology development confirm the massive investment into breast cancer c
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