A model to optimize public health care and downstage breast cancer in limited-resource populations in southern Brazil. (Porto Alegre Breast Health Intervention Cohort)

Breast Cancer Knowledge Assessment of Health Workers in Ibadan, Southwest Nigeria

PURPOSE

Breast cancer is the most common cancer among women, and in low- to middle-income countries late-stage diagnosis contributes to significant mortality. Previous research at the University College Hospital, a tertiary hospital in Ibadan, Nigeria, on social factors contributing to late diagnosis revealed that many patients received inappropriate initial treatment.

METHODS

The level of breast cancer knowledge among health practitioners at various levels of the health system was assessed. We developed a tool tailored to local needs to assess knowledge of symptoms, risk factors, treatments, and cultural beliefs. The recruitment included doctors, nurses, and pharmacists in public hospitals, physicians and pharmacists in private practice, nurses and health care workers from primary health care centers, community birth attendants, and students in a health care field from state schools.

RESULTS

A total of 1,061 questionnaires were distributed, and 725 providers responded (68%). Seventy-eight percent were female, and > 90% were Yoruba, the dominant local ethnic group. The majority were Christian, and 18% were Muslim. Median knowledge score was 31 out of 56, and the differences in scores between health care worker types were statistically significant (P < .001). Nearly 60% of the participants believed breast cancer is always deadly. More than 40% of participants believed that keeping money in the bra causes breast cancer, and approximately 10% believed that breast cancer is caused by a spiritual attack.

CONCLUSION

Our questionnaire revealed that, even at the tertiary care level, significant gaps in knowledge exist, and knowledge of breast cancer is unacceptably low at the level of community providers. In addition to efforts aimed at strengthening health systems, greater knowledge among community health care workers has the potential to reduce delays in diagnosis for Nigerian patients with breast cancer.

p53 signaling pathway polymorphisms, cancer risk and tumor phenotype in TP53 R337H mutation carriers

Li-Fraumeni and Li-Fraumeni-like syndrome (LFS/LFL) are clinically heterogeneous cancer predisposition syndromes characterized by diagnosis of early-onset and often multiple cancers with variable tumor patterns and incomplete penetrance. To date, the genetic modifiers described in LFS/LFL have been shown to map to either TP53 or its main negative regulator, MDM2. Additionally, all studies were focused on families with different TP53 germline mutations. Hence, in this study we explored the effect of the most studied polymorphisms of p53 pathway genes on clinical manifestations of individuals carrying the founder TP53 mutation R337H (n = 136) and controls (n = 186). Cancer-affected carriers had been diagnosed either with adrenocortical carcinoma (ACC, n = 29) or breast cancer (BC, n = 43). Allelic discrimation using TaqMan assay was used for genotyping MDM2 SNP 309 (rs2279744) as well as MDM4 (rs1563828) and USP7 (rs1529916) polymorphisms. We found significantly higher MDM2 SNP 309 GG genotype and G allele frequencies in the LFS cohort than in controls. Furthermore, median age at first diagnosis was earlier in MDM2 SNP309 GG carriers when compared to other genotypes for both cancers (ACC: age 1 vs. 2 years; BC: age 35 vs. 43 years, respectively), although not statistically different. The allelic and genotypic frequencies for all SNPs did not differ between cancer affected and unaffected carriers, neither between patients with ACC or BC. In conclusion, our results suggest that MDM2 SNP 309 may contribute to the LFL phenotype and also to an earlier age at diagnosis of ACC and BC cancer in carriers of the R337H founder mutation.

Body image (dis)satisfaction among low-income adult women

BACKGROUND & AIMS

A better understanding of the factors that affect self-perception of body characteristics may play an important role in weight control practices. The objective of this study was to analyze body weight perception and body image satisfaction in low-income adult women in Southern Brazil.

METHODS

This was a cross-sectional survey study in a cohort of women recruited from areas of social vulnerability in the city of Porto Alegre, RS. A random sample (n = 218) of women was interviewed, and socioeconomic and lifestyle factors, body image perception using the Stunkard Scale, body weight estimation, weight concern and duplicate anthropometric measurements were obtained.

RESULTS

The average age of the low-income women was 56.3 ± 9.5 years. The prevalences of overweight and obese individuals were 34.1% and 52.5%, respectively. Among all women, 83.0% were dissatisfied with their body image, and 68.9% of the women estimated their body weight correctly. In addition to BMI (body mass index), the proportions of women with a higher income (p = 0.05), smoking history (p < 0.01) and history of hypertension (p = 0.04) were significantly different between groups according to body image satisfaction. Multivariate analyses using Poisson regression showed that black/mixed race, higher income, and underweight and obese women were more likely to be dissatisfied with their body image.

CONCLUSIONS

The majority of women know their body weight and have body image dissatisfaction. Skin color, higher income and BMI were significantly associated with dissatisfaction. In addition, these women consider the "healthiest" body image to be thinner than the "ideal" body image, and the "ideal" image is one of normal weight and not too thin.

Body Weight and Breast Cancer: Nested Case-Control Study in Southern Brazil

BACKGROUND

Current studies have shown that fast weight gain may be more important than body mass index on the incidence of breast cancer. The aim of this study was to evaluate the association between body weight and breast cancer.

PATIENTS AND METHODS

This was a case-control study nested in a cohort of a breast cancer mammography screening program in Southern Brazil. A trained investigator administered a standardized interview to collect sociodemographic and clinical data, and body weight history (weight at menarche, at marriage, at first and last pregnancy, and at menopause). Current anthropometric measurements were also made.

RESULTS

Fifty-seven women with cancer (66.7% postmenopausal) and 159 controls were included. Current age (60.3 ± 10.4 vs. 55.8 ± 8.4 years, P < .01), marital status (49.1% vs. 64.8% with a partner, P = .03), and physical activity (48.2% vs. 32.3% sedentary, P = .01) were significantly different between cases and controls, respectively. Odds ratio showed that age and current waist circumference were associated with postmenopausal cancer. No difference was found in relation to body weight at different stages of life.

CONCLUSION

Women with social vulnerability recruited at a mammography screening program in Southern Brazil showed a large weight gain during life, but no significant differences were found in body weight between women with or without breast cancer.

Assessment of potential risk factors for breast cancer in a population in Southern Brazil

PURPOSE

The aim of this study is to assess potential risk factors for breast cancer in a population in Southern Brazil and build a multivariate logistic model using these factors for breast cancer risk prediction.

METHODS

A total of 4242 women between 40 and 69 years of age without a history of breast cancer were selected at primary healthcare facilities in Porto Alegre and submitted to mammographic screening. They were evaluated for potential risk factors.

RESULTS

In all, 73 participants among the 4242 women had a breast cancer diagnosis during the follow-up of the project (10 years). The multivariate analysis considering all the patients aged 40-69 years showed that older age (OR 1.08, 95% CI 1.04-1.12), higher height (OR 1.04, 95% CI 1.01-1.09), and history of previous breast biopsy (OR 2.66, 95% CI 1.38-5.13) were associated with the development of breast cancer. Conversely, the number of pregnancies (OR 0.87, 95% CI 0.78-0.98) and use of hormone replacement therapy (OR 0.39, 95% CI 0.20-0.75) were considered a protective factor. Additionally, we performed an analysis separating the participants into groups of 40-49 and 50-69 years old, since a risk factor could have a specific behavior in these age groups. No additional risk factors were identified within these age brackets, and some factors lost statistical significance.

CONCLUSION

The risk prediction model indicates that the following variables should be assessed in this specific population: age, height, having had previous breast biopsies, number of pregnancies, and use of hormone replacement therapy. These findings may help to better understand the causal model of breast cancer in Southern Brazil.

Breast cancer screening in Brazil. Barriers related to the health system

Objective:

Identify factors related to the health system that lead to a late diagnosis of breast cancer in Brazil.

Method:

We performed a systematic review in the PubMed and LILACS databases using as keywords "Breast cancer," "system of health" and "Brazil or Brasil." We evaluated the content of the articles using the PRISMA methodology based on PICTOS. The final date was 12/16/2015. We were able to identify 94 publications in PubMed and 43 publications in LILACS. After assessing the title and summary, and excluding 21 repeated publications, we selected 51 publications for full evaluation. At this stage, we excluded 21 articles, with 30 publications remaining for study.

Results:

The population coverage is low, and there are problems related to the quality of mammography. Patients with lower income, nonwhite and less educated are more vulnerable. We observed punctual and initial experiences in breast cancer screening. Diagnosis and treatment flows must be improved. The inequality in mortality reflects the differences related to screening structure and treatment. Better results are observed in well-structured services.

Conclusion:

There are several barriers in the health system leading to advanced stage at diagnosis and limiting the survival outcomes. The establishment of a rapid and effective order for diagnosis and treatment, based on hierarchical flow, are important steps to be improved in the public health context.

[Cost-effectiveness of an organized breast cancer screening program in Southern Brazil]

The aim of this study was to evaluate the cost-effectiveness of an organized breast cancer mammographic screening program implemented in Porto Alegre (Núcleo Mama Porto Alegre - NMPOA), Rio Grande do Sul State, Brazil. A Markov model was constructed to estimate the incremental cost-effectiveness ratio of NMPOA compared to current BC diagnosis and care in the Brazilian public health system, in a hypothetical cohort of women aged 40-69 years at risk of developing breast cancer. Model parameters were collected from NMPOA and the national literature. In the NMPOA strategy, effectiveness was modeled taking into account the actual observed screening adherence. Effectiveness was measured in quality-adjusted life years (QALYs). Incremental cost-effectiveness ratio in the base case was R$ 13,426 per QALY. This result was not sensitive to variation in the main model parameters in sensitivity analyses. Considering the threshold usually suggested as highly attractive in Brazil, breast cancer screening as performed in NMPOA is cost-effective in cities with high incidence of breast cancer.

Predicting the stage shift as a result of breast cancer screening in low- and middle-income countries: a proof of concept

OBJECTIVE

To provide proof of concept for a simple model to estimate the stage shift as a result of breast cancer screening in low- and middle-income countries (LMICs). Stage shift is an essential early detection indicator and an important proxy for the performance and possible further impact of screening programmes. Our model could help LIMCs to choose appropriate control strategies.

METHODS

We assessed our model concept in three steps. First, we calculated the proportional performance rates (i.e. index number Z) based on 16 screening rounds of the Nijmegen Screening Program (384,884 screened women). Second, we used linear regression to assess the association between Z and the amount of stage shift observed in the programme. Third, we hypothesized how Z could be used to estimate the stage shift as a result of breast cancer screening in LMICs.

RESULTS

Stage shifts can be estimated by the proportional performance rates (Zs) using linear regression. Zs calculated for each screening round are highly associated with the observed stage shifts in the Nijmegen Screening Program (Pearson's R: 0.798, R square: 0.637).

CONCLUSIONS

Our model can predict the stage shifts in the Nijmegen Screening Program, and could be applied to settings with different characteristics, although it should not be straightforwardly used to estimate the impact on mortality. Further research should investigate the extrapolation of our model to other settings. As stage shift is an essential screening performance indicator, our model could provide important information on the performance of breast cancer screening programmes that LMICs consider implementing.

Apolipoprotein E genetic polymorphism, serum lipoprotein levels and breast cancer risk: A case-control study

The purpose of this study was to evaluate the association between apolipoprotein E (APOE) allelic frequency, serum lipoproteins and breast cancer (BC). We conducted a nested case-control study within a cohort including 47 cases and 165 controls. Polymerase chain reaction-restriction fragment length polymorphism analyses of the APOE polymorphism were performed. In general, participants with the genotype including alleles e2 and e3 tended to have lower serum triglycerides, total cholesterol and low-density lipoprotein cholesterol levels and higher high-density lipoprotein (HDL) cholesterol levels compared to participants homozygous for the e3 allele and participants heterozygous for the e3 and e4 alleles, respectively. BC patients exhibited higher mean levels of total serum cholesterol (P=0.070), dietary fat intake (P=0.020) and dietary cholesterol intake (P=0.017) compared to control subjects. The allelic distribution between the two groups revealed that the presence of the e2 allele was positively associated with the absence of BC, whereas the e4 allele was positively associated with the BC case group (P=0.019). The distribution of the APOE genotypes was not significantly different between cases and controls (P=0.172). The concomitant presence of the e2 and e4 alleles was positively associated with the absence of BC and e4/e4 homozygosity was positively associated with BC (P=0.021). Our findings suggested that APOE polymorphism plays an important role in the development of BC, particularly when associated with higher serum triglyceride levels.

Temporal variation of breast cancer surgical treatment in a university hospital in Brazil's Central West region

OBJECTIVE

To assess the types of surgical treatments for breast cancer performed by the Mastology program of the Clinics Hospital, Federal University of Goiás (HC-UFG).

METHODS

We conducted a cross-sectional, cohort study on the breast operations performed at HC-UFG from January 2002 to December 2009. We evaluated the surgical records for: surgical time and size, surgeon, type of operation, diagnosis, and type of anesthesia. The medical charts were researched for: pathology report of the tumor, lymph node involvement, primary tumor size, staging and performance of neoadjuvant therapies. We excluded operations for the removal of benign breast tumors. The temporal variation was analyzed using Poisson regression, considering the annual percentage change (APC).

RESULTS

403 operations were performed for breast cancer during the study period, with an average of 50.38 operations per year. The most common histological type was invasive ductal carcinoma (72.6%). The mean age of patients was 52 years, and 29% had disease in stages III and IV. The temporal trend revealed a significant increase in tumor size (p <0.01), the clinical stages III and IV (p = 0.01) and the use of neoadjuvant chemotherapy (p = 0.02). There was increase in mastectomies (APC = 9 cases/year, p = .04). There was no increase in cases of breast conservation treatments or of mastectomies with immediate reconstruction.

CONCLUSION

In recent years, the HC-UFG has had an increased number of mastectomies as a result of increased incidence of locoregionally advanced breast cancer.

Association of adipokines and adhesion molecules with indicators of obesity in women undergoing mammography screening

BACKGROUND

The soluble cell adhesion molecules and adipokines are elevated in patients with obesity, hypertension, type 2 diabetes mellitus, breast cancer and atherosclerosis.

OBJECTIVE

To investigate the relationship between anthropometric profile, dietary intake, lipid profile and fasting glycemia with serum levels of adipokines (adiponectin and PAI-1) and adhesion molecules (ICAM-1 and VCAM-1) in women without breast cancer undergoing routine mammographic screening.

DESIGN

Transversal study.

SUBJECTS

One hundred and forty-five women over 40-years old participated in this study.

RESULTS

In 39.3% of cases the BMI was above 30 kg/m2; 46.9% had hypertension, 14.5% had type 2 Diabetes Mellitus, 31.7% had dyslipidemia and 88.3% presented a waist-to-hip ratio ≥ 0.8. A linear correlation was found between serum levels of PAI-1 and triglycerides, between serum levels of PAI-1 and WHR and between serum levels of VCAM-1 and BMI.

CONCLUSION

We found a high prevalence of obesity and metabolic syndrome. PAI-1 and VCAM-1 levels were correlated with clinical indicators of obesity and overweight.

Disparities in female breast cancer mortality rates in Brazil between 1980 and 2009

OBJECTIVE

To describe the temporal trends in female breast cancer mortality rates in Brazil in its macro-regions and states between 1980 and 2009.

METHODS

This was an ecological time-series study using data on breast cancer deaths registered in the Mortality Data System (SIM/WHO) and census data on the resident population collected by the Brazilian Institute of Geography and Statistics (IBGE/WHO). Joinpoint regression analyses were used to identify the significant changes in trends and to estimate the annual percentage change (APC) in mortality rates.

RESULTS

Female breast cancer mortality rates in Brazil tended to stabilize from 1994 onward (APC = 0.4%). Considering the Brazilian macro-regions, the annual mortality rates decreased in the Southeast, stabilized in the South and increased in the Northeast, North, and Midwest. Only the states of Sao Paulo (APC = -1.9%), Rio Grande do Sul (APC = -0.8%) and Rio de Janeiro (APC = -0.6%) presented a significant decline in mortality rates. The greatest increases were found in Maranhao (APC=12%), Paraiba (APC=11.9%), and Piaui (APC=10.9%).

CONCLUSION

Although there has been a trend toward stabilization in female breast cancer mortality rates in Brazil, when the mortality rate of each macro-region and state is analyzed individually, considerable inequalities are found, with rate decline or stabilization in states with higher socioeconomic levels and a substantial increase in those with lower socioeconomic levels.

[Estimated mammogram coverage in Goiás State, Brazil]

This cross-sectional study aimed to estimate mammogram coverage in the State of Goiás, Brazil, describing the supply, demand, and variations in different age groups, evaluating 98 mammography services as observational units. We estimated the mammogram rates by age group and type of health service, as well as the number of tests required to cover 70% and 100% of the target population. We assessed the association between mammograms, geographical distribution of mammography machines, type of service, and age group. Full coverage estimates, considering 100% of women in the 40-69 and 50-69-year age brackets, were 61% and 66%, of which the Brazilian Unified National Health System provided 13% and 14%, respectively. To achieve 70% coverage, 43,424 additional mammograms would be needed. All the associations showed statistically significant differences (p < 0.001). We conclude that mammogram coverage is unevenly distributed in the State of Goiás and that fewer tests are performed than required.

Strategies for increasing mammography screening in primary care in Chile: results of a randomized clinical trial

BACKGROUND

Breast cancer is the cancer with the highest incidence among women in Chile and in many Latin American countries. Breast cancer screening has very low compliance among Chilean women.

METHODS

We compared the effects on mammography screening rates of standard care, of a low-intensity intervention based on mail contact, and of a high-intensity intervention based on mail plus telephone or personal contact. A random sample of 500 women with the age of 50 to 70 years registered at a community clinic in Santiago who had not had a mammogram in the past 2 years were randomly assigned to one of the three intervention groups. Six months after randomization, participants were re-evaluated for their compliance with mammography screening. The outcome was measured by self-report and by electronic clinical records. An intention to treat model was used to analyze the results.

RESULTS

Between 92% and 93% of participants completed the study. Based on electronic records, mammography screening rates increased significantly from 6% in the control group to 51.8% in the low-intensity group and 70.1% in the high-intensity group. About 14% of participants in each group received opportunistic advice, 100% of participants in the low- and high-intensity groups received the mail contact, and 50% in the high-intensity group received a telephone or personal contact.

CONCLUSION

A primary care intervention based on mail or brief personal contact could significantly improve mammogram screening rates.

IMPACT

A relatively simple intervention could have a strong impact in breast cancer prevention in underserved communities.

Adherence to a breast cancer screening program and its predictors in underserved women in southern Brazil

BACKGROUND

Adherence to breast cancer screening is a key element to ensure effectiveness of programs aiming at downstaging of breast cancer. In this study, we evaluated adherence to a screening program and its predictors in underserved women in southern Brazil.

METHODS

Attendance to the program, which is based on yearly mammogram and clinical examination, was evaluated prospectively. Mean time frames between visits were calculated. Possible predictors of adherence (defined as mean intervals ≤18 mo), such as socioeconomic indicators and health/lifestyle behaviors, were investigated.

RESULTS

A total of 3,749 women (age 51 ± 8 y, illiteracy rate of 6.8%, 57.4% with parity ≥3) were analyzed. Median time between screening rounds was 16.5 months (interquartile range, 13.1-25.7), and median number of rounds attended was 3 (interquartile range, 2-4); 57.6% had mean intervals ≤18, and 71% ≤24 months. The most important independent predictors of adherence were high genetic risk [relative risk (RR), 1.25; 95% confidence interval (95% CI), 1.11-1.40], illiteracy (RR, 0.77; 95% CI, 0.67-0.90), parity ≥5 (RR, 0.89; 95% CI, 0.83-0.96), and smoking (RR, 0.82; 95% CI, 0.77-0.88).

CONCLUSIONS

Although the proposed screening interval was 1 year, compliance to biannual screening (accepted in several international programs) was high, especially when considering the low socioeconomic level of the sample.

IMPACT

This project aims to test a breast cancer screening model for underserved populations in limited-resource countries where adherence is an issue. The identification of worst adherence predictors can point to interventions to improve outcomes of similar public health screening strategies.

Development and validation of a simple questionnaire for the identification of hereditary breast cancer in primary care

Background

Breast cancer is a significant public health problem worldwide and the development of tools to identify individuals at-risk for hereditary breast cancer syndromes, where specific interventions can be proposed to reduce risk, has become increasingly relevant. A previous study in Southern Brazil has shown that a family history suggestive of these syndromes may be prevalent at the primary care level. Development of a simple and sensitive instrument, easily applicable in primary care units, would be particularly helpful in underserved communities in which identification and referral of high-risk individuals is difficult.

Methods

A simple 7-question instrument about family history of breast, ovarian and colorectal cancer, FHS-7, was developed to screen for individuals with an increased risk for hereditary breast cancer syndromes. FHS-7 was applied to 9218 women during routine visits to primary care units in Southern Brazil. Two consecutive samples of 885 women and 910 women who answered positively to at least one question and negatively to all questions were included, respectively. The sensitivity, specificity and positive and negative predictive values were determined.

Results

Of the 885 women reporting a positive family history, 211 (23.8%; CI95%: 21.5–26.2) had a pedigree suggestive of a hereditary breast and/or breast and colorectal cancer syndrome. Using as cut point one positive answer, the sensitivity and specificity of the instrument were 87.6% and 56.4%, respectively. Concordance between answers in two different applications was given by a intra-class correlation (ICC) of 0.84 for at least one positive answer. Temporal stability of the instrument was adequate (ICC = 0.65).

Conclusion

A simple instrument for the identification of the most common hereditary breast cancer syndrome phenotypes, showing good specificity and temporal stability was developed and could be used as a screening tool in primary care to refer at-risk individuals for genetic evaluations.

Population prevalence of hereditary breast cancer phenotypes and implementation of a genetic cancer risk assessment program in southern Brazil

In 2004, a population-based cohort (the Núcleo Mama Porto Alegre - NMPOA Cohort) was started in Porto Alegre, southern Brazil and within that cohort, a hereditary breast cancer study was initiated, aiming to determine the prevalence of hereditary breast cancer phenotypes and evaluate acceptance of a genetic cancer risk assessment (GCRA) program. Women from that cohort who reported a positive family history of cancer were referred to GCRA. Of the 9218 women enrolled, 1286 (13.9%) reported a family history of cancer. Of the 902 women who attended GCRA, 55 (8%) had an estimated lifetime risk of breast cancer ≥ 20% and 214 (23.7%) had pedigrees suggestive of a breast cancer predisposition syndrome; an unexpectedly high number of these fulfilled criteria for Li-Fraumeni-like syndrome (122 families, 66.7%). The overall prevalence of a hereditary breast cancer phenotype was 6.2% (95%CI: 5.67-6.65). These findings identified a problem of significant magnitude in the region and indicate that genetic cancer risk evaluation should be undertaken in a considerable proportion of the women from this community. The large proportion of women who attended GCRA (72.3%) indicates that the program was well-accepted by the community, regardless of the potential cultural, economic and social barriers.