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EARLY BREAST CANCER DETECTIONTHROUGH
CLINICAL BREAST EXAMINATION TRAINING FOR MIDWIVES
IN RURAL JAKARTA, INDONESIA
Project Investigator:Kardinah (Dharmais Cancer Hospital, National Cancer Center/Jakarta Breast Health Foundation)
Sri Indiyastutik (Yappika)
Funded by Breast Health Global Initiative (PRP019)June 2007 – March 2009
Presented November 10 2009
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Backgroundó Stage III and IV
ó Limited Resources
ó Unawareness among health provider
ó Breast cancer early detection program has not been developed yet (2007)
Down staged breast cancer
through CBE training for midwives ?
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Breast Health Global Initiativewww.fhcrc.org
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How to implement BHGI recommendation ?
Level of resources
Services Record Keeping Cancer Care Facility Breast Care Center
Basic Diagnostic Pathology
Nursing Services
Oncology ServicesPalliative servicesPsychosocial servicesPrimary care servicesSurgical services
Individual medical records and service based patient registration
Health Facility
Operating FacilityOutpatient care facilityPharmacyHome Hospice supportExternal consultationPathology laboratory
Breast healthcareaccess integrated into health care infrastructure
Limited Imaging services
Peer support servicesRadiation Oncology services
Facility based medical records and centralized patient registration
Hospital level Cancer Registry
Clinical information system
Health system network
Internal pathology laboratory
Radiation therapy
Breast Center with clinician. Staff and breast imaging access
Breast prostheses for mastectomy patients
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Level of resources
Patient and Family Education
Human Resource Capacity Building
Patient Navigation
Basic General education regarding primary prevention of cancer, early detection and self examination
Development of culturally adapted patient and family education services
Primary care provider education re breast cancer detection, diagnosis and treatment
Nursing education re cancer patient management and emotional support
Field nurse, midwife or health care provider triages patients to central facility for diagnosis and treatment
Human Resources Allocation
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Purpose
ó Increasing CBE ability in midwives
ó Increasing awareness in health provider
ó Strengthen referral system from primary care to district hospital
ó Increasing awareness among volunteers about:
-Breast health access in community
-Awareness of early detection in breast cancer
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Sub district KOJA – JAKARTA UTARA
Location
Population : 592.586 peoplesMale : 308.957 peoplesFemale : 283.626 peoplesPrimary health care : 6
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Participation
1. KelurahanRawaBadak Selatan
2. KelurahanTugu Utara
3. KelurahanLagoa
4. Islamic Center
5. KecamatanKoja
6. RumahsusunKoja
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Method
• Female health provider
• Primary health care
Midwives
CBE
Single view
Mammography
ó Public Participation
ó Public awareness
Volunteer
Organizing the activity
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Training
ó CBE training for midwives (target 30 person)
ó Half day
ó Short lecture about breast cancer
ó Practice of CBE
with breast phantom
ó Hospital tour
ó Early detection of breast cancer for volunteers (target 30 volunteers)
ó Half day
ó Short lecture about breast cancer
ó Hospital tour
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Activities on location• Midwives: presenting
how to do breast self examination to participant
• Practice CBE supervising by experienced physician
• A midwife - examined ±50 women with mammography
• Organizing presentation with title:
How to do Breast Self Examination
(approx. 60 women)
• Organizing mobile mammography (Jakarta Breast Health Foundation) and mobile audiovisual aid (Yappika Life)
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Result
ó Midwives training:
30 person
ó Midwives actively perform CBE : 25 person
ó Volunteer training 15 person
ó Organizing 30 presentation on 6 locations
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Participants
óBreast Check Up
óWomen came to have breast check up more than expected
óGroup CBE and Mammography (> 35 yr)
óGroup CBE only
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CBE and Mammography: 1179 participants
CBE Normal CBE abnormal
Mammography/Single view
Normal Abnormal
MammographySingle view
NormalAbnormal
Diagnostic imaging: UltrasoundParticipants recall
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CBE : 1174 participants
CBE
Normal
Ultrasound
Normal Participants Recall
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Result
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Result
1139
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Result
Outcome + Outcome - Total
CBE + 14 147 161
CBE - 1 977 978
Total 15 1124 1139
Outcome + Outcome - Total
Mammo + 15 136 151
Mammo - 0 988 988
Total 15 1124 1139
False Positive : 12%
False Positive : 13 %
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Result
1131
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Result
Outcome + Outcome - Total
CBE + 2 75 77
CBE - 0 1054 1054
Total 2 1129 1131
False Positive : 7 %
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Age group Frequency Breast Ca Prevalence(%)
20-29 4
30-39 208
40-49 546 10 1,8 %
50-59 323 4 1,2 %
60-69 50 1 2,0 %
70-79 7
80-89 1
1139 15
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Tumor size
Size (cm) CBE(N=2)
CBE +Mammography
(N=15)
Mean 4.3(3 - 5.6)
3.7(1.1 - 5.6)
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Result : 15 patients
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Conclusionó CBE training for health provider personnel
could detect smaller size tumor
ó Mammography add only 1/14 breast cancer diagnosis
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Further studyó Well design research : Epidemiologist
ó Expand the samples to have more statistically significant data
ó Focus on highest cancer age group : above 40 year
ó Group recall and Diagnostic breast imaging : immediately to prevent patients drops out
ó Surgical Oncologist : Early breast cancer management
ó Well informed primary health care about breast health program
ó Involving trained local health personnel and cadres : to open breast health access