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

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 ?

Breast Health Global Initiativewww.fhcrc.org

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

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

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

Sub district KOJA – JAKARTA UTARA

Location

Population : 592.586 peoplesMale : 308.957 peoplesFemale : 283.626 peoplesPrimary health care : 6

Participation

1. KelurahanRawaBadak Selatan

2. KelurahanTugu Utara

3. KelurahanLagoa

4. Islamic Center

5. KecamatanKoja

6. RumahsusunKoja

Method

• Female health provider

• Primary health care

Midwives

CBE

Single view

Mammography

ó Public Participation

ó Public awareness

Volunteer

Organizing the activity

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

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)

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

Participants

óBreast Check Up

óWomen came to have breast check up more than expected

óGroup CBE and Mammography (> 35 yr)

óGroup CBE only

CBE and Mammography: 1179 participants

CBE Normal CBE abnormal

Mammography/Single view

Normal Abnormal

MammographySingle view

NormalAbnormal

Diagnostic imaging: UltrasoundParticipants recall

CBE : 1174 participants

CBE

Normal

Ultrasound

Normal Participants Recall

Result

Result

1139

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 %

Result

1131

Result

Outcome + Outcome - Total

CBE + 2 75 77

CBE - 0 1054 1054

Total 2 1129 1131

False Positive : 7 %

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

Tumor size

Size (cm) CBE(N=2)

CBE +Mammography

(N=15)

Mean 4.3(3 - 5.6)

3.7(1.1 - 5.6)

Result : 15 patients

Conclusionó CBE training for health provider personnel

could detect smaller size tumor

ó Mammography add only 1/14 breast cancer diagnosis

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