Breast-related Complaints Research Articles

A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2-year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever-screened and never-screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health-seeking behavior for gynecological and breast-related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.

Characterizing Breast Symptoms in Family Practice

The frequency and outcome of breast symptoms have not been well characterized in primary care settings. To enhance and inform physician practice, this study aims to establish the proportion of visits and resultant diagnoses by age by examining longitudinal data on breast-related reasons for encounter. We used data from a prospective longitudinal sample of patients seeking care in Dutch family physician offices between 1985 and 2003 to provide routine family practice data on breast symptoms as the reason for encounter; all visits were coded using the International Classification of Primary Care. Data on breast symptom prevalence are based upon 84,285 active female patients and 367,834 total encounters. Overall breast symptoms were reported in about 3% of all visits by female patients (29.7 per 1,000 active female patients per year); breast pain and breast mass were the most common breast-related complaints. Breast symptom complaints were highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000). Of the women complaining of breast symptoms, 81 (3.2%) had breast cancer diagnosed. Breast mass had a markedly elevated positive likelihood ratio for breast cancer (15.04; 95% confidence interval, 11.74-19.28). As expected, of patients with breast symptoms only a small subset was subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass was associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses.

Management strategies for patients with nipple discharge

The aim of this study was to assess management strategies for patients with nipple discharge (ND). The records of 13,443 women with breast-related complaints who were examined by the same surgeon between 1 January 1960 and 31 December 2000 were retrospectively assessed. Patients with ND were grouped according to whether they had had a spontaneous or provoked discharge. The parameters investigated in each group were age, physical findings, number of pregnancies, duration of lactation, duration of discharge, colour of discharge, and histopathological features. Chi-square and Mann-Whitney U-tests were used for statistical analysis. ND was the presenting symptom in 603 (4.5%) of the cases. Two hundred and eighty-seven (48%) of the 603 patients showed spontaneous nipple discharge (SND group) and the other 316 (52%) showed provoked nipple discharge (PND group). In the SND group, 124 (43%) tissue specimens were obtained by either biopsy or sub-areolar exploration. Histopathological examination revealed that the most frequent causes of ND in these cases were intraductal papilloma (49 patients; 40%), intraductal carcinoma (35 patients; 28%), and cystic disease (15 patients; 12%). Twenty tissue specimens were obtained from the group with PND. In these cases, the most frequently identified causes of ND were cystic disease (seven patients; 35%), intraductal papilloma (six patients; 30%), ductal ectasia (two patients; 10%), and carcinoma (one patient; 5%). The SND and PND groups differed significantly with respect to age (P = 0.001) and duration of ND (P = 0.008). The incidence of cancer was higher in the SND specimens than in the PND specimens (28% vs 5%, respectively; P = 0.01). The number of pregnancies was significantly higher and the duration of lactation was significantly longer in the SND group (P = 0.03 and P = 0.02, respectively). The study confirms previous reports that patients with SND have a higher incidence of carcinoma than those with PND. The results suggest that older age, higher number of pregnancies, and longer duration of lactation may predispose to cancer development in patients with SND. The possibility of breast cancer should also be kept in mind when one is assessing patients with PND. Careful physical examination and close follow-up is the optimal management strategy for patients with any type of ND.

Quality assurance in a multidisciplinary symptomatic breast assessment clinic

Although quality assurance guidelines for surgeons have been issued and adopted for use in population-based breast screening programs in Australia, similar guidelines are unavailable for women referred with symptomatic breast problems. Six hundred and ninety-six women who attended the Royal Adelaide Hospital Women's Health Centre between February and November 1998 for investigation and management of a new breast-related complaint were prospectively evaluated. Investigation strategies and outcomes of the initial consultation were determined and the results compared with the performance quality standards for symptomatic breast disease according to the British Association of Surgical Oncology (BASO) Breast Surgeons' Group. A breast lump was the presenting symptom in 45%, while breast pain was present in 26%. Ninety per cent of women referred with breast symptoms were given a definitive benign or malignant diagnosis at the initial clinic visit. Although the median time delay between the date of general practitioner referral and breast clinic appointments for all patients was < or =7 days, the time delay for 'urgent' cases was not met according to BASO performance indicators. All other Royal Adelaide Hospital Breast Clinic audit data were within the range suggested by BASO performance indicators for new consultations in a symptomatic breast assessment clinic. A multidisciplinary breast clinic in a public hospital setting is able to provide clinical services to symptomatic women, with the majority of patients obtaining a confident diagnosis at the first presentation. Performance indicators for symptomatic breast disease are useful in identifying inadequacies at the clerical or clinical level which, following the implementation of subsequent changes, may lead to improvement in patient outcomes.

ECMO.

<b>PURPOSE</b> The frequency and outcome of breast symptoms have not been well characterized in primary care settings. To enhance and inform physician practice, this study aims to establish the proportion of visits and resultant diagnoses by age by examining longitudinal data on breast-related reasons for encounter. <b>METHODS</b> We used data from a prospective longitudinal sample of patients seeking care in Dutch family physician offices between 1985 and 2003 to provide routine family practice data on breast symptoms as the reason for encounter; all visits were coded using the <i>International Classification of Primary Care</i>. Data on breast symptom prevalence are based upon 84,285 active female patients and 367,834 total encounters. <b>RESULTS</b> Overall breast symptoms were reported in about 3% of all visits by female patients (29.7 per 1,000 active female patients per year); breast pain and breast mass were the most common breast-related complaints. Breast symptom complaints were highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000). Of the women complaining of breast symptoms, 81 (3.2%) had breast cancer diagnosed. Breast mass had a markedly elevated positive likelihood ratio for breast cancer (15.04; 95% confidence interval, 11.74–19.28). <b>CONCLUSIONS</b> As expected, of patients with breast symptoms only a small subset was subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass was associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses.

Breast cancer screening in Tel Aviv

Optimal breast cancer screening includes both physical examination and mammography. In anticipation of the addition of routine mammographic screening to Israel's 25-year-old early breast cancer detection program, we examined the demographic characteristics of almost one thousand women attending a breast cancer screening examination in Tel Aviv for the first time. The specific objective of the survey was to see whether women attending screening were those who stood a good chance of benefiting from it. Only half the women were aged 40 or older, and there was a preponderance of women of Western origin. Almost half had a breast-related complaint at the time of the visit. Targeted public education and appropriate administrative measures are necessary to ensure that women who can benefit from screening attend screening clinics and that clinics are not filled to capacity by women needing diagnostic evaluation and followup rather than routine screening. Tel Aviv general practitioners appeared to be aware of the advantages of breast cancer screening.

Management of Breast Lumps

This article discusses the management of the client who presents with a breast lump or abnormality. Approximately 25 percent of women who seek advice in a primary care setting do so because of a breast-related complaint. The practitioner can be instrumental not only in discovering breast abnormalities, but also in facilitating referral for further diagnostic measures, teaching BSE and providing psychological support to the client who has a breast lesion.