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Fulltext Guideline implementation for breast healthcare in low- and middle-income countries: early detection resource allocation

Yip CH, Smith RA, Anderson BO, Miller AB, Thomas DB, Ang ES, et al.

Cancer, 2008 Oct 15;113(8 Suppl):2244-56.
PMID: 18837017 DOI: 10.1002/cncr.23842

A key determinant of breast cancer outcome in any population is the degree to which cancers are detected at early stages of disease. Populations in which cancers are detected at earlier stages have lower breast cancer mortality rates. The Breast Health Global Initiative (BHGI) held its third Global Summit in Budapest, Hungary in October 2007, bringing together internationally recognized experts to address the implementation of breast healthcare guidelines for early detection, diagnosis, and treatment in low- and middle-income countries (LMCs). A multidisciplinary panel of experts specifically addressed the implementation of BHGI guidelines for the early detection of disease as they related to resource allocation for public education and awareness, cancer detection methods, and evaluation goals. Public education and awareness are the key first steps, because early detection programs cannot be successful if the public is unaware of the value of early detection. The effectiveness and efficiency of screening modalities, including screening mammography, clinical breast examination (CBE), and breast self-examination, were reviewed in the context of resource availability and population-based need by the panel. Social and cultural barriers should be considered when early detection programs are being established, and the evaluation of early detection programs should include the use of well developed, methodologically sound process metrics to determine the effectiveness of program implementation. The approach and scope of any screening program will determine the success of any early detection program as measured by cancer stage at diagnosis and will drive the breadth of resource allocation needed for program implementation.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Reliability and validity of Champion's Health Belief Model Scale for breast cancer screening among Malaysian women

Parsa P, Kandiah M, Mohd Nasir MT, Hejar AR, Nor Afiah MZ

Singapore Med J, 2008 Nov;49(11):897-903.
PMID: 19037556

Breast cancer is the leading cause of cancer deaths in Malaysian women, and the use of breast self-examination (BSE), clinical breast examination (CBE) and mammography remain low in Malaysia. Therefore, there is a need to develop a valid and reliable tool to measure the beliefs that influence breast cancer screening practices. The Champion's Health Belief Model Scale (CHBMS) is a valid and reliable tool to measure beliefs about breast cancer and screening methods in the Western culture. The purpose of this study was to translate the use of CHBMS into the Malaysian context and validate the scale among Malaysian women.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Knowledge and behavior regarding breast cancer screening among female teachers in Selangor, Malaysia

Parsa P, Kandiah M, Mohd Zulkefli NA, Rahman HA

Asian Pac J Cancer Prev, 2008 Apr-Jun;9(2):221-7.
PMID: 18712963

A cross-sectional study was carried out to determine the knowledge and practices of 425 female secondary school teachers from 20 selected secondary schools in Selangor, Malaysia on breast cancer screening (BCS). A self-administered, structured questionnaire was used for data collection. This study showed moderate to low knowledge on breast cancer (BC) and BCS among teachers. Only 19%, 25% and 13.6% eligible women performed breast self-examination (BSE), clinical breast examination (CBE) and mammography respectively, on a regular basis. Level of breast cancer knowledge was significantly associated with BSE (p<0.001). Having heard/ read about BCS, and regular visit with a physician were associated with BCS behaviors (P<0.05). There was no association between BCS behaviors (P>0.05) and age, family history of breast cancer, marital status or having health insurance. Efforts are needed to increase knowledge and remove misconceptions about breast cancer and screening practices among Malaysian women.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Does a positive family history influence the presentation of breast cancer?

Yip CH, bt Mohd Taib NA, Lau PC

Asian Pac J Cancer Prev, 2008 Jan-Mar;9(1):63-5.
PMID: 18439076

INTRODUCTION: An important risk factor for developing breast cancer is a positive family history of breast cancer. In Malaysia, there is no population-based breast screening programme, but the clinical practice guidelines suggest increased surveillance for those with a positive family history ie mammography for those 40 years old and above, breast self-examination and clinical breast examination yearly.
OBJECTIVE: To determine if women with a family history of breast cancer present with earlier stages of disease.
METHODOLOGY: From Jan 2001 to Dec 2006, 1553 women with breast cancer presenting to the University Malaya, where family history was recorded, were eligible for this study. Women with a first or second degree relative with breast cancer were compared with those who have no family history with regard to their race, age, stage, size and duration of symptoms. The Chi Square test of significance was used for analysis.
RESULTS: Out of 1553 patients, 252 (16.2%) were found to have a relative with breast cancer out of which 174 (11.2%) had at least one affected first degree relative. There were no significant difference in the incidence of positive family history between the Malays, Chinese and Indians. 20% below the age of 40 years old had a positive family history compared with 12.6% in women with no family history. (p<0.05). There was no significant difference in stage at diagnosis between those with and without family history, ie 24.2% late stages (Stage 3 and 4) in the group with no family history compared with 21.8% in the group with family history. (p>0.05). The mean size in the group with no family history was 4.4 cm compared to 4.1 cm in the group with family history. There was a significant difference in screen-detected cancers in the women with family history, 10.7% compared with 5.1% of screen-detected cancers in the group without a family history. However there was no difference in the duration of symptoms between the 2 groups--25.8% in the women without a family history presented after 1 year of symptoms compared with 22.4% in the group with a family history (p>0.05).
CONCLUSION: Having a family history of breast cancer does not appear to have much impact on the health-seeking behavior of women. Even though there were more screen detected cancers, these comprised only 10% of the group with family history. Public education should target women at risk ie with family history to encourage these women to present earlier and to undergo screening for breast cancer.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Relationship between selenium and breast cancer: a case-control study in the Klang Valley

Suzana S, Cham BG, Ahmad Rohi G, Mohd Rizal R, Fairulnizal MN, Normah H, et al.

Singapore Med J, 2009 Mar;50(3):265-9.
PMID: 19352569

The purpose of this study was to assess the relationship between selenium status and intake among breast cancer patients from the Klang Valley.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Myoid hamartoma of breast with chondroid metaplasia: a case report

Khoo JJ, Alwi RI, Abd-Rahman I

Malays J Pathol, 2009 Jun;31(1):77-80.
PMID: 19694319 MyJurnal

Breast hamartoma is an uncommon poorly recognised benign breast neoplasm. Hamartoma displaying marked smooth muscle components known as myoid hamartoma of the breast is a much rarer entity. We present a case of myoid hamartoma of breast with chondroid differentiation in a 46-year-old woman. The painless breast lump was circumscribed and mammography showed a well-encapsulated large, dense mass with no calcification. Core needle biopsy was reported as fibroadenoma. The lesion was excised. Microscopically, it composed of many groups of mammary glandular components with dense fibrous stroma, adipose tissue and marked groups of smooth muscle fibres. Foci of chondroid differentiation were noted in the lesion. The smooth muscle cells showed strong and diffuse immunoreactivity for vimentin, myogloblin, alpha-smooth muscle actin, desmin and CD34 and failed to express pan-cytokeratin or S100 protein. The ducts lined by epithelial cells were reactive to pan-cytokeratin while the myoepithelial cells were reactive to S100 protein. The various immuno-histochemical staining as well as the cyto-histological changes encountered in myoid hamartomas are discussed with clinical, radiological and pathological correlation to differentiate it from other benign and malignant breast lesions.

Matched MeSH terms: Breast Neoplasms/diagnosis
Fulltext Trends of breast cancer treatment in Sabah, Malaysia: a problem with lack of awareness

Leong BD, Chuah JA, Kumar VM, Rohamini S, Siti ZS, Yip CH

Singapore Med J, 2009 Aug;50(8):772-6.
PMID: 19710974

Sabah, formerly known as North Borneo, is part of East Malaysia. 52.2 percent of patients with breast cancer in Sabah presented at advanced stages and up to 20.4 percent of patients defaulted proper treatment, opting for traditional therapy. We performed a two-year prospective study looking at the treatment trends of breast cancer in Sabah.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Clinical and pathologic differences between BRCA1-, BRCA2-, and non-BRCA-associated breast cancers in a multiracial developing country

Yip CH, Taib NA, Choo WY, Rampal S, Thong MK, Teo SH

World J Surg, 2009 Oct;33(10):2077-81.
PMID: 19649760 DOI: 10.1007/s00268-009-0146-8

Mutations in BRCA1 and BRCA2 confer an increased risk to breast and other cancers, but to date there have only been limited numbers of studies of BRCA1- and BRCA2-associated cancers among Asians. Malaysia is a multiracial country with three main races: Malays, Chinese, Indians. We determined whether tumor pathologic features and clinical features differ in patients with and without BRCA mutations in this Asian population.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Mammography screening: Female doctors'attitudes and practice in Sana'a, Yemen

Al-Naggar RA, Isa ZM, Shah SA, Chen R, Kadir SY

Asian Pac J Cancer Prev, 2009;10(5):743-6.
PMID: 20104962

A cross-sectional study was conducted at the main hospitals in Sana'a, Yemen to determine the attitude and practice of Yemen female doctors on mammography screening. Study subjects were all female doctors who were on duty during the questionnaire distribution. Those who agreed to participate were given the questionnaire to complete. Descriptive statistics were used to analyse socio-demographic variables and variables related to general health. Participants in this study were 105 female doctors with mean age of 32.1 years (SD = 7.17). Thirty-four respondents (36.6%) did not send asymptomatic women for mammography screening. The reasons were because of high cost (58.0%, n= 25), availability of other methods (23.3%, n= 10), instrument not available (11.6%, n= 5) and high risk of radiation (7.0%, n= 3). Twenty-five participants (26.9%) sent patients on regular basis if there was a family or personal history of breast cancer. Twenty-three participants (24.7%) sent the patients for mammogram screening every year regardless of the patients'history or symptoms. Although most doctors (36.5%) do not refer patients for mammography screening, seventy-seven (74.0%) indicated that they would refer patients for mammography screening on personal request by the patients. This study showed a low percentage of doctors who referred patients for routine mammography. The major reason given was the high cost of the procedure.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Targeting health disparity in breast cancer: insights into women's knowledge of their cancer profile in Malaysia

Loh S, Packer TL, Yip CH, Passmore A

Asian Pac J Cancer Prev, 2009 Oct-Dec;10(4):631-6.
PMID: 19827884

OBJECTIVE: Poor health literacy is positively associated with poorer quality of health decision-making and health outcomes in women facing a cancer diagnosis. In developing countries, poor access to complete and accurate information continues to pose a challenge for women. This paper describes the knowledge of Malaysian women with regard to breast cancer and how participation in a self-management program can improve the situation.

METHODS: Secondary analysis of data collected during a clinical trial on women newly diagnosed with breast cancer (n=147) was performed to examine baseline knowledge of breast cancer profile. Knowledge levels of women in the experimental (n= 69) group attending a self-management program were compared to a control group (n= 78) to determine change in the level of knowledge over time.

RESULTS: At baseline, a high percentage of women were unaware of their breast cancer profile. Not a single woman had knowledge of all six basic characteristics; 83% did not know their HER2 status, type of breast cancer (68%), grade of cancer cell (64%), hormonal receptor status (55%), size of breast cancer (18%) and/or their stage of breast cancer (13%). At post intervention, there was significantly better knowledge within the experimental group.

CONCLUSION: Malaysian women in this cohort study demonstrated very low levels of knowledge of their cancer profile. Clinical implications for countering treatment-decision difficulties include the need for a shift in the way information and services are delivered to allow women to take a more active role in their own care. Multi-modal efforts including basic information dissemination to increase women's knowledge can contribute to narrowing of the gap in health disparity.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Fine needle aspiration biopsy, core needle biopsy or excision biopsy to diagnose breast cancer - which is the ideal method?

Tham TM, Iyengar KR, Taib NA, Yip CH

Asian Pac J Cancer Prev, 2009 Jan-Mar;10(1):155-8.
PMID: 19469645

BACKGROUND: The ideal method for diagnosis of breast cancer is debatable.
METHODS: The methods of diagnosis of 436 new cases of breast adenocarcinoma presenting from Jan 2005 till Dec 2006 at the University Malaya Medical Centre (UMMC) were examined in this study.
RESULTS: A total of 388 cases presented to the breast unit in UMMC primarily and 48 cases were diagnosed in non-breast units in other hospitals and referred for management. Fine needle aspiration cytology (FNAC) was the commonest mode of initial diagnosis in 278 cases followed by core needle biopsy and surgical excision. In UMMC, FNAC was the commonest initial method (68.3%) compared to cases diagnosed outside UMMC, where 37.5% of cases were diagnosed by excision. Tumours less than 2cm were more likely to be diagnosed by excision biopsy.
CONCLUSION: The biopsy method used to confirm the diagnosis is influenced by where the patient first presents, and by the size of the tumour.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Breast cancer in Asia

Yip CH

Methods Mol Biol, 2009;471:51-64.
PMID: 19109774 DOI: 10.1007/978-1-59745-416-2_3

Breast cancer is the commonest cancer in most countries in Asia. The incidence rates remain low, although increasing at a more rapid rate than in western countries, due to changes in the lifestyle and diet. There are many differences between breast cancer in Asia compared with western countries. The mean age at onset is younger than in the west, and unlike the west, the age-specific incidence decreases after the age of 50 years. Because there is no population-based breast cancer screening program in the majority of Asian countries, the majority of patients present with advanced disease. There is a higher proportion of hormone receptor-negative patients, and some evidence that the cancers in Asia are of a higher grade. Most of the Asian countries are low- and middle-income countries, where access to effective care is limited. Because of the late detection and inadequate access to care, survival of women with breast cancer in Asia is lower than in western countries. Improving breast health in most of the Asian countries remains a challenge that may be overcome with collaboration from multiple sectors, both public and private.

Matched MeSH terms: Breast Neoplasms/diagnosis*
A comparison of wavelet and curvelet for breast cancer diagnosis in digital mammogram

Meselhy Eltoukhy M, Faye I, Belhaouari Samir B

Comput Biol Med, 2010 Apr;40(4):384-91.
PMID: 20163793 DOI: 10.1016/j.compbiomed.2010.02.002

This paper presents a comparative study between wavelet and curvelet transform for breast cancer diagnosis in digital mammogram. Using multiresolution analysis, mammogram images are decomposed into different resolution levels, which are sensitive to different frequency bands. A set of the biggest coefficients from each decomposition level is extracted. Then a supervised classifier system based on Euclidian distance is constructed. The performance of the classifier is evaluated using a 2 x 5-fold cross validation followed by a statistical analysis. The experimental results suggest that curvelet transform outperforms wavelet transform and the difference is statistically significant.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Experience with hookwire localisation excision biopsy at a medical centre in Malaysia

Ng CH, Lee KT, Taib NA, Yip CH

Singapore Med J, 2010 Apr;51(4):306-10.
PMID: 20505908

With an increasing number of women undergoing breast screening, an effective method of removing non-palpable lumps detected by mammography or sonography is by hookwire localisation excision biopsy (HWLB). The aim of this paper was to audit the practice of HWLB at the University Malaya Medical Centre.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Knowledge, attitudes and practice of breast self-examination among women in a suburban area in Terengganu, Malaysia

Rosmawati NH

Asian Pac J Cancer Prev, 2010;11(6):1503-8.
PMID: 21338188

INTRODUCTION: Breast cancer is the most frequently diagnosed cancer in Malaysian women, irrespective of age group and ethnicity. The observed low survival rates are related to late stage at presentation despite the availability of breast self examination (BSE) as a reliable screening method for early detection.

MATERIALS AND METHODS: This cross-sectional study was designed to determine the knowledge, attitude and practice towards BSE amongst women aged 15 years old and above. Systemic random sampling was applied and information gathered through guided interview by using a structured questionnaire.

RESULTS: A total of 86 respondents were recruited, with a mean age of 40.5 years (SD: 15.51), more than 80% having a secondary or tertiary level of education. The total score was 16.9 (total mean percent: 60.4%) for knowledge, 37.1 (77.3%) for attitude and 9.56 (34.1%) for practice. The proportions of respondents with good score for knowledge, attitude and practice were 38.4%, 73.3% and 7.0%, respectively. Not knowing the correct method of BSE, lack of knowledge on cancer signs and lack of motivational support from parents, spouse or friends appeared to be related with the poor practices.

CONCLUSION: Enhancement of breast cancer awareness and focusing on recognized barriers by health care professionals with the involvement of spouses, family and community would have a substantial beneficial impact on BSE practice.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Prognostic factors for elderly breast cancer patients in University Malaya Medical Centre, Malaysia

Phua CE, Bustam AZ, Yip CH, Taib NA

Asian Pac J Cancer Prev, 2010;11(5):1205-11.
PMID: 21198264

BACKGROUND: Information about elderly breast cancer patients' outcome is limited. This study aimed to evaluate the treatment outcomes in women aged 70 and above with specific analysis on prognostic clinicopathological features and treatment modalities.
MATERIALS AND METHODS: This retrospective study examined breast cancer patients between 1st January 1994 and 31st December 2004 in UMMC. Survival analysis was performed using the Kaplan-Meier method and comparisons between groups using the log-rank test. Univariate and multivariate analysis on prognostic factors were carried out using the Cox's proportionate hazard model for patient demographics, and tumour and treatment factors.
RESULTS: One hundred and thirty six patients were identified, with a median age at diagnosis of 75 years. Most had at least one co-morbidity (61.8%). Only 75.0% had a good performance status (ECOG 0-1). Mean tumour size was 4.4 cm. Primary tumour stages (T stages) 3 and 4 were present in 8.1% and 30.1% of patients respectively, and 30.9% had stage III and 8.8% had stage IV disease based on overall AJCC staging. ER positivity was 58.1%. PR status was positive in 30.1%. Surgery was performed in 69.1% of the patients and mastectomy and axillary clearance were the commonest surgical procedures (50.7%). Some 79.4% of patients received hormonal therapy, 30.1% radiotherapy and only 3.6% chemotherapy. Non-standard treatment was given to 39.0% of patients due to a variety of reasons. The cumulative 5 years overall, relapse free and cause specific survivals were 51.9%, 79.7% and 73.3% respectively. Performance status, T3-4 tumour, presence of metastasis, tumour grade and ER status were independent prognostic factors for overall survival. For cause specific survival they were T4 tumour, presence of metastasis and ER status.
CONCLUSION: The 5 years overall survival rate was 51.9% and 41.8% of deaths were non-breast cancer related deaths. Low survival rate was related to low life expectancy in this population. Locally advanced disease, metastatic disease and high ER negative rates play a major role in the survival of elderly breast cancer patients in Malaysia.

Matched MeSH terms: Breast Neoplasms/diagnosis
Fulltext The usage and knowledge of mammography among women in sub-urban area in Terengganu, Malaysia

Rosmawati NH

Asian Pac J Cancer Prev, 2010;11(3):767-71.
PMID: 21039051

INTRODUCTION: Breast cancer is the leading cancer in women today and the major challenge is late presentation then later contributes to poor outcome and high fatality rate. Mammography is effective in early detection of breast cancer and consequently significantly improves the breast cancer survival.

MATERIALS AND METHODS: This cross-sectional study was used to study the knowledge and awareness towards mammogram amongst women aged 15 years old and above. A systemic random sampling was applied and information gathered through guided interview by using a structured questionnaire.

RESULTS: Eighty-six respondents were recruited. The mean age of respondents was 40.5 years (SD: 15.51) and more than 80% had secondary and tertiary level of education. The percentage of respondents ever performed mammogram was 10.5% (95% CI: 4.0%-17.0%). The rate of correct answers was between 8.1% and 48.8%. Most of the respondents do not sure the answer (45.3%-61.6%) rather than wrongly answer (4.7%-43.0%). Only about 8% truly answer that mammogram should be done once in a life. There are 10.5% of women claimed that mammogram had no serious side effect and not a painful procedure. Nearly half of respondents (48.8%) correctly mentioned that Mammogram can detect breast cancer in early stage.

CONCLUSION: Only a small percentage of women ever performed mammogram and there are seriously unaware and poor knowledge pertaining to mammography screening for breast cancer among women in sub urban area. A massive health education campaign through multiple methods and agencies are needed to enhance the knowledge and awareness on mammogram.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Predictors of adherence to clinical breast examination and mammography screening among Malaysian women

Parsa P, Kandiah M

Asian Pac J Cancer Prev, 2010;11(3):681-8.
PMID: 21039036

Breast cancer is the most common cancer among Malaysian women and early detection can play an important role in reducing cancer morbidity and mortality. The aim of this cross-sectional study was to determine the rates and factors related to clinical breast examination (CBE) and mammography among 425 female teachers in Selangor, Malaysia. A self-administered questionnaire that included questions on socio-demography, cancer-related knowledge and practice and an adapted version of Champion's revised Health Belief Model Scale was employed. The mean age of participants was 37.2 ± 7.16 years. Only 25% of the women ever had a CBE. Of women over the age 40 (n=138), 13.6% reported having had a mammography. The results showed higher susceptibility to breast cancer, higher benefits of doing CBE and regular visits with a physician to be significant predictors for undergoing CBE (p < 0.05). In addition, higher a perceived susceptibility to breast cancer and regular undergoing CBE were significant predictors for having a mammography. The findings clearly suggest a need for improving women's awareness on breast cancer screening, its importance and recommended guidelines.

Study site: Secondary school teachers in Selangor, Malaysia.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Fulltext Does performance of breast self-exams increase the probability of using mammography: evidence from Malaysia

Dunn RA, Tan A, Samad I

Asian Pac J Cancer Prev, 2010;11(2):417-21.
PMID: 20843127

OBJECTIVES: Breast self-examination (BSE) was evaluated to see if it is a significant predictor of mammography.

METHODS: The decisions of females above age 40 in Malaysia to test for breast cancer using BSE and mammography are jointly modeled using a bivariate probit so that unobserved attributes affecting mammography usage are also allowed to affect BSE. Data come from the Malaysia Non-Communicable Disease Surveillance-1, which was collected between September 2005 and February 2006.

RESULTS: Having ever performed BSE is positively associated with having ever undergone mammography among Malay (adjusted OR=7.343, CI=2.686, 20.079) and Chinese (adjusted OR=3.466, CI=1.330, 9.031) females after adjusting for household income, education, marital status and residential location. Neither relationship is affected by jointly modelling the decision problem. Although the association is also positive for Indian females when mammography is modelled separately (adjusted OR=5.959, CI=1.546 - 22.970), the relationship is reversed when both decisions are modelled separately.

CONCLUSIONS: De-emphasizing BSE in Malaysia may reduce mammography screening among a large proportion of the population. Previous work on the issue in developed countries may not apply to nations with limited resources.

Matched MeSH terms: Breast Neoplasms/diagnosis*
Using autoencoders for mammogram compression

Tan CC, Eswaran C

J Med Syst, 2011 Feb;35(1):49-58.
PMID: 20703586 DOI: 10.1007/s10916-009-9340-3

This paper presents the results obtained for medical image compression using autoencoder neural networks. Since mammograms (medical images) are usually of big sizes, training of autoencoders becomes extremely tedious and difficult if the whole image is used for training. We show in this paper that the autoencoders can be trained successfully by using image patches instead of the whole image. The compression performances of different types of autoencoders are compared based on two parameters, namely mean square error and structural similarity index. It is found from the experimental results that the autoencoder which does not use Restricted Boltzmann Machine pre-training yields better results than those which use this pre-training method.

Matched MeSH terms: Breast Neoplasms/diagnosis

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