Iraqi national breast cancer screening program-current situation & obstacles -
Global Breast cancer facts: is the top cancer in women worldwide comprising 26% of all female cancers. the second leading cause of cancer related mortality in women today (after lung cancer ) . Yearly 1.38 million new cases .%30
Breast cancer incidencesBELGIUM : 145 .2/100000 USA : 124.3 /100000 England : 120.7 / 100000 BAHRAIN : 121.7 /100000 Lebanon : 84 /100000 Saudi Arabia : 61 / 100000 Egypt : 42.5 / 100000 Jordan : 38 / 100000 Iraq : 33 / 100000
breast cancer constitutes 34% of total iraqi women cancer. It is number one cancer in total population & in iraqi women . Most cases presented late that mandates complete resection of the breast & axillary clearance to be followed by adjuvant therapy . it is increasing in number with the years many cases start to present in young cases . Average age of patients is 50-54 year while in western countries it is 65 year .
Breast Cancer in Iraq 2008 According to Provinces
Breast cancer presentation 2008In situ : 29 case ----- 1.1%Stage 1 : 267 case -----10.47% stage 2 A : 215 case ---- 8.15% stage 2 B: 518 case ----22.02% stage 3 : 362 case ----13.73% stage 4 : 133 case----- 5.04% not applicable: 48 case– 1.82% unknown : 993 case---- 37.6 %
Age specific incidence rate-2008
distribution by age, sex, and histological classification 2008
Total : 2729 Male : 92 Female : 2637 Most affected age group in female is 50-54 year = 433 patients constituting 15.8% of total . Before 50 year = 50.7 % After 50 year = 49.3 % Most affected age group in male is 40-42 year = 12 patients constituting 13 % of the totalimplementation of evidence-based strategies for: prevention, early detection diagnosis, treatment, palliation of breast cancer making the best use of available resources.
Prevention
It is action taken to lower the chance of getting cancer. By preventing cancer, the number of new cases of cancer in a group or population is lowered ,hopefully, this will lower the number of caused by cancer deaths Some of risk factors for cancer can be avoided, but many cannot. in case of breast cancer , avoidable risks : 1.changing lifestyle or eating habits (healthy diet & exercises & wt reduction 2. avoiding smoking & alcohol intake. 3. avoiding taking PHT, oral contraceptives 4. having children prior age 30 year . 5. Encouraging breast feeding . 6. prophylactic tomaxifen or Raloxifene for high risk patientsearly detection means using an approach that allows earlier diagnosis of breast cancer than otherwise might have occurred . There are two early detection methods: Early diagnosis : via raising public awareness of early signs and symptoms in symptomatic populations in order to facilitate early diagnosis and early treatment . Screening : refers to the use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms .
فوق 50سنة 49-40سنة 39-30سنة 29-20سنة الفحص شهريا شهريا شهريا شهريا الفحص الذاتى للثدي سنويا سنويا مرة كل3 سنوات مرة كل 3سنوات الفحص السريري للثدي كل 3 سنوات كل 5 سنوات .....
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فحص الماموكرام BC screening plan in normal risk woman :
women with increase risk of breast cancer women with a strong family history of breast or ovarian cancer (2 or more relatives, male relative , premenapausal breast cancer ,family with BRCA1 or BRCA2 even still not having the cancer yet ). women who were treated for Hodgkin disease with chest radiation between age 10-30 year ,. women with a personal history of breast cancer of other breast . women with carcinoma in situ, atypical hyperplasia .
Screening/ Age
20-29 سنة 30-39سنة 40-49سنة 50+ سنة الفحص الذاتي شهريا شهريا شهريا شهريا الفحص السريري سنويا سنويا سنويا سنويا فحص الماموكرام ----------5سنوات سنويا سنويا
Ultrasound can be offered as a screening tool for women:
are at high risk for breast cancer based on family history, personal history of breast cancer, or prior biopsy showing an abnormal result and unable to tolerate an mammo examination. . have dense breasts. have silicone breast implants and very little tissue can be included on the mammogram. are pregnant or should not to be exposed to mammogram.
screening MRI is recommended for : screening women with greater life time risk of breast cancer. extremely dense breasts on mamo . Inconclusive findings in conventional imaging (i.e., BI-RADS 0) .
BIRAD,S
Breast Imaging Reporting and Data System : This reporting system is designed to provide an organized approach to image interpretation and reporting .BI-RADS 0: Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison . BI-RADS 1 : Negative . BI-RADS 2 : Benign Finding BI-RADS 3 : Probably Benign Finding ….Initial Short-Interval Follow Up BI-RADS 4 : Suspicious Abnormality… Biopsy Should Be Considered .BI-RADS 5 : Highly Suggestive of Malignancy…Appropriate Action BI-RADS 6 : Known Biopsy ProvenMalignancy. Appropriate Action Should Be TakenThe conditions that can be initially managed in primary care clinic team are the followings : 1. young women (<35 years)or older women with symmetrical with tender, lumpy breasts nodularity , provided that they have no localized abnormality .
While other conditions that have to be referred to breast clinics in hospitals are the followings: 1.LUMP : any new discrete lump . new lump in pre-existing nodularity . a symmetrical nodularity that persists at review after menstruation . abscess or breast inflammation which does not settle after one coarse of antibiotics . cyst persistently refilling or recurrent cyst .
Nipple discharge
Physiological compression multiple ducts bilateral Pathological spontaneous unilateral duct bloody with massCURRENT SITUATION
النساء المراجعات الى المراكز او العيادات التخصصية للسنوات 2009 -2011 سنة 2009 :عدد النساء الكلي : 19994 عدد النساء المحالات : 4978 عدد الحالات السرطانية : 346 نسبة الحالات السرطانية : 1.7 %سنة 2010 :عدد النساء الكلي : 72263 عدد النساء المحالات : 17907 عدد الحالات السرطانية : 456 نسبة الحالات السرطانية : 0.63% سنة 2011 : عدد النساء الكلي 84917 عدد النساءالمحالات : 23970 عدد الحالات السرطانية :821 نسبة الحالات السرطانية : 3.45 %عدد المريضات اللاتي تم فحصهن بواسطة جهاز الماموجرافي في العيادات للسنوات 2009- 2011 ان عدد المريضات اللاتي تم فحصهن بواسطة جهاز الماموجرافي :في عام 2009 كان 1322 النسبة من مجموع المراجعات 6.6% .في عام 2010 اصبح 6264 والنسبة هي 8.67% .في عام 2011 العدد 10022 والنسبة هي 11.8% .
عدد المريضات اللاتي تم فحصهن بواسطة جهاز السونارفي العيادات للسنوات 2009 -2011 ان عدد المريضات اللاتي تم فحصهن بواسطة جهاز السونار :عام 2009 كان 2466 والنسبة من المراجعات 12.1%.عام 2010 اصبح 3552 والنسبة من المراجعات 4.9 % .عام 2011 اصبح 26369 والنسبة من المراجعات 31.1 % .
عدد الندوات التثقيفية التي تقيمها اللجنة والعيادات ومراكز الرعاية الصحية الاولية في السنوات 2009-2011 في عام 2009 تم اقامة حوالي 2232 ندوة مسجلة . في عام 2010 تم اقامة حوالي 4714 ندوة مسجلة .في عام 2011 تم اقامة 7200 ندوة مسجلة .
Problems faced during implementation
Improper coordination & communication between health care providers .all clinics are in major cities with lack of facilities in other smaller cities
Incomplete referral system with poor feed back of referred women
professional
Lack of optimum facilities in the breast clinics : proper Place, personnelles , sonars , IT , ….. Still lack of trained female radiologists & mammographists .
society
In proper role of media in public health awarenessLevel of illiteracy is still high among females .
Although BAGHDAD has most incidence of women attendance still there is lack of breast cancer awareness specially in under served areas .
some of women detected with breast cancer in our program refuse or escape from any management
suggested solutions …. Provide an increasing no. of high quality breast clinics with optimum services to cover the need of target group .
Improve the present referral system with feedback to ensure access of maximum no. of the target group .
Proper development of our training system for all required staff in the screening program .
Trying to use mobile mammo. units to ensure the access of screening services & cover the needs of target group in remote areas.
Achievement of large campaigns in Baghdad & other cities to examine all women above 40 years clinically & mammographically.
Encourage the use of media, religious advisors to improve breast cancer awareness.
Updating our present statistical & clinic case sheets that lack many essential data .