Fernando Perry

Patient delay among Colombian women with breast cancer

OBJECTIVE Characterize diagnosis and treatment of breast cancer in Bogota, Colombia and examine the extent and determinants of patient delay. MATERIAL AND METHODS Using a census approach we identified 1 106 women with breast cancer. Information was gathered through personal interviews and the review of medical records. Patient delay was defined as the time elapsed from first symptoms to initial consultation. RESULTS More than 80% of the women (902) consulted due to symptoms; the majority had advanced-stage disease. Patient delay was established in 20.3% and the main related factors were older age, lack of social security and advanced clinical stage. Higher education in patients was associated with reduced delays. DISCUSSION Women do not recognize breast cancer symptoms. Patient delay and related factors are similar to those found in other studies. There is an urgent need to develop communication and education strategies regarding breast cancer symptoms and early detection.

Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia

Objective. Establish provider delay for breast cancer and related factors. Material and Methods. 1 106 women with breast cancer were approached in health care institutions of Bogota, Colombia. According to the history of first consultation, we established diagnostic and treatment incidence rates, which were compared for different variables. A Cox hazard model was established. Results. Median time from first consultation to diagnosis and start of treatment were 91 days (CI95%:82-97 days) and 137 days (CI95%:127-147 days) respectively. Diagnosis and treatment were faster in women with higher educational level, affiliated to the “special” social security, with better socioeconomic conditions and in screening-detected breast cancers. Conclusion. Provider delay is excessive. There are clear inequities in access to services and a need of reducing the waiting times for women with a suspicion of breast cancer.

Pilot Implementation of Breast Cancer Early Detection Programs in Colombia.

Breast cancer is increasing in developing countries, and Colombia has a double burden from cervical and breast cancer. Suitable guidelines for breast cancer early detection are needed, and the Breast Health Global Initiative provides a favorable framework for breast cancer control in low resource nations. The Colombian National Cancer Institute developed evidence-based guidelines for breast cancer early detection in which coordinated early detection in symptomatic women and hospital-based screening in women aged 50–69 are recommended. A pilot project to evaluate programmatic approaches (opportunistic screening) was designed, and it is expected that organized hospital-based screening for breast cancer will represent a move towards population-based screening in the near future in accordance with country specific conditions.

Cobertura de examen clínico y mamografía de tamización para cáncer de mama en mujeres bogotanas

Resumen Objetivo Determinar la cobertura de examen clinico y mamografia de tamizacion para cancer de mama en un grupo de mujeres bogotanas afiliadas a seguros de salud. Metodos Se realizo una encuesta telefonica a 4.526 mujeres entre 50 y 69 anos, residentes en Bogota y en municipios vecinos, afiliadas a tres companias de seguros de salud. Se excluyeron las mujeres con antecedente personal de cancer de mama. La cobertura de tamizacion se valoro como la proporcion de mujeres con antecedente de mamografia y examen clinico de la mama. Se estimo la frecuencia en la vida, en los ultimos dos anos y en el ultimo ano. Se analizaron factores asociados a la practica de tamizacion, mediante el calculo de OR ajustados. Resultados La frecuencia de vida de uso del examen clinico y mamografia fue de 59,3% y 79,8% respectivamente; el 49,7% y el 65,6% de las mujeres se realizo los examenes con fines de tamizacion; el resto, con fines diagnosticos (sintomaticas). El 34,2% tenia examen clinico en el ultimo ano, y el 54%, mamografia en los ultimos dos anos. La educacion y el antecedente familiar de cancer de mama estuvieron asociados a la practica de tamizacion. Conclusiones La cobertura de examen clinico de la mama como metodo de tamizacion es baja. Las coberturas de mamografia son superiores a lo exigido por el sistema colombiano, pero inferiores a las coberturas utiles reportadas en paises desarrollados.

Increased breast cancer screening and downstaging in Colombian women: A randomized trial of opportunistic breast-screening.

The lack of breast cancer screening in low and middle‐income countries results in later stage diagnosis and worsened outcomes for women. A cluster randomized trial was performed in Bogotá, Colombia between 2008 and 2012 to evaluate effects of opportunistic breast cancer screening. Thirteen clinics were randomized to an intervention arm and 13 to a control arm. Physicians in intervention clinics were instructed to perform clinical breast examination on all women aged 50–69 years attending clinics for non‐breast health issues, and then refer them for mammographic screening. Physicians in control clinics were not explicitly instructed to perform breast screening or mammography referrals, but could do so if they thought it indicated (“usual care”). Women were followed for 2‐years postrandomization. 7,436 women were enrolled and 7,419 (99.8%) screened in intervention clinics, versus 8,419 enrolled and 1,108 (13.1%) screened in control clinics. Incidence ratios (IR) of early, advanced and all breast cancers were 2.9 (95% CI 1.1–9.2), 1.0 (0.3–3.5) and 1.9 (0.9–4.1) in the first (screening) year of the trial, and the cumulative IR for all breast cancers converged to 1.4 (0.7–2.8) by the end of follow‐up (Year 2). Eighteen (69.2%) of 26 women with early stage disease had breast conservation surgery (BCS) versus 6 (42.5%) of 14 women with late‐stage disease (p = 0.02). Fifteen (68.2%) of 22 women with breast cancer in the intervention group had BCS versus nine (50.0%) of 18 women in the control group (p = 0.34). Well‐designed opportunistic clinic‐based breast cancer screening programs may be useful for early breast cancer detection in LMICs.

Accuracy of mammography and clinical breast examination in the implementation of breast cancer screening programs in Colombia

Most evidence on breast cancer screening accuracy derives from high income countries. We evaluated screening accuracy and factors related to program implementation in Bogota, Colombia. Between 2008 and 2012 participants underwent clinical breast examination (CBE) and mammography. Positive results underwent histological verification. Adherence to screening protocols was analyzed. Sensitivity, specificity, and predictive values were estimated and adjusted by overdiagnosis. Impact of alternative screening algorithms on follow-up was explored, including combined screening tests and modified coding systems for mammography. In total, 7436 women aged 50-69 were enrolled; 400 discontinued and 1003 non-compliant with screening protocols. 23 cancer cases were diagnosed. Mammography sensitivity and specificity were 78.3% (95%CI 77.3-99.3) and 99.4% (95%CI 99.2-99.6). CBE sensitivity was 39.1% (95%CI 37.9-40.3) and specificity 83.4% (95%CI 82.6-84.3). Parallel mammography and CBE showed the highest sensitivity (95.6%) and combined as serial tests the lowest (positive CBE followed by mammography 13.0%). A simplified coding system for mammography (recall/no-recall) had 6.3% of positive results and a minor reduction in specificity compared with standard mammography, but reported the best balance between recall rates and screening protocol compliance. Call-backs had high rates of loss-to-follow-up; thus, alternative screening algorithms might help increase screening compliance and follow-up in low and middle income countries, particularly in populations with poor screening history and low access to health services.

Increased breast cancer screening and downstaging in Colombian women

The lack of breast cancer screening in low and middle‐income countries results in later stage diagnosis and worsened outcomes for women. A cluster randomized trial was performed in Bogotá, Colombia between 2008 and 2012 to evaluate effects of opportunistic breast cancer screening. Thirteen clinics were randomized to an intervention arm and 13 to a control arm. Physicians in intervention clinics were instructed to perform clinical breast examination on all women aged 50–69 years attending clinics for non‐breast health issues, and then refer them for mammographic screening. Physicians in control clinics were not explicitly instructed to perform breast screening or mammography referrals, but could do so if they thought it indicated (“usual care”). Women were followed for 2‐years postrandomization. 7,436 women were enrolled and 7,419 (99.8%) screened in intervention clinics, versus 8,419 enrolled and 1,108 (13.1%) screened in control clinics. Incidence ratios (IR) of early, advanced and all breast cancers were 2.9 (95% CI 1.1–9.2), 1.0 (0.3–3.5) and 1.9 (0.9–4.1) in the first (screening) year of the trial, and the cumulative IR for all breast cancers converged to 1.4 (0.7–2.8) by the end of follow‐up (Year 2). Eighteen (69.2%) of 26 women with early stage disease had breast conservation surgery (BCS) versus 6 (42.5%) of 14 women with late‐stage disease (p = 0.02). Fifteen (68.2%) of 22 women with breast cancer in the intervention group had BCS versus nine (50.0%) of 18 women in the control group (p = 0.34). Well‐designed opportunistic clinic‐based breast cancer screening programs may be useful for early breast cancer detection in LMICs.

Increased breast cancer screening and downstaging in Colombian women: A randomized trial of opportunistic breast-screening: Downstaging with Opportunistic Screening for Breast Cancer in Colombia

The lack of breast cancer screening in low and middle‐income countries results in later stage diagnosis and worsened outcomes for women. A cluster randomized trial was performed in Bogotá, Colombia between 2008 and 2012 to evaluate effects of opportunistic breast cancer screening. Thirteen clinics were randomized to an intervention arm and 13 to a control arm. Physicians in intervention clinics were instructed to perform clinical breast examination on all women aged 50–69 years attending clinics for non‐breast health issues, and then refer them for mammographic screening. Physicians in control clinics were not explicitly instructed to perform breast screening or mammography referrals, but could do so if they thought it indicated (“usual care”). Women were followed for 2‐years postrandomization. 7,436 women were enrolled and 7,419 (99.8%) screened in intervention clinics, versus 8,419 enrolled and 1,108 (13.1%) screened in control clinics. Incidence ratios (IR) of early, advanced and all breast cancers were 2.9 (95% CI 1.1–9.2), 1.0 (0.3–3.5) and 1.9 (0.9–4.1) in the first (screening) year of the trial, and the cumulative IR for all breast cancers converged to 1.4 (0.7–2.8) by the end of follow‐up (Year 2). Eighteen (69.2%) of 26 women with early stage disease had breast conservation surgery (BCS) versus 6 (42.5%) of 14 women with late‐stage disease (p = 0.02). Fifteen (68.2%) of 22 women with breast cancer in the intervention group had BCS versus nine (50.0%) of 18 women in the control group (p = 0.34). Well‐designed opportunistic clinic‐based breast cancer screening programs may be useful for early breast cancer detection in LMICs.

Ganglio centinela en melanoma maligno cutáneo de tronco y extremidades. Experiencia en el Instituto Nacional de Cancerología, Bogotá, Colombia, 2000–2007

Resumen Objetivo Determinar la tasa de recurrencia regional en pacientes diagnosticados con melanoma maligno cutaneo localizado en tronco y extremidades, con una biopsia de ganglio centinela negativa. Metodos Serie de casos. Se revisaron los registros de pacientes estadio clinico IB, IIA, IIB, IIIC tratados con biopsia de ganglio centinela entre enero de 2000 y diciembre de 2007. Se realizaron analisis descriptivos y se analizo la supervivencia mediante el metodo de Kaplan-Meier. Resultados Se incluyo a 170 pacientes. La mediana de seguimiento fue de 21,5 meses, con una tasa de recurrencia regional del 11,76%. La supervivencia global a 24 meses en ganglio centinela negativo fue del 100%. Conclusiones La tasa de recurrencia regional en la serie analizada de pacientes con melanoma y ganglio linfatico centinela negativo se halla dentro de lo reportado en la literatura, aunque el tiempo de seguimiento es relativamente corto.