René Aloisio da Costa Vieira

Program for prostate cancer screening using a mobile unit: results from Brazil.

OBJECTIVES To evaluate the initial results of a prostate cancer screening program using mobile units in Brazil. METHODS Since 2004, we have conducted a program of prostate cancer screening using mobile units across 231 municipalities from 6 Brazilian states. RESULTS A total of 17 571 men were evaluated by clinical history, digital rectal examination (DRE), and serum free and total prostate-specific antigen (PSA) levels. The recommendations for biopsy were a PSA level of ≥ 4.0 ng/mL, DRE findings suspicious for cancer, or a PSA level of 2.5-4.0 ng/mL with a percent-free PSA level < 15%. The biopsy protocol included 12 biopsy cores from the peripheral zone, 2 from the transition zone, and additional sampling of suspicious areas. The cumulative cancer detection rate was 3.7%. The main indication for biopsy was a PSA level of ≥ 4.0 ng/mL (51.2%), with a positive predictive value (PPV) of 44.1%. Another 19.7% of biopsied men had suspicious DRE findings with a normal PSA level (PPV 23.5%). A percent-free PSA level of < 15% in men with a PSA level of 2.5-4.0 ng/mL and normal DRE findings yielded a PPV of 31.1%. The PPV was greater (70.9%) for the 7.1% of men with both suspicious DRE findings and a PSA level of ≥ 4.0 ng/mL. Most cancers were Stage T1-T2 (93.4%), and the percentage of Gleason score of ≥ 7 was 32.5%. The proportion of insignificant cancers according to Epsteins criteria was 13.5%. CONCLUSIONS A mobile prostate cancer screening unit enabled an underserved population to gain access to specialized care through the public healthcare system. The cancer detection rate in this population was similar to those from international studies.

Digital photography in skin cancer screening by mobile units in remote areas of Brazil

BackgroundNon-melanoma skin cancer (NMSC) is one of the most common neoplasms in the world. Despite the low mortality rates, NMSC can still cause severe sequelae when diagnosed at advanced stages. Malignant melanoma, the third most common type of skin cancer, has more aggressive behavior and a worse prognosis. Teledermatology provides a new tool for monitoring skin cancer, especially in countries with a large area and unequal population distribution.This study sought to evaluate the performance of digital photography in skin cancer diagnosis in remote areas of Brazil.MethodsA physician in a Mobile Prevention Unit (MPU) took four hundred sixteen digital images of suspicious lesions between April 2010 and July 2011. All of the photographs were electronically sent to two oncologists at Barretos Cancer Hospital who blindly evaluated the images and provided a diagnosis (benign or malignant). The absolute agreement rates between the diagnoses made by direct visual inspection (by the MPU physician) and through the use of digital imaging (by the two oncologists) were calculated. The oncologists’ accuracy in predicting skin cancer using digital imaging was assessed by means of overall accuracy (correct classification rate), sensitivity, specificity and predictive value (positive and negative). A skin biopsy was considered the gold standard.ResultsOncologist #1 classified 59 lesions as benign with the digital images, while oncologist #2 classified 27 lesions as benign using the same images. The absolute agreement rates with direct visual inspection were 85.8% for oncologist #1 (95% CI: 77.1-95.2) and 93.5% for oncologist #2 (95% CI: 84.5-100.0). The overall accuracy of the two oncologists did not differ significantly.ConclusionsGiven the high sensitivity and PPV, Teledermatology seems to be a suitable tool for skin cancer screening by MPU in remote areas of Brazil.

Comparison of Clinical and Pathologic Findings of Prostate Cancers Detected Through Screening Versus Conventional Referral in Brazil

INTRODUCTION Data regarding prostate cancer screening in Brazil are limited. We compared features of prostate cancers detected through screening versus those referred for treatment in Brazil. PATIENTS AND METHODS Group I included 500 of 13,754 men whose cancers were detected through screening, and Group II included 2731 men referred for treatment through the habitual public health system. We used Mann-Whitney and χ(2) tests to compare clinical and pathologic findings, considering significant any P < 0.05. RESULTS Median prostate-specific antigen (PSA) was lower among screened patients (5.5 ng/mL versus 10.0 ng/mL; P < 0.001). Of the screened patients, 170 (34%) had biopsy Gleason score ≥ 7, compared with 1265 (46.3%) in the referred group (P < 0.001). Lymph node metastases were suspected in 8.6% of the referred versus 3.2% of the screened men (P = 0.002). Distant metastases were more common in the referred men (9.3% vs. 3.0%; P < 0.001). Only 6.0% of the screened cancers were locally advanced at diagnosis (T3 or T4) versus 26.5% of the referred (P < 0.001). Screened patients had a higher proportion of localized tumors after surgery (67.7% vs. 54.2%; P = 0.002). Pathology Gleason scores were also lower among screened men (P < 0.01). Lymphadenectomies were performed in 166/636 men (26.1%). No nodal metastases were found in screened cancers (0/28; 0.0%), while 6/138 referred cancers (4.3%) presented nodal involvement (P = 0.3). CONCLUSION Clinical and pathologic characteristics of screen-detected cancers are more favorable than those of tumors diagnosed through the Brazilian health system.

Can mobile units improve the strategies for cervical cancer prevention

Cervical cancer is a serious public health problem in women in developing countries because of absence or ineffectiveness of screening programs. Several biases to access medical care and inequity of public health system in a continental country like Brazil limit the implementation of adequate programs to appropriately prevent the cervical cancer. Therefore, the aim of this study was to evaluate the results of applying the mobile unit (MU) for cervical cancer screening. From May 2003 to May 2004, a cervical cancer screening was offered to women aged 20–69 years, residing in 19 municipal districts of the Barretos county region, in São Paulo. Out of the 9,560 examination available, 2,964 (31%) women underwent screening. The medium distance traveled by the MU was 45 km. The medium time spent by women in the MU for completion of the questionnaire and doing the exam was 20 minutes. It was observed that 17.0% of women screened had never had the test or had not had it repeated within the last 3 years. The negative response was more common among women aged 20 to 29 years and 60 to 69 years and among women with less schooling and lower socio‐economic income (P < 0.05). MU can significantly overcome the chronic deficiency of public health system accessibility offering opportunity to these women to participate in screening programs. Diagn. Cytopathol. 2010;38:727–730.

Opportunistic screening for skin cancer using a mobile unit in Brazil.

BackgroundSkin cancer is the most common malignancy in the white population worldwide. In Brazil, the National Cancer Institute (INCA) estimates that in 2010 there will be 119,780 and 5,930 new cases of non-melanoma skin cancer and melanoma, respectively. The aim of this study was to evaluate the use of a mobile unit in the diagnosis and treatment of skin cancer in several poor regions of Brazil.MethodsThe diagnosis of skin cancer was accomplished through active medical screening in the prevention Mobile Unit (MU) of Barretos Cancer Hospital (BCH). The study population consisted of patients examined in the MU between 2004 and 2007, and their suspicious lesions were subjected to histopathological evaluation. Data were collected prospectively from standardized forms and analyzed.ResultsDuring the screening, 17,857 consultations were carried out. A total of 2012 (11.2%) cases of skin cancer were diagnosed. The predominant histological type reported was basal cell carcinoma (n = 1,642 or 81.6%), followed by squamous cell carcinoma (n = 303 or 15.1%), Bowens disease (n = 25 or 1.2%), malignant melanoma (n = 23 or 1.1%), basosquamous cell carcinoma (n = 3 or 0.1%), miscellaneous lesions (12 or 0.6%), and metatypical carcinoma (n = 4 or 0.2%). Only 0.6% of lesions were stage III. There were no stage IV non-melanoma skin lesions, as well as no melanomas stages III and IV, found.ConclusionsIt was observed that the MU can be a useful tool for early skin cancer diagnosis and treatment. This program probably is important, especially in developing countries with inadequate public health systems and social inequality.

Risk Factors for Arm Lymphedema in a Cohort of Breast Cancer Patients Followed up for 10 Years

Background: The etiology of lymphedema is multifactorial, and definition criteria of lymphedema, its limitation, and follow-up must be considered in studies related to risk factors. The aim of this study is to evaluate risk factors related to arm lymphedema in a cohort study with a long follow-up. Patients and Methods: The study was performed in 622 breast cancer patients. The main endpoint reported was the presence of clinical lymphedema reported in medical records. Univariate and multivariate regression analyses were performed to identify factors related to lymphedema. Results: 66.4% of the patients were submitted to mastectomy, 88.4% to level III axillary lymphadenectomy, 34.9% to radiotherapy in the supraclavicular fossa, and 4.3% to axillary radiotherapy. The mean follow-up was 96.7 months. 45 patients (7.2%) developed lymphedema, of which 82.2% had developed lymphedema at 60 months. Univariate regression analysis showed that supraclavicular radiotherapy, adjuvant/palliative chemotherapy, ≥ 15 lymph nodes dissected, and axillary surgery increase the lymphedema rate by 1.87, 2.28, 2.03, and 6.17, respectively. Adjusted multivariate regression analysis showed that the combination of axillary dissection and number of lymph nodes dissected was the main factor related to lymphedema (p = 0.017). Conclusion: In the pre-sentinel era, axillary dissection and the number of lymph nodes resected are related to 10-year lymphedema.

Barreiras no rastreamento do câncer de mama e o papel da enfermagem: revisão integrativa

La deteccion del cancer de mama por mamografia es un hecho en los paises desarrollados. Enfermeria actua de diferentes maneras en este proceso, asumiendo un papel importante en los obstaculos relacionados con la falta de adherencia a los examenes. A pesar de su importancia, existe un numero limitado de ensayos clinicos sobre este tema. Se realizo una revision integrada de la literatura en PubMed y LILACS (Literatura Latinoamericana), evaluando ensayos clinicos sobre el papel de la enfermera en el rastreamento del cancer de mama. Utilizo-se las palabras clave deteccion del cancer de mama, enfermeria y estudios clinicos. De 110 publicaciones en PubMed, 18 eran ensayos clinicos que mostraron el papel de la enfermera en la deteccion del cancer de mama, pero ninguna publicacion estaba presente en la base de datos LILACS. Esta revision muestra la eficacia de la enfermeria en la deteccion del cancer de mama, presentando un nuevo papel de la enfermera en el equipo multidisciplinario y calificando las acciones relacionadas con la salud de la mujer.Mammographic breast cancer screening is a fact in developed countries. Nursing acts in different ways in this process, having an important role in the barriers related to non-adherence to screening, but its effectiveness is little proven, with limited number of clinical trials about this topic. An integrative review of the literature in PubMed and LILACS (Latin American Literature) was conducted, aiming to evaluate controlled clinical trials about nurses role in breast cancer screening. It was used the key words breast cancer screening, clinical trials and nurse. From 110 publications in PubMed, 18 were clinical trials and showed the nurses role in breast cancer screening. None publication was observed in LILACS database. This review shows the effectiveness of nursing in breast cancer screening, presenting new nurses role in the multidisciplinary team that qualify actions related to womens health.O rastreamento para o câncer de mama ou a realizacao regular do exame de mamografia e uma realidade em paises desenvolvidos. A enfermagem atua de diferentes maneiras neste processo, tendo importante papel no enfrentamento das barreiras relacionadas com a nao adesao ao rastreamento; porem, sua efetividade e pouco comprovada, havendo limitado numero de estudos clinicos sobre o tema. Realizou-se revisao integrativa sobre o tema na PubMed e na literatura latino-americana LILACS, avaliando estudos clinicos controlados que comprovassem a efetividade das acoes de enfermagem, utilizando as palavras-chave rastreamento para o câncer de mama, enfermagem e estudos clinicos. Na PubMed foram identificadas 110 publicacoes sobre o tema, das quais 18 estudos clinicos apresentando as acoes de enfermagem. Nao se identificou nenhum estudo na LILACS. A presente revisao mostrou a efetividade da enfermagem no contexto do rastreamento do câncer de mama, apresentando novas perspectivas de atuacao profissional, dentro de um contexto multidisciplinar de qualificacao de acoes relacionadas a saude da mulher.

Barriers related to non-adherence in a mammography breast-screening program during the implementation period in the interior of Sao Paulo State, Brazil

Mammography is the best exam for early diagnosis of breast cancer. Developing countries frequently have a low income of mammography and absence of organized screening. The knowledge of vulnerable population and strategies to increase adherence are important to improve the implementation of an organized breast-screening program. A mammography regional-screening program was implemented in a place around 54.238 women, aged 40–69 years old. It was proposed to perform biannual mammography free of cost for the women. We analyze the first 2 years of the implementation of the project. Mammography was realized in 17.964 women. 42.1% of the women hadn’t done de mammography in their lives and these women were principally from low socio-economic status (OR = 2.99), low education (OR = 3.00). The best strategies to include these women were mobile unit (OR = 1.43) and Family Health Program (OR = 1.79). The incidence of early breast tumors before the project was 14.5%, a fact that changed to 43.2% in this phase. Multivariate analysis showed that the association of illiterate and the mobile unit achieve more women who had not performed mammography in their lives. The strategies to increase adherence to mammography must be multiple and a large organization is necessary to overpass the barriers related to system health and education.

Use of low free to total PSA ratio in prostate cancer screening: detection rates, clinical and pathological findings in Brazilian men with serum PSA levels <4.0 ng/mL

Study Type – Diagnostic (inception cohort)

The role of oncoplastic breast conserving treatment for locally advanced breast tumors. A matching case-control study

Background Breast conserving surgery (BCS) after neoadjuvant chemotherapy (NC) in patients with locally advanced breast cancer (LABC) is an infrequent procedure. In these patients the association with BCS and oncoplastic surgery (OS) is reported as a possible procedure in case-series, but there are limited case-control studies. Methods A matched case-control study evaluated LABC submitted to NC and BCS. We evaluated 78 patients submitted to doxorubicin-cyclophosphamide regimen followed by paclitaxel regimen. The match case-control proportion was 2:1 and the patients were selected by tumor size, clinical T stage and year of diagnosis. Results 52 underwent classic BCS and 26 OS. The average size tumor was 5.25 cm and 88.5% of the tumors were larger than 3 cm. The clinical and pathological group characteristics were similar, except the weight of surgical specimens (p = 0.004), and surgical margins (p = 0.06), which were higher in OS group. The rate of complete pathologic response was 26.9%. 97.4% received postoperative radiotherapy. At 67.1 months of follow up, 10.2% had local recurrence (LR) and 12.8% locoregional recurrence (LRR) and 19.2% died because disease progression. The overall survival at 60 months was 81.7%. After surgery the disease free-survival at 60 months was 76.5%. The was no difference between groups related to pathologic response (p = 0.42), LR (p = 0.71), LRR (p = 1.00), overall survival (p = 0.99) and disease specific survival (p = 0.87). Conclusion This study corroborates the fact that OS is a safety procedure for LABC, offering the similar oncologic results observed in patients submitted to classic BCS.