Gutnik Lily, Lee Clara, Msosa Vanessa, Moses Agnes, Stanley Christopher, Mzumara Suzgo, Liomba N George, Gopal Satish
UNC Project-Malawi, Lilongwe, Malawi.
UNC Project-Malawi, Lilongwe, Malawi; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.
J Surg Res. 2016 Jul;204(1):61-7. doi: 10.1016/j.jss.2016.04.017. Epub 2016 Apr 22.
Breast cancer awareness and early detection are limited in sub-Saharan Africa. Resource limitations make screening mammography or clinical breast examination (CBE) by physicians or nurses impractical in many settings. We aimed to assess feasibility and performance of CBE by laywomen in urban health clinics in Malawi.
Four laywomen were trained to deliver breast cancer educational talks and conduct CBE. After training, screening was implemented in diverse urban health clinics. Eligible women were ≥30 y, with no prior breast cancer or breast surgery, and clinic attendance for reasons other than a breast concern. Women with abnormal CBE were referred to a study surgeon. All palpable masses confirmed by surgeon examination were pathologically sampled. Patients with abnormal screening CBE but normal surgeon examination underwent breast ultrasound confirmation. In addition, 50 randomly selected women with normal screening CBE underwent breast ultrasound, and 45 different women with normal CBE were randomly assigned to surgeon examination.
Among 1220 eligible women, 1000 (82%) agreed to CBE. Lack of time (69%) was the commonest reason for refusal. Educational talk attendance was associated with higher CBE participation (83% versus 77%, P = 0.012). Among 1000 women screened, 7% had abnormal CBE. Of 45 women with normal CBE randomized to physician examination, 43 had normal examinations and two had axillary lymphadenopathy not detected by CBE. Sixty of 67 women (90%) with abnormal CBE attended the referral visit. Of these, 29 (48%) had concordant abnormal physician examination. Thirty-one women (52%) had discordant normal physician examination, all of whom also had normal breast ultrasounds. Compared with physician examination, sensitivity for CBE by laywomen was 94% (confidence interval [CI] 79%-99%), specificity 58% (CI, 46%-70%), positive predictive value 48% (CI, 35%-62%), and negative predictive value 96% (CI, 85%-100%). Of 13 women who underwent recommended pathologic sampling of a breast lesion, two had cytologic dysplasia and all others benign results.
CBE uptake in Lilongwe clinics was high. CBE by laywomen compared favorably with physician examination and follow-up was good. Our intervention can serve as a model for wider implementation. Performance in rural areas, effects on cancer stage and mortality, and cost effectiveness require evaluation.
撒哈拉以南非洲地区对乳腺癌的认知和早期检测较为有限。资源限制使得在许多情况下，由医生或护士进行乳腺钼靶筛查或临床乳腺检查（CBE）不切实际。我们旨在评估马拉维城市健康诊所中由外行人女性进行CBE的可行性和效果。
培训了四名外行人女性来进行乳腺癌教育讲座并开展CBE。培训后，在不同的城市健康诊所实施筛查。符合条件的女性年龄≥30岁，既往无乳腺癌或乳腺手术史，且因非乳腺相关问题前来诊所就诊。CBE异常的女性被转诊至研究外科医生处。外科医生检查确认的所有可触及肿块均进行病理取样。CBE筛查异常但外科医生检查正常的患者接受乳腺超声检查以确诊。此外，随机选择50名CBE筛查正常的女性进行乳腺超声检查，随机分配45名CBE正常的不同女性接受外科医生检查。
在1220名符合条件的女性中，1000名（82%）同意接受CBE。拒绝的最常见原因是时间不足（69%）。参加教育讲座与更高的CBE参与率相关（83%对77%，P = 0.012）。在1000名接受筛查的女性中，7%的CBE结果异常。在随机分配接受医生检查的45名CBE正常的女性中，43名检查结果正常，两名有CBE未检测到的腋窝淋巴结病。67名CBE异常的女性中有60名（90%）参加了转诊就诊。其中，29名（48%）医生检查结果异常与之相符。31名女性（52%）医生检查结果正常与之不符，她们的乳腺超声检查也均正常。与医生检查相比，外行人女性进行CBE的敏感性为94%（置信区间[CI]79%-99%），特异性为58%（CI，46%-70%），阳性预测值为48%（CI，35%-62%），阴性预测值为96%（CI，85%-100%）。在13名接受推荐的乳腺病变病理取样的女性中，两名有细胞学发育异常，其他均为良性结果。
利隆圭诊所中CBE的接受度较高。外行人女性进行的CBE与医生检查相比效果良好，随访情况也较好。我们的干预措施可作为更广泛实施的模式。农村地区的效果、对癌症分期和死亡率的影响以及成本效益需要评估。
