EARLY BREAST CANCER DETECTION

THROUGH
CLINICAL BREAST EXAMINATION TRAINING
FOR MIDWIVES
IN
RURAL JAKARTA, INDONESIA

Project Investigator:
Kardinah (Dharmais Cancer Hospital, National Cancer Center/Jakarta Breast Health
Foundation)
Sri Indiyastutik (Yappika)

Funded by Breast Health Global Initiative (PRP019)

June 2007 – March 2009
Presented November 10 2008
Background

• Stage III and IV

• Limited Resources
• Unawareness among health provider
• No cancer program developed yet

Down staged breast cancer?

How to implement BHGI recommendation ?
Purpose

• Increasing CBE • Increasing

ability in midwives awareness among
• Increasing volunteers about
awareness in -Breast health
health provider access in
• Strengthen community
referral system -Awareness of
from primary care early detection in
to district hospital breast cancer
Location

Sub district KOJA – JAKARTA UTARA

Population : 592.586 peoples

Male : 308.957 peoples
Female : 283.626 peoples
Primary health care : 6
Participation
• Kelurahan Rawa Badak Selatan
• Kelurahan Tugu Utara
• Kelurahan Lagoa
• Islamic Center
• Kecamatan Koja
• Rumah susun Koja
Project summary

• Female health • Public Participation

provider • Public awareness
• Primary health care
Midwives
Volunteer
CBE

Validating with Organizing the

mammography activity
Activities

• CBE training for • Early detection

midwives (target of breast cancer
30 person) for volunteers
• Half day
(target 30
• Short lecture about
breast cancer volunteers)
• Practice of CBE • Half day
with breast • Short lecture
phantom about breast
• Hospital tour cancer
• Hospital tour
Activities on location
• Midwives: presenting • Organizing
how to do breast self presentation with title:
examination How to do Breast Self
Examination
• Practice CBE (approx. 60 women)
supervising by
experienced physician • Organizing mobile
mammography(Jakart
• A midwife - examined a Breast Health
50 women with Foundation) and
mammography mobile audiovisual aid
validation (Yappika Life)
Preliminary result

• Midwives • Volunteer
training: training 15
30 person person
• Midwives actively • Organizing 30
perform CBE : 25 presentation
person • Participants:
1072 (CBE only)
1179 (CBE and
mammography)
Variable N Percentage
Age
≤ 35 yr 52 4.2
> 35 yr 1177 95.8

Presentation
Yes 1227 99.8
No 2 0.2

CBE
Yes 1163 94.6
No 66 5.4

Questioner
Yes 1178 95.9
No 51 4.1

Mammography
Yes 1229 100
No 0 0
First Menarche
≤ 12 yr 339 27.8
> 12 yr 882 72.2

Menopause
≤ 50 yr 332 69.6
> 50 yr 145 30.4

First Pregnancy
≤ 35 yr
> 35 yr 1088 88.5
56 4.6
Contraception
(Pill)
≤ 5 yr 246 63.2
> 5 yr 143 36.8

Contraception
(Injection)
≤ 5 yr 268 54.7
> 5 yr 222 45.3
Others
Contraception
Implant 8 6
Spiral 108 80
IUD 5 3.7
Sterile 9 6.7
Condom 1 0.7
Others 4 3

History of
Gynecology
Surgery
Yes 43 3.5
No 1186 96.5

History of Breast
Surgery
Yes 35 2.8
No 1194 97.2

Family History
Yes 92 7.5
No 1137 92.5
CBE and Mammography

CBE Normal CBE abnormal

Mammography Mammography

Normal Abnormal Abnormal Normal

Diagnostic imaging: Ultrasound

Breast Imaging
• Breast Imaging Reporting Data System
(BIRADS)

• BIRADS 1: NORMAL
• BIRADS 2: BENIGN
• BIRADS 3: SUSPICOUS BENIGN
• BIRADS 4: SUSPICIOUS MALIGNANT
• BIRADS 5 : MALIGNANT
Variable N %

CBE Result
Normal 1011 85.8
Abnormal 168 14.2

Mammography
Result
Normal 1045 85
Abnormal 184 15

USG Diagnostic
Yes 196 16.4
No 1001 83.6

USG Result
Normal 72 50
Benign 11 7.6
Malignant 13 9
Cystic 29 20.1
Others 5 3.5
Not Coming 14 9.7
 Mammography Result
CBE Result Total
Abnormal Normal
(+) (-)
Abnormal
62 106 168
(+)
Normal
118 893 1011
(-)

Total 180 999 1179

Sensitivity : 62/180 x 100% = 34.4%

Specificity : 893/999 x 100% = 89.4%
Tumor size (CBE and Mammography)
Age (year) 50.8 Tumor size (cm) 3.3 cm

42 2.1 x 2.0
56 3.5 x 2.1
48 2.4 x 2.3
42 2.2 x 1.4
53 3.9 x 3.5
47 1.4 x 1.1
48 3.3 x 2.0
53 5.1 x 3.4
45 4.4 x 3.4
54 6.5 x 5.1
40 5.1 x 3.2
42 2.2 x 2.1
46 2.6 x 1.4
Further result
• Management of malignant lesions: pathology ,
radiation, chemotherapy, complication
• Discordances in CBE and Mammography
should be performed breast ultrasound
• Abnormal CBE (only) group : Breast Ultrasound
• Mammography quality : Positioning and Mean
Glandular Dose (MGD)
CBE Only

CBE

Normal Abnormal

Ultrasound

Normal Abnormal
Obstacles
• Non continuing equipment maintenance will
cause below standard quality of mammogram

• Inhibition access to the community for

volunteers due to lack of support from
government officer (sub districts) and local
primary health care
Tentative conclusion
• CBE could be a first line • Volunteers are an
examination to detect important factor to
cancer increase information
• Ultrasound is useful access of breast health
breast imaging for lump • Government support is
evaluation essential to increase of
• Mammography quality is community empowerment
depend on the equipment
condition, processing the
film and competency of
radiographer
(technologist)