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 2009
Background
— Stage III and IV

— Limited Resources

— Unawareness among health provider

— Breast cancer early detection program has not been developed

yet (2007)

Down staged breast cancer

through CBE training for midwives ?

Breast Health Global Initiative
www.fhcrc.org
How to implement BHGI recommendation ?

Level of Services Record Keeping Cancer Care Facility Breast Care Center
resources

Basic Diagnostic Pathology Individual medical Health Facility Breast healthcare

records and service access integrated
Nursing Services based patient Operating Facility into health care
registration Outpatient care facility infrastructure
Oncology Services Pharmacy
Palliative services Home Hospice support
Psychosocial services External consultation
Primary care services Pathology laboratory
Surgical services

Limited Imaging services Facility based Clinical information Breast Center with
medical records system clinician. Staff and
Peer support services and centralized breast imaging
Radiation Oncology patient registration Health system network access
services
Hospital level Internal pathology Breast
Cancer Registry laboratory prostheses for
mastectomy
Radiation therapy patients
Human Resources Allocation
Level of Patient and Human Resource Patient
resources Family Education Capacity Building Navigation

Basic General Primary care Field nurse,

education provider midwife or
regarding primary education re health care
prevention of breast cancer provider triages
cancer, early detection, patients to
detection and self diagnosis and central facility
examination treatment for diagnosis
and treatment
Development of Nursing education
culturally re cancer patient
adapted patient management and
and family emotional support
education
services
Purpose

— Increasing CBE ability — Increasing awareness

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

Sub district KOJA – JAKARTA UTARA

Population : 592.586 peoples

Male : 308.957 peoples
Female : 283.626 peoples
Primary health care : 6
Participation
1. KelurahanRawaBadak Selatan

2. KelurahanTugu Utara

3. KelurahanLagoa

4. Islamic Center

5. KecamatanKoja

6. RumahsusunKoja
Method

• Female health — Public Participation

provider
— Public awareness
• Primary health care
Midwives

Volunteer
CBE

Single view
Organizing the activity
Mammography
Training

— CBE training for — Early detection of

midwives (target 30 breast cancer for
person) volunteers (target
— Half day 30 volunteers)
— Short lecture about — Half day
breast cancer
— Short lecture
— Practice of CBE about breast
with breast phantom cancer
— Hospital tour — Hospital tour
Activities on location
• Midwives: presenting • Organizing
how to do breast self presentation with
examination to title:
participant
How to do Breast Self
Examination
• Practice CBE (approx. 60 women)
supervising by
experienced physician
• Organizing mobile
mammography
• A midwife - examined (Jakarta Breast Health
±50 women with Foundation) and
mammography mobile audiovisual aid
(Yappika Life)
Result
— Midwives training: — Volunteer training
15 person
30 person
— Organizing 30
— Midwives actively presentation on 6
perform CBE : 25 locations
person
Participants

— Breast Check Up — Group CBE and

Mammography
— Women came to
(> 35 yr)
have breast
check up more — Group CBE only
than expected
CBE and Mammography:
1179 participants

CBE Normal CBE abnormal

Mammography/ Mammography
Single view Single view

Normal Abnormal Abnormal Normal

Participants recall Diagnostic imaging: Ultrasound

CBE : 1174 participants
CBE

Normal

Ultrasound

Normal Participants
Recall
Result
Result

1139
Result
Outcome + Outcome - Total
CBE + 14 147 161
CBE - 1 977 978
Total 15 1124 1139

False Positive : 13 %

Outcome + Outcome - Total

Mammo + 15 136 151
Mammo - 0 988 988
Total 15 1124 1139

False Positive : 12%

Result

1131
Result
Outcome + Outcome - Total
CBE + 2 75 77
CBE - 0 1054 1054
Total 2 1129 1131

False Positive : 7 %
Age group Frequency Breast Ca Prevalence
(%)
20-29 4
30-39 208
40-49 546 10 1,8 %
50-59 323 4 1,2 %
60-69 50 1 2,0 %
70-79 7
80-89 1
1139 15
 Tumor size

Size (cm) CBE CBE +

(N=2) Mammography
(N=15)

Mean 4.3 3.7

(3 - 5.6) (1.1 - 5.6)
Result : 15 patients
Conclusion
— CBE training for health provider personnel
could detect smaller size tumor
— Mammography add only 1/14 breast cancer
diagnosis
Further study
— Well design research : Epidemiologist

— Expand the samples to have more statistically significant data

— Focus on highest cancer age group : above 40 year

— Group recall and Diagnostic breast imaging : immediately to

prevent patients drops out

— Surgical Oncologist : Early breast cancer management

— Well informed primary health care about breast health

program

— Involving trained local health personnel and cadres : to open

breast health access