Breast disorders diagnostic service
in a primary care clinic

By Alfredo Hevia Martín and Míriam de la C. Rodríguez Menéndez

ABSTRACT: Five hundred and ten women ages 15-75 from the community receiving medical attention at the HéroesdeGirón Community Teaching Polyclinic of Cerro Municipality, Havana, were given survey forms and examined between October, 1994 and July, 1995. Patients with high risk for breast cancer were also included in the study prior to mammography screening, to evaluate and detect mammary disorders in general. Patients with clinical signs upon physical examination were studied by using ultrasonography, mammography or fine needle aspiration cytology, as required, in coordination with the Radiology Service of the HermanosAmeijeiras Clinical and Surgical Hospital and with the Surgical Service of the Joaquín Albarrán Clinical and Surgical Hospital. Of the 127 symptomatic patients admitted to our service, 61 received a positive clinical diagnosis upon physical examination. Of these patients, 29 were operated on for benign tumors. Three asymptomatic breast carcinomas were detected.

Subject Headings: BREAST DISORDERS/diagnosis; PRIMARY HEALTH CARE; ASSESSMENT; DIAGNOSTIC SERVICES; MAMMOGRAPHY; BREAST SELF-EXAMINATION; BREAST ULTRASONOGRAPHY; NEEDLE ASPIRATION BIOPSY; PHYSICAL EXAMINATION

According to the Cuban Ministry of Public Health's 1993 Statistical Yearbook, malignant tumors are the number one cause of death in Cuba among persons ages 50-60, and the number two cause of death among those 15-49 and those over 65, surpassed only by car accidents and heart disease respectively. 1-4

Breast cancer is the fourth cause of death due to tumors—both sexes included—and is the number one cause of death due to malignant tumors in women, with a rate of 16.9 per 100, 000 inhabitants in 1993. The number of deaths due to breast cancer has markedly increased since 1970. 1

In Havana's Cerro Municipality, 21 women died of breast cancer in 1993 and 22 in 1994.

These figures, plus an increasing number of patients with breast-related symptoms requiring specialized attention in hospitals as a result of not having been properly examined by their family doctors at an earlier stage, prompted the decision to establish the Breast Disorders Diagnostic Service, in coordination with the corresponding specialty services of the Hermanos Ameijeiras and the Joaquín Albarrán Clinical and Surgical Hospitals. The primary goal of the new Service is the early detection of breast disorders in women who receive medical attention at the Héroes de Girón Community Teaching Polyclinic—where the results of these family doctor consultations are evaluated. Patients with positive signs are referred for further examination, including ultrasonography, fine needle aspiration cytology, mammography and detection of estrogenic receptors in surgical samples.

Patients included in a group previously identified for regular mammography screening were also examined and given survey forms.

Hence, it is our aim to evaluate the advantages of creating this kind of diagnostic service at the primary care level, as well as to compare the data obtained by physical examination with those obtained by complementary examinations, in order both to increase our patients' awareness of the breast self-examination technique and to lay the foundations for the creation of models and computer software for this task.

Methods

A diagnostic service for initial assessment of mammary disorders was created in a primary healthcare clinic, in coordination with the Radiology Service of the Hermanos Ameijeiras Hospital, one of whose specialists heads the Program for Early Detection of Breast Cancer in the Cerro Municipality and has been mentor to our work. We have also worked in coordination with a similar diagnostic service in the Joaquín Albarrán Hospital.

Following a training course at the Mammary Disorders Service of the National Oncology and Radiology Institute (INOR) plus extensive individual study, the author of this work was named head of the diagnostic service, with supervision provided by a specialist in Comprehensive General Medicine, also mentor for the project.

The Cuban Ministry of Public Health's Form 68-23 has been modified for use as a survey data collection instrument. The final version (2.0) of this form was created by using computerized systems designed for this purpose. Results are shown in Tables 1, 2 and 3 utilizing an alphanumeric code system.

This code system speeds up the combined data collection process from survey forms, physical examinations, complementary examinations and outcome assessments, and makes it possible to use computers for processing data.

Database management software was developed by specialists from the José Antonio Echevarría Higher Polytechnic Institute (ISPJAE), using the SUPER G DBASE program generating system. The software was then used by the author to input and process data.

Our sample included all women, regardless of their age, who came to our diagnostic service (which was widely publicized through the efforts of the Polyclinic Director and heads of our primary care medical teams); women referred to the service by their family doctors; and a random group of women considered high risk for breast cancer who were being regularly checked by the family doctor and had been referred to the national mammogram/screening program.

In all cases, the women were given a full physical examination and asked to complete the survey, including the variables cited in Tables 1, 2 and 3.

In order to corroborate clinical findings, all patients who had palpable lumps or suspicious symptoms were referred for complementary tests (ultrasonography, fine needle aspiration cytology and/or mammography). Those patients who were asymptomatic, with no clinical signs, but who were included in the National Breast Cancer Screening Program, also had a mammogram. Findings upon physical examination vs. findings in complementary tests were compared.

All complementary tests were carried out by highly qualified professionals in the above mentioned hospitals. These specialists decided which test was to be used in each case, and submitted the results to us for analysis.

Patients who were found to have malignant tumors and who were included in the National Breast Cancer Screening Program were operated on in the Hermanos Ameijeiras Hospital. Patients diagnosed with benign tumors requiring surgical intervention were treated at the Outpatient Surgical Service of the Joaquín Albarrán Hospital. All patients received follow-up in our diagnostic service.

We have used percentage as the statistical indicator in our work.

Results

Figure 1 shows the distribution by age of the women who were examined and given survey forms. The largest sample included 182 women (36.0%) ages 56-65, followed by a sample of 101 women (19.8%) ages 46-55, and another sample of 82 women (16.0%) ages 66-75. Of these, 383 (75.0%) were symptom-free, and 127 (24.9%) symptomatic. Figure 2 shows the distribution of symptoms.

Figure 1: Patients admitted to Breast Disorders Service by age.

Source: Breast Disorders Service.

Of all the surveyed women, only 36.3% (187) were familiar with breast self-examination technique and carried it out regularly. The rest (63.3% or 323 women) either were unfamiliar with the technique and/or simply did not use it. (See Table 1).

Table 1. Awareness of Breast Self-examination Technique

Sixty-one patients (11.9% of the sample) were found to have local signs upon physical examination.

The size of tumors detected by physical examination is shown in Table 2, most in the 10-50 mm range. Of these patients, 51 were further studied usingultrasonography, 12 by mammograms, and 48 had fine needle aspiration cytology. The results are shown in Table 3.

Table 2. Size of Palpable Tumors

Mammograms were indicated for 395 of the patients who were examined—1,441 mammograms were performed, including those indicated as part of the Program for Early Detection of Breast Cancer.

Twenty-nine cases were diagnosed with solid tumors, whose distribution is shown in Table 3.

Table 3. Results Obtained from Complementary Tests

Discussion

The three most significant age groups in our study correspond to those with the highest incidence of breast cancer, as described in the literature consulted. Therefore, we consider our sample to have included a significant group of patients at high risk for developing breast cancer, most of whom presented additional associated risk factors. 1-3

We found pain to have been the major reason for seeking medical attention, followed by lumps felt by the patients themselves. Most patients who experienced pain had no signs upon physical examination. We found that when patients are properly and thoroughly examined and educated in the physiology of menstruation-related mastalgia, the number of hospital consultations for premenstrual mastalgia is reduced, as well as the number of follow-up consultations after treatment.

After finishing the physical examination our service's physician explained to each patient and where appropriate to the accompanying family member as well, how to carry out breast self-examination. Thus, the service has also served to promote this practice.

The size of the tumors we found in these patients corresponds to size and reports by other authors. 4-6

All patients who had a mammogram—of those included in the Program—could not be given survey forms or examined to be included in this study, due to time constraints for data processing.

Using the mammography-screening test, we were able to diagnose three patients with breast carcinoma. These patients were also examined. They showed no pathological signs upon physical examination nor referred to any symptoms. Mammogram results revealed microcalcifications—which cannot be detected by physical examination—demonstrating the importance of mammography in the early detection of breast cancer. 7-9

All cases with solid tumors (29) had fine needle aspiration cytology and tumorectomy at the Outpatient Surgical Service of the Joaquín Albarrán Hospital. We followed up with these patients in our service—a follow-up that we consider to have been successful in 100% of the cases.

Those patients who were diagnosed with cysts were also studied by using fine needle aspiration cytology—which served both as a diagnostic and therapeutic method. This coincides with what we have found in the medical literature consulted. 10, 11

Those patients diagnosed with fibrocystic disorders by microscopic examination are being treated with progestins, anti-inflammatories and vitamins, and are examined every six months.

The cases diagnosed with breast carcinoma are being treated in the Hermanos Ameijeiras Hospital, the reference center for our polyclinic.

Conclusions

1. Initial evaluation of symptomatic patients in The Breast Disorders Diagnostic Service reduced the number of patients seeking specialized attention in hospitals, thus allowing for a more rational use of both human and material resources.
2. The diagnosis, treatment and follow up of patients with benign mammary disorders in primary care clinics, in coordination with general hospitals, is both feasible and beneficial.
3. Fibrocystic disease (Reclus' disease) was the most common histological finding.
4. A large number of the women surveyed did not know of or did not perform breast self-examination technique. Our service has greatly contributed to the promotion of this practice.
5. The service facilitates the detection of so called "interval tumors" in primary care clinics.

Suggestions

1. Strongly advise all women aged 30 and over to carry out breast self-examination.
2. Develop and implement a more widespread educational program that promotes awareness of the importance of breast self-examination and of mammography.
3. Establish breast disorders diagnostic services with qualified staff in other polyclinics in order to make more appropriate use of specialized consultations in hospitals as well as more rational use of both human and material resources. 

References

1. Funkhouser E, Waterbor JW. Mammographic patterns and breast cancer risk factors among women having elective screening. South Med J 1993; 86(2):177-80
2. Harris Jay R, Lippman Marc E, Veronesi, Willet. Breast cancer. N Engl J Med 1992; 327(5):319-28.
3. Bondy ML. Identification of women at increased risk for breast cancer in a population-based screening program. Cancer Epidemiol Biomarkers Prev 1992;1(2):143-7.
4. Suárez Fernández JM. Prevención, profilaxis, diagnóstico preccoz y tratamiento del carcinoma mamario. Havana: Ciencias Médicas Publishing House, 1987:5-74.
5. Isselbacher Kurt J, Braunwald, Wilson D, Martín B, Fauci Anthony S, Kasper Denis L: Section 3 Neoplastic Diseases. 319 Breast cancer. In: Henderson Craig. Harrison's. Principles of Internal Medicine . Michigan: Medicine Books-Grajan Publishers, 1994:1840-50.
6. Morimoto-T. The quality of mass screening for breast cancer by physical examination. Surg Today 1993; 23(3):200-4.
7. Sienko DG. Mammography use and outcomes in community. The Greater Lansing Area Mammography Study. Cancer 1993;71(5):18019.
8. Miller AB, Baines CJ. Canadian National Breast Screening Study: Breast Cancer detection and death rates among women aged 40-49 years. Can Med Assoc 1992;1-47(10):1459-76.
9. Von-Fournier D. Breast cancer screening. State of the art and introduction to preventive measures. Radiologe 1993;33(5):227-35.
10. Bates AT. Delay in the diagnosis of breast cancer: The effect of needle aspiration cytology to a breast clinic. Eur Surg Onc J 1992; 18(5):433-7.
11. Costa MJ, Tadros T, Hilton G. Breast fine needle aspiration cytology. Utility as screening tool for clinically palpable lesions. Act Citolog 1993;37(4):461-71.

This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral , Vol. 13, No. 4, (pp. 317-24), July-August, 1997.

 

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