ORIGINAL RESEARCH

Factors associated with changes in mammograms

Neide Derenzo^I; Elen Ferraz Teston^II; Willian Augusto de Melo^III; Maria Antonia Ramos Costa^IV; Marcelo Picinin Bernuci^V

^I Nurse. Master. Permanent Professor, State University of Paraná - Paranavaí campus. Brazil. E-mail: neidederenzo@hotmail.com
^II Nurse. PhD. Assistant Professor, State University of Paraná - Paranavaí campus. Brazil. E-mail: elen-1208@hotmail.com
^III Nurse. PhD. Permanent Professor, State University of Paraná - Paranavaí campus. Brazil. E-mail: profewill@yahoo.com.br
^IV Nurse. PhD. Permanent Professor, State University of Paraná - Paranavaí campus. Brazil. E-mail: enfunespar1982@hotmail.com
^IV Nurse. PhD. Assistant Professor, State University of Paraná - Paranavaí campus. Brazil. E-mail: elen-1208@hotmail.com
^V Biological Sciences. Post PhD. Permanent Professor, University Center of Maringá. Brazil. E-mail: mbernuci@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.31640

ABSTRACT

Objective: to examine factors associated with changes in mammograms. Method: in this cross-sectional study of 145 women receiving care under the family health strategy in a municipality in northwestern Paraná, Brazil, data were collected by semi-structured interviews between August 2014 and October 2015 and analyzed using Pearson's Chi-square test and Fisher's exact test. The project was approved by the research ethics committee. Results: the women were of mean age 52.5 years. Those who were white (OR = 0.17), nulliparous (OR = 4.53), with alterations at self-examination (OR = 12.72), clinical examination (OR= 35.75) and a history of previous problems (OR = 9.45) presented a greater likelihood of changes in mammography. Conclusion: the factors associated with altered mammography were white skin color, nulliparity, alterations during self-examination and clinical examination, and a previous breast problem.

Descriptors: Prevention of diseases; self exam; mammography; healthcare professional.

INTRODUCTION

Cancer is the leading cause of death in the world and in Brazil. Estimates for the biennium 2016-2017, indicate the occurrence of about 600 thousand new cases¹. In developing countries 70% of deaths are due to cancer, and most cases are diagnosed in more advanced stages making treatment difficult¹.

Among the most prevalent types of cancer is breast cancer. The high incidence is influenced by the increase in life expectancy, the process of urbanization and industrialization^2,3 as well as the improvement of diagnostic technology and the expansion of screening programs ^4,5. However, increased incidence and mortality trends reflect differences in the patterns of risk factors, access and availability of screening for early detection and timely treatment^5,6.

A number of factors are related to the late diagnosis of neoplasms such as difficult access to health services, incomplete or non-existent information regarding the self-examination and prevention tests, and even the predominant screening strategy, characterized by spontaneous search of the target population⁷.

Knowing these risk factors associated with the occurrence of breast cancer allows the planning of new intervention strategies to optimize early detection and favor the survival of women^8,9. In this aspect, this study aimed to analyze the factors associated with mammographic changes of women inserted in the family health strategy (FHS).

LITERATURE REVIEW

Breast cancer is the second most common type of cancer in the world and the most common among women, representing a permanent source of concern in public health services. It is worth mentioning that early detection is a form of secondary prevention and aims at identifying cancer in early stages, when the disease has a greater chance of better prognosis, and also generating lower costs to the health care system³.

In the Brazilian context, a study pointed out that, since 2004, cancer has become a priority and has gained visibility in the agenda of public policies, advancing since then in structuring the health care network at different levels of attention, with a focus on screening and early diagnosis¹⁰. The objective of the screening is to perform relatively simple tests in healthy people in order to identify diseases in pre-clinical (asymptomatic) stages. At the same time, the purpose of early diagnosis is to identify people with initial signs and symptoms of a particular disease, emphasizing the quality and guarantee of comprehensive care at all stages of the disease⁴.

In Brazil, according to the review of the Guidelines for the Early Detection of Breast Cancer, screening actions for breast cancer include primarily mammographic examination, breast self-examination (BSE) and clinical breast examination (CBE)³. In view of this, studies about the knowledge women about screening tests for breast cancer are necessary, so that health services can have subsidies for the planning of active search strategies, development of educational actions and prevention of the disease.

We reiterate the need for holistic and comprehensive care for women in primary health care beyond the focus on the physical pregnant body, providing knowledge on self-care actions in relation to their general health¹¹. The study found that women's knowledge of the importance of self-examination of the breasts, when stimulated by health professionals, works as a protective factor for the early detection of cancer and promotes sexual and reproductive health¹².

METHODOLOGY

This is a cross-sectional and analytical study developed in a municipality in the northwestern region of PR, with a population of 81,590 inhabitants, of which 42,308 are women¹³. The 24 FHS teams cover 100% of the population and are distributed in 12 basic health units.

In August 2014, 14,638 women aged between 35 and 69 years were enrolled in the FHS teams. From this total, a probabilistic and systematic sample of cadastral records was calculated, adopting the prevalence of breast cancer of 80 per 100 thousand women and considering a 95% confidence level and a 5% probabilistic error. After inclusion of a further 30% to cover possible losses, a final sample of 145 women was obtained.

After clarification regarding the objectives and method of the research, data were collected through semi-structured interviews using an adapted instrument developed by Batiston¹⁴, from August 2014 to October 2015. This was composed of three blocks of questions referring to the independent variables: sociodemographic characteristics (age, marital status, schooling, ethnicity, professional occupation and income); reproductive history (age of first menstruation, age at first sexual intercourse, number of children, maternal age at first child, time of breastfeeding, use of oral contraceptives); and reported knowledge about risk factors for development of breast cancer, with open and closed alternatives of multiple choices. The response variable was mammography with or without alterations.

A pilot test was conducted with 30 women out of the original sample plan in order to verify possible inconsistencies and/or difficulties in interpreting the questions in relation to the research objective.

Measurements of simple proportions and measures of central tendency (mean and median) were verified through descriptive statistics; for bivariate analysis, the Pearson chi-square test and the Fisher's exact test were used when one of the research variables presented a frequency of less than six. The adjusted odds ratio was calculated to estimate the measures of association between variables. A significance level of 5% (p < 0.05) and a 95% confidence interval were considered for all analyses. Analyses were performed with the Excel for Windows software, version 2010 and Epi Info version 7.2.1.

The study was approved by the Committee of Ethics in Research with Human Beings of the Cesumar University Center (UniCesumar) under Opinion nº 977.791.

RESULTS AND DISCUSSION

The mean age of women was 52.5 years (± 9.3 of standard deviation) and white women were 5.6-fold more likely (p = 0.0054, OR = 0.17, 95% CI = 04-0.63) to present mammographic changes, as shown in Table 1.

TABLE 1: Sociodemographic characteristics according to the results of mammographies reported by women assisted at by FHS teams. Paranavaí, Paraná, Brazil, 2014-2015.

^(*) Descriptive level for Pearson's Chi-square test
^(**) Descriptive level for Fisher's Exact Test
^(***) MW - Minimum Wage (Year 2014 = R $ 724.00, Year 2015 = R $ 788.00)

The prevalence of altered mammographies in women aged between 50 and 69 years corroborates the literature; menopausal women are at higher risk to develop breast cancer due to intense hormonal variations. However, although it is not a routine condition, breast cancer has now been observed in a significant number of young women, especially those with a positive family history of premenopausal breast cancer and genetic risk factors ^3,15,16. Given the knowledge of risk factors, it is important to emphasize the importance of health education actions that stimulate early detection because this would be an important strategy for better prognosis.

Regarding color, although historically white women had the highest rates of breast cancer incidence, the rates are converging towards white and African American women due to the etiological heterogeneity and the different effects of risk factors such as obesity and parity, for example ^17,18. In this context, considering the reproductive history, women who did not have children presented 4.5-fold higher chances to present mammographic changes (OR = 4.53, CI_95% = 1.18-17.32), according to Table 2.

TABLE 2: Reproductive and gynecological history according to results of mammographies reported by women assisted by FHS teams. Paranavaí, Paraná, Brazil, 2014-2015.

^(*) Descriptive level for Fisher's Exact Test

It is worth noting that nulliparity has been also pointed out by other studies as a risk factor for breast cancer because breastfeeding is a protective factor due to the complete differentiation of breast cells and shorter time of exposure to the action of sex hormones that decrease during amenorrhea, induced by lactation^19,20.

It should be noted that health professionals are the main source of information on risk factors, prevention and characteristics of the disease. Moreover, the importance of establishing an effective communication process between professionals and patients is reiterated. Besides passing on information, professionals must encourage women's awareness of self-care actions²¹.

Although there are innumerable strategies and programs to guide and stimulate breast cancer prevention, the way these measures are implemented is still questionable, since most women seek help when the disease is manifesting signs and symptoms^22,23. Furthermore, the worst prognosis of women assisted in the Brazilian public service has also contributed to diagnosis of the disease at a very advanced stage ²⁴.

Thus, it should be emphasized that although there are national and regional policies aimed at early detection, breast cancer in Brazil is still an important public health problem due to late diagnosis. This can be attributed to difficulties in accessing public health services, the imbalance between supply and demand for services, and the inefficient management of the municipal and state spheres to define demand flows, especially for suspected cases of breast cancer, and the lack of knowledge about possible risk factors and treatment methods²⁴.

Regarding the changes perceived by women in self-examination, they were approximately 13-fold more likely to be confirmed by mammography (OR = 12.72, 95% CI = 3.72-43.45, p < 0.01). Likewise, lesions detected in the clinical examination and history of previous problems were also statistically associated with posterior mammographic confirmation (p < 0.01) (See Table 3).

TABLE 3: Screening for breast cancer according to mammographic results reported by women assisted by FHS teams. Paranavaí, Paraná, Brazil, 2014-2015.

^(*) Descriptive level for Pearson's Chi-square test
^(**) Descriptive level for Fisher's Exact Test

Self-examination and clinical examination of the breasts represent the main methods of early detection of breast cancer and have a positive impact on the reduction of morbidity and mortality. However, in the current context of the health services, not only the explanation on how to perform the self-examination is needed, but also the practical demonstration during the clinical examination in order to stimulate the learning by the women. Therefore, the inclusion of this practice should be prioritized in all consultations of women regardless of the existence of complaints. A study carried out in Ethiopia with health professionals evidenced a reduced practice of self-examination among the professionals themselves and pointed out the need to invest in actions to stimulate self-examination, initially among professionals, in order to effectively reach the community ^25,26.

Besides the awareness of professionals, the need for continuous training on the technique of clinical examination of the breasts, the differentiation of the main findings and the distribution of the different points of attention for the adequate and timely referral of patients also stand out. A study indicated that 75% of the women affirmed having done the clinical examination of the breasts and the last cytopathological examination for cervical cancer, but some of them reported that the presence of nodules was not detected during the examination although the nodule was already present ²⁵.

Finally, we emphasize the importance of comprehensive and qualified care for women, as well as active listening on the part of professionals and a detailed anamnesis in order to identify risk factors for the development of cancer, such as a history of breast problems. Knowing the patients, the context in which they are inserted, and their behaviors and risk factors allows the multidisciplinary team to provide a person-centered care, attending specificities and adapting the proposals of intervention to the patients²⁷.

CONCLUSION

The factors associated with mammographic changes were white women, nulliparity, identification of changes during self-examination and clinical examination, and the existence of a previous breast problem.

These findings reinforce that health education actions need to emphasize and enable women to adequately perform self-examination of the breasts. Health professionals also need ongoing training to perform the clinical examination of the breasts and identify changes. This has direct implications for managers of health services, in the sense that they should make continuing education possible in the health service, contemplating the improvement of the techniques and the follow-up of protocols.

Although performed only in one municipality, we believe that the results of the present study contribute to the ongoing discussion among health teams regarding the quality of the breast cancer prevention strategies implemented.

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