Awareness of Self-Examination, Screening, and Risk Factors for Breast Cancer Among Women Awaiting Care at the Outpatient Clinic of a Mastology Unit.

This study aimed to evaluate the awareness and practice of breast self-examination (BSE) and the awareness of screening and risk factors for breast cancer among patients from a mastology clinic and to associate such findings with sociodemographic factors of that population. A total of 202 randomly selected patients from the outpatient clinic of the Mastology Unit of São Paulo School of Medicine were interviewed. A structured questionnaire was used and included questions regarding sociodemographic variables, questions to assess the knowledge and practice of BSE, and knowledge of mammographic screening and risk factors for breast cancer. The vast majority of patients were aware of the existence of BSE (93.1%). BSE was performed by most patients (64.9%), although only 20.3% performed it adequately. Only 21.8% of respondents showed awareness of the best screening method for breast cancer. Furthermore, 17.3% of patients showed adequate awareness of risk factors for breast cancer. The analysis of sociodemographic variables showed that older, postmenopausal, and less-educated women showed better practice of BSE. Overall, the patients had no adequate awareness of BSE, mammographic screening, and risk factors for breast cancer, and the majority failed to practice BSE adequately, particularly the group of patients with the higher level of education. These data show that educational measures regarding the practice of BSE and, especially, mammograms should be emphasized, regardless of education level or family income of the patient.

Exercise Protocol With Limited Shoulder Range of Motion for 15 or 30 Days After Conservative Surgery for Breast Cancer With Oncoplastic Technique: A Randomized Clinical Trial.

OBJECTIVE: The objective is to evaluate the effect of limiting shoulder range of motion (ROM) for 15 or 30 days on surgical complications and on shoulder ROM, pain, and upper limb function of breast cancer patients following conservative oncoplastic surgery. MATERIALS AND METHODS: A randomized clinical trial was conducted with 60 women with breast cancer who underwent conservative oncoplastic surgery. The day after surgery, all patients started an exercise protocol with shoulder exercises limited to 90 degrees. Two weeks after surgery they were randomized into Free ROM Group (n=30) or Limited ROM Group (n=30). The Free ROM Group was allowed to perform shoulder exercises with unlimited ROM; the Limited ROM Group continued with shoulder movement restricted at 90 degrees until 30 days after surgery, at which time they were also allowed free ROM. The primary outcome was the incidence of postoperative complications (dehiscence, seroma, infection, and necrosis) and secondary outcomes were shoulder ROM, pain, and upper limb function. RESULTS: No difference in the incidence of postoperative scar complications between groups was noted. There was no difference between the groups in shoulder joint amplitude, pain, or upper limb function. CONCLUSIONS: The free ROM exercise protocol 15 days post surgery was safe concerning cicatricial complications.

Meta-analysis of long-term efficacy and safety of hypofractionated radiotherapy in the treatment of early breast cancer.

PURPOSE: To evaluate the efficacy and safety of hypofractionated radiotherapy in women with early stage breast cancer after breast conservative surgery. METHODS: We performed a search for randomized controlled trials (RCTs) that compare conventional fractioning and hypofractioned radiotherapy. The studied outcomes were local and loco-regional recurrence, disease-free survival, mortality, cardiac ischemia, rib fracture and pulmonary fibrosis up to 5 years and 5 years after treatment. Shrinkage of the breast, breast tightening, telangiectasia, breast edema, shoulder stiffness and arm edema were evaluated within 10 years. Cosmesis and acute skin radiation toxicity were evaluated. RESULTS: Ten publications of six RCTs were included. No statistical difference in local and loco-regional recurrence, disease-free survival, mortality, cardiac ischemia, ribs fracture and pulmonary fibrosis, shrinkage of the breast, breast tightening, shoulder stiffness, arm edema and cosmesis was found. However, there was a significant difference in favor of hypofractionated for breast edema (RR 0.68, 95% CI 0.53 to 0.88, p = 0.003, 4675 patients), telangiectasia (RR 0.41, 95% CI 0.19 a 0.87, p = 0.02, 5167 patients), and acute skin radiation toxicity (RR 0.34, 95% CI 0.19 to 0.61, p = 0.0003, 347 patients). CONCLUSION: There is no difference between conventional fractionation and hypofractionated in terms of efficacy when we evaluate local recurrence, loco-regional recurrence, distance recurrence, disease-free survival and mortality. There is also no difference concerning safety when we assess the occurrence of fibrosis, ischemia and ribs fractures. Hypofractionated showed better results in relation to breast edema, telangiectasia, and acute skin radiation toxicity.

Diagnosis of Axillary Web Syndrome in Patients After Breast Cancer Surgery: Epidemiology, Risk Factors, and Clinical Aspects: A Prospective Study.

OBJECTIVES: Axillary web syndrome (AWS) is a complication after breast cancer surgery associated with the axillary approach. We defined a diagnosis tool as well as evaluated cord frequency, characteristics, and risk factors. METHODS: A prospective cohort study of 173 women followed-up at Breast Diseases Division of Universidade Federal de São Paulo between July 2014 and September 2015 was established as an evaluation protocol to diagnose AWS. Sociodemographic status, anthropometric values, range of motion, comorbidities, pain, cord frequency, and characteristics (localization, number, palpable, and/or visible) among other data were collected at different time points before and after surgery. RESULTS: The majority of the cords appeared by the seventh day (66.1%), and the total incidence of the cords was 90.9% at the 180th day. The axilla was the place for 80% of the occurrence of AWS, and >70% of the cords were palpable. Flexion and abduction of the shoulder showed reduced range of motion. Pain was present in 39.7% of the patients. Lymphadenectomy as well as hypertension were associated with increased risk of cord development; diabetes was associated with a decreased risk. CONCLUSIONS: The evaluation protocol applied here showed a high incidence of AWS, with palpable cords more frequent than visible ones. The significance of hypertension and diabetes mellitus as risk factors for cord development in AWS should be evaluated in future studies. The evaluation protocol developed in this study seems to be of great importance for early detection of AWS and could also be valuable for future treatment planning.

The influence of the initiation of an exercise programme on seroma formation and dehiscence following breast cancer surgery.

AIMS AND OBJECTIVES: To verify whether early (first post-operative day) or late initiation (after removal of the continuous suction drain) of a functional rehabilitation exercise programme influences the incidence of seroma formation and dehiscence for women after breast cancer surgery. BACKGROUND: Benefits of early implementation of an exercise programme initiated with women in the first days following breast cancer surgery are widely known. However, the safe initiation of the exercises is still a controversial issue and some authors correlate early initiation of the exercises with an increase in seroma formation. DESIGN: A prospective, randomised, controlled clinical trial. METHODS: Seventy-seven women were randomly assigned to initiate the programme on post-operative day 1 (early group = 40) or after removal of the drain (late group = 37) and were monitored until the 45th post-operative day. Patients in the early group were instructed to perform the exercises daily at home, beginning on post-operative day 1, while those of the late group began the exercises after the drain was removed. The assessment for seroma formation and dehiscence was performed on post-operative days 7 and 45. RESULTS: There was no statistically significant difference regard to seroma formation between early group and late group. Also there was no association between the presence of dehiscence and early exercises. CONCLUSION: The early initiation of the exercises for women, following breast cancer surgery, constitutes a safe practice for the rehabilitation. However, these findings need to be further explored and confirmed in a larger sample. RELEVANCE TO CLINICAL PRACTICE: Studies showing evidence that early functional rehabilitation process is a safe practice for women having surgery for breast cancer, as well as the present research, are of interest to health professionals who care for these patients and contribute to the wider global clinical community.

Effect of combined oral contraceptives on breast epithelial proliferation in young women.

The mammary gland undergoes morphologic changes during the menstrual cycle. Proliferation of normal breast epithelium is most extensive during the natural luteal phase. To determine the impact of one cycle of a combined oral contraceptive (COC) on breast homeostasis, we evaluated the proliferation index (PI), determined by KI-67 expression, in normal human mammary epithelial cells and correlated it with cellular proliferation in spontaneous menstrual cycles during the same period. Normal breast tissue samples were obtained from 82 patients randomized in two groups. Forty-two women in group A received one cycle of a COC (30 mug ethinyl estradiol and 150 mug levonorgestrel) administrated daily for 21 days, beginning on the first day of the menstrual cycle. Group B patients (n = 40) experienced a natural menstrual cycle. Menstrual cycle phase characterization was based on the date of the last period and subsequent menses and on progesterone serum levels obtained at the time of biopsy. The PI (number of Ki-67-positive nuclei per 1,000 epithelial cells), was significantly larger in group A (5.47 +/- 3.87), than in group B (3.27 +/- 3.24), p < 0.01. A cyclical variation of PI was observed in COC cycles. The rise in PI in the first week of the COC cycles was significantly higher than in the natural cycle (COC = 7.02 +/- 4.94; non-COC = 1.10 +/- 0.67; p < 0.0011). There was no significant difference between the two groups during the other weeks. Additionally, there was an inverse correlation between proliferation and chronological age, irrespective of the stage of the cycle. The PI of COC (p = 0.175) and natural cycles (p = 0.466) were not statistically different in younger patients. COC users have increased proliferative activity at the beginning of the menstrual cycle. This alteration in the pattern of proliferative activity may relate to the increased risk of breast cancer that has been associated with COCs.

Assessment of the proliferative, apoptotic and cellular renovation indices of the human mammary epithelium during the follicular and luteal phases of the menstrual cycle.

INTRODUCTION: During the menstrual cycle, the mammary gland goes through sequential waves of proliferation and apoptosis. In mammary epithelial cells, hormonal and non-hormonal factors regulate apoptosis. To determine the cyclical effects of gonadal steroids on breast homeostasis, we evaluated the apoptotic index (AI) determined by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining in human mammary epithelial cells during the spontaneous menstrual cycle and correlated it with cellular proliferation as determined by the expression of Ki-67 during the same period. METHODS: Normal breast tissue samples were obtained from 42 randomly selected patients in the proliferative (n = 21) and luteal (n = 21) phases. Menstrual cycle phase characterization was based on the date of the last and subsequent menses, and on progesterone serum levels obtained at the time of biopsy. RESULTS: The proliferation index (PI), defined as the number of Ki-67-positive nuclei per 1,000 epithelial cells, was significantly larger in the luteal phase (30.46) than in the follicular phase (13.45; P = 0.0033). The AI was defined as the number of TUNEL-positive cells per 1,000 epithelial cells. The average AI values in both phases of the menstrual cycle were not statistically significant (P = 0.21). However, the cell renewal index (CRI = PI/AI) was significantly higher in the luteal phase (P = 0.033). A significant cyclical variation of PI, AI and CRI was observed. PI and AI peaks occurred on about the 24th day of the menstrual cycle, whereas the CRI reached higher values on the 28th day. CONCLUSIONS: We conclude that proliferative activity is dependent mainly on hormonal fluctuations, whereas apoptotic activity is probably regulated by hormonal and non-hormonal factors.

Avaliaçäo histeroscópica do endométrio de pacientes com carcinoma de mama na pós-menopausa antes e após o uso de tamoxifeno / Hysteroscopical evaluation of the endometrium of post-menopausic patients with breast cancer before and after tamoxifen use

Objetivo: avaliar a influência do tamoxifeno no aspecto histeroscópico e histopatológico do endométrio de pacientes com câncer de mama na pós-menopausa, por meio da histeroscopia. Método: estudaram-se, prospectivamente, 46 pacientes, das quais 20 utilizaram a droga por período médio de 12 meses. Efetuou-se, antes e após o tratamento pelo fármaco, a histeroscopia associada à biópsia endometrial. Resultados: a taxa de endométrio ativo, antes e após a hormonioterapia adjuvante com tamoxifeno näo aumentou a taxa de atividade proliferativa endometrial em pacientes com câncer de mama na pós-menopausa. Observaram-se numerosas vesículas disseminadas por toda a cavidade uterina e isso constituiu o aspecto histeroscópico mais usual, talvez devido à atrofia cística do endométrio

Aspectos clínicos e terapêuticos do carcinoma de mama em pacientes idosas: estudo de 72 casos / Clinical and therapeutic aspects of breast carcinoma in elderly patients: study of 72 cases

O carcinoma de mama na paciente idosa apresenta crescente incidência e, ao contrário das jovens, aumento nos índices de mortalidade. Estudou-se 72 pacientes com idade superior a 65 anos, tratadas no Setor de Mastologia da Disciplina de Ginecologia da Escola Paulista de Medicina, de janeiro de 1990 a janeiro de 1994. O diagnóstico foi tardio em 62 por cento das pacientes e o comprometimento linfonodal axilar foi de 51,7 por cento. A mastectomia com linfadenectomia foi a cirurgia de escolha com mortalidade inferior a 1 por cento e controle loco-regional em 40 meses de 93,7 por cento. Indicou-se a radioterapia apenas como complemento da quadrantectomia ou de casos avançados. No tratamento sistêmico empregou-se, preferencialmente, tamoxifeno (20 mg/dia) por tempo mínimo de 24 meses. Os autores ressaltam ainda a importância do rastreamento da neoplasia endometrial nessas pacientes. A quimioterapia ficou restrita a pacientes em bom estado geral com tumores inoperáveis e hormônio resistentes.