Breast cancer screening programme: experience from Eastern province, Saudi Arabia.

Programmes for early diagnosis of breast cancer are lacking in most countries in the Eastern Mediterranean Region. This paper reviews a nongovernmental screening programme launched in October 2009 in the Eastern Province of Saudi Arabia, in which 14 health centres were covered by 2 mobile mammography machines. Annual screening was offered to all women aged 40 years and above. Up to February 2014 a total of 8061 women were screened, an uptake rate of 15.0%. The recall rate was 7.9%. The number of cancers detected was 47, a cancer detection rate of 5.83 per 1000 women screened; 70.2% of the cancers detected had either no mass or the lesions were smaller than 2 cm. The mean age of women with cancer was 50.4 (SD 7.6) years. The screening parameters of our study correlated well with international standards. Despite the controversies regarding universal breast cancer screening, a national breast cancer screening programme for Saudi Arabia is needed.

Knowledge and attitude towards screening mammography among 400 women in the eastern province of saudi arabia.

OBJECTIVE: Assess knowledge and attitude of Saudi females towards screening mammography. MATERIAL AND METHODS: A sample of four hundred Saudi females were interviewed using a structured questionnaire. RESULTS: Positive family history of breast cancer was the most significant factor that was positively associated with individual knowledge and attitude towards screening mammography (p<0.00001). There was no significant association with the level of education. Poor knowledge and attitude were observed among 41.8% of all participants, especially in relation to not having mammography done or not wishing to have it done. There were 51 (12.8%) participants who had not had mammography done, but wished to have it, 25 (6.3%) participants who were undecided about having mammography done in the future, while 67 (16.8%) wished to have it done every one to two years. CONCLUSION: This study showed that there has been deficient knowledge and attitude towards screening mammography even among the highly educated, and stressed the need for health education on the importance of screening.

Breast cancer in the eastern province of Saudi Arabia.

In the Kingdom of Saudi Arabia (KSA), hospital and population based statistics have shown that breast cancer has the highest crude frequency rate among Saudi women. The scarcity of reports about the disease in the KSA has been the impetus to this analysis about breast cancer in the eastern province of KSA. Data on female patients with invasive breast carcinoma seen at King Fahd Hospital of the University in the eastern province of KSA, were retrospectively reviewed. The analysis intended to examine the pattern of the disease and the outcome for patients. Between 1985 and 1995, 292 patients were identified. Their median age +/- SD (standard deviation) was 42 +/- 10.5 years. Most patients were younger than 50 years (78%) and were predominantly premenopausals (79%). Only 25 (9%) of patients had stage I cancer, whilst 130 (44%), 90 (30%), and 47 (16%) had stage II, III, and IV, respectively. Among patients with known axillary nodal status (242 patients), only 37% were node-negative whilst 32% and 31% had 1-3, and > or = 4 positive nodes, respectively. Adjuvant chemotherapy and tamoxifen were commonly offered; nonetheless, other adjuvant modalities were rarely utilised. The median follow-up +/- SD of all patients was 62.3 +/- 8.9 months: 152 patients (52%) were alive with no evidence of disease, 25 (9%) were alive with evidence of disease, and 115 (39%) were dead from breast cancer or its related complications. The median survival of the entire group was not obtained, but the 10-year projected survival was 55%. For stage I and II patients, 118 (76%) were alive with a projected 10-year actuarial survival of 64%. On the other hand, only 51 (57%) of patients with stage III disease were alive with a median survival of 41.5 months (95% Confidence interval (CI), 18.9 to 51.3). Patients with stage IV disease demonstrated a poor outcome with a median survival of 23.5 (95%, CI 12.2 to 31.4). Multivariate analyses were performed to explore the influence of independent variables on overall survival (OS) for patients with non-metastatic disease. Besides the expected adverse effect of disease progression, the favourable influence of adjuvant chemotherapy and tamoxifen prevailed. The amount of benefit gained from tamoxifen, however, was small. Similar analyses were undertaken to determine the influence of independent variables on progression-free survival (PFS). These analyses ascertained the adverse effects of advanced stage and the favourable impact of adjuvant chemotherapy. Breast cancer in the KSA has features that are distinctive from those of industrialised countries. Survival data, however, were comparable. The favourable influence of adjuvant chemotherapy was evident on both OS and PFS. Adjuvant tamoxifen, however, had little effect. Due to its infrequent use, the role of other adjuvant modalities could not be asserted.

Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients.

OBJECTIVE: The study was designed to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. MATERIAL AND METHODS: In a prospective open study, adult cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corporation, Kenilworth, NJ) prepared as mouthwash solution (5 to 10 µgm /ml). GM-CSF was administered within 24 hours of occurrence of oral mucositis at a frequency of 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. RESULTS: Forty-nine patients were recruited but nine were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 40 patients were all evaluable. Most patients had either Grade 3 or 4 gross (71%) or functional (70%) mucositis. The mean ± SEM gross oral mucositis scores for all 40 patients combined decreased from 3.3 ± 0.11 at baseline to 2.1 ± 0.12 (p<0.0001) after 2 days, 0.95 ± 0.11 (p<0.0001) after 5 days and 0.23 ± 0.07 (p <0.0001) after 10 days of therapy. Likewise, the mean ± SEM functional oral mucositis scores decreased from 3.03 ± 0.13 at baseline to 1.58 ± 0.13 (p<0.0001) after 2 days, 0.68 ± 0.11 (p<0.0001) after 5 days, and 0.15 ± 0.06 (p<0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis grading score) was evident in 12 (30%), 29 (73%), and 40 (100%) patients by the 2(nd), 5(th) and 10(th) day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis grading score) reported in 19 (48%), 31 (78%), and 40 (100%) patients by the 2(nd), 5(th) and 10(th) day of therapy, respectively. The use of GM-CSF mouthwash was not associated with any apparent ill effect. CONCLUSION: GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosage and schedule.

Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients.

The aim of this study was to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. In a prospective open study, 30 cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corp, Kenilworth, NJ) prepared as a mouthwash solution (5-10 micrograms ml-1). GM-CSF was administered within 24 hours of occurrence of oral mucositis x 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. Six patients were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 24 patients were all evaluable. Most patients had either Grade 3 or 4 gross (76%) or functional (54%) mucositis. The mean +/- SEM gross oral mucositis scores for all 24 patients combined decreased from 3.08 +/- 0.18 at baseline to 2.04 +/- 0.19 (p < 0.0001) after 2 days, 0.92 +/- 0.16 (p < 0.0001) after 5 days, and 0.25 +/- 0.09 (p < 0.0001) after 10 days of therapy. Likewise, the mean +/- SEM functional oral mucositis scores decreased from 2.71 +/- 0.18 at baseline to 1.58 +/- 0.19 (p < 0.0001) after 2 days, 0.75 +/- 0.16 (p < 0.0001) after 5 days, and 0.17 +/- 0.08 (p < 0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis score) was evident in seven (29%), 20 (83%), and 24 (100%) patients by the 2nd, 5th, and 10th day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis score) reported in 13 (54%), 19 (79%), and 24 (100%) by the 2nd, 5th, and 10th day of therapy respectively. It was found that GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosages and schedule.

Chemotherapy with MECOP-B for intermediate-grade and high-grade non-Hodgkin's lymphoma in Saudi Arabia: clinical results and analysis of prognostic factors.

Between August 1985 and January 1994, 73 evaluable adult patients with bulky localized or advanced-stage, intermediate- and high-grade de novo non-Hodgkin's lymphoma (NHL) were treated with MECOP-B (methotrexate and leucovorin rescue, epirubicin, cyclophosphamide, vincristine, prednisone, and bleomycin). Over a median follow-up of 32 months (range, 4-98 months), 55 patients (75%) achieved complete remission (CR) (95% confidence interval, 81-69%) and 3 attained partial remission (PR) (4%) for an overall response rate of 79%. Using a multiple regression analysis where the dependent variable was response to therapy (CR vs. PR + treatment failure), poor performance status, and the presence of a bulky disease were negatively associated with the likelihood of achieving CR. Survival analysis showed that 49 (67%) patients (95% confidence interval, 74 and 60%) were alive, of whom 47 (64%) were disease-free. While the median survival has not been reached, the actuarial survival probability at 5 years +/- SE was 64 +/- 6%. Time to treatment failure for those attaining CR was also estimated. While the median survival has not been reached, probability of freedom from treatment failure at 5 years +/- SE was estimated as 74 +/- 7%. However, the long-term CR (CR rate times disease-free survival rate) was only 48%, and the 'measurement of efficacy' was 53%. These results were inferior to those from our earlier reports. The proportional hazards model of Cox identified poor performance status, older age, and high lactate dehydrogenase as factors with an adverse effect on survival. Using the results of the model, patients were categorized into three predefined risk groups with significant differences in outcome. Toxicity of the regimen was high, but comparable to that reported in the literature with a toxic death rate of 8%. We conclude that MECOP-B is an effective therapy for patients with aggressive NHL; however, based on the current results as compared with our earlier analysis, besides the emergence of prognostic factors, therapy of NHL should be individualized. Less expensive, less toxic regimens should be used for lower-risk patients, while the use of more intense, more toxic, more expensive programs should only be offered to those with a predicted poor outcome.

Magnetic resonance imaging of tuberculous spondylitis.

STUDY DESIGN: This retrospective study analyzed the magnetic resonance imaging characteristics of tuberculous spondylitis. OBJECTIVE: To describe the magnetic resonance imaging characteristics of tuberculous spondylitis and compare the diagnostic yield of magnetic resonance imaging versus other modalities. SUMMARY OF BACKGROUND DATA: Tuberculous spondylitis is not an uncommon occurrence with extrapulmonary disease. It requires prompt diagnosis and management. In the pre-magnetic resonance imaging era, computed tomography was used to delineate the associated radiologic changes. Data are limited that describe the magnetic resonance imaging pattern of tuberculous spondylitis and the effect of post-contrast enhancement. METHODS: The magnetic resonance imaging characteristics of 28 vertebrae in 12 patients with tuberculous spondylitis were studied. RESULTS: The thoracic spine was the most commonly involved region, with involvement occurring in the thoracic spine alone in 12 vertebrae (43%) and with other areas of the spine in an additional five (18%). Partial involvement was detected in the majority of the vertebral lesions (24; 86%). Magnetic resonance imaging evidence of disc space involvement was apparent in only 46% of the lesions. Paraspinal abscess and epidural extension were documented by magnetic resonance imaging in 71% and 61% of lesions, respectively. Decreased signal intensity on T1-weighted images was demonstrated in 13 vertebrae (46%), with increased signal intensity on T2-weighted images seen only in five (18%). CONCLUSION: Magnetic resonance imaging is a useful diagnostic modality for patients with suspected tuberculous spondylitis. Partial vertebral involvement and paraspinal and epidural extension were delineated. Study of the signal intensity on T1- and T2-weighted images revealed a pattern that may be dissimilar to that commonly reported. Post-contrast enhancement adds more certainty to the diagnosis of tuberculous spondylitis.

Magnetic resonance imaging of the spine: An initial experience.

Retrospective analysis was carried out for 447 magnetic resonance imaging (MRI) studies of the spine. The overall mean age +/- SD of the entire series was 38.7 +/- 12.9 years. Degenerative spinal lesions and prolapsed intervertebral disks were detected in 62% and 73% of all the studies and of those which showed spinal abnormalities respectively. Postoperative granulation tissue was the third most common abnormality detected (12%). MRI was superior to computed tomography (CT) and CT myelograms in the diagnosis of disk prolapse (97% versus 66%), degenerative disease of the spine (94% versus 48%), and postsurgical granulation tissue (100% versus 6%). Comparing the numbers of CT and CT myelograms requested in the year prior to the installation of the MRI to the numbers requested during the year where the MRI was functioning did not show any change in the frequency of ordering CT studies. We conclude that our hospital-based series has shown an interesting pattern for spinal disorders. The first year experience of the utilization of MRI in various spinal diseases has been satisfactory with prevailing diagnostic superiority for that modality.

Fatty infiltration of the liver: analysis of prevalence, radiological and clinical features and influence on patient management.

Over a 6-year period, in 1425 adult computed tomographic studies, radiological evidence of fatty infiltration of the liver (FIL) was found in 138 patients (9.7%). Patients with FIL had a mean age +/- SD of 45.9 +/- 15.7 years and 57% were males; the majority were Saudis (73%). Most patients (95%) had one or more underlying aetiological causes. Haematological and non-haematological malignancies with or without liver involvement were the most frequently encountered aetiological factors (66% of patients). FIL contributed to hepatomegaly or was associated with abnormality in one or more of the liver function tests in 30% and 39% of patients, respectively. Assessment of the various radiological patterns showed diffuse fatty changes in 68% of patients and solitary or multiple focal changes in 9% and 22%, respectively. 13 patients (9%) showed sparing of the caudate lobe within a diffuse fatty process. Patients with diffuse FIL had significantly higher values for alkaline phosphatase (p = 0.0016) and serum asparate aminotransferase (p = 0.0251) than those who had the focal pattern. FIL in 20 patients (14%) imposed a difficulty in making an appropriate diagnosis, led to inaccurate impressions, or forced unnecessary invasive or non-invasive investigations. We conclude from our large series of patients that FIL is not uncommon in hospital practice and among those at risk should always be considered as an appropriate diagnosis.

Tuberculosis in patients with malignant disease.

Of 2,143 biopsy proven cancer patients seen at our hospital over a six year period, 4 (0.19%) patients developed active tuberculosis (TB) during anticancer therapy or shortly after its completion. The cancer diagnoses of those patients were non-Hodgkin's lymphoma, breast cancer, chronic myelogenous leukemia, and astrocytoma. Institution of antituberculous therapy was successful in three patients, however, the TB course was rapidly fatal in the fourth patient with non-Hodgkin's lymphoma despite therapy. The association between TB and neoplasia is emphasized. TB complicating malignant disorders represents complex problem regarding its early recognition and its managements.

Non-Hodgkin's lymphoma in Saudi Arabia: prognostic factors and an analysis of the outcome of combination chemotherapy only, for both localized and advanced disease.

Seventy-eight previously untreated patients with clinical stage (CS) I and II (42 patients) and CS III and IV (36 patients) and non-Hodgkin's lymphoma (NHL) were treated with systemic chemotherapy only. All patients had intermediate or high grade lymphoma. Two different regimens were used: bleomycin, adriamycin, cyclophosphamide, vincristine and prednisone (BACOP); and a combination of methotrexate with folinic acid rescue, epirubicin, cyclophosphamide, vincristine, prednisone and bleomycin (MECOP-B), for 57 and 21 patients respectively. Objective clinical remission was achieved in 90% of the cases, of which 73% were complete. Complete remission (CR) was demonstrated in 90% and 53% of patients with CS I + II and III + IV respectively (P = 0.0008). Two variables, bone marrow and liver involvement, were negatively associated with CR rate in a multivariate analysis. The actuarial overall survival for the entire group was 65%. The median survival for complete responders has not been reached, but a projected 80% relapse-free survival at 3 years is estimated. The Cox proportional hazards model predicted that advanced stage (CS III and IV) and pretreatment lactic dehydrogenase serum level above 400 iu/l (N less than 200 iu/l) independently influenced survival adversely. The latter prognostic variables were used to identify several groups with different risk probabilities. Despite an apparent comparability between patients receiving the two regimens, no significant difference in response or survival rates was noted between the two protocols. We conclude that the results of systemic chemotherapy compared favorably with radiation therapy for early stage disease and is an acceptable strategy for developing countries with limited availability of radiotherapy facilities. Based on certain risk factors, therapy should be individualized so that more intense regimens, with or without radiation, should be offered only to those patients in the high risk group at highly specialized centers.