Dissertations / Theses on the topic 'Breast screening services'

Problem: There is a lack of knowledge about women who are screened for breast cancer, have an abnormal finding on mammogram, and then do not return in a timely manner for diagnostics and treatment. Lack of follow- up likely constitutes delayed treatment and poorer outcomes. Delays may result in later entry into the health system with advanced disease, more extensive and expensive care, burdening resources. Late stage breast cancer likely results in poorer health outcomes or early death.Purpose and Aims: The purpose of this research is to describe contextual characteristics at the health delivery level as well as individual characteristics of women with abnormal mammography, and their association with use of follow- up health services. Particularly, this research examines the differences between women who are early and late responders after an abnormal mammogram.Population: The participants were a convenience sample of 380 women who participated in mobile breast cancer screening. A subset of women with inconclusive or abnormal mammogram findings was the focus of analysis.Methods: This research utilized a descriptive design with quantitative data collection through participant survey at mobile mammogram screening events in multiple urban and rural Arizona sites. Participants requiring further health care were followed by chart review. Analysis of correlations with the outcome variable: time to first follow- up appointment for recommended health care in women with abnormal mammograms was conducted.Findings: Data indicated the time to the first follow- up appointment ranged from 1- 110 days with follow- up for 77.4% of participants within 60 days, 6.5% within 60-90 days, and 16.1% without follow- up after 90 days. Significant relationships between contextual and individual characteristics and follow- up were found. Categories included organizational health system characteristics of geographic location, clinical breast exam and shared case management; individual characteristics of beliefs including value of health care; finance including out of pocket costs and perceptions of financial assistance; perceived needs including breast symptoms; and satisfaction with the last health visit and mammograms in general.Implications: Recognition of barriers to follow- up after breast cancer screening is important for development of interventions to improve outcomes and has implications for screening and treatment management programs, community health centers and private practice. Health disparity related to screening without adequate options for access to health care is ethically untenable. Nurses are well positioned to reduce barriers to health care.

Background: Breast cancer is considered the most common cancer among females followed by cancers of the cervix, lung, and stomach. Its mortality can be avoided by early detection. Aim: This thesis aimed to explore Saudi women’s barriers facilitators and experiences, when accessing breast and cervical cancer screening services in the United Kingdom (UK) and Saudi Arabia. Methods: A mixed method approach was used to fulfil the thesis objectives. A quantitative questionnaire was administered to 503 Saudi women living in the United Kingdom and in Kingdom of Saudi Arabia. This was followed up by a qualitative study using seven focus groups discussions. Results: Survey and focus groups provided some consistent findings regarding Saudi women’s perceptions, knowledge, beliefs of the barriers and facilitators in accessing both breast and cervical cancer screening services in the UK and Saudi Arabia. Fear of having cancer and lack of knowledge of the importance of early detection, particularly in cervical cancer were major findings with regard to barriers to attend screening services. However, being employed and highly educated was correlated with better knowledge and awareness of the signs, symptoms, and treatment of both breast and cervical cancer. Participants shared their responsibilities with health professionals and the structure of the health system in the arrangement of early screening of breast and cervical cancers. Additionally, they suggested the role of media, education, and use of places such as mosques in disseminating information about the importance of early cancer detection. Conclusion: While the data reported in this thesis are encouraging, rich and diverse, conclusions must be drawn with caution. Important barriers included health and cultural beliefs and attitudes, language and unsupportive attitudes of health professionals. A majority of Saudi participants believed educational programs would increase breast and cervical cancer awareness and knowledge and use of screening services. The health belief model was utilized to structure and explain the thesis findings and analysis.

Despite there being pragmatic national guidelines for assigning risk to women with a family history of breast cancer, the evidence base is still sparse. There are three major questions: First, how can an assignment of "low" risk be made most efficiently? Second, what are the actual outcomes for higher-risk women enrolled in special surveillance programmes? Third, what are the costs and benefits of current management of members of breast cancer families? My thesis reviews the evolution of clinical services for familial breast cancer and the existing literature in the field. I describe the gathering of information from the service records of the Tayside Breast Cancer Family History Clinic and from specific research exercises that involved collaboration with other centres in the UK and abroad. My findings are as follows: 1. Histories provided by the families are not sufficient to assign risk accurately. They must be extended and verified from other records by clinical geneticists. Women assigned a low risk can be informed by post, but some may require further support. The 2004 NICE guidelines for assigning risk are fairly accurate, but may under-estimate it for some women aged 45--55 years. 2. Annual screening of young women at increased risk results in detection of most cancers at a curable stage. Women who carry BRCA1 mutations fare less well, even when tumours are detected at an apparently early stage. 3. Costs of accurate risk assessment are outweighed by savings from the better targeting of surveillance programmes. Early cancer detection in young women enrolled in these programmes achieves a substantial gain in life expectancy at a cost of £3,700 per quality adjusted life year (QALY). Prophylactic surgery for carriers of BRCA1 mutations is highly cost-effective. The thesis concludes with a discussion as to how these findings might be extended and clinical practice improved in the future.

A qualitative feminist study, informed by social constructionist epistemology, antiracist theories and intersectionality perspectives, was conducted in order to understand South Asian immigrant women’s access to and experiences with breast and cervical cancer screening services in Canada. Particular attention was paid to the wider context of their lives and their experiences of migration, resettlement, integration and general access to the Canadian healthcare system. The study also explored how the broader systems, structures and policies in Canadian society shape South Asian immigrant women’s participation in and access to cancer screening services. Thirty one South Asian immigrant women were interviewed in individual, couple and group settings in greater Vancouver. Research findings indicated that women’s age, length of stay since immigration, educational and generational status, not/having a family history or symptoms impact their use or lack of use of cancer screening services; but these factors also intersect in complex ways with various systemic and structural issues including not having a recommendation from physicians, women’s financial instability, access to income, employment, settlement services and community resources, levels of socioeconomic integration and familiarity with the Canadian healthcare system, and gender roles and responsibilities. Women’s narratives also showed that the immigration factor amplify the intersecting forms of inequities and the social determinants of health such as gender, class, poverty, racialization and discrimination, and affect women’s physical and mental health and access to healthcare services, cancer screening being one of them. An intersectional analysis revealed that the gendered and racialized immigration and integration policies, multicultural discourses and neoliberal ideologies and practices intersect to situate South Asian immigrant women into racialized and disadvantaged situations as the ‘other’ wherein access to preventive cancer screening services becomes especially challenging. South Asian women’s access to cancer screening and other healthcare services needs to be understood beyond the attempts to know their cultural health beliefs and practices, and beyond the neoliberal ideas of ‘self-care,’ ‘individual responsibility,’ ‘patient empowerment,’ and ‘culturally sensitive care.’ Also, equitable access to health care cannot be ensured without resisting these women’s racialized position as the ‘other’ and addressing the social, political, historical, material and structural inequities in Canadian society.

L'inici del programa de detecció precoç del càncer de mama en els districtes de Ciutat Vella i Sant Martí de la ciutat de Barcelona, va motivar la realització del primer estudi en el barri de la Barceloneta, amb l'objectiu d'analitzar diferents factors associats a la participació. La resposta després de la primera citació ha estat del 65%. S'ha relacionat amb l'historial clínic previ augmentant en quasi 4 vegades l'ods de resposta, i amb el receptor de la carta de citació, variant del 75% quan és la mateixa interessada fins el 47% quan la carta és dipositada a la bústia, i el 32% quan l'adreça és insegura. La resposta després de les citacions successives ha estat del 26%. S'ha relacionat amb l'historial clínic previ augmentant en quasi 8 vegades l'ods de resposta, i amb la raó de no haver vingut després de la primera citació, passant del 50% quan és circumstancial fins el 11% quan s'atribueix a manca d'interès. La taxa de cobertura (79%) disminueix amb l'edat, i augmenta amb el nivell educatiu.

El segon estudi permet apreciar com prèviament al programa les mamografies no s'adequaven a les directrius europees. Un 59% de les dones entrevistades dels barris El Clot, Camp de l'Arpa i La Verneda, s'han fet una mamografia de cribratge en els últims quatre anys. Existeix una major utilització en dones més joves, de major nivell educatiu i que tenen historial clínic. La periodicitat era anyal en un 35%, biennal en un 38% i cada 2-4 anys en el 27% restant. El 58% de les mamografies s'han realitzat en la sanitat pública, que mostra el major percentatge (42%) de periodicitat biennal. En les dones participants, la visita al ginecòleg i la pràctica de citologia uterina han presentat la major associació (probabilitats 4 vegades superiors) amb la mamografia prèvia de cribratge. També s'han associat a una major utilització els antecedents personals de patologia mamària i familiars de càncer de mama, l'autoexploració mamària i la visita mèdica recent, mentre que l'autopercepció de salut ha presentat una relació inversa.

Finalment, el tercer estudi és un assaig controlat aleatoritzat on s'han comparat tres diferents estratègies utilitzades per a invitar dones d'entre 50 a 64 anys a participar en el programa. L'estratègia del contacte directe incrementa de forma significativa fins un 22% la probabilitat de resposta després de la primera citació en les dones del barri de Raval Nord invitades. En el grup de contacte directe aquesta resposta era del 63%, comparat amb un 55% quan la carta era enviada pels professionals sanitaris del CAP, i un 52% quan era remesa pels responsables del programa. Aquest increment en el grup de contacte directe s'observa encara que sols s'ha aconseguit contactar en un 45% dels casos directament amb la mateixa dona. Quan aquest fet s'assoleix la resposta és del 72%. La utilització de professionals no sanitaris per a aconsellar les dones sembla ser una estratègia efectiva, particularment entre les dones de baix nivell educatiu.
The beginning of the breast cancer screening program in the Ciutat Vella and Sant Martí districts of Barcelona was the origin of the first study in the Barceloneta quarter, with the aim of analyzing different factors related to participation. The response after the first citation was 65%. Having a previous clinical history, increased in nearly 4 times the response odds. Response after the first citation was influenced by who the recipient of the citation letter was, ranging from 75% when this was the same person concerned to 47% when the letter was left in the letter-box, and to 32% when the address was uncertain. The response after subsequent citations was 26%. Having previous clinical history increased the response odds in almost 8 times. The response after successive citations, ranged from 50% when it was for circumstantial reasons, to 11 % when it was due to lack of interest. Coverage rate (79%) decreased with age, and increased with education level.

The second study shows that, previously to the program, mammography screening did not comply with European guidelines. A screening mammography had been performed on 59 % of women interviewed in the El Clot, Camp de l'Arpa and La Verneda quarters. The utilization of mammography was higher among younger women, women with a higher education level, or who had previous visits to a physician. Periodicity was once a year in 35% of cases, once every two years in 38%, and every 2-4 years in the remaining 27 %. Mammographies were performed at the Public Heath Service in 58 % of cases. The Public Health Service shows the highest percentage (42 %) of biennial periodicity. The variables more strongly associated with the use of screening mammography (probabilities 4 times higher) were: visit to a gynecologist and performance of a pap smear. Also related to the utilization of screening mammography were: personal history of breast pathology, family history of breast cancer, breast self-examination, and recent visit to a general practitioner. Self-perceived health presented an inverse relation with screening mammography use.

Finally, the third study is a randomized controlled trial where three different strategies of inviting 50 to 64 years old women to participate in the program were compared. The strategy of direct contact increased in a significant way, up to 22%, the possibility of response after the first citation among women invited in the Raval Nord quarter. The response rate in the direct contact group was 62%, compared to 55% when the letter was sent by Primary Health Care Team, and 52% when it was sent by those responsible of the program. This increase in the direct contact group is noticeable even though only in 45 % of cases it was possible to contact the subject herself. When this was achieved, response raised to 72%. Use of non-health professionals to advise women seems to be an effective strategy, especially among women with a lower educational level.

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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES
Introduction: Among governmental measures in support of strategies to control and prevent breast cancer in Brazil, the implementation of the Breast Cancer Control Information System (SISMAMA) has made it possible for Single Health System (SUS) managers to identify users and diagnostic centers and provide data to the National Mammmogram Quality Program (PNQM) as a way of guaranteeing adequate tracking and establishing indicators for monitoring mammography results in each region of the country. Objective: To evaluate the opportunistic mammographic screening program carried out by the Single Health System in the municipality of Goiânia en 2010 in regard to the performance of diagnostic centers and indicators for monitoring results. Method: This was an ecological study in which the results of mammograms performed by SUS on the female population of Goiânia from January to December, 2010 and reported by diagnostic centers to SISMAMA were analyzed. The data were collected from the “export data” file of the state coordination module and the variables studied were analyzed in the two articles produced on the basis of this study. In Article 1, the variables studied were test production by diagnostic center, monthly test volume, tests by clinical indication, screening tests by age group and screening tests by diagnostic conclusion using BIRADS® categories (0,1,2,3,4 and 5). To evaluate the conformity of the diagnostic centers, an arbitrary variation limit of ± 30% of the relative frequency of all diagnostic centers in each BIRADS® category was established. Those centers found to be within this limit were considered to be in conformity. Centers with the same conformity percentage were considered to have the same performance. For Article 2 the variables were mammography distribution by age group, diagnostic conclusion, earlier mammograms and those indicated for biopsy. The following indicators for monitoring the results for the 50- 69 year age group were calculated: participation (coverage) rate, test rate by BIRADS® category (1,2,3,4 and 5), recall rate (BIRADS® 0), percentage of positive mammograms (BIRADS® 0, 4 and 5) and the biopsy indication rate (BIRADS® 4 and 5). Results: In Artlcle 1, of the 31,454 tests carried out on women residing in Goiânia, 8,268 (26.3%) were reported by the proprietary SUS diagnostic center network and 23,186 by the accredited network. Test distribution by age group and type of network shows that 43.3% of tests were carried out on women in the 40-49 year age bracket and 44.8% on women from 50 to 69 years old. Diagnostic conclusion performance was uneven among the diagnostic centers for BIRADS® categories 1,2,3,4 and 5 as well as for BIRADS® category 0 in comparison with the other categories, with p<0.001. In Article 2, for the 50-69 year age bracket, the biennial screening coverage estimate was 25.2% and the mammography ratio for 2010 was 0.14. The indicators for monitoring the results of the SUS opportunistic mammography screening program were the following: the recall rate was 9.6% (BIRADS® 0) and the normal test rate (BIRADS® 1 and 2) was 86.1% while the percentage of positive mammograms (BIRADS® 0, 4 and 5) was 10.9% and the biopsy indication rate was 1.3% (BIRADS® 4 and 5). Conclusion: An analysis of the results makes it possible to construct the first opportunistic mammography screening indicators for Goiânia. These will serve as parameters for monitoring early breast cancer detection measures. MMG services’ unequal diagnostic conclusion performance points to the necessity of implementing result auditing in screening programs to monitor the quality of mammographic test interpretation.
Introdução: Em meio às ações governamentais que subsidiam as estratégias para o controle e prevenção do câncer de mama no Brasil, a implantação do Sistema de Informação do Controle do Câncer de Mama (SISMAMA) possibilitou aos gestores do Sistema Único de Saúde (SUS) o mapeamento das usuárias e dos centros de diagnóstico, fornecendo dados para o Programa Nacional de Qualidade em Mamografia (PNQM), como forma de garantir um rastreamento adequado, bem como estabelecer indicadores para monitoramento dos resultados dos exames mamográficos em cada região do país. Objetivo: Avaliar o programa de rastreamento mamográfico oportunístico realizado pelo Sistema Único de Saúde, no município de Goiânia, em 2010, no que diz respeito ao desempenho dos centros de diagnóstico e aos indicadores para monitoramento dos resultados. Método: Estudo ecológico no qual foram analisados os dados reportados pelos centros de diagnóstico ao SISMAMA sobre os exames de mamografia realizados pelo SUS, no período de janeiro a dezembro de 2010, na população feminina residente no município de Goiânia, em 2010. Os dados foram levantados a partir do arquivo “exporta dados” do módulo coordenação estadual, e as variáveis estudadas foram conduzidas conforme os dois artigos produzidos por esse estudo. Para o Artigo 1, as variáveis estudadas foram: produção de exames por centro de diagnóstico, produção de exames mensal, exames por indicação clínica, exames de rastreamento por faixa etária, exames de rastreamento por conclusão diagnóstica de acordo com as categorias BIRADS® (0, 1, 2, 3, 4 e 5). Para avaliar a conformidade dos centros de diagnóstico, estabeleceu-se para a presente pesquisa um limite de variação arbitrário de ± 30% da frequência relativa apresentada por todos os centros de diagnóstico para cada categoria BIRADS®. Aqueles centros que se encontravam dentro desse limite, considerou-se que apresentavam conformidade. Considerou-se como centros de desempenho iguais, aqueles que apresentaram percentuais de conformidade iguais.. Para o Artigo 2, as variáveis foram: distribuição de mamografias por faixa etária, conclusão diagnóstica, realização de mamografia anterior e aquelas com indicação para biópsia. Foram calculados os seguintes indicadores para monitoramento dos resultados, para a faixa etária de 50 a 69 anos: taxa de participação (cobertura); taxa de exames por categoria BIRADS® (1, 2, 3, 4 e 5); taxa de reconvocação (BIRADS® 0); percentual de mamografias positivas (BIRADS® 0, 4 e 5) e taxa de indicação de biópsia (BIRADS® 4 e 5). Resultados: No Artigo 1, dos 31.454 exames realizados em mulheres residentes em Goiânia, 8.268 (26,3%) foram reportados pelos centros de diagnóstico da rede própria e 23.186 (73,7%) pela rede conveniada. A distribuição de exames por faixa etária, segundo o tipo de rede, mostra que 43,3% foram realizados na faixa de 40 a 49 anos e 44,8%, na faixa de 50 a 69 anos. Observou-se desempenho desigual na análise entre todos os centros de diagnóstico com relação à conclusão diagnóstica para as categorias BIRADS® 1, 2, 3, 4 e 5, bem como para categoria BIRADS® 0 com as outras categorias, com p<0,001. No Artigo 2, para a faixa etária de 50 a 69 anos, a estimativa de cobertura foi de 25,2% para rastreamento bienal, e a razão de mamografias para 2010 foi de 0,14. Com relação aos indicadores para monitoramento dos resultados do programa de rastreamento mamográfico oportunístico do SUS, a taxa de reconvocação foi de 9,6% (BIRADS® 0). A taxa de exames normais (BIRADS® 1 e 2) foi de 86,1%, enquanto que o percentual de mamografias positivas (BIRADS® 0, 4 e 5) foi de 10,9% e 1,3% para a taxa de indicação de biópsia (BIRADS® 4 e 5). Conclusão: A análise dos resultados permitiu a construção dos primeiros indicadores do rastreamento mamográfico oportunístico realizado em Goiânia e esses servirão de parâmetros para o monitoramento das ações de detecção precoce do câncer de mama e que a desigualdade no desempenho dos serviços de MMG na conclusão diagnóstica aponta a necessidade de implantação de auditorias de resultados em programas de rastreamento para o monitoramento da qualidade da interpretação dos exames mamográficos.

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Objetivo: Descrever os achados mamográficos, avaliar os indicadores de desempenho das mamografias e descrever o custo direto dos mutirões de mamografia dos anos de 2005 e 2006 na Direção Regional de Saúde de Marília. Métodos: Trata-se de um estudo observacional transversal dos achados radiográficos dos mutirões de mamografia dos anos de 2005 e 2006, na região da Direção Regional de Saúde de Marília. Foram realizadas 11.952 mamografias em 8 serviços, em mulheres dos 37 municípios da região, a classificação do resultado da mamografia foi pelo sistema padronizado BI-RADS, os indicadores de desempenho analisados foram os utilizados em auditoria de resultados e a análise de custos foi baseada nos valores pagos pelo Sistema Único de Saúde com base nas Tabelas SIA/SUS e SIH/SUS de 2005. Os dados foram armazenados em planilhas do Excel e posteriormente analisados utilizando o pacote estatístico SPSS Versão 15. Resultados: Das 11.592 mamografias, 9,35% (1.117) foram classificadas na Categoria BI-RADS 0, nas categorias BI-RADS 1 e 2 foram 87,86% (10.501), na categoria BI-RADS 3 foram 2,53% (302) e nas categorias 4 e 5 de 0,26%. A maior participação nos mutirões foi de mulheres na faixa etária de 40 a 49 anos. As faixas etárias de 50 a 59 e 60 a 69 anos representaram 45,59% do total. O Valor Preditivo Positivo dos BI-RADS 4 e 5 foram de 29,63% e 50% respectivamente. Foram diagnosticados 10 casos de câncer de mama (0,84 por 1.000 mamografias), 70% estavam na faixa etária de 50 a 69 anos. O custo total desses mutirões e acompanhamento foi de R{dollar} 450.019,91, sendo R{dollar} 431.467,20 com o pagamento de 11.952 mamografias e R{dollar}18.552,71 para a investigação diagnóstica de 29 casos suspeitos, para o tratamento de três casos de tumores benignos e de 6 casos de câncer. O custo de cada caso diagnosticado foi de R{dollar} 43.268,10. Conclusões: A prescrição médica de exames mamográficos fora da faixa etária recomendada pelo Ministério da Saúde, a baixa proporção de casos de câncer de mama detectados pelos exames e o alto custo de cada caso diagnosticado apontam para a necessidade de implementação de programas de rastreamento efetivos e de qualidade da mamografia nesta região do estado, investimento em programas de capacitação médica em todos os níveis de atenção à saúde, garantia de acesso rápido aos centros secundários e terciários para atendimento integrado e resolutivo dessa população.
Objective: to describe the mammography findings, and to evaluate the performance indicators of the mammographies and describe the direct cost of the mammography campaigns in 2005 and 2006 realized by the Regional Health Section of Marilia. Methods: It is a cross sectional observational study of the radiographic findings during the mammography campaigns of 2005 and 2006, in the Regional Health Section of Marilia. A total of 11.952 mammographies, in 8 health institutions, comprising women from 37 nearby municipalities and the classification of the mammographies outcomes was done according to BI-RADS; the performance indicators analyzed were the ones employed in outcomes auditory and the cost analysis was based on the amount paid by the Unique Health System (SUS), based on the Tables SIA/SUS of 2005. The data were stored in Excel and furthermore analyzed, employing the statistical method SPSS, version 15. Results: From the 11.592 mammographies, 9.35% (1.117) were classified into BI-RADS 0 and for BI-RADS 1 and 2 87.86% (10.501), for the classification BI-RADS 3, 2.53% (302) and for classification 4 and 5, was 0.26%. The highest participation on the campaign comprised women from 40 to 49 years old. Women whose ages ranged from 50 to 59 and 60 to 69 represented 45.59%. The predictive positive value of BI-RADS 4 and 5 were 29.63 and 50% respectively. A total of 10 cases of breast cancer were diagnosed (0.84 per 1000 mammographies), 70% of the ages ranged from 50 to 69 years. The cost of these campaigns and the follow-up cost totaled R{dollar} 450.019.91, considering that R{dollar} 431.467.20 was destined for he payment of 11.952 mammographies and R{dollar}18.552.71 for the diagnoses of 29 suspicious cases, for the treatment of 3 cases of benign tumors and 6 cases of cancer. The cost of each diagnosed case was R{dollar} 43.268.10. Conclusion: The medical prescription for mammographic exams out of the age range recommended by the Ministry of Health, the low proportion of breast cancer cases detected by the exams and the high cost of each diagnosed case, indicate the necessity of implementation of effective screening programs in this region of the state, investing in specific medical programs comprising all levels of health care and fast access to secondary and third party health units for integrated and effective attendance to this specific population.
TEDE
BV UNIFESP: Teses e dissertações

Contexte. L’augmentation de la participation au dépistage organisé des cancers et la réduction des inégalités sociales et géographiques de participation représentent un enjeu de santé publique majeur. Objectifs. Evaluer l’efficience de 2 interventions visant à augmenter la participation et à réduire les inégalités dans le dépistage organisé des cancers en France. Méthodes. Nous avons réalisé une analyse coût-efficacité du point de vue du financeur: 1) d’une invitation à une unité de mammographie mobile (MM) dans le dépistage du cancer du sein à partir de données rétrospectives (n=37461), 2) d’un accompagnement personnalisé (AP) («patient navigation») dans le dépistage du cancer colorectal à partir d’un essai contrôlé randomisé (n=16250). Résultats. Le coût incrémentiel par dépistage supplémentaire comparé au dépistage habituel était: 1) de 611€ [492-821] pour l‘invitation au MM (+3.8% [2,8-4,8], +23.21€ [22.64-23.78]), et 2) de 1212€ [872-1978] pour l‘AP (+3.3% [1.5-5.0], +39.70€). L’efficacité et l’efficience étaient plus importantes dans les zones défavorisées et dans les zones éloignées pour le MM, alors qu’elles étaient moins favorables dans les zones défavorisées pour l’AP. Conclusion. La MM et l’AP peuvent réduire les inégalités en étant plus efficient dans les zones éloignées et les zones défavorisées pour la MM, alors que pour y parvenir, l’AP devrait cibler les sujets défavorisés, bien que n’étant pas la stratégie la plus efficiente. Les recherches doivent être poursuivies pour déterminer les conditions optimales de l’intégration du MM dans le dépistage, et pour améliorer l’efficacité et l’efficience de l’AP, qui ne peut être recommandé en l’état pour l’instant
Background. Increasing participation in organized cancers screening and reducing social and geographical inequalities in participation represent a major public health issue. Objectives. To determine the costeffectiveness of 2 interventions aiming at increasing participation and reducing inequalities in organized cancer screening in France Methods. We conducted a cost-effectiveness analysis from the payer's perspective: 1) of an invitation to a mobile mammography unit (MM) unit for breast cancer screening from retrospective data (n = 37461), 2) of a patient navigation program (PN) for colorectal cancer screening from a randomized controlled trial (n = 16250). Results. The incremental cost per additional screen compared with usual screening was: 1) € 611 [492-821] for the invitation to the MM (+ 3.8% [2.8-4.8], + € 23.21 [22.64-23.78] ), and 2) of € 1 212 [872-1 978] for PN (+ 3.3% [1.5-5.0], + 39.70 €). Effectiveness and cost-effectiveness were greater in deprived areas and in remote areas for MM, whereas they were less favorable in deprived areas for PN. Conclusion. MM and PN can reduce inequalities while being more efficient in remote areas and in deprived areas for MM, while, to achieve this, PN should target deprived people, even if being not the most efficient strategy. Research needs to be pursued to determine the optimal conditions for MM integration in organized breast cancer screening, and to improve the effectiveness and cost-effectiveness of PN, which can not be recommended as experimented for now

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Among the available methods for the diagnosis and early detection of breast cancer, the most indicated for mass screening is the mammography. To guarantee its effectiveness, this exam needs to be performed using high quality standards and the lowest radiation dose possible. Therefore, the present research aimed to assess the infrastructure and performance of the equipments available at the mammography services in the state of Goiás, regarding coverage, quality, and radiological protection (dose) of patients, in order to provide early detection of breast cancer by an opportunistic screening. A prospective study was carried out, from 2007 to 2010, to observe the diagnostic imaging services which perform mammography, initially for the Brazilian Unified National Health System (SUS) and, in 2010, the services of the private system were included. Data collection was divided into two phases: the first, to collect information on infrastructure and the second, to apply tests in order to evaluate the performance characteristics of equipment and materials used. We calculated the conformity of the assessed items in terms of quality of image and equipment performance and estimated the average dose in glandular tissue and the risk of radioinduced carcinogenesis, as well as the risk of mortality by radioinduced tumors. The results were presented in four articles. In the first, we showed that mammography coverage in the state of Goiás in 2008 was 66% among women in the 50 69-year age group, considering biennial mammography. In the second article, we concluded that the implementation of the Mammography Quality Control Program was effective to achieve better quality mammography in SUS services. In the beginning of our research, only 2.9% of SUS services were within the desired range of quality and, after two interventions (2008 and 2009), 20% of them reached it. The results of the third article, in which we verified the infrastructure and quality of services performing mammography, both for SUS and private systems, showed no difference in quality of exams between them. However, the evaluation between types of technology used showed difference between radiation doses (p < 0.001) applied during mammography. In the fourth article, we estimated the benefit risk balance of screening mammography carried out in the state of Goiás in 2010. The excess absolute risk of radioinduced cancer and the lifetime risk presented significant difference for types of technology (p < 0.001) and types of health system (p < 0.019) according to the age group of screening. The ratio lives saved/lives lost was 75.5/1 for screening at the 40 70-year age group and 166.5/1 at the 50 70-year age group. The results showed that coverage of the 50 69-year age group in the state of Goiás is near the recommended standards for the beginning of organized screenings. However, when assessed per regional health unit, coverage was non-uniform, presenting high concentration of equipments and exames at the Central Regional. The initial evaluation of equipment performance indicated the need to implant actions for controlling mammography quality and risk. The actions of the Mammography Quality Control Program proved to be effective to enhance the quality of mammography, although the same does not remain true for the radiation dose used in mammography. These doses are lower in conventional mammography equipments than in those coupled to image digitization systems. Regarding radiological protection, screening women who are 50 70 years old, when performed biennially using conventional mammography equipments, presented more benefit.
Entre os métodos disponíveis para diagnóstico e detecção precoce de câncer de mama, o mais indicado para o rastreamento em massa é a mamografia. Para garantir sua efetividade, é preciso que esse exame seja realizado com padrão de qualidade ótimo e a menor dose possível. Nesse contexto, a presente pesquisa teve como proposta avaliar a infraestrutura e o desempenho dos equipamentos instalados nos serviços de mamografia no estado de Goiás, no que se refere à cobertura, qualidade da mamografia e proteção radiológica (dose de exposição) das pacientes, tendo em vista a proposta de detecção precoce do câncer de mama por meio de rastreamento oportunístico. Realizouse um estudo prospectivo, que compreendeu o período de 2007 a 2010, durante o qual foram observados os serviços de diagnóstico por imagem que realizavam mamografia, inicialmente para o Sistema Único de Saúde (SUS) e, em 2010, incluíram-se os serviços do sistema privado. Dividiu-se a coleta de dados em duas etapas: a primeira, para levantamento de informações sobre infraestrutura e a segunda, para aplicação de testes com o objetivo de avaliar os parâmetros de desempenho dos equipamentos e materiais utilizados. Foram calculados: o percentual de conformidade nos itens avaliados referentes a qualidade da imagem e desempenho dos equipamentos, e estimada a dose média no tecido glandular mamário e os riscos de carcinogênese radioinduzida, bem como, o risco de mortalidade por tumores radioinduzidos. Os resultados foram apresentados em quatro artigos científicos. No primeiro, mostrou-se que a cobertura da mamografia no estado de Goiás em 2008 foi de 66% entre as mulheres na faixa etária de 50 a 69 anos, considerando-se a realização de mamografia bienal. No segundo artigo, concluiu-se que a implantação do Programa de Controle de Qualidade em Mamografia foi efetiva para a melhoria da qualidade da mamografia nos serviços do SUS. No início da pesquisa, somente 2,9% dos serviços do SUS estavam na faixa desejável de qualidade e, após duas intervenções (2008 e 2009), 20% deles a atingiram. Os resultados do terceiro artigo, em que se verificou a infraestrutura e a qualidade dos serviços que realizavam mamografia, tanto para o sistema SUS, como para o sistema privado, mostraram não haver diferença na qualidade do exame entre eles. Porém, a avaliação entre os tipos de tecnologia empregados mostrou diferença entre as doses (p < 0,001) de radiação aplicadas durante a mamografia. No quarto artigo, estimou-se a relação benefício risco do rastreamento mamográfico realizado no estado de Goiás em 2010. O risco absoluto de excesso de câncer radioinduzido e o risco ao longo da vida apresentaram diferença significativa para os tipos de tecnologia (p < 0,001) e o tipo de atendimento dos serviços (p < 0,019) segundo a faixa etária de rastreamento. A razão de vidas salvas/vidas perdidas foi de 75,5/1 para o rastreamento na faixa de 40 a 70 anos e de 166,5/1 na faixa de 50 a 70 anos. Os resultados apontaram que a cobertura para a faixa de 50 a 69 anos no estado de Goiás está próxima do recomendado para o início de rastreamento organizado. Entretanto, quando avaliada por regional de saúde, a cobertura mostrou-se desigual e com grande concentração de equipamentos e exames na Regional Central. A avaliação inicial do desempenho dos equipamentos indicou a necessidade de implantação de ações para controle da qualidade da mamografia e do risco. As ações do Programa de Controle de Qualidade em Mamografia mostraram-se efetivas para a melhoria da qualidade da mamografia, embora o mesmo não tenha ocorrido com a dose de radiação empregada na mamografia. As doses nos mamógrafos convencionais são mais baixas do que nos mamógrafos acoplados aos digitalizadores de imagem. Em termos de proteção radiológica, o rastreamento na faixa etária de 50 a 70 anos, quando realizado bienalmente em mamógrafos com tecnologia convencional, apresentou maior benefício.

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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES
INTRODUCTION: In Brazil, access to mammography is performed by the Unified Health System (SUS) or by the Supplementary Health System, or by direct contracting of the individual with the health service. The SUS is the official system of government and came to meet constitutional law, which establishes that health is a right of all citizens and a duty of the State. OBJECTIVE: To evaluate the contribution of SUS to the mammographic screening of Brazil, in its macro-regions, Federal Units (UF) and Federal District (DF). METHOD: An ecological study where the information about breast cancer screening was analyzed through the mammograms performed, as well as the amount of equipment available for SUS in Brazil, in its macro regions, in the UF and DF, from 2008 to 2016 The study considered as target population, mammograms performed in women between the ages of 40 and 49 and between 50 and 69 years. Data on the production of exams were taken from the Outpatient Information System of the Department of Informatics of SUS (SIA / DATASUS), about the target population were extracted from the DATASUS Demographic and Socioeconomic Information System of Health and the Brazilian Institute of Geography and Statistics (IBGE), and on the equipment available for SUS, from the National Registry of Health Establishments (CNES). Based on this information, we evaluated the contribution of SUS to mammography screening in 2013, the temporal evolution of mammographic coverage during the period from 2008 to 2016, and the geographic evaluation of mammography access. RESULTS: The estimated mammographic coverage in the screening performed by SUS in Brazil in 2013 was 24.8%. The prevalence of mammograms ranged from 12.0% in the northern macroregion to 31.3% in the Southern Region. When stratified by UF, the lowest coverage was in Pará (7.5%) and the highest coverage was in Santa Catarina (35.7%). In Brazil, from 2008 to 2016, about 19 million mammograms were performed by the SUS in the female populationaged 50 to 69 years, costing approximately R$ 844 million. The Annual Percent Changes (APC) estimate allowed us to infer that mammographic coverage in Brazil increased in the period from 2008 to 2012 and stabilized in the following years. The Northeast macroregion was the only one that presented increased coverage throughout the studied period, while the South was the one that initially presented increase, with subsequent reduction. The North, Southeast and Midwest macro-regions showed increase, followed by a stabilization. Of the 26 UF, 31% (eight) showed a significant increase in mammographic screening coverage over the study period, 19% (five) presented APC stabilization, 46% (twelve) had an initial increase, and after that period, 92% (Eleven) stabilized and 0.8% (one) there was a reduction in coverage. Ceará presented initial stabilization, followed by an increase. The DF showed stabilization for an initial period and reduction after this period. In 2016, in Brazil, there were 4,628 mammographs. Of these, 4,492 (97%) were in use and 2,113 (47%) were available to perform tests for SUS. When considering the number of Mammograms (NM) necessary according to the indication of exams, it would be necessary for mammography screening in Brazil 2,068 devices. Regarding the production of examinations, the mammography network would be able to carry out 14,279,654 examinations and 4,073,079 were performed, equivalent to 29% of the total production capacity in the country in 2016. With regard to the maximum distance of 60km for It was verified that small areas of Brazil did not meet this indicator. CONCLUSION: The contribution of SUS to mammographic screening in Brazil is low and unequal, however, an increase has been occurring in recent years. The Brazilian population's access to mammographic screening is associated with insufficient production of mammographic network exams available for the SUS.
Introdução: No Brasil, o acesso à mamografia é realizado pelo Sistema Único de Saúde (SUS) ou pelo Sistema de Saúde Suplementar, ou ainda, mediante contratação direta do indivíduo com o serviço de saúde. O SUS é o sistema oficial do governo e veio para atender o direito constitucional, o qual estabelece que a saúde seja um direito de todos os cidadãos e um dever do Estado. Objetivo: Avaliar a contribuição do SUS no rastreamento mamográfico do Brasil, em suas macrorregiões, Unidades da Federação (UF) e Distrito Federal (DF). Método:Estudo ecológico onde foram analisadas as informações referentes ao rastreamento do câncer de mama por meio das mamografias realizadas, bem como a quantidade de equipamentos disponíveis para o SUS no Brasil, em suas macrorregiões, nas UF e DF, no período de 2008 a 2016. O estudo considerou como população alvo, mamografias realizadasem mulheres na faixa etária de 40 a 49 anos e de 50 a 69 anos. Os dados sobre a produção de exames foram retirados do Sistema de Informações Ambulatorial do Departamento de Informática do SUS (SIA/DATASUS), sobre a população alvo foram extraídos do Sistema de Informações Demográficas e Socioeconômicas de Saúde do DATASUS e do Instituto Brasileiro de Geografia e Estatística (IBGE), e sobre os equipamentos disponíveis para o SUS, do Cadastro Nacional de Estabelecimentos de Saúde (CNES). Mediante essas informações, foram avaliadas: a contribuição do SUS no rastreamento mamográfico em 2013, a evolução temporal da cobertura mamográfica ao longo do período de 2008 a 2016 e a avaliação geográfica do acesso à mamografia. Resultados:A estimativa da cobertura mamográfica no rastreamento realizado pelo SUS no Brasil, em 2013, foi de 24,8%. A cobertura mamográfica variou de 12,0% na macrorregião Norte a 31,3% na Região Sul. Ao estratificar por UF, a menor cobertura foi no Pará (7,5%) e a maior cobertura foi em Santa Catarina (35,7%). No Brasil, no período de 2008 a 2016, foram realizadas pelo SUS cerca de 19 milhões de mamografias na população feminina de 50 a 69 anos, com custo aproximado de R$ 844 milhões. A estimativa da Mudança Percentual Anual (MPA) permitiu inferir que a cobertura mamográfica no Brasil, aumentou no período de 2008 a 2012 e estabilizou nos anos seguintes. A macrorregião Nordeste foi a única que apresentou aumento da cobertura em todo o período estudado, enquanto a Sul foi a que inicialmente apresentou aumento, com posterior redução. As macrorregiões Norte, Sudeste e Centro Oeste apresentaram aumento, seguido por uma estabilização. Das 26 UF, 31% (oito) mostraram aumento significativo da cobertura do rastreamento mamográfico ao longo do período estudado, 19% (cinco) apresentaram estabilização da MPA, 46% (doze) apresentaram aumento inicial, sendo que após esse período, 92% (onze) estabilizaram e 0,8% (uma) houve redução da cobertura. Ceará apresentou estabilização inicial, seguida por um aumento. O DF apresentou estabilização por um período inicial e redução após esse período. Em 2016, no Brasil, existiam 4.628 mamógrafos. Desses, 4.492 (97%) estavam em uso e 2.113 (47%) estavam disponíveis para realizar exames para o SUS. Ao considerar o Número de Mamografias (NM) necessárias de acordo com a indicação de exames, seriam necessários, para o rastreamento mamográfico no Brasil, 2.068 equipamentos. Sobre a produção de exames, a rede de mamógrafos teria condições para realizar 14.279.654 exames e foram realizados 4.073.079, o que equivale a 29% da capacidade total de produção no país, em 2016. Com relação à distância máxima de 60 km para se ter acesso ao exame, verificou-se que pequenas áreas do Brasil não atendiam a este indicador. CONCLUSÃO: A contribuição do SUS para o rastreamento mamográfico no Brasil é baixa e desigual, entretanto, vem ocorrendo um incremento ao longo dos últimos anos. O acesso da população brasileira ao rastreamento mamográfico está associado à insuficiência na produção de exames da rede de mamógrafos disponíveis para o SUS.

碩士
高雄醫學大學
公共衛生學系公共衛生學碩士班
106
Background: In 2010, the government required the hospital changing the cancer screening services from passive to proactive comprehensively, including breast cancer screening (BCS). While BCS rate has improved significantly, it is still lower than the Occident. Objectives: Using Structural equation model (SEM), the research aims to examining factors associated with women receiving BCS and the access to inreach and outreach screening services. Methods: The cross-section survey is majorly adopted throughout the research targeting women who access to inreach and outreach with the health belief model, breast cancer and BCS knowledge, and health literacy (HL) questionnaires. The chi-square test, independent-sample t test, and SEM were used to analyze the data and conclude the correlation among research variables and the women receive BCS and where they receive it. Results: The inference found on the SEM is women in older age, employment, receiving other cancer screening within two years, and better scored in HBM are more likely to undergo BCS. Women with high education, chronic disease, and better-scored HL are more likely to receive BCS in hospital. Besides, women with higher age and jobless are more likely to receive BCS in community. Conclusions: To improve BCS, it is necessary to understand women''s attitudes toward health belief and reduce their perceived barriers. Hospitals should formulate appropriate BCS strategies for women who choose inreach or outreach.

Indiana University-Purdue University Indianapolis (IUPUI)
A study design has been developed that employs a dual modeling approach to identify factors associated with facility-level cancer screening improvement and how this is mediated by the use of clinical decision support. This dual modeling approach combines principles of (1) Health Informatics, (2) Cancer Prevention and Control, (3) Health Services Research, and (4) Organizational Change/Theory. The study design builds upon the constructs of a conceptual framework developed by Jane Zapka, namely, (1) organizational and/or practice settings, (2) provider characteristics, and (3) patient population characteristics. These constructs have been operationalized as measures in a 2005 HRSA/NCI Health Disparities Cancer Collaborative inventory of 44 community health centers. The first, statistical models will use: sequential, multivariable regression models to test for the organizational determinants that may account for the presence and intensity-of-use of clinical decision support (CDS) and information systems (IS) within community health centers for use in colorectal, breast, and cervical cancer screening. A subsequent test will assess the impact of CDS/IS on provider reported cancer screening improvement rates. The second, computational models will use a multi-agent model of network evolution called CONSTRUCT® to identify the agents, tasks, knowledge, groups, and beliefs associated with cancer screening practices and CDS/IS use to inform both CDS/IS implementation and cancer screening intervention strategies. This virtual experiment will facilitate hypothesis-generation through computer simulation exercises. The outcome of this research will be to identify barriers and facilitators to improving community health center facility-level cancer screening performance using CDS/IS as an agent of change. Stakeholders for this work include both national and local community health center IT leadership, as well as clinical managers deploying IT strategies to improve cancer screening among vulnerable patient populations.

"Although there has been an increasing incidence of breast cancer among Non-English speaking background (NESB) women in many developed countries, existing screening services are being underused by these women. Studies show that the barriers to the accessibility of breast cancer screening by NESB women include their lack of awareness, low level of education, low self-efficacy and lack of social interaction with other women. This study aimed to investigate the knowledge relating to breast cancer and mammography, self-efficacy and barriers to mammography use among NESB women in an Australian regional city before and after their attendance at a health education session. This health education session aimed to increase the awareness and use of mammography among these NESB women. Two widely used behaviour theories, Health belief model and Social Cognitive Theory, were applied as the theoretical framework for this study. A quasi-experimental study was conducted in which the health education session was used as an intervention. Pre-test and post-test questionnaires were completed by study participants before and after the health education session. Their knowledge of breast cancer and mammography was assessed. In addition, their self-efficacy and barriers to the use of mammography were also analysed. Results indicated that informal recruitment strategies were more effective with these NESB women. Initially 49 women were recruited. Of these, 23 women (47%) attended the health education session. As data showed tertiary educated and employed women who already had mammogram/s were more likely to attend the session. After attending the health education session, the womens knowledge relating to breast cancer and mammography was improved and the perceived barriers to the use of mammography were reduced. During a three month follow-up period, there was no change of mammogram use by the women. However, the results showed a trend of increased intention to use the mammogram over a period of two years (41.7%) compared to six months (25.0%). Based on these results, further studies are recommended to explore the beneficial outcomes of health promotion programs targeting NESB women who are not in the workforce or have a low level of education." -- abstract.

This dissertation is focused on medical care field, introduces common issues of oncology illnesses. Presents the system and particularity of women's breast cancer care and looks into patient's rights and importace of foreknowledge. Also presents activities of non-state nonprofit organization focused on this sphere. The aim of this dissertation is to map involved organizations and analysis of their work. Investigates foreknowledge of patients about knowing of them and also finds topics of their intersect. Key words oncology diagnosis, breast cancer, patients organizations, prevention, second opinion, health service, non-profit non-govermental organizations, information asymmetry, mammography screening, informační asymetrie, mamografický screening