Decision Aids for Decision Making about Locally Advance Breast Cancer: A Systematic Review.

Locally advanced breast cancer (LABC) is a subset of breast cancer with locoregional progression without distant metastasis. The multimodality treatment (surgery, chemotherapy, radiotherapy, hormonal and targeted therapy if required) could significantly improve results in this specific group of patients. The complex and multiple options of treatment with similar mortality rates but different outcomes depending on the patient's desires, preferences and social environment require aid to facilitate the individual patient's decisions (e.g. Decision Aids (DAs) targeting patients considering primary or adjuvant treatment in LABC). In this context, DAs have been proven fundamental to help patients and clinicians share and agree on the best value option. The current systematic review aimed to evaluate the existing DAs related to these patients with LABC and identify current status and possible improvement areas (possible scarcity and heterogeneity of instruments, the status of their development, explanation of their purpose,…). No previous systematic reviews have been published on this topic. Following Prospero registration no: CRD42021286173, studies about LABC DAs were identified, without data or language restrictions, through a systematic search of bibliographic databases in December 2021. Quality was assessed using Qualsyst criteria (range 0.0-1.0). The quality of the 17 selected studies ranged from 0.46 to 0.95. Of them, 14/17 (82%) were DAs about treatment, only one (6%) about diagnosis, and 2/17 (12%) about the employment of DAs. No screening or follow-up DAs were retrieved. Twelve (70.6%) DAs were online tools. They varied broadly regarding their characteristics and purposes. Most of the studies focused on developing and testing different DAs (5/17; 29.4%) and their impact (7/17; 41.2%). Only 4/17 (23.5%) analysed their implementation and cost. These instruments have proven to improve patient's knowledge and decision-making, decrease patient anxiety, and patients tend to undergo treatment. However, nowadays, there is still a need for further research and consensus on methodology to develop practical DAs.

Clinical practice guidelines and consensus for the screening of breast cancer: A systematic appraisal of their quality and reporting.

INTRODUCTION: Clinical practice guidelines (CPGs) and consensus statements (CSs) are being promoted to provide high-quality healthcare guidance. This systematic review has assessed the breast cancer (BC) screening CPGs and CSs quality and reporting. METHODS: A search of bibliographic databases (MEDLINE, Embase, Web of Science, Scopus and CDSR), 12 guideline databases and 51 professional society websites was performed without language restrictions from January 2017 to June 2020, following prospective registration (Prospero no.: CRD42020203807). AGREE II (% of maximum score) and RIGHT (% of total 35 items) appraised quality and reporting individually, extracting data in duplicate; reviewer agreement was 98% and 93%, respectively. RESULTS: Forty guidances with median overall quality and reporting 51% (interquartile range [IQR] 39-63) and 48% (IQR 35-65), respectively. Twenty-two (55%) and 20 (50%) did not reach the minimum standards (scores <50%). The guidances that deployed systematic reviews had better quality (74.2% vs. 46.9%; p = 0.001) and reporting (80.5% vs. 42.6%; p = 0.001). Guidances reporting a tool referral scored better (AGREE II: 72.8% vs. 43.1%, p = 0.002; RIGHT: 75.0% vs. 46.9%, p = 0.004). CONCLUSION: BC screening CPGs and CSs suffered poor quality and reporting. More than half did not reach the minimum standards. They would improve if systematic reviews were used to underpin the recommendations made.

Encuesta sobre el uso de la toma de decisiones compartida en el tratamiento del cáncer de mama de los profesionales involucrados en el manejo del cáncer de mama en Argentina / Survey on the use of shared decision-making in the treatment of breast cancer by professionals involved in the management of breast cancer in Argentina

Introducción: La toma de decisiones compartida (TDC) es un proceso colaborativo que involucra al paciente y al profesional para llegar a una decisión conjunta sobre su atención. Objetivos: Evaluar el conocimiento, la actitud y la aplicación de la TDC entre los profesionales de la salud involucrados en el tratamiento del cáncer de mama (CM). Material y método: Estudio transversal basado en un cuestionario online ad hoc envia- do por varias sociedades profesionales relacionadas con el CM. Este evaluó el grado de conocimiento, actitud, aptitud y uso de la TDC por los profesionales implicados en el manejo del CM. Resultados: La mayoría refirieron conocer los conceptos y los fundamentos sobre la TDC, sin embargo, fueron pocos los profesionales (<30%) que usan la TDC en práctica clínica habitual. Los mastólogos y los profesiona- les que trabajan en Unidades de Mastología refirieron tener mayor conocimiento sobre los fundamentos de la TDC (85.6% vs 76.4%; p < 0.05) y tener más experiencia en su utilización (34.4 vs 24.3; p<0.05). Las principales ventajas destacadas fueron la satisfacción del pacien- te, la mejora en la relación médico-paciente y la reducción del estrés del paciente al ayudarlo a comprender su enfermedad. En cuanto a los obstáculos, destacó la falta de apoyo institucional, la falta de recursos y la falta tiempo en la consulta. Todos los encuestados coin- cidieron que la TDC es una herramienta necesaria para proporcionar una asistencia medica de alta calidad. Conclusiones: Se deben diseñar nuevas políticas para la adecuada formación de los profesionales en la integración de la TDC en la práctica clínica, preparándolos para utilizar la TDC con los recursos y el tiempo adecuados.

Introduction: Shared decision making (SDM) is a collaborative process that involves the patient and the professional to reach a joint decision about care. Objetives: To evaluate the knowledge, attitude and application of SDM among health professionals involved in the treatment of breast cancer (BC). Material and method: Cross-sectional study based on an ad hoc online questionnaire sent by various professional societies to professionals involved in the management of BC. A questionnaire was developed to evaluate the degree of knowledge, attitude, aptitude and use of SDM by the parti- cipating professionals. Results: Most reported knowing the concepts and fundamentals of SDM; however, few professionals (<30%) use SDM in routine clinical prac- tice. Mastologists and professionals who work in Mastology Units reported having greater knowledge about the fundamentals of SDM (85.6% vs 76.4%; p <0.05) and having more experience in its use (34.4 vs 24.3; p <0.05). The main advantages highlighted were patient sa- tisfaction, improved doctor-patient relationship, and reduced patient stress by helping them understand their illness. Regarding the obs- tacles, he highlighted the lack of institutional support, resources and time in the consultation. All respondents agreed that SDM is a neces- sary tool to provide high-quality medical care. Conclusions: New policies should be designed for the adequate training of profes- sionals in integrating SDM in clinical practice, preparing them to use SDM with adequate resources and time.

Valor pronóstico de la baja expresión del receptor de estrógeno en pacientes con cáncer de mama LUMINAL HER2 negativo / Prognostic value of low estrogen receptor expression in patients with luminal HER2-negative breast cancer

Introducción: El subtipo luminal de cáncer de mama es sensible a la terapia antiestrógenica y muestra un mejor pronóstico que el del cáncer de mama con receptor del factor de crecimiento epidérmico humano 2 enriquecido (HER2) o triple negativo. Sin embargo, el cáncer de mama tipo luminal es heterogéneo y puede tener características clínicas agresivas. Investigamos las implicaciones clínicas y pronósticas de la baja expresión del receptor de estrógeno en un grupo de carcinomas luminales HER2 negativos. Material y método: Recolectamos los datos de un grupo de 367 cánceres de mama luminales HER2 negativo que eran receptor de estrógeno (RE) positivos y receptor de progesterona (RP) positivos o negativos y los dividimos en RE+ alto (RE) y RE+ bajo (REB). Se definió REB de acuerdo a la úl- tima actualización ASCO /CAP de las recomendaciones del testeo de de RH en cáncer de mama como aquellos con expresión entre 1 y 10%. Analizamos los datos clínico-patológicos y la supervivencia según los grupos de RE y REB. Resultados: Edad media 63,9+12.8 años. Tamaño tumoral: 1,9 +0.9 cm. Se realizó Mastectomía radical modificada en 61% de los pacientes. Tipo histológico más frecuente: Ductal Infiltrante en 89,5% de los casos. Hallazgos que concuerdan con publicaciones de otros centros. Discusión: Los tumores REB resultaron en 1,6%. No hubo diferencias estadísticas en el estadio TNM y tipo histológico. Sin embargo, el grupo REB se asoció con menor edad (47 vs 57 años), tipo luminal B, mayor grado histológico y Ki 67 alto (>30%). Si bien las diferencias en supervivencia global (SG) no fueron significativas (p=0,279), observamos que a partir de los 60 meses de seguimiento la SG fue menor en el grupo REB que en el grupo RE. Conclusiones: La baja expresión del RE se asoció peor pronóstico. Podríamos considerar la baja expresión del RE como marcador pronóstico en el subtipo luminal HER2 negativo de cáncer de mama. Debido a la baja incidencia de casos REB consideramos necesario estudios adicionales con mayor número de pacientes que podrían revelar su papel negativo en el cáncer de mama.

Introduction: The luminal subtype of breast cancer is sensitive to antiestrogenic therapy and shows a better prognosis than human epidermal grow- th factor receptor 2 (HER2) enriched or triple negative breast cancer. However, luminal type breast cancer is heterogeneous and can have aggressive clinical features. We investigated the clinical and prognostic implications of low estrogen receptor expression in a group of HER2-negative luminal carcinomas. Material and method: We collected data from a group of 367 HER2 negative luminal breast cancers that were estrogen receptor (ER) positive and progesterone receptor (PR) positive or negative and divided them into ER + high (ER) and ER + low (ERL). ERL was defined when RE expression was < 10%. We analyzed the clinical-pathological data and survival accor- ding to the ER and ERL groups. Results: ERL tumors resulted in 1.6%. There were no statistical differences in TNM stage and histological type. However, the ERL group was as- sociated with younger age (47 vs 57 years), luminal type B, higher histological grade, and high Ki 67 (> 30% ). Although the differences in overall survival (OS) were not significant (p = 0.279), we observed that after 60 months of follow-up the OS was lower in the ERL group than in the ER group. Conclusions: Low ER expression was associated with a worse prognosis. We could consider low ER expression as a prognostic marker in the HER2-ne- gative luminal subtype of breast cancer. Due to the low incidence of ERL cases, we consider necessary additional studies with a larger number of patients that could reveal its negative role in breast cancer.

Shared decision making in breast cancer screening guidelines: a systematic review of their quality and reporting.

BACKGROUND: Shared decision making (SDM) is a key component of evidence-based and patient-centred care. The aim of this study is to systematically review the quality of SDM proposals in clinical practice guidelines (CPGs) and consensus statements (CSs) concerning breast cancer (BC) screening. METHODS: Guidances were identified, without language restrictions, using a prospectively planned systematic search (MEDLINE, EMBASE, Web of Science, Scopus and guideline websites) from January 2010 to August 2020. Duplicate data extraction used a 31-item SDM quality assessment tool; reviewer agreement was 98%. RESULTS: SDM appeared only in 38 (49.4%) (33/68 CPGs, 4/9 CSs) documents (overall compliance with the quality tool: mean 5.74, IQR 3-8). CPGs and CSs specifically mentioning the term SDM (n = 12) had higher quality (mean 6.8, IQR 4-9 vs. mean 2.1, IQR 0-3; P = 0.001). No differences were found in mean quality comparing CPGs with CSs (3 vs. 1.6; P = 0.634), use of systematic review (4.2 vs. 2.9; P = 0.929) and publication in a journal (4 vs. 1.9; P = 0.094). Guidances with SDM were more recently reported than those without it (mean 41 vs. 57 months; P = 0.042). CONCLUSION: More than half of all the guidelines did not meet SDM quality criteria. Those that explored it were more recently reported. There is an urgent need for promoting SDM in guidances concerning BC screening issued by institutions, professional associations and medical journals.

Evaluation of the Use of Shared Decision Making in Breast Cancer: International Survey.

OBJECTIVES: To assess shared decision-making (SDM) knowledge, attitude and application among health professionals involved in breast cancer (BC) treatment. MATERIALS AND METHODS: A cross-sectional study based on an online questionnaire, sent by several professional societies to health professionals involved in BC management. There were 26 questions which combined demographic and professional data with some items measured on a Likert-type scale. RESULTS: The participation (459/541; 84.84%) and completion (443/459; 96.51%) rates were high. Participants strongly agreed or agreed in 69.57% (16/23) of their responses. The majority stated that they knew of SDM (mean 4.43 (4.36-4.55)) and were in favour of its implementation (mean 4.58 (4.51-4.64)). They highlighted that SDM practice was not adequate due to lack of resources (3.46 (3.37-3.55)) and agreed on policies that improved its implementation (3.96 (3.88-4.04)). The main advantage of SDM for participants was patient satisfaction (38%), and the main disadvantage was the patients' paucity of knowledge to understand their disease (24%). The main obstacle indicated was the lack of time and resources (40%). CONCLUSIONS: New policies must be designed for adequate training of professionals in integrating SDM in clinical practice, preparing them to use SDM with adequate resources and time provided.

Correlación entre características clinicopatológicas e inmunohistoquímicas del cáncer de mama en mujeres argentinas / Correlation between clinicopathological and immunohistochemical characteristics of breast cancer in Argentine women

Introducción: El cáncer de mama se clasifica en 4 subgrupos moleculares de tumores. Estos factores biológicos junto al grado histológico, han tomado importancia en la nueva clasificación TNM ya que permite establecer pronósticos de sobrevida. Objetivo: Analizar la correlación entre los distintos subtipos moleculares de los carcinomas de mama con factores clínico-patológico, la presencia de metástasis axilares y en la re-estadificación de los tumores según la nueva Clasificación TNM de la AJCC. Material y método: Estudio observacional y descriptivo de series de casos, registrados en Registro de Cáncer de Mama (RCM), en Argentina entre los años 2006 a 2016. Resultados: La mayoría de los tumores fueron Luminales. Los estadios avanzados fueron en edades tempranas. El mayor compromiso axilar perteneció a HER2 neu positivos. Se consiguió re estadificar las pacientes aumentando el número de pacientes con estadios IA y IB y descendiendo los estadios IIA, IIIA, IIIB y IIIC. Conclusiones: De los subtipos moleculares con factores clinicopatológicos más desfavorables fueron los Triples Negativos y Her2 neu. La importancia de los factores biológicos a la hora de re estadificar los pacientes según TNM 8° edición, favorece los tratamientos conservadores y específicos contra el tumor evitando el sobre tratamiento e implican menores costos que las plataformas genómcias.

Introduction: Breast cancer is classified into 4 molecular subgroups. These biological factors, together with the histological grade, are important factors in the 8th edition of the TNM Classification, and allow establishing survival prognoses in patients with breast cancer. Objetive: The main objetive was to analyse the correlation between different molecular subtypes of breast carcinomas, the presence of axillary metastases and the correlation of tumours in the new TNM Classification. Material and method: Observational and descriptive restrospective study of case series registred in RCM, in Argentina between 2006 and 2016. Results: Most of the tumours were Luminals. The clinical presentation of advanced stages was more frequent at early ages. The molecular subtypes with the highest axillary involvement were HER2 neu tumours. We managed to re-stage the patients to the TNM Classification 8th edition, increasing the number of patients with stages IA and IB and decreasing the stage IIA, IIIA, IIIB and IIIC. Conclusions: Triples negative tumours were diagnosed in more advanced stages, according to the new TNM Classification, than the Luminals. The surgical decision was not modified according to the molecular subtype. We conclude the importance of biological factors when re-staging patients according to the new TNM Classification 8th edition because it increases the number of conservative treatments, and more targets treatment.

Quality and reporting of clinical guidelines for breast cancer treatment: A systematic review.

BACKGROUND: High-quality, well-reported clinical practice guidelines (CPGs) and consensus statements (CSs) underpinned by systematic reviews are needed. We appraised the quality and reporting of CPGs and CSs for breast cancer (BC) treatment. METHODS: Following protocol registration (Prospero no: CRD42020164801), CPGs and CSs on BC treatment were identified, without language restrictions, through a systematic search of bibliographic databases (MEDLINE, EMBASE, Web of Science, Scopus, CDSR) and online sources (12 guideline databases and 51 professional society websites) from January 2017 to June 2020. Data were extracted in duplicate assessing overall quality using AGREE II (% of maximum score) and reporting compliance using RIGHT (% of total 35 items); reviewer agreement was 98% and 96% respectively. RESULTS: There were 59 relevant guidance documents (43 CPGs, 16 CSs), of which 20 used systematic reviews for evidence synthesis. The median overall quality was 54.0% (IQR 35.9-74.3) and the median overall reporting compliance was 60.9% (IQR 44.5-84.4). The correlation between quality and reporting was 0.9. Compared to CSs, CPGs had better quality (55.4% vs 44.2%; p = 0.032) and reporting (67.18% vs 44.5%; p = 0.005). Compared to subjective methods of evidence analysis, guidance documents that used systematic reviews had better quality (76.3% vs 51.4%; p = 0.001) and reporting (87.1% vs 59.4%; p = 0.001). CONCLUSION: The quality and reporting of CPGs and CSs in BC treatment were moderately strong. Systematic reviews should be used to improve the quality and reporting of CPGs and CSs.

Shared decision making in breast cancer treatment guidelines: Development of a quality assessment tool and a systematic review.

BACKGROUND: It is not clear whether clinical practice guidelines (CPGs) and consensus statements (CSs) are adequately promoting shared decision making (SDM). OBJECTIVE: To evaluate the recommendations about SDM in CPGs and CSs concerning breast cancer (BC) treatment. SEARCH STRATEGY: Following protocol registration (Prospero no.: CRD42018106643), CPGs and CSs on BC treatment were identified, without language restrictions, through systematic search of bibliographic databases (MEDLINE, EMBASE, Web of Science, Scopus, CDSR) and online sources (12 guideline databases and 51 professional society websites) from January 2010 to December 2019. INCLUSION CRITERIA: CPGs and CSs on BC treatment were selected whether published in a journal or in an online document. DATA EXTRACTION AND SYNTHESIS: A 31-item SDM quality assessment tool was developed and used to extract data in duplicate. MAIN RESULTS: There were 167 relevant CPGs (139) and CSs (28); SDM was reported in only 40% of the studies. SDM was reported more often in recent publications after 2015 (42/101 (41.6 %) vs 46/66 (69.7 %), P = .0003) but less often in medical journal publications (44/101 (43.5 %) vs 17/66 (25.7 %), P = .009). In CPGs and CSs with SDM, only 8/66 (12%) met one-fifth (6 of 31) of the quality items; only 14/66 (8%) provided clear and precise SDM recommendations. DISCUSSION AND CONCLUSIONS: SDM descriptions and recommendations in CPGs and CSs concerning BC treatment need improvement. SDM was more frequently reported in CPGs and CSs in recent years, but surprisingly it was less often covered in medical journals, a feature that needs attention.

Rendimiento de la ecografía axilar en cáncer de mama / Axillary ultrasound performance in breast cancer

Objetivo El estatus axilar sigue siendo el factor pronóstico más importante en cáncer de mama. Nuestro objetivo fue evaluar el rendimiento diagnóstico de la ecografía axilar para la detección de ganglio metastásico. Material y método Se evaluaron por ecografía axilar preoperatoria 530 pacientes con cáncer de mama menor o igual a 5 cm con axila clínicamente negativa. Se consideró sospechoso, todo ganglio que cumpliera con la clasificación de Bedi 3, 4, 5 y 6. La sospecha se corroboró con biopsia axilar bajo guía ecográfica, biopsia selectiva del ganglio centinela intraoperatorio y/o disección axilar. Resultados Obtuvimos una sensibilidad del 67,11% y una especificidad del 97,88%. Conclusiones El rendimiento diagnóstico de la ecografía axilar preoperatoria en pacientes con cáncer de mama y axila clínicamente negativa es sensible y específica en la detección de ganglio metastásico

Objective Axillary status remains the most important prognostic factor in breast cancer. Our objective was to evaluate the diagnostic performance of axillary ultrasound for the detection of metastatic nodes. Materials and methods 530 patients with breast cancer less than or equal to 5 cm with clinically negative axilla were evaluated by preoperative axillary ultrasound. It was considered suspicion any node that complies with the Bedi classification 3, 4, 5 and 6. The suspicion was corroborated with axillary biopsy under ultrasound guidance, selective biopsy of the intraoperative sentinel node and / or axillary dissection. Results We obtained a sensitivity of 67.11% and a specificity of 97.88%. Conclusions The diagnostic performance of preoperative axillary ultrasound in patients with breast cancer and clinically negative axillary is sensitive and specific in the detection of metastatic nodes

Características clínico-patológicas y de tratamiento en pacientes de edad avanzada con cáncer de mama atendidas en el Policlínico pami I de Rosario / Tumor characteristics and treatment in elderly patients with breast cancer attended at pami I Polyclinic, Rosario

Introducción Las mujeres de edad avanzada con cáncer de mama se encuentran subrepresentadas en la mayoría de los ensayos aleatorizados. Por lo tanto, los datos sobre las características y el tratamiento del cáncer en este subgrupo de pacientes suelen ser inconsistentes. En este estudio retrospectivo, comparamos las características clínico-patológicas y de tratamiento en mujeres ≥70 años vs mujeres más jóvenes. Objetivos El objetivo general del presente estudio es analizar las características tumorales clínicas e histopatológicas y el tratamiento administrado a mujeres posmenopáusicas de edad avanzada con cáncer de mama invasivo, no metastásico, diagnosticadas y tratadas en el Policlínico pami I de la ciudad de Rosario durante el periodo comprendido entre el 1 de enero de 2012 y el 31 de diciembre de 2017. Material y método Se analizaron las historias clínicas de 112 mujeres ≥70 años con cáncer de mama invasivo, no metastásico y de 65 mujeres posmenopáusicas de menor edad (49-69 años) atendidas en el Policlínico pami I de la ciudad de Rosario entre enero de 2012 y diciembre de 2017. Resultados Comparadas con las más jóvenes, las pacientes de edad avanzada se presentan con tumores de mayor tamaño al diagnóstico (pT 25 mm vs 18 mm, p=0,007) y sin mayor compromiso axilar (p=0,967). Existe una prevalencia alta de tumores luminales (87,04%) y baja prevalencia de subtipos agresivos (9,3% de tn y 3,7% de her2+), ilv (33,7%) y tumores de alto grado histopronóstico (19,6% GIII). Las mujeres mayores reciben más mastectomías (p=0,018), menos tratamiento adyuvante (p=0,001) y, en casos seleccionados, son pasibles de omitir tratamientos considerados estándar como la cirugía primaria, la bgc y la rdt post cirugía conservadora. No se encontraron diferencias significativas en sobrevida global (p=0,109), sobrevida específica por cáncer de mama (p=0,793) y sobrevida libre de enfermedad (p=0,974) entre ambos grupos. Conclusiones Existe una tendencia a sobretratar quirúrgicamente a las pacientes de edad avanzada y subtratarlas en términos de tratamiento adyuvante. El impacto de esta estrategia terapéutica en la sobrevida de las pacientes debe ser evaluado en estudios prospectivos, a gran escala y con seguimiento prolongado

Introduction Older women with breast cancer are underrepresented in most randomized trials. Therefore, data on the characteristics and treatment of cancer in this subgroup of patients are often inconsistent. In this retrospective study, we compared the clinic pathological and treatment characteristics in women ≥70 years vs younger women. Objectives The general objective of the present study is to analyze the clinical and histopathological tumor characteristics and the treatment administered to postmenopausal elderly women with invasive, non-metastatic breast cancer, diagnosed and treated at the pami I Polyclinic in the city of Rosario during the period between January 1, 2012 and December 31, 2017. Materials and method We analyzed the medical records of 112 women ≥ 70 years with invasive, non-metastatic breast cancer and 65 younger postmenopausal women (49-69 years) attended at the pami I Polyclinic in the city of Rosario from January 2012 to December 2017. Results Compared with the youngest, elderly patients have larger tumors at diagnosis (pT 25 mm vs 18 mm, p=0.007) but no major axillary involvement (p=0.967). There is a high prevalence of luminal tumors (87.04%) and low prevalence of aggressive subtypes (9.3% of tn and 3.7% of her2+), ilv (33.7%) and highgrade histopronostic tumors (19.6% GIII). Older women receive more mastectomies (p=0.018), less adjuvant treatment (p=0.001) and, in selected cases, they are able to omit standard treatments such as primary surgery; bgc and adjuvant rdt post conservative surgery. No significant differences were found in overall survival (p=0.109), specific survival for breast cancer (p=0.793) and disease-free survival (p=0.974). Conclusions There is a trend to over treat surgically elderly patients and under treat them in terms of adjuvant treatment. The impact of this therapeutic strategy on the survival of patients should be evaluated in prospective, large-scale trials and with prolonged follow-up

Barreras y facilitadores en las trayectorias de mujeres con cáncer de mama usuarias de hospitales públicos / Barriers And Facilitators of Health Seeking Behavior Among Women with Breast Cancer Users of Public Hospitals

El cáncer de mama (CM) es el segundo más común en el mundo y el más frecuente entre las mujeres. La incidencia varía entre regiones. Además, el CM es la quinta causa de muerte por cáncer a nivel mundial, la más frecuente en las regiones menos desarrolladas y la segunda en las más desarrolladas y en Sudamérica. En Argentina, registra las mayores tasas de incidencia y mortalidad entre las mujeres. OBJETIVOS: Comprender los motivos de las demoras, las consecuencias y las estrategias usadas por mujeres con diagnóstico de CM para afrontar barreras durante sus trayectorias de atención. MÉTODOS: Se realizó un estudio descriptivo transversal con abordaje cualitativo, basado en mujeres diagnosticadas con CM en dos hospitales públicos de la provincia de Santa Fe. Se efectuaron entrevistas semiestructuradas, que fueron grabadas previo consentimiento informado. Se utilizó el programa Atlas-ti (V.7.2) para el análisis del material. RESULTADOS: Se identificaron barreras a nivel personal (cuestiones financieras, creencias de las pacientes), interpersonal (cuestiones laborales, responsabilidad familiar, comunicación médico-paciente) y del sistema de salud (organización de servicios, calidad de atención). CONCLUSIONES: La investigación aporta evidencia para comprender las barreras que enfrentan las mujeres diagnosticadas con CM y muestra las oportunidades para implementar la estrategia de navegación de pacientes a fin de reducir o mitigar las demoras en la atención

Demoras en el proceso de atención de pacientes con cáncer de mama en dos hospitales públicos de la provincia de Santa Fe / Delays in the process of care of patients with breast cancer in two public hospitals in the province of Santa Fe

INTRODUCCIÓN: el retraso en el inicio de untratamiento efectivo del cáncer de mama reduce la tasa desupervivencia y está asociado a estadios más avanzados aldiagnóstico y a la necesidad de tratamientos más agresivos ycostosos. OBJETIVOS: Describir la trayectoria de la atención médicade mujeres con diagnóstico de cáncer de mama desde la apariciónde un signo o síntoma hasta la finalización del tratamiento.MÉTODOS: Se realizó un estudio descriptivo retrospectivo, quecombinó técnicas cuantitativas y cualitativas. Se estimaron lostiempos utilizados en cada etapa del proceso de atención de cáncerde mama en mujeres diagnosticadas y/o tratadas durante 2012 endos hospitales de la provincia de Santa Fe. RESULTADOS: Se incluyóa 62 pacientes en la muestra. El 20,3% obtuvo su diagnósticodentro del mes posterior a la mamografía y/o ecografía, y sólola mitad fue operada dentro del mes posterior al diagnóstico. El60% de las pacientes con necesidad de quimioterapia adyuvantey el 72,4% con necesidad de radioterapia tras la cirugía tuvierondemoras mayores a 60 días. Ninguna de las pacientes en estadio IVcomenzó el tratamiento antes de los 30 días. CONCLUSIONES: Si secompara con los parámetros establecidos en la guía del ProgramaNacional de Cáncer de Mama, hay demoras en todas las etapas. Esnecesario establecer estrategias que reduzcan los tiempos para laconfirmación diagnóstica en mujeres con sospecha, así como lostiempos de tratamiento en pacientes con cáncer confirmado.

INTRODUCTION: the delay to start an effectivetreatment for breast cancer reduces survival rate and is associatedto advanced stages at diagnosis and to the need for moreaggressive and costly treatments. OBJECTIVES: To describe thehealth care path of women with diagnosis of breast cancersince the first sign or symptom until the end of the treatment.METHODS: A retrospective descriptive study was performed,combining quantitative and qualitative techniques. It estimatedthe time used in each stage of the health care process amongwomen with breast cancer, diagnosed and/or treated during2012 in two hospitals of the province of Santa Fe, Argentina.RESULTS: A total of 62 patients were included in the sample.Of them, 20.3% received her diagnosis within 30 days of themammogram and/or ultrasound and 50% were operatedwithin one month of the diagnosis. There were delays of morethan 60 days in 60% and 72.4% of the patients who had toundergo adjuvant chemotherapy and radiotherapy, respectively.None of the patients with stage IV began the treatment withinthe first 30 days. CONCLUSIONS: Compared to the guidelinesof the National Program of Breast Cancer, there are delaysat all stages. It is necessary to develop strategies to shortenthe time for diagnosis confirmation in women with suspectedbreast cancer and for the access to treatment in patients withcancer confirmed.

Carcinoma lobular invasivo versus carcinoma ductal invasivo. Evaluación de resultados del tratamiento conservador / Invasive lobular carcinoma versus invasive ductal carcinoma. Evaluation of conservative treatment results

Introducción :El carcinoma lobular invasivo (CLI) suele presentarse con características clínicas e imaginológicas diferentes al carcinoma ductal invasivo (CDI), lo que podría asociarse a peores resultados quirúrgicos cuando se seleccionan a las pacientes candidatas a cirugía conservadora mediante un examen clínico y senográfico. El objetivo del presente trabajo fue comparar las tasas de reoperaciones por márgenes positivos, conversión a mastectomía y tasas de recaída local/regional entre pacientes con diagnóstico de cáncer lobular invasivo y cáncer ductal invasivo, tratadas de inicio con cirugía conservadora. Material y métodos: Se seleccionó un grupo de 43 pacientes con diagnóstico de CLI tratado de inicio con cirugía conservadora y 86 pacientes diagnosticadas con CDI, pareadas por edad, estado menopáusico y año de diagnóstico. Se compararon los resultados oncológicos a largo plazo. Resultados: El CDI no presentó diferencias con el CLI en la tasa de reoperación por márgenes positivos (8,13% vs. 11,6% ), conversión a mastectomía (5,81% vs. 6,97% ) ni recaída local/regional (10,4% vs. 9,3%) en 86 meses promedio de seguimiento. Conclusiones: Los resultados de este estudio demuestran que las pacientes con CLI tratadas con cirugía conservadora y radioterapia, presentan resultados similares a largo plazo, comparadas con las pacientes diagnosticadas con CDI, en tanto sean seleccionadas mediante un correcto examen clínico y senográfico.

Mastectomía conservadora de piel. Experiencia en el Centro de Mastología de Rosario / Skin-sparing mastectomía. Experience in Centro de Mastología de Rosario

Introducción: La mastectomía conservadora de piel (SSM) y la mastectomía conservadora de piel y pezón (NSM), están paulatinamente ganando terreno en el tratamiento del cáncer de mama, en desmedro de la mastectomía subradical tradicional. Inicialmente las preguntas sobre su seguridad oncológica limitó su uso. A pesar de ello año a año se suma evidencia que sostiene su práctica, sea para la mastectomía profiláctica o para el tratamiento del cáncer de mama, ampliando su uso y sus indicaciones. Materiales y métodos: Usando una base de datos actualizada prospectivamente, se revisaron 126 mastectomías realizadas en 108 pacientes entre enero de 2006 y junio de 2012. Resultados: Se analizaron tres grupos de pacientes: tratamiento primario del cáncer demama (84/108), tratamiento de la recidiva (21/108) y mastectomías profilácticas (21 procedimientos). Se preservó pezón (NSM) en el 51% del grupo tratamiento primario, en el 62% del grupo tratamiento recidiva y en todas las profilácticas. Hubieron sólo 3 recidivas locales (2,3%) y ninguna en el pezón de las que realizaron NSM. En la estrategia reconstructiva se necesitó sólo una cirugía en 100 procedimientos (84%), se trataron 22 complicaciones moderadas a graves (17%), pero se obtuvo un buen resultado estético en 97 procedimientos (76%). Conclusión: Las tendencias muestran la progresiva aceptación de la mastectomía conservadora de piel como tratamiento del cáncer primario, de la recidiva y como intervención profiláctica, con una tasa de recaída local escasa y alto número de buenos resultados estéticos. A pesar de que la mastectomía conservadora de piel no es estándar en el tratamiento del cáncer de mama, nuestra experiencia sostiene el uso selectivo del procedimiento en los tres grupos de pacientes estudiados.

Factors predisposing women to chronic pelvic pain: systematic review.

OBJECTIVE: To evaluate factors predisposing women to chronic and recurrent pelvic pain. DESIGN, DATA SOURCES, AND METHODS: Systematic review of relevant studies without language restrictions identified through Medline, Embase, PsycINFO, Cochrane Library. SCISEARCH, conference papers, and bibliographies of retrieved primary and review articles. Two reviewers independently extracted data on study characteristics, quality, and results. Exposure to risk factors was compared between women with and without pelvic pain. Results were pooled within subgroups defined by type of pain and risk factors. RESULTS: There were 122 studies (in 111 articles) of which 63 (in 64,286 women) evaluated 54 risk factors for dysmenorrhoea, 19 (in 18,601 women) evaluated 14 risk factors for dyspareunia, and 40 (in 12,040 women) evaluated 48 factors for non-cyclical pelvic pain. Age < 30 years, low body mass index, smoking, earlier menarche (< 12 years), longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse, and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise, and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety, and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic inflammatory disease, previous caesarean section, pelvic pathology, abuse, and psychological comorbidity were associated with an increased risk of non-cyclical pelvic pain. CONCLUSION: Several gynaecological and psychosocial factors are strongly associated with chronic pelvic pain. Randomised controlled trials of interventions targeting these potentially modifiable factors are needed to assess their clinical relevance in chronic pelvic pain.