PRACTICE OF ANTENATAL CLINICAL BREAST EXAMINATION IN CALABAR

Reports of a rising incidence of breast cancer and the consistent finding of a significantly younger population of breast cancer patients in the country than in the west led to this study to determine the proportion of women who have a clinical breast examination at the booking visit for antenatal care in the University of Calabar Teaching Hospital (UCTH).The booking information on the antenatal cards of patients who registered within a one-month period was examined. Clinical breast examination (CBE) was performed on 41.6% of the women. Women who were reviewed by consultants recorded a rate of 78.2% while the rates for women attended to by resident doctors and interns were 41.2% and 19.6% respectively (P=0.00). The CBE rate was 57.6% among women who were reviewed by female physicians and 38.3% among those reviewed by male physicians (P = 0.00). The practice of CBE in UCTH is low and is significantly related to the cadre and gender of the attending physician. Obstetricians must embrace the practice fully and utilize measures such as increased supervision and departmental seminars to sensitize doctors they train to emulate them.


INTRODUCTION
Breast Cancer is one of the two leading causes of female malignancy death in Nigeria (Ajayi 2002).The incidence is increasing at an alarming rate with a 100% rise from 13.8-15.3/ 100,000 women in 1980 to 116 / 100,000 women in 2001 (Adebamowo and Ajayi 2000).The fiveyear survival rate of patients in the country is less than 10% as against more than 70% in western countries (Okobia et al 2006).The remarkable survival rates in these nations are attributable to their screening programs which encourage early detection of premalignant and malignant lesions (Peto et al 2000).Breast examination by a physician otherwise known as clinical breast examination (CBE) is one of the measures adopted in such programs.In Nigeria as with many other developing countries, there are no such national programs.As a result, more than two-thirds of patients present in hospital with advanced disease (Okobia et al 2006, Ihekwaba 1993, Anyawu 2000, Adesunkanmi et al 1999).
The lack of an organized screening program in the country has raised the need for opportunistic screening during health care encounters for other reasons (Smith et al 2002, USAID 2005).In developing nations, most healthy women only visit health facilities for physical examination during pregnancy (Kauser 2004).It has also been estimated that 3% of breast cancers occur in pregnancy (Rao et al 2001).The rate in the country may be higher since the peak age is at least a decade earlier than for Caucasians and significantly more patients fall within the reproductive age range (Anyawu 2000, Adesunkanmi et al 1999, Nggada et al 2008, Adebamwo 1998, Ijaduola and Smith 1998).The routine practice of antenatal CBE at the booking visit is therefore important in our setting.The extent of this practice in our centre has not yet been assessed.Hence, this study aims to determine the proportion of women who have a CBE on booking for antenatal care at the University of Calabar Teaching Hospital (UCTH).It is hoped that the findings of this audit will A. Udo, Dept. of Obstetrics and Gynaecology, Univ. of Calabar Teaching Hospital, Calabar, Nigeria M. Ekott, Dept. of Obstetrics and Gynaecology, Univ. of Calabar Teaching Hospital, Calabar, Nigeria E. E. Efiok, Dept. of Obstetrics and Gynaecology, Univ. of Calabar Teaching Hospital, Calabar, Nigeria E. Ekanem, Dept. of Obstetrics and Gynaecology, Univ. of Calabar Teaching Hospital, Calabar, Nigeria E. Udoma, Dept. of Obstetrics and Gynaecology, Univ. of Calabar Teaching Hospital, Calabar, Nigeria encourage and entrench the culture of CBE in all doctors who train in the maternity unit.This will result in early detection and treatment of suspicious breast lesions in our women with possible good prognosis.

PATIENTS AND METHOD
Case notes of women who booked for antenatal care in UCTH between 7th February, 2007 and 7 th March, 2007 were retrieved for the study.The booking information on each antenatal card was scrutinized to determine the cadre and gender of the doctor who attended to the woman and to note if physical examination of the breasts was part of this assessment.The proportion of women who had a CBE and those who had none and the proportion of doctors of each cadre and gender who attended to each of the two groups of women were compared using chi-square tests.

RESULT
Four hundred and twenty-four women booked to receive antenatal care during the study period and 413 (97.4%) case notes were available for the study.Breast examination was performed on only 172 (41.6%) of the women, while 241 (58.4%) had no CBE.Seven women had a past surgical history of breast lump removal.Of this number, two (28.6%) had a CBE.Table 1 compares the rate of performance of CBE by the various cadres of doctors who attended to the women.Of the 107 women who were reviewed by interns, 21 (19.6%) had CBE while CBE was performed on 94 (41.2%) of the 228 women reviewed by resident doctors and 61 (78.2%) of the 78 women attended to by consultants.There was a significant association between the cadre of the attending physician and the rate of performance of CBE (P = 0.00).Table 2 on the gender of the physician and the rate of CBE shows that female physicians performed CBE on 57.6% of patients they reviewed, significantly higher than 38.3% recorded for patients reviewed by male physicians (P = 0.00).

DISCUSSION
The study revealed that less than half of the women who booked for antenatal care during the period had a CBE.It is also important to note that CBE was performed on only 2 of the 7 patients documented by the nurses as having had a past history of breast lump removal.Although it is common knowledge that in the country patients are frequently lost to follow up after surgery, the attending physicians overlooked the need to exclude a possible recurrence of a premalignant or malignant lump.A worse situation seems to exist in southeastern Nigeria as a study also conducted in a tertiary health facility reported that only 3% of antenatal clinic attendees had a CBE (Onwere et al 2008).
Women who were reviewed by consultants recorded a CBE rate of 78% while the rates for women attended to by resident doctors and interns were 41% and 20% respectively.These findings suggest that not only have obstetricians not fully imbibed the practice of antenatal CBE; those who have are yet to impart the practice to doctors under their supervision.This is cause for concern as the hospital is an academic centre and obstetrics and gynaecology is a specialty that caters to the health needs of women.There is need for regular departmental seminars on breast cancer to heighten the awareness of doctors on its increasing incidence in the country and to remind them of the preventive strategies to reduce mortality.Strategically placed posters in consulting rooms would also serve as useful reminders to physicians to perform CBEs (Gorin et al 2006).
The study also noted that the women who were reviewed by female physicians recorded a higher rate of CBEs than those who were seen by male physicians.This is similar to the report of a study conducted in Minnesota (Lurie et al 1993).Another study seeking to explain the Minnesota finding revealed that female physicians feel more personal responsibility for ensuring that patients receive breast cancer screening and are more comfortable in performing breast examinations (Lurie et al 1997).Regular departmental seminars on breast cancer are again important in this regard.Not only would subtopics which specifically address this issue help to narrow the gender gap, the seminars would also enhance breast health awareness among nurses in the department.A nurse acting as chaperone (a regular role nurses play in the antenatal clinics) who is breast health aware is more likely to notice and remind the physician to perform a CBE should he forget.Such a nurse will also be more committed to educating women on breast health awareness during the routine health talks thus empowering them to request for CBE when examined by the physician.

CONCLUSION
The level of practice of antenatal CBE in UCTH is low and a wide gap exists between the level of practice by consultants and doctors they supervise and among female physicians and their male colleagues.The lack of a national screening program has resulted in most women who present at the antenatal clinics not having ever been examined for suspicious breast lesions.There is therefore the need for obstetricians to fully embrace the practice of antenatal CBE and initiate measures to ensure that all doctors training under them are adequately sensitized to do same.This will ensure that every woman who registers for antenatal care at the UCTH has this additional health benefit.