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Oncologist Perspectives on Breast Cancer Screening in India-Results from a Qualitative Study in Andhra Pradesh

Authors:

Abstract

Background: It is important to understand the perceptions of oncologists to understand the comprehensive picture of clinical presentation of breast cancer. In the absence of clear evidence, clinical practice involving patients of breast cancer in India should provide insights into stages of breast cancer with which women present to their clinics and mode of screening of breast cancer prevalent in Andhra Pradesh. Materials and methods: A qualitative study was conducted to understand the perceptions of oncologists regarding clinical presentation of breast cancer, stages at which women present to clinics, and mode of screening of breast cancer prevalent in Andhra Pradesh. In-depth interviews (IDI) were conducted with ten practising oncologists from various public and private cancer hospitals in Hyderabad city to understand their perspectives on breast cancer and screening. The data were triangulated to draw inferences suitable for the current public Health scenario. Results: Late presentation was indicated as the most important cause of decreased survival among women. Most women present at Stage 3 and 4 when there is no opportunity for surgical intervention. The results indicate that there is a huge gap in awareness about breast cancer, especially in rural areas and among poor socioeconomic groups. Even despite knowledge, most women delay in reporting due to reasons like fear, embarrassment, cost, ignorance, negligence, and easy going attitude. Conclusions: It is important to improve awareness about breast cancer and screening methods for promoting early screening. The study inferred that it would be beneficial to establish cancer registries in rural areas. Also, the policymakers need to make key decisions which among three methods (breast self examination (BSE), clinical breast examination and mammography) can best be used as a screening tool and how to successfully implement population wide screening program to prevent mortality and morbidity from breast cancer in India.
 5817
DOI:http://dx.doi.org/10.7314/APJCP.2013.14.10.5817
Oncologist Perspectives on Breast Cancer Screening in India - Qualitative Study Results from Andhra Pradesh
Asian Pac J Cancer Prev, 14 (10), 5817-5823
Introduction
The urban cancer registries at 5 metropolitan cities
located at Bangalore, Bhopal, Chennai and Mumbai
in India are important sources of data regarding breast
cancer in India (Kamarana et al., 2003). The data from
these registries tend to focus greatly on the cancers near
surrounding urban areas and have very limited inclusion
of rural geographic areas (Babu, 2009). The pooled data
on the number of Breast cancer cases among females
in (Takiar and Vijay, 2010) inidcates that the absoulte
numbers of breast cancers grew by 38% from 1998-2005.
However, the available evidence does not provide
useful interpretations for identifying local prevalence of
breast cancer and plan public health actions accordingly.
It is not possible to answer one putative question: whether
breast cancer is highly prevalent or not in rural areas of
Andhra Pradesh or other such states in India, as we just

In order to understand the epidemiological correlates,
we followed two prong approach. One, we conducted a
systematic review of evidence available on epidemiologic
1Indian Institute of Public Health, 2Public Health Foundation of India, Hyderabad, India &Equal contributors *For correspondence:
giridhar@iiphh.org
Abstract
Background: It is important to understand the perceptions of oncologists to understand the comprehensive
picture of clinical presentation of breast cancer. In the absence of clear evidence, clinical practice involving
patients of breast cancer in India should provide insights into stages of breast cancer with which women present
to their clinics and mode of screening of breast cancer prevalent in Andhra Pradesh. Materials and Methods:
A qualitative study was conducted to understand the perceptions of oncologists regarding clinical presentation
of breast cancer, stages at which women present to clinics, and mode of screening of breast cancer prevalent in
Andhra Pradesh. In-depth interviews (IDI) were conducted with ten practising oncologists from various public
and private cancer hospitals in Hyderabad city to understand their perspectives on breast cancer and screening.
The data were triangulated to draw inferences suitable for the current public Health scenario. Results: Late
presentation was indicated as the most important cause of decreased survival among women. Most women present
at Stage 3 and 4 when there is no opportunity for surgical intervention. The results indicate that there is a huge
gap in awareness about breast cancer, especially in rural areas and among poor socioeconomic groups. Even
despite knowledge, most women delay in reporting due to reasons like fear, embarrassment, cost, ignorance,
negligence, and easy going attitude. Conclusions: It is important to improve awareness about breast cancer and
   
cancer registries in rural areas. Also, the policymakers need to make key decisions which among three methods
(breast self examination (BSE), clinical breast examination and mammography) can best be used as a screening
tool and how to successfully implement population wide screening program to prevent mortality and morbidity
from breast cancer in India.
Keywords: Breast cancer screening - oncologists - factors causing breast cancer - preventive measures - Andhra Pradesh
RESEARCH ARTICLE
Oncologist Perspectives on Breast Cancer Screening in India-
Results from a Qualitative Study in Andhra Pradesh
Srikanthi Lakshmi Bodapati1,2&, Giridhara Rathnaiah Babu2&*
correlates of breast cancer addressing incidence,
prevalence, and associated factors like age, reproductive

on screening procedures in southern India (Babu et al.,
2013). Second, we conducted a qualitative study to
understand the perceptions of the oncologists regarding
clinical presentation of breast cancer, stages of breast
cancer with which women present to these clinics, mode
of screening of breast cancer prevalent in Andhra Pradesh.
The current article describes the results from qualitative
study. The two prong approach was designed to understand
comprehensive nature of determinants, which may be
useful to plan for future public health programs.
Treating doctors from public and private tertiary
oncology hospitals and institutes will have better insights
into the problems of early screening among women and
also provide inputs for betterment of the existing screening
methods. Our study was planned to capture the opinion of
these important stakeholders in cancer control. It is vital
to understand their insights in order to understand the
correlates of screening among women in Andhra Pradesh,
India. This will help in planning educational programs,
Srikanthi Lakshmi Bodapati and Giridhara Rathnaiah Babu

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
for breast cancer screening in India.
Materials and Methods
The objective of this paper was to understand
physician perspectives regarding current trends in clincial
presentation, clinical features and screening methods
followed by women with Breast cancer in Andhra Pradesh.
Practicing Oncologists working in different public
and private hospitals in Hyderabad city were approached
for gathering information. They were selected as per
their convenience and availability for the interview.
Prior appointment was sought from the Oncologists after
seeking their administrative approval. They were met
at the date and time given by them. They were briefed
about the study, taken consent for the interview. They
were assured that anonymity will be maintained by the
researcher and the information provided by them will
      
the interview was sought from them. The interview was
conducted in English language as per the Guidelines
developed (Table 1) and recorded both in the tape as well
as transcribed by note taking. Each interview lasted for 10
min to 40 min duration with an average duration of 20-25
min, based on the response of the Oncologist and their
available time. Like this, 10 interviews were conducted
with different types of Oncologists (refer Results section).
Following questions were asked in the interview guide
(Table 1) for conducting the interviews: Epidemiology
of Breast Cancer in Andhra Pradesh, Presentation of
Breast cancer by women in AP, Prognosis of Breast
Cancer, screening, Risk & Recommendations to Health
Perceptions and Knowledge and recommendations for
Improved Practices.
Data management
MS-Excel was used to code the qualitative information
from each of the interview. From each interview, the
data was divided into Key themes with many subthemes
under it, based on the guidelines used for conducting the
interview. The information was then coded into these
themes and subthemes. Where possible, relevant quotes
used by the Oncologists were used for supplementing the
information provided under each sub theme. The coded
information was analysed and the themes emerging out of

repeatedly to identify and list important and recurrent
themes in women’s accounts of their experiences. This
framework of themes and patterns generated an index of
major themes and sub-themes, each of which was assigned
a number so that the index could be applied systematically
to all the transcripts.
Results
A total of 10 Oncologists were interviewed for
the purpose of the study, of which 4 were Radiation
Oncologists, 2 Medical Oncologists, 2 Surgical Oncologists
and 2 were Gynec Oncologists. There were 4 Female
Oncologists and 6 Male Oncologists among the group.
Among the 4 hospitals visited, one hospital was public
sector Oncology Institute, which caters to the rural low
and middle socio economic groups while the remaining
3 hospitals were private Institutes which mainly cater to
the middle and high socioeconomic groups. Two of the
Oncologists did not give consent for audio recording of
the interview while the remaining 8 of them consented.
The summary of the results is presented in Table 2.
Epidemiology of breast cancer
Lack of Cancer Registries: In India, lack of proper
cancer registries was the major barrier in providing
estimate on Cancer epidemiology. However, Breast cancer
has now become more an urban disease as compared to
rural areas, Reasons include, life style factors, availability
of facilities for screening.
Majority of Oncologists commented that Breast cancer
is more an urban disease than rural. Major factors for
increased urban incidence are due to increase in awareness
levels and also facilities for diagnosis.
Current incidence
Three of them could not comment on the incidence

India.
I cannot comment on the incidence and prevalence
of breast cancer as we do not have a tumour registry in
Andhra Pradesh. What I see is many younger women are
being affected Medical Oncologist, 38 years.
The average number of new cases in a month were
reported to be around 15-20, we get 15-20 cases per
month in this hospital. Prevalence is 10 cases. Age group
affected is 40-50 years- Radiation Oncologist, 52 years,
Govt Cancer Hospital.
Our hospital will get about 10000 cases every year,
out of which people with breast cancer are around 1500.
20 to 50yrs age group. Largely of middle age. In Andhra
Pradesh, women of the age group 40-55 are more affected’
One of them mentioned the incidence to be 1 in 12-15

1 in 10. Depending on the size and accessibility of the
hospitals, the new case load in private hospitals was
reported to be 20-50 (which is related to the reported high
urban incidence). Among the rural poor, the incidence was
reported to be 5-8% Radiotherapist, 35 years.
Current prevalence
 
10 cases per month who are already diagnosed with breast
cancer.
‘‘We get 15-20cases per month in this hospital.
Prevalence is 10 cases. Age group affected is 40-50 years
Radiologist, 50 years.
Age group of women affected
Most (7 out of 10)of the Oncologists said that Older
age group (40-60 years) of women are being more affected
than those in younger age. However, Breast Cancer is seen
targeting more towards younger age group women (22-40
years also), mainly from urban background due to various

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DOI:http://dx.doi.org/10.7314/APJCP.2013.14.10.5817
Oncologist Perspectives on Breast Cancer Screening in India - Qualitative Study Results from Andhra Pradesh
Table 1. Guide for In-depth Individual Interview, Phase 1
Introduction
1. Greet the participant.
2. Introduce yourself.
 
are not recorded. Explain that we want to know about their work environment and how it affects them, and that this information is not
available anywhere else. When asking questions, prompt for more information at times by asking “anything else?”
4. Explain that their answers will remain anonymous and that the information will be combined with other answers only in statistical summaries.
 
6. Thank the person for having agreed to participate.
I. Demographic Information
1 How do you classify your role in Oncology discipline? Medical oncologist 1
Onco-surgeon 2
Radiotherapist 3
Others 4
2A
2B
What is your birth date? OR
How old were you on your last birthday? [in years]
DD-MM-YYYY
3 What is the highest grade of education you have completed to date? MD or Postgraduation 1
DM 2
MCH 3
Others 4
II. Epidemiology of Breast cancer and Diagnosis
1. Please comment on epidemiology of breast cancer?
 
a. Current incidence (estimated new cases) or prevalence?
b. Age groups of women affected?
c. What type of breast cancer is common? Who are affected?
d. What percentages of women are dying exclusively from breast cancer in AP? What could be the reasons?
 
3. What do you dislike about presentation of breast cancer as a treating oncologist?
(such as types of Breast cancer as presenting symptom, treatments at primary health care level, economic level of women etc.,)
4. What do you think are the opportunities in terms of better prognosis for patients? (such as type, which age group, etc?)
5. What do you think are the factors determining POOR prognosis for patients? (such as type, which age group, etc?)
Note: Questions 3 and 5 are similar but the interviewer needs to identify from the treating doctor regarding what factors are responsible poor outcomes for patients with
breast cancer for advocacy and improving their health. Questions need not be repeated as they are here, but discussions should be pursued keeping all the pointers in mind.
III. Screening
1. Enlist 5 key preventive measures, which according to you help prevent the incidence of breast cancer among women.
Why do you think these are important? Comment on the current status of screening and prevention among women?
2. At what stage do women get diagnosed for breast cancer? (move this to section.2, but make a connection)
3. What is the current state of screening procedures/ what procedures are adopted for screening for breast cancer?
4. Are there any standard guidelines/ recommendations that you may want women to follow for routine screening/diagnosis?
can you brief regarding these guidelines?
5. According to you, are there any side effects caused due to any of the screening procedures mentioned above? How do you address these?
6 If you were to advice Government of India to implement population screening program for Breast cancer, what method you would recommend?
 
Do women follow them? Why and why not?
8. What are the associated risks and costs of screening?
IV. “Risks to Health” Perceptions and Knowledge
1. Do you think that women have adequate knowledge and information about these screening measures?
2. What are the expected delays in case reporting of breast cancer? Why do you think these delays are happening?
3. What are the various barriers for the delay in case reporting, especially in AP?
V. Recommendations for improved practices
1. What could be the expected rise in breast cancer cases among women if the barriers outlined earlier by you are not addressed?
2. What measures need to be taken to overcome the barriers in screening? Diagnosis and treatment of breast cancer among women in AP
3. What measures can be taken to prevent the delays in case reporting of breast cancer?
4. What age groups of women need to be targeted for preventing breast cancer incidence in AP and also in India?
5. How should the preventive measures be focused? What should change at the individual, social, structural and policy level changes, according
to you?
Thank you so much for your time and valuable information for the study
It is affecting 25-40 years group. Most young women
Medical Oncologist, 38 years.
Type of breast cancer
Intraductile, Infiltrating Ductal Carcinoma and
Globular Carcinoma were found to be more commonly
seen types among women in AP.
Intraductile and infiltrating carcinoma is more
common’ Radiation Oncologist, 35 years.
Ductal carcinoma, globular carcinoma, depending
on the type of origin in the breast tissue. Common is
ductal carcinoma. In govt set up advanced stages are
seen. In corporate set up, we get early stages Radiation
Oncologist, 35 years.
Mortality from breast cancer
One of them reported the mortality among women
due to breast cancer to be 4-5%. However, the survival
Srikanthi Lakshmi Bodapati and Giridhara Rathnaiah Babu

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rates depend on the stage of BC, age group affected. In younger
women the mortality rate due to BC is high due to the aggressive
nature of the tumour, hormone receptor status and genetic factors
(among those with hereditary risk of BC).
Mortality among the age group 40-50 is low, but those whom
we treat under 30 years, mortality is high’ Radiation Oncologist,
52 years.
Survival rates for stage 1 would be at highest 90% to stage
4 is around 8 months to 1 year Medical Oncologist, 38 years.

Breast cancer, unfortunately like cervical cancer is not a
preventable disease. It is not possible to prevent the disease. Every
woman can get it. Our focus should be early detection. Only in
10% of women is breast cancer genetically inherited, where as
in 90% of women, cancers are non genetic. There are two genes
BRCA1 and BRCA2 which are predominant among the 10 %
of women with genetic predisposition. If they are cancer +ve,
prophylactic removal and/very close observation can be done.
Some of the factors like obesity, diabetes mellitus, nulliparity,
stress etc can be contributing to the breast cancer, but it is not
generally caused by a single factor.’ Surgi cal O nc olog ist, 43 year s.
Two types of risk factors are accounted to be responsible for
increase in BC. This was told my almost every Oncologist. These


     
use of Oral Contraceptive pills (which increases the estrogen
content in the blood). Environmental factors like use of foods
which generate high estrogen like vegetables and fruits grown in
areas with soil highly contaminated with Plastic, Consumption of
chemical sprayed fruits, use of Melamin containers for cooking
and consumption of food which is highly carcinogenic. Some of
the food products like chicken, milk etc have high estrogen due to
the hormonal injections given to the animals. Consumption of such
foods is causing early menarche among the girls, which causes
        
predisposition, early menarche, late menopause,age, nulliparity,

factors. Presence of BRCA1 genes in the women also contribute
to the risk among those with family history of BC.
Traditional risk factors like Nulliparity, obesity etc are no
more contributing to breast cancer. We see a woman with 5
children is also affected. Hence it is multifactorial. Surgical
Oncologist, 43 years.
Presentation of breast cancer by women in AP
Late presentation is the cause of decreased survival among
women. All the Oncologists expressed their concern for the stage
at which women are presenting to them with Breast Cancer.
They said that women present at Stage 3 and 4 when there is no
opportunity for surgical intervention. They have to go for radical
treatment, with radiotherapy and chemotherapy being the options
left for them. In locally advanced stages, it is very challenging
to treat the cases. The survival rate in Stage 1 is 90%, since the
baby cancer is not aggressive while the survival rates decrease as
the stage progresses from stage 2-4 and falls to 15% in stage 4.
In some conditions, the women wait till the fungating growth
appears on the breast with foul smelling discharge. This is more so
among Muslim communities and women living in joint families.
Reasons outlined for late presentation is Fear being an important
Table 2. Summary of Recommendations with Suggested Strategies
Sl Strategy Method/Process Target group Stakeholders
1. Health Education on Self Breast Examination House to house survey and education. Videos, media Women ANMs, Nurses at the community level
2. Promoting Breast cancer awareness Using brand ambassador, Breast cancer walk, Celebrating breast cancer week etc Everyone in the community Government
3. Maintenance and Streamlining of Cancer Registries -Making cancer registry mandatory at Public and Private facilities, diagnostic centres
-Licencing to private providers to be given by making Registries maintenance mandatory
Public and Private and semi private sector
Oncology Institutes, Diagnostic centres
Government
4. Screening to detect Preinvasive cancer -Setting up early detection centres
-Promoting mammography using Digital Mammograms
-Screening of High risk groups (genetic predisposition, People wth obesity,
hormonal imbalance etc)
-Clinical Examination by Physicians at PHC level, followed by mammogram
-Allowing private doctors to provide service in Government hospitals
-Providing subsidies for screening facilities
-Routing of patients for screening through Arogyasree prog
Women, service providers Government, Primary level to tertiary
level health personnel
5. Promoting Life style changes -Promotion of breast feeding, Regular exercise, smoking and alcohol ban Women District level doctors, Nurses, ANMs
6. Information Dissemination on Facilities and newer technologies -Top down and bottom approach to identify gaps and transfer of right kind of information
-Providing information on a continuous basis
-Networking of different public and private hospitals and providers for sharing of information
Public and Private Health care provid-
ers
 5821
DOI:http://dx.doi.org/10.7314/APJCP.2013.14.10.5817
Oncologist Perspectives on Breast Cancer Screening in India - Qualitative Study Results from Andhra Pradesh
factor, followed by stigma, negligence and easy attitude
of women.
Poor people and rural areas people have low access
to facilities. Urban people-especially muslims come at a
later stage due to conservative attitude, it is not the cost
that matters. They take it easy and when foul smelling
discharge starts they go to the hospital. Radiation
Oncologist, 35 years.
They take it as it is when we get it lets see is the
attitude. It depends on the education level.’ Radiation
Oncologist, 35 years.
Prognosis of breast cancer
Older age, ER PR positive status determine good
prognosis. Patient factors like old age, absence of co
morbid conditions (like Diabetes Mellitus, Hypertension,
no family history of BC). ERPR+ receptor status have
good prognosis. Among the treatment factor, molecular
treatment and targeted therapy have good prognosis.
Age of the women, stage of presentation, ER PR+ status,
nodal positivity determines the systemic spread of the
disease. Apart from this, aggressiveness of the tumour
itself, hormonal status, gene mutations, family history,
incomplete treatment also determine poor prognosis.
Radiation Oncologist, 35 years.
Screening
Fi ve Key preventive measures to pre ve nt the
incidence: Primordial prevention is the only way to
reduce the incidence of breast cancer, as suggested by
the Oncologists. Key preventive measures suggested by
them include; Awareness generation on Breast cancer
detection and screening method screening through
Self breast examination, clinical examination followed
by mammogram, Fine needle aspiration cytology test


decrease intake of Oral contraceptive pills. Improvement
in screening facilities and treatment facilities at the
secondary level
Consistency in awareness generation efforts
Awareness on Screening limited to higher
socioeconomic strata: Oncologists expressed that urban
women have good awareness regarding screening and also
access to facilities. Commonly used Screening procedure
is Mammogram. Breast Self Examination is being done,
but only among women who have attended awareness
camps. But in practice it is not being done much. Those
women with a malignancy of one breast, those who are
at risk of breast cancer (family history) are advised for
self breast examination at the facilities when their family
member/ relatives come for treatment.
Other modalities of screening currently in use are
Sonomammogram, Fine Needle Aspiration Cytology

Other advanced tests like testing for ERPR positivity

to the higher end corporate hospitals.
We don’t know the affect of screening for breast
cancer women. So is it economically viable to do? Is it
cost effective? Does it really improve mortality from breast
cancer? We don’t have answers for all these. So what we
can do is only extrapolate from the western data. If or if
not applied to others, conditions Medical Oncologist, 38
years.
Currently American Cancer Society Guidelines (ACS)
are being followed for screening, which says that every
woman above 40 years need to be screened. Other than
this, National Cancer Control (NCC) and WHO screening
guidelines are also being followed.
Side effects caused due to screening
There are no documented side effects due to screening,
except for the pain and embarrassment for the women
during the process.
Repeated exposure to radiation increases risk
of sarcoma, which is another malignancy because of
repeated radiation, but again the radiation level is been
so low, that comes to 30 40 mammograms done in a life
time will not be a very high exposure.Medical Oncologist,
38 years.
Most of the Oncologists adviced Clinical Examination
by a Physician to be the best option for Population based
screening, as it does not require a specialist doctor and
can be done by Physician or trained nurse. This should
be followed by Mammogram, in case of any suspicion by
the Physician.
They imagine it as grave disease. They get panicky
and fear about further treatment’ Radiation Oncologist,
52 years.
Risks and costs of screening: No risks are involved
with screening. Cost of Mammogram ranges from Rs800-
3000 in Private facilities while in Government tertiary
hospital it is only Rs300.
Risk to health perceptions and knowledge
Huge gap in awareness about breast cancer is seen by
different socioeconomic groups. Awareness among urban
women was found to be more about screening. Where as
in rural areas, there still exists a huge gap, as is felt by
most of the Oncologists. Sometimes, fear is the major
barrier which is causing delay in screening and treatment,
since women feel cancer is dangerous and there is stigma
associated to the fear of losing hair, breast and cosmetic
appearance
They are ignorant. They think lumps formed are those
seen during pregnancy and lactation. Not that somebody
advices them but they themselves think that way. Rural
women neglect the disease due to fear and ignorance.
Where as urban women come running to the hospital
once they see any lump, since they watch TV’ Radiation
Oncologist, 52 years.
I think the culture of screening is not there here.
Anyone doesn’t go even my mother doesn’t go when I
say her to go. many women think that if they have breast
cancer they will have their entire breast removed Medical
Oncologist, 38 years
Expected delays in case reporting of BC and reasons for
the delays.
Despite knowing, most women delay in reporting
Srikanthi Lakshmi Bodapati and Giridhara Rathnaiah Babu

5822
due to reasons like fear, embarrassment, ignorance,
negligence, easy going attitude.
Women feel, anyway it’s something which don’t get
better so why bother others. So it’s got to do with the
culture of our women also. They don’t want to put other
family members into any kind of trouble, whatever happens
that happens.’ Medical Oncologist, 38 years.
Barriers for the delay in case reporting
Cost, fear and negligence are the major barriers
for delay in case reporting. Cost is the major barrier,
especially among rural women. Apart from this, Fear,
stigma, negligence, lack of facilities for early screening
and diagnosis are other barriers outlined.
They imagine it as grave disease. They get panicky
and fear about further treatment.’ Gynec Oncologist, 50
years.
Recommendations for improved practices
Early Screening should detect more number of
Cases, thereby rising the incidence. They opined that
they expected rise in Breast Cancer if the barriers are not
addressed. Oncologists felt that through early screening
and detection, incidence of breast cancer should be more,
which help in identifying more women in Stage 1. Hence
barriers need to be removed to promote more screening
among women, especially self breast examination
Mammogram is not available everywhere but
sonomammogram is available everywhere. Self breast
examination is also being done by women, as we are
advising them during the visits here. If they have tumour
in one breast, we advice them to examine the opposite
breast also Radiotherapist, 52 years.
Discussion
As found from our study results, the incidence of
breast cancer in developing countries is rapidly on the
rise. It is alarming that breast cancer is generally detected
at advanced stages when a cure is not possible. The
incidence of breast cancer increases with increasing age
across the globe. However, the average age of presentation
for breast cancer in the Indian population is widely
reported to be around 10 years younger compared to the
developed world and can have devastating effect on this
predominantly young population (Sabu et al., 2010).
It is important to detect the breast cancer early to save
millions of lives. Stigma, limited awareness, knowledge
and lack of population wide screening program have
led to late detection of most breast cancers (Gakwaya et
al., 2008). Early detection of breast cancer makes more
treatment choices available and also there are greater
chances of long-term survival (Chong et al., 2002). If
detected earlier, breast cancer has better survival rate
than other cancers (Sharif et al., 2010). When detected
at the early stage, breast cancer is curable, with a 100%
survival rate for stage 0 and 1 (Thomas et al., 2002).
Studies have suggested that in the Indian scenario, the
shift to routine use of mammography as a screening tool

2008). Economically viable strategies would be to promote
Breast Self Examination and Clinical examination at the
primary health care level (Babu et al., 2011).

Pradesh present predominately at either stage III and IV.
Stage at diagnosis is an important determinant of the
overall survival rates. On average, 50% of breast cancer
cases in India present at late stage (stage III and IV)
(Chopra, 2001). As found in our study, it is very important
when women with breast cancer are aware of their disease
and how early the treatment can be given. In developed
countries like the United states, only 12% of the breast
cancer cases are diagnosed at an advanced stage (Goel
et al., 1995).
Our qualitative study found that early detection of
genetic mutations in BRCA1 and BRCAs genes among
women with a family history of breast cancer helps in better
prognosis. Earlier, it was thought that the contribution
of BRCA2 mutations seems rather low among Indian
women (Saxena et al., 2006). However, the contribution
of environmental factors are equally important to address
in India. More than 80 studies looking at the association
of physical activity and breast cancer have found physical
activity to have a protective effect (Marmot et al., 2007).
This protective effect is due to a multitude of factors
which include reduction in circulating levels of and
cumulative exposure to sex steroid hormones, changes
to insulin-related factors and adipocytokines, modulation

cellular metabolism pathways (Friedenreich and Cust,
       
including obesity reduction through physical exercise,
diet regulation and consumption of low caloric diet

This study also reports the association between Estrogen
receptor positive status and decreased breast cancer risk.
The controversial effects of oral contraceptives (OCPs)
on breast cancer have been extensively studied but there
  
role of OCPs in causation of breast cancer (Calle et al.,
1996). Our results from systematic review and qualitative
interviews also noted the protective effect of breast feeding
in reducing risk for breast cancer (Babu et al., 2013). There
are several studies done in India showing similar results
(Gajalakshmi et al., 2009; Meshram et al., 2009).
As found in our study, the late presentation is the
cause of decreased survival among women in south India.
This was due to presentation at Stage 3 and 4 when there
is no opportunity for surgical intervention.. This can be
addressed by improving awareness about breast cancer
especially in rural areas and among poor socioeconomic
groups. On the other hand, despite having the knowledge,
most women delayed in reporting due to reasons like
fear, embarrassment, ignorance, negligence, easy going
attitude. These need to be addressed by reinforcement of
knowledge and Adating interventions to bring changes
in behavior among these women. Studies can be piloted
in Urban India to understand how successful behaviour
change interventions can be done. Other reasons for later
reporting were due to cost. This can be addressed by
inclusion of breast cancer treatment costs in existing health
schemes such as Arogyashri and Yeshaswini. Though the
 5823
DOI:http://dx.doi.org/10.7314/APJCP.2013.14.10.5817
Oncologist Perspectives on Breast Cancer Screening in India - Qualitative Study Results from Andhra Pradesh
oncologists opined for BRCA gene screening, the country
has a long way to go in implementing this. High costs of
genetic screening is the major limitation prohibhitng the
wide use of this method. To begin with, genetic mutations
in BRCA genes can be done among women with a family
history of breast cancer.
In conclusions, based on the qualitative study, the
most reasonable way forward would be to establish
cancer registries covering rural areas. Alternatively, doing
national representative surveys (annual, repeated every
year) to estimate the serial cross sectional data on cancer
incidence might be helpful. Next logical step would be
to examine age-wise, gender wise cancers and establish
national priorities. It is also important to improve the
awareness among women to be aware of the importance
of early screening. Concurrently, the policymakers need to
make key decisions which among three methods (Breast
self examination (BSE), Clinical Breast Examination and
Mammography) can be used as a screening tool and how
to successfully implement population wide screening
program to prevent mortality and morbidity from breast
cancer in India.
Acknowledgements
We sincerely thank Prof.GVS Murthy, Director
and Prof. Jayaram, Registrar, Indian Institute of Public
Health, Hyderabad (IIPHH) for facilitating and helping
in reaching out to the busy practicing oncologists for
indepth interviews. We sincerely thank Prof. Shamanna for
helpful technical inputs in planning and implementation
of the study.
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... However, further studies have been shown to obtain contradictory results (Rivera-Franco and Leon-Rodriguez, 2018). Meanwhile, higher formal education and socioeconomic status could reduce delayed diagnosis, even though several studies, contrastingly, did not report similar results (Bodapati and Babu, 2013;Lim et al., 2015;Roy et al., 2015;Dyanti and Suariyani, 2016;Solikhah et al., 2020). Residential status and distances to healthcare facilities were also among factors related to delayed diagnosis in breast cancer (Bodapati and Babu, 2013;Thakur et al., 2015). ...
... Meanwhile, higher formal education and socioeconomic status could reduce delayed diagnosis, even though several studies, contrastingly, did not report similar results (Bodapati and Babu, 2013;Lim et al., 2015;Roy et al., 2015;Dyanti and Suariyani, 2016;Solikhah et al., 2020). Residential status and distances to healthcare facilities were also among factors related to delayed diagnosis in breast cancer (Bodapati and Babu, 2013;Thakur et al., 2015). Among maternity status, age at first birth significantly reduced delayed diagnosis, but its categorization (>20 years old and 21-25 years old) was not well related to breast cancer's biomolecular background (Poum et al., 2014;Kumar et al., 2019). ...
... From qualitative evidence, those factors were known to influence the act of seeking a professional health provider and avoiding alternative therapy, in addition to a less negative attitude toward medical services. Psychosocial factors, such as the perception of fear, denial, embarrassment, ignorance, and emotional burdens were reinforcing factors that need support and motivation from close relatives and the environment (Norsa'adah et al., 2012;Bodapati and Babu, 2013;Iskandarsyah et al., 2014;Huo et al., 2015). In most Asian countries, family bonds along with husbands' or fathers' decisions have a strong impact on women's actions (including health issues); therefore, education on the importance of breast cancer screening and early diagnosis should reach all family members and community members. ...
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Background: Advance in screening strategies and management had steadily decreased the mortality rates of breast cancer. In developing countries, conducting screening and early diagnosis of breast cancers may face several problems. This systematic review aims to determine factors affecting the delayed diagnosis of breast cancer in developing countries in Asia. Methods: Literature research was conducted through Pubmed, ScienceDirect, Scopus, EbscoHost, Cochrane Library, and Google Scholar. The main keywords were "breast cancer", "delayed diagnosis" and "developing countries". Both quantitative and qualitative studies were included. Results: A total of 26 studies were included. The definition of delayed presentation or diagnosis varied from 1 month to 6 months. Among all the factors from patients and providers, breast symptoms and examinations consistently showed a significant contribution in reducing delayed diagnosis. Strengthened by qualitative studies, patients' knowledge and perception also had a major role in delayed diagnosis. Conclusion: Among Asian developing countries, breast symptoms and examination, as well as individual knowledge and perception, are the main factors related to delayed diagnosis of breast cancer.
... Previous studies on BrCa screening published mostly in the developed world have found that several socioeconomic, demographic, and geographic variables are associated with breast cancer screening. Similarly, some studies from the developing world also show that socioeconomic determinants such age, education, marital status, and income-are important determinants associated with the likelihood of receiving breast cancer screening [4,[14][15][16][17][18][19][20]. ...
... We also found increasing age was significantly associated with the uptake of undergoing breast examination in our study but a coverage reported among the younger age group in our study [15][16][17][18][19][20][21][22][23][24][25] may be either suggestive of margin of error in self-report of BE or instrumentation issues, as the likelihood of a BE in this age group is extremely low. Additionally, in the present study, we found that Muslim and Christian women had highest wealth-related inequality in BE coverage, with coverage concentrated among wealthier populations. ...
... Importantly, the study showed that magnitude of inequalities may differ when measuring them in absolute or relative terms. Additionally, a qualitative study conducted in rural Andhra Pradesh to understand physician's perspective on screening methods followed by women diagnosed with breast cancer reflected that awareness of screening is limited to higher socioeconomic groups [20]. A community-based study where screening programme of women age 30-64 was implemented in urban slums of Mumbai, India found that literacy was a positive predictor of participation in screening while belonging to Muslim religion was a negative predictors of participation in screening [17,18]. ...
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Background Breast cancer incidence rates are increasing in developing countries including India. With 1.3 million new cases of cancer been diagnosed annually, breast cancer is the most common women’s cancer in India. India’s National Family Health Survey (NFHS-4) data 2015–2016 shows that only 9.8% of women between the ages of 15 and 49 had ever undergone breast examination (BE). Further, access to screening and treatment is unequally distributed, with inequalities by socio-economic status. It is unclear, however, if socio-economic inequalities in breast examination are similar across population subgroups. Methods We compared BE coverage in population sub-groups categorised by place of residence, religion, caste/tribal groups, education levels, age, marital status, and employment status in their intersection with economic status in India. We analysed data for 699,686 women aged 15–49 using the NFHS-4 data set conducted during 2015–2016. Descriptive (mean, standard errors, and confidence intervals) of women undergoing BE disaggregated by dimensions of inequality (education, caste/tribal groups, religion, place of residence) and their intersections with wealth were computed with national weights using STATA 12. Chi-square tests were performed to assess the association between socio-demographic factors and breast screening. Additionally, the World Health Organisation’s Health Equity Assessment Toolkit Plus was used to compute summary measures of inequality: Slope index for inequality (SII) and Relative Concentration Indices (RCI) for each intersecting dimension. Results BE coverage was concentrated among wealthier groups regardless of other intersecting population subgroups. Wealth-related inequalities in BE coverage were most pronounced among Christians (SII; 20.6, 95% CI: 18.5–22.7), married (SII; 14.1, 95% CI: 13.8–14.4), employed (SII: 14.6, 95%CI: 13.9, 15.3), and rural women (SII; 10.8, 95% CI: 10.5–11.1). Overall, relative summary measures (RCI) were consistent with our absolute summary measures (SII). Conclusions Breast examination coverage in India is concentrated among wealthier populations across population groups defined by place of residence, religion, age, employment, and marital status. Apart from this national analysis, subnational analyses may also help identify strategies for programme rollout and ensure equity in women’s cancer screening.
... This study explored both patient-related and healthcare system-related reasons for late diagnosis of breast cancer from patients', family members', and health care providers' perspectives. Information on breast cancer risk factors, methods of early detection, initial symptoms, and its treatments are important for encouraging women to seek medical care immediately after recognition of the first symptoms [22,23]. Our study, however, revealed a poor community awareness and common misperceptions about breast cancer, with little recognition of susceptibility or the benefits of early care seeking after symptom recognition. ...
... This is mainly due to the view in the community that cancer is a deadly disease, and incurable with the existing conventional treatment in the country. Similar perceptions were noted in other studies from Ethiopia [16,31], India [23], and Iran [26], and studies have reported women refraining from visiting health facility for fear of a confirmed cancer diagnosis [26,31,32]. This finding suggests that educating the community about the benefits of early diagnosis and treatment initiation could help to correct the misperceptions and improve health-seeking behavior of women with symptoms suggestive of cancer [33]. ...
... The affordability of medical care [24] and quality of the health service [23,37] determine the health care utilization of women who decide to seek care. Shortcomings in either of these could affect a woman's decision to seek care from the health facilities or push them to seek care from traditional healers [31]. ...
... This study explored both patient-related and healthcare system-related reasons for late diagnosis of breast cancer from patients', family members', and health care providers' perspectives. Information on breast cancer risk factors, methods of early detection, initial symptoms, and its treatments are important for encouraging women to seek medical care immediately after recognition of the first symptoms [22,23]. Our study, however, revealed a poor community awareness and common misperceptions about breast cancer, with little recognition of susceptibility or the benefits of early care seeking after symptom recognition. ...
... This is mainly due to the view in the community that cancer is a deadly disease, and incurable with the existing conventional treatment in the country. Similar perceptions were noted in other studies from Ethiopia [16,31], India [23], and Iran [26], and studies have reported women refraining from visiting health facility for fear of a confirmed cancer diagnosis [26,31,32]. This finding suggests that educating the community about the benefits of early diagnosis and treatment initiation could help to correct the misperceptions and improve health-seeking behavior of women with symptoms suggestive of cancer [33]. ...
... The affordability of medical care [24] and quality of the health service [23,37] determine the health care utilization of women who decide to seek care. Shortcomings in either of these could affect a woman's decision to seek care from the health facilities or push them to seek care from traditional healers [31]. ...
Article
Full-text available
Background: Most women with breast cancer in Ethiopia are diagnosed at an advanced stage of the disease, but the reasons for this have not been systematically investigated. This study, therefore, aimed to explore the main reasons for diagnosis of advanced stage breast cancer from the perspective of patients, family members, and health care providers. Methods: A qualitative study with in-depth interviews was conducted with 23 selected participants at Tikur Anbessa Specialized Hospital, Oncology Clinic using a semi-structured interview guide. These participants were 13 breast cancer patients, 5 family members, and 5 health care providers. Data were transcribed into English, coded and analyzed using thematic analysis. Results: Awareness about the causes, risk, initial symptoms, early detection methods, and treatment of breast cancer were uncommon, and misconceptions about the disease prevailed among breast cancer patients and family members. There was a sense of hopelessness and uncertainty about the effectiveness of conventional medicine amongst patients and family members. Consequently, performing spiritual acts (using holy water) or seeking care from traditional healers recurred amongst the interviewees. Not taking initial symptoms of breast cancer seriously by the patients, reliance on traditional medicines, competing priorities, financial hardship, older age, fear of diagnosis of cancer, and weak health systems (e.g., delay in referral and long waiting period for consultation) were noted as the main contributors to late diagnosis. In contrast, persuasion by family members and friends, higher educational attainment, and prior experience of neighboring women with breast cancer were mentioned to be facilitators of early diagnosis of breast cancer. Conclusions: The causes of late diagnosis of breast cancer in Ethiopia are multi-factorial and include individual, cultural, and health system factors. Interventions targeting these factors could alleviate the misconceptions and knowledge gap about breast cancer in the community, and shorten waiting time between symptom recognition and diagnosis of breast cancer.
... A study conducted in the region of Punjab found 42.8% (out of 1279) depression among MDR-TB patients 7 . There are also few studies conducted in different region of Pakistan are evident of psychiatric co-morbidity among MDR-TB patients 5,6,8 . ...
... Usually in DR-TB programs, the bio-medical model dominates the entire treatment approach and psycho-social factors remain overlooked 9 . This is the main cause that mental health issues are highly prevalent among MDR/RR-TB patients 5,6,8 . They usually remain undiagnosed, untreated and contribute to poor treatment adherence for treatment 7 . ...
Article
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Aim: To assess psychiatric co-morbidity (i.e., depression and anxiety) and its associated risk factors among Multidrug/Rifampicin Resistant Tuberculosis (MDR/RR-TB) patients. Methods: It was an analytical cross-sectional study carried out in Department of Chest Medicine, Jinnah Post Graduate Medical Centre from February to August, 2015. Eighty diagnosed and registered patients of MDR/RR-TB, able to comprehend Urdu language, between the age range of 18 to 60 years were approached by using convenient sampling technique. Psychiatric co-morbidity i.e., depression and anxiety were assessed by using the Urdu adapted version of Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD-7). Results: By applying the standard cut off score of 10 or more on PHQ-9 and GAD-7, the frequency of depression was 58 (72.5%) and for anxiety it was 53 (66.25%) out of 80 MDR/RR-TB patients. The multivariant analysis, intensive phase of TB treatment (OR = 3.02; 95% CI = 0.97-9.41) was found to be significantly associated with depression by using PHQ-9 and age group of 18 to 30 years (OR=0.156; 95% CI= 0.02-0.86), pulmonary TB (OR=6.33e+7; 95% CI=0.00-inf) and intensive phase of treatment (OR= 3.892; 95% CI=1.14-13.20) were significantly associated with anxiety by using GAD-7. Conclusion: Frequency of psychiatric co-morbidity was higher among MDR/RR-TB patients. Age group of 18 to 30 years, pulmonary TB and intensive phase of treatment were found to be the risk factors for depression and anxiety among TB patients. Psycho-social factors are strong factors in the successful treatment of tuberculosis. Early detection and proper management of psychiatric co-morbidity during the treatment of MDR-TB needs special attention.
... Some studies opined that this 'Primary Delay' or 'delay due to patient factor' is responsible as the major cause for delayed presentation, followed by system delay ('secondary, tertiary or quaternary delays') [16]. Factors like lack of awareness, ignorance, posteriority, social stigma financial constraints, beliefs like "cutting on a cancer" may cause it to spread, herbal remedies, over-the-counter medications, chiropractic regimens, prayer, and reliance on God to heal the disorder, residence in rural area, older age, fear, embarrassment and shyness about breast as a private organ, posteriority and social stigma are some of the other significant patient factors responsible for delayed presentation [10,[17][18][19]. ...
Article
Full-text available
Causes of delay in presentation of breast cancer has been categorised into 'Primary Delay' (delay by the patient or her family); 'Secondary Delay' (delay by the doctors in the first contact-family physician or quacks/alternative medicine practitioners); 'Tertiary Delay' (delay in the system in a specialist breast care unit e.g. waiting list, delayed reporting, doctors on leave, strikes); and 'Quaternary Delay' (e.g. patient hopping from one competent breast cancer specialist to another or mid-course attrition to alternative treatments). In India, many patients have blind belief and high attrition towards the quacks and alternative medicine practitioners. Our study was to assess whether these 'Secondary and Quaternary Delays', particularly the attrition towards the alternative non-modern medical practitioners, have any effect on the delayed presentation and advancement of the overall anatomical staging among the breast cancer patients. We performed a retrospective observational study, based on 'Triple Assessment' and pre-structured Questionnaire. All pathologically confirmed female breast cancer patients admitted from 02/2017 to 08/2018 in the department of General Surgery in our Institute were included. Male breast cancer, histopathologically unconfirmed/inconclusive breast lumps, patients with previous breast surgery/radiotherapy/chemotherapy were excluded. Data from 267 patients was analysed. The mean age at presentation of breast cancer was 47.54 years. The average delay between the onset of the first symptom and the histological diagnosis was 13.76 ± SD 13.08 months. About half (50.2%) of our patients visited the non-modern medical practitioners at least once during their disease. The mean delay in diagnosis was significantly higher (p < 0.0001) among them. The average 'Secondary Delay' was significantly higher among those who visited the non-modern medical practitioners (9.7 ± SD 9.38 months). The average delay between the visit to the first doctor and the histological diagnosis was also significantly higher among them (18.35 ± 14 months). Patients with attrition to non-modern medical practitioners also were diagnosed in higher cT stages: cT4a (66.67%, 2 of 3) and cT4b (60%, 33 of 55). Most (56.9%) of stage IIIB patients visited the non-modern medical practitioners before their diagnosis. Patients who visited the non-modern medical practitioners had significantly more delay in the diagnosis of breast cancer. The 'Secondary and Quaternary Delays' form the major portion in the overall delay and lead to advancement of the anatomical staging of the disease. Creating public awareness, proper training and 'continued medical education' for primary care physicians, and the AYUSH practitioners are required. Further population-based studies are advised.
... The developed countries account for almost 50% of breast cancers diagnosed worldwide [8]. It is estimated that about half (60%) of breast cancer deaths occur in economically developing countries [3,9]. The lowest breast cancer incidence is reported from Far Eastern and South East Asian countries [10,11] and it is expected that in coming decades, these countries would account for majority of new breast cancer patients diagnosed globally. ...
... Leading agencies working for BC prevention have recommended monthly BSE to women. [5,10,11] Study done by Kim et al. in 2019 concluded oral and listening literacies are contributing factors to lifetime breast cancer screening and up-to-date cervical cancer screening. [12] ...
Article
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Background and aims: Breast and cervical cancers are two of the most common cancer diagnosed and are leading cause of death among females. Mortality and complication rates are higher in countries with lower awareness regarding breast and cervical cancer. The aim of this study is to assess the community inquisitive insight regarding breast and cervical carcinoma after sensitising them with health education. Setting and design: This is a qualitative research done on adolescent school going girls. The analysis is done using the verbal and written queries during group interaction sessions after the health education regarding breast and cervical cancer was imparted. Results and conclusion: A community specific health education material regarding breast and cervical cancers should include information regarding normal physiological process like menstruation, available preventive, and screening and management modalities of common cancers, the explanations for myths and redressal of stigma prevailing in the specific community.
... 36 37 Knowledge on the risk of breast cancer, screening and other early detection methods, initial symptoms, and its treatment is important for appraisal of first symptoms and for seeking timely medical care. [38][39][40] However, a third of the women with breast cancer in our study had never previously heard of breast cancer. Only 8% of the patients suspected their first symptom to be a symptom of breast cancer. ...
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Objectives This study aimed to estimate the magnitude of patient and diagnostic delays and associated factors among women with breast cancer in Addis Ababa. Design This is a cross-sectional study. Settings and participants All women newly diagnosed with breast cancer in seven major healthcare facilities in Addis Ababa (n=441) were included in the study. Main outcomes and measures Patient interval (time from recognition of first symptom to medical consultation) and diagnostic interval (time from first consultation to diagnosis). Patient intervals >90 days and diagnostic intervals >30 days were considered delays, and associated factors were determined using multivariable Poisson regressions with robust variance. Results Thirty-six percent (95% CI [31.1%, 40.3%]) of the patients had patient intervals of >90 days, and 69% (95% CI [64.6%, 73.3%]) of the patients had diagnostic intervals of >30 days. Diagnostic interval exceeded 1 year for 18% of patients. Ninety-five percent of the patients detected the first symptoms of breast cancer by themselves, with breast lump (78.0%) as the most common first symptom. Only 8.0% were concerned about cancer initially, with most attributing their symptoms to other factors. In the multivariable analysis, using traditional medicine before consultation was significantly associated with increased prevalence of patient delay (adjusted prevalence ratio (PR) = 2.13, 95% CI [1.68, 2.71]). First consultation at health centres (adjusted PR = 1.19, 95% CI [1.02, 1.39]) and visiting ≥4 facilities (adjusted PR = 1.24, 95% CI [1.10, 1.40]) were associated with higher prevalence of diagnostic delay. However, progression of symptoms before consultation (adjusted PR = 0.73, 95% CI [0.60, 0.90]) was associated with decreased prevalence of diagnostic delay. Conclusions Patients with breast cancer in Addis Ababa have prolonged patient and diagnostic intervals. These underscore the need for public health programme to increase knowledge about breast cancer symptoms and the importance of early presentation and early diagnosis among the general public and healthcare providers.
Article
Introduction: Around the World, Breast cancer has become one of the common cancers among women. Prevalence and mortality of Breast cancer in India are 18 lakh & 12.7 per lakh cases respectively. One of the important reasons behind late presentation & high death rate is the lack of breast cancer awareness. Objectives: To assess the barriers in diagnosis and treatment among breast cancer patients and to explore the perception about cancer prevention among them. Methods: A qualitative study was done among women with confirmed breast cancer who were admitted to KIMS, Hubballi, and Cancer hospital, Navanagar in April 2019. Data collection was done by the In-depth interview method and analyzed as per qualitative study protocol standards. Results: The data was collected among 14 participants. Themes were generated accordingly. The findings showed lack of awareness, myths, financial constraints, negligence were the major barriers to the early presentation of breast cancer. Conclusion: This study showed barriers such as lack of awareness, negligence, fear, financial constraints, myths and misconceptions, social stigma, lack of family support. Measures taken to reduce mortality by early diagnosis and treatment.
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Background: Breast cancer is the most frequent cancer in women globally and represents the second leading cause of cancer death among women (after lung cancer). India is going through epidemiologic transition. It is reported that the incidence of breast cancer is rising rapidly as a result of changes in reproductive risk factors, dietary habits and increasing life expectancy, acting in concert with genetic factors. Materials and methods: In order to understand the existing epidemiological correlates of breast cancer in South India, a systematic review of evidence available on epidemiologic correlates of breast cancer addressing incidence, prevalence, and associated factors like age, reproductive factors, cultural and religious factors was performed with specific focus on screening procedures in southern India. Results: An increase in breast cancer incidence due to various modifiable risk factors was noted, especially in women over 40 years of age, with late stage of presentation, lack of awareness about screening, costs, fear and stigma associated with the disease serving as major barriers for early presentation. Conclusions: Educational strategies should be aimed at modifying the life style, early planning of pregnancy, promoting breast feeding and physical activity. It is very important to obtain reliable data for planning policies, decision-making and setting up the priorities.
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Breast cancer is the second most common cancer amongst women, in Iran comprising 21.4% of female cancers. There are several screening modalities for breast cancer including breast self-examination, clinical breast examination and mammography. This research reviews the literature surrounding the implementation of these screening approaches in the Islamic Republic of Iran. After initial results produced approximately 208 articles, a total of 96 articles were included because they specifically addressed epidemiological characteristics of breast cancer, culture, religion, health seeking behavior, screening programs and the health system in Iran. Literature showed that breast self-examination and clinical breast examination were most common as there is no population-based mammography screening program in Iran. Additionally, most women appear to obtain information through the mass media. Results also indicate that Islamic beliefs and preventative medicine are very much aligned and can be used to promote breast cancer screening in Iran. These results highlight that there is a need for aggressive preventative measures focusing on breast self examination and gradually moving towards national mammography programs in Iran ideally disseminated through the media with government support.
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The changes in the cancer pattern are often studied with the help of changes in the rank of leading sites, changes in the Age Adjusted Rates of the sites over the time or with the help of time trends. However, these methods do not quantify the changes in relation to overall changes that occurred in the total cancer cases over the period of time. An alternative approach was therefore used to assess the changes in cancer pattern in relation to overall changes in time and also an attempt was made to identify the most emerging new cancers in India. The cancer incidence data of various sites for women, over the periods 1988-90 and 2003-05 in India, for five urban registries namely Bangalore, Bhopal, Chennai, Delhi and Mumbai, functioning under the network of National Cancer Registry Programme (ICMR), formed the sources of data for the present analysis. The changes in incidence cases by various cancer sites for women were assessed by calculating the differences in incidence cases over the two period of time. Based on the contribution of each site to total change, the ten most leading sites were identified separately for each registry. The relative changes in the sites with time were taken to identify the most emerging new cancer cases over the period of time. The pooled cancer cases for women among five urban registries increased from 29447 cases in 1988-90 to 48472 cases in 2003-05 registering an increased of about 63.3%. The lowest percentage of increase was observed in the registry of Chennai (41.5%) and the maximum in Bhopal (102.0%). Based on the pooled figures, the breast cancer contributed to the maximum % change (38%), followed by ovarian (8.0%), gallbladder (5.1%), corpus uteri (4.9%) and cervix uteri (4.1%). Based on the pooled data and relative changes, the emerging new cancers were corpus uteri (187%), gallbladder (162.1%) and lung cancer (136.1%). The % change by sites and the emerging new cancers varied between the registries.
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Background: Breast cancer is second most important cancer among Indian women. Although risk factors are not much prevalent as in western countries, incidence rate is increasing in India. The study was undertaken to study various risk factors associated with breast cancer. Methods: A hospital based group matched case control study was undertaken to identify risk factors. The study consisted of 105 hospitalized cases confirmed on histopathology and 210 group matched controls selected from urban field practice area, Sadar, without any malignancy. Bivariate analyses included odds ratio (OR), 95% confidence interval (CI) for odds ratio. Results: Earlier age at menarche ≤ 12 years of age, late age at first full term delivery, nulliparity, Lack of breast-feeding were found to be significantly associated with the risk of breast cancer in both pre menopausal & post menopausal women while age at menopause at or after 50 years was significantly associated with the risk in post menopausal women. Conclusions: Study suggests that the changes in menstrual and reproductive patterns among women i.e. early age at menarche and late age at first childbirth and some environmental factors in Central India may have contributed to the increase in breast cancer risk, particularly among younger women.
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Breast cancer among women is a relatively common with a more favorable expected survival rates than other forms of cancers. This study aimed to determine the improved quality of life for post-mastectomy women through peer education. Using pre and post test follow up and control design approach, 99 women with stage I and II of breast cancer diagnosis were followed one year after modified radical mastectomy. To measure the quality of life an instrument designed by the European organization for research and treatment of cancer, known as the Quality of Life Question (QLQ-30) and its breast cancer supplementary measure (QLQ-BR23) at three points in time (before, immediately and two months after intervention) for both groups were used. The participant selection was a convenient sampling method and women were randomly assigned into two experimental and control groups. The experimental group was randomly assigned to five groups and peer educators conducted weekly educational programs for one month. Tabulated data were analyzed using chi square, t test, and repeated measurement multivariate to compare the quality of life differences over time. For the experimental group, the results showed statistically significant improvement in all performance aspects of life quality and symptom reduction (P < 0.001), while the control group had no significant differences in all aspects of life quality. The findings of this study suggest that peer led education is a useful intervention for post-mastectomy women to improve their quality of life.
Article
Background The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on the relation between breast cancer risk and use of hormonal contraceptives. Methods Individual data on 53297 women with breast cancer and 100 239 women without breast cancer from 54 studies conducted in 25 countries were collected, checked, and analysed centrally. Estimates of the relative risk for breast cancer were obtained by a modification of the Mantel-Haenszel method. All analyses were stratified by study, age at diagnosis, parity, and, where appropriate, the age a woman was when her first child was born, and the age she was when her risk of conception ceased. Findings The results provide strong evidence for two main conclusions. First, while women are taking combined oral contraceptives and in the 10 years after stopping there is a small increase in the relative risk of having breast cancer diagnosed (relative risk [95% CI] in current users 1.24 [1.15-1.33], 2p<0.00001; 1-4 years after stopping 1.16 [1.08-1.23], 2p=0.00001; 5-9 years after stopping 1.07 [1.02-1.13], 2p=0.009). Second, there is no significant excess risk of having breast cancer diagnosed 10 or more years after stopping use (relative risk 1.01 [0.96-1.05], NS). The cancers diagnosed in women who had used combined oral contraceptives were less advanced clinically than those diagnosed in women who had never used these contraceptives: for ever-users compared with never-users, the relative risk for tumours that had spread beyond the breast compared with localised tumours was 0.88 (0.81-0.95; 2p=0.002). There was no pronounced variation in the results for recency of use between women with different background risks of breast cancer, including women from different countries and ethnic groups, women with different reproductive histories, and those with or without a family history of breast cancer. The studies included in this collaboration represent about 90% of the epidemiological information on the topic, and what is known about the other studies suggests that their omission has not materially affected the main conclusions. Other features of hormonal contraceptive use such as duration of use, age at first use, and the dose and type of hormone within the contraceptives had little additional effect on breast cancer risk, once recency of use had been taken into account. Women who began use before age 20 had higher relative risks of having breast cancer diagnosed while they were using combined oral contraceptives and in the 5 years after stopping than women who began use at older ages, but the higher relative risks apply at ages when breast cancer is rare and, for a given duration of use, earlier use does not result in more cancers being diagnosed than use beginning at older ages. Because breast cancer incidence rises steeply with age, the estimated excess number of cancers diagnosed in the period between starting use and 10 years after stopping increases with age at last use: for example, among 10 000 women from Europe or North America who used oral contraceptives from age 16 to 19, from age 20 to 24, and from age 25 to 29, respectively, the estimated excess number of cancers diagnosed up to 10 years after stopping use is 0.5 (95% CI 0.3-0.7), 1.5 (0.7-2.3), and 4.7 (2.7-6.7). Up to 20 years after cessation of use the difference between ever-users and never-users is not so much in the total number of cancers diagnosed, but in their clinical presentation, with the breast cancers diagnosed in ever-users being less advanced clinically than those diagnosed in never-users. The relation observed between breast cancer risk and hormone exposure is unusual, and it is not possible to infer from these data whether it is due to an earlier diagnosis of breast cancer in ever-users, the biological effects of hormonal contraceptives, or a combination of reasons. Interpretation Women who are currently using combined oral contraceptives or have used them in the past 10 years are at a slightly increased risk of having breast cancer diagnosed, although the additional cancers diagnosed tend to be localised to the breast. There is no evidence of an increase in the risk of having breast cancer diagnosed 10 or more years after cessation of use, and the cancers diagnosed then are less advanced clinically than the cancers diagnosed in never-users.
Article
BACKGROUND The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on the relation between breast cancer risk and use of hormonal contraceptives. METHODS Individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 studies conducted in 25 countries were collected, checked, and analysed centrally. Estimates of the relative risk for breast cancer were obtained by a modification of the Mantel-Haenszel method. All analyses were stratified by study, age at diagnosis, parity, and, where appropriate, the age a woman was when her first child was born, and the age she was when her risk of conception ceased. FINDINGS The results provide strong evidence for two main conclusions. First, while women are taking combined oral contraceptives and in the 10 years after stopping there is a small increase in the relative risk of having breast cancer diagnosed (relative risk [95 percent CI] in current users 1.24 [1.15-1.33], 2p<0.00001; 1-4 years after stopping 1.16 [1.08-1.23], 2p=0.00001; 5-9 years after stopping 1.07 [1.02-1.13], 2p=0.009). Second, there is no significant excess risk of having breast cancer diagnosed 10 or more years after stopping use (relative risk 1.01 [0.96-1.05], NS). The cancers diagnosed in women who had used combined oral contraceptives were less advanced clinically than those diagnosed in women who had never used these contraceptives for ever-users compared with never-users, the relative risk for tumours that had spread beyond the breast compared with localised tumours was 0.88 (0.81-0.95; 2p=0.002). There was no pronounced variation in the results for recency of use between women with different background risks of breast cancer, including women from different countries and ethnic groups, women with different reproductive histories, and those with or without a family history of breast cancer. The studies included in this collaboration represent about 90 percent of the epidemiological information on the topic, and what is known about the other studies suggests that their omission has not materially affected the main conclusions. Other features of hormonal contraceptive use such as duration of use, age at first use, and the dose and type of hormone within the contraceptives had little additional effect on breast cancer risk, once recency of use had been taken into account. Women who began use before age 20 had higher relative risks of having breast cancer diagnosed while they were using combined oral contraceptives and in the 5 years after stopping than women who began use at older ages, but the higher relative risks apply at ages when breast cancer is rare and, for a given duration of use, earlier use does not result in more cancers being diagnosed than use beginning at older ages. Because breast cancer incidence rises steeply with age, the estimated excess number of cancers diagnosed in the period between starting use and 10 years after stopping increases with age at last use: for example, among 10 000 women from Europe or North America who used oral contraceptives from age 16 to 19, from age 20 to 24, and from age 25 to 29, respectively, the estimated excess number of cancers diagnosed up to 10 years after stopping use is 0.5 (95 percent CI 0.3-0.7), 1.5 (0.7-2.3), and 4.7 (2.7-6.7). Up to 20 years after cessation of use the difference between ever-users and never-users is not so much in the total number of cancers diagnosed, but in their clinical presentation, with the breast cancers diagnosed in ever-users being less advanced clinically than those diagnosed in never-users. The relation observed between breast cancer risk and hormone exposure is unusual, and it is not possible to infer from these data whether it is due to an earlier diagnosis of breast cancer in ever-users, the biological effects of hormonal contraceptives, or a combination of reasons...
Article
  Although incidence, mortality, and survival rates vary fourfold in the world's regions, in the world as a whole, the incidence of breast cancer is increasing, and in regions without early detection programs, mortality is also increasing. The growing burden of breast cancer in low-resource countries demands adaptive strategies that can improve on the too common pattern of disease presentation at a stage when prognosis is very poor. In January 2005, the Breast Health Global Initiative (BHGI) held its second summit in Bethesda, MD. The Early Detection and Access to Care Panel reaffirmed the core principle that a requirement at all resource levels is that women should be supported in seeking care and should have access to appropriate, affordable diagnostic tests and treatment. In terms of earlier diagnosis, the panel recommended that breast health awareness should be promoted to all women. Enhancements to basic facilities might include the following, in order of resources: effective training of relevant staff in clinical breast examination (CBE) both for symptomatic and asymptomatic women; opportunistic screening with CBE; demonstration projects or trials of organized screening using CBE or breast self-examination; and finally, feasibility studies of mammographic screening. Ideally, for complete evaluation, such projects require notification of deaths among breast cancer cases and staging of diagnosed tumors.