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

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.

Full text

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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
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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