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Rethinking: Ideal Screening Age for Breast Cancer in Developing Countries
Abstract
Objective:
The aim is to identify the ideal screening age for women in developing countries and to determine the suitable method for early detection of breast cancer based on age and readiness of the community.
Materials and methods:
A 30-year retrospective review (from 1984 to 2014) was undertaken at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Medical records of those diagnosed with breast cancer from the outpatient department and hospital admission records were reviewed, focusing mainly on demographic data, age, and time at presentation. Radiological and histopathological records were also reviewed for confirmation of diagnosis. Age-based statistical review was undertaken of the female population within the hospital catchment area.
Results:
The total number of patients was 1.832, accounting for 0.8 % affected patients when plotted against the 235,339 females within the catchment area. Considering the standard screening age of 40 years, patients were divided into two groups: group I included those below the age of 40 years at the time of diagnosis, accounting for 641patients (35%), and group II included those above the age of 40 years, accounting for 1191 patients (65%). Group I patients were mostly reassured in primary healthcare centers, diagnostic modalities were used with reservation, relying solely on ultrasonography 276 (43%); whereas in group II patients, mammography was used liberally, which aided in the diagnosis in all 1191 (100%).
Conclusion:
Despite the undisputable notion that breast cancer has higher predilection for women above the age of 40 years, there is a substantial subset of affected younger women in developing countries, which contradicts this concept. However, the scarcity of structured sessions in developing countries dictates Western-based early detection strategies, but the validity of such programs is culture-governed. Rigorously tailored screening programs directed towards individual communities are mandatory. Reducing the screening age by a decade in developing countries may increase the capture of early breast cancer and improve the outcomes.
... The unpopular Breast Cancer Awareness programs (BCAP) are focused on didactic educational lectures with repetitive information. These programs usually dish out basic knowledge on breast cancer, early detection methods, and risk factors, however; they generally fail to fully disseminate information or disclose treatment options [2]. Radiotherapy as an integral treatment modality in cancer therapy that dictates its demand. ...
Aim: The lack of structured breast cancer awareness programs (BCAP) in developing countries coupled by the scarcity of radiation oncology centers limit the available surgical options. The aim of this study is to Probe the use Intraoperative radiotherapy (IORT) treatment as a stem to initiate positive impact on early disease detection and propagate breast conserving surgery (BCS). Materials and Methods: This observational review was undertaken at King Fahd hospital of the university, AL Khobar, Eastern province of Saudi Arabia between 2012- 2016. All patients diagnosed with breast cancer were reviewed. Strict recruitment criteria were adopted for patients to receive IORT. Selected candidates where only those who were eligible and consented to undergo BCS and IORT. Special emphasis was placed on demographic data, tumor size at the initial presentation, post Neo-adjuvant chemotherapy response, post–pathology cavity size and applicator size used. Results: The total number of patients diagnosed with breast cancer were 330 out of which 69 (20%) patient were eligible for IORT. Age ranged from31-75years with the Median age 50 years. Applicator sizes used ranged from 2.0-5.0. Tumor size ranged between 0.6-4.0 centimeters. 1 (1%) was post pathology case with excision performed two weeks prior to presentation. 0-1 in 8(11%), 1.1-2 in 22(31%), 2.1-3 in 24(34%), and 3.1- 4.0 in 15 (21%) patients. 7(10%) patients received Neo-adjuvant chemotherapy with positive response and were included. The applicator sizes available ranged between 1.5-5.0 centimeters. Applicator sizes were size 2.0 in 2 (3%), size 2.5
in 10 (14%), size 3.0 in 18(26%), size 3.5 in 16 (23%), size 4.0 in 10 (14%), size 4.5 in 6 cases (9%) and size 5.0 in 7 cases (10%). Smaller applicator sizes 2.0-3.5 centimeter in diameter were used in 46 (66%) of cases suggesting that smaller lesions are currently been diagnosed. Conclusion: The introduction of Intraoperative radiotherapy (IORT) intended as boost therapy is a break through treatment of early breast cancer. While developing countries remain disadvantaged by the lack of adequate radiotherapy centers to cover its population needs, IORT can offer an alternative solution for a selected subset of women with early breast cancer as an exclusive or boost therapy. Its positive impact on the early detection is well illustrated in this observational study. In addition, its use supported the promotion of BCS in early breast cancer thus, it braced a positive impact on early detection strategies.
... The unpopular Breast Cancer Awareness programs (BCAP) are focused on didactic educational lectures with repetitive information. These programs usually dish out basic knowledge on breast cancer, early detection methods, and risk factors, however; they generally fail to fully disseminate information or disclose treatment options [2]. Radiotherapy as an integral treatment modality in cancer therapy that dictates its demand. ...
Aim: The lack of structured breast cancer awareness programs (BCAP) in developing countries coupled by the scarcity of radiation oncology centers limit the available surgical options. The aim of this study is to Probe the use Intraoperative radiotherapy (IORT) treatment as a stem to initiate positive impact on early disease detection and propagate breast conserving surgery (BCS). Materials and Methods: This observational review was undertaken at King Fahd hospital of the university, AL Khobar, Eastern province of Saudi Arabia between 2012-2016. All patients diagnosed with breast cancer were reviewed. Strict recruitment criteria were adopted for patients to receive IORT. Selected candidates where only those who were eligible and consented to undergo BCS and IORT. Special emphasis was placed on demographic data, tumor size at the initial presentation, post Neo-adjuvant chemotherapy response, post-pathology cavity size and applicator size used. Results: The total number of patients diagnosed with breast cancer were 330 out of which 69 (20%) patient were eligible for IORT. Age ranged from31-75years with the Median age 50 years. Applicator sizes used ranged from 2.0-5.0. Tumor size ranged between 0.6-4.0 centimeters. 1 (1%) was post pathology case with excision performed two weeks prior to presentation. 0-1 in 8(11%), 1.1-2 in 22(31%), 2.1-3 in 24(34%), and 3.1-4.0 in 15 (21%) patients. 7(10%) patients received Neo-adjuvant chemotherapy with positive response and were included. The applicator sizes available ranged between 1.5-5.0 centimeters. Applicator sizes were size 2.0 in 2 (3%), size 2.5 in 10 (14%), size 3.0 in 18(26%), size 3.5 in 16 (23%), size 4.0 in 10 (14%), size 4.5 in 6 cases (9%) and size 5.0 in 7 cases (10%). Smaller applicator sizes 2.0-3.5 centimeter in diameter were used in 46 (66%) of cases suggesting that smaller lesions are currently been diagnosed. Conclusion: The introduction of Intraoperative radiotherapy (IORT) intended as boost therapy is a break through treatment of early breast cancer. While developing countries remain disadvantaged by the lack of adequate radiotherapy centers to cover its population needs, IORT can offer an alternative solution for a selected subset of
Background. Within the developing world, many personal, sociocultural, and economic factors cause delayed patient presentation, a prolonged interval from initial symptom discovery to provider presentation. Understanding these barriers to care is crucial to optimizing interventions that pre-empt patient delay. Methods. A systematic review was conducted querying: PubMed, Embase, Web of Science, CINAHL, Cochrane Library, J East, CAB, African Index Medicus, and LiLACS. Of 763 unique abstracts, 122 were extracted for full review and 13 included in final analysis. Results. Studies posed variable risks of bias and produced mixed results. There is strong evidence that lower education level and lesser income status contribute to patient delay. There is weaker and, sometimes, contradictory evidence that other factors may also contribute. Discussion. Poverty emerges as the underlying common denominator preventing earlier presentation in these settings. The evidence for sociocultural variables is less strong, but may reflect current paucity of high-quality research. Conflicting results may be due to heterogeneity of the developing world itself. Conclusion. Future research is required that includes patients with and without delay, utilizes a validated questionnaire, and controls for potential confounders. Current evidence suggests that interventions should primarily increase proximal and affordable healthcare access and secondarily enhance breast cancer awareness, to productively reduce patient delay.
New evidence on breast Magnetic Resonance Imaging (MRI) screening has become available since the American Cancer Society (ACS) last issued guidelines for the early detection of breast cancer in 2003. A guideline panel has reviewed this evidence and developed new recommendations for women at different defined levels of risk. Screening MRI is recommended for women with an approximately 20-25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated for Hodgkin disease. There are several risk subgroups for which the available data are insufficient to recommend for or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography. Diagnostic uses of MRI were not considered to be within the scope of this review.
Breast cancer is commonly diagnosed at late stages in countries with limited resources. Efforts aimed at early detection can reduce the stage at diagnosis, potentially improving the odds of survival and cure, and enabling simpler and more cost-effective treatment. Early detection of breast cancer entails both early diagnosis in symptomatic women and screening in asymptomatic women. Key prerequisites for early detection are ensuring that women are supported in seeking care and that they have access to appropriate, affordable diagnostic tests and treatment. We therefore propose the following sequential action plan: 1) promote the empowerment of women to obtain health care, 2) develop infrastructure for the diagnosis and treatment of breast cancer, 3) begin early detection efforts through breast cancer education and awareness, and 4) when resources permit, expand early detection efforts to include mammographic screening. Public education and awareness can promote earlier diagnosis, and these goals can be achieved in simple and cost-effective ways, such as dissemination of messages through mass media. All women have the right to education about breast cancer, but it must be culturally appropriate and targeted and tailored to the specific population. When resources become available for screening, they should be invested in screening mammography, as it is the only modality that has thus far been shown to reduce breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) are important components of routine breast care in countries with access to mammography and are important for general breast health education in all countries. However, the evidence does not support the use of CBE and BSE as lifesaving screening methods at this time, recognizing that data from countries with very limited resource are lacking. When widespread screening is not possible, screening can begin in an institution, city, or region, or by targeting screening to women at highest risk. A pilot program can be an ideal way to define the best approach to screening. To succeed, early detection efforts must include the health care providers with whom women have contact; these providers may be physicians, nurses, midwives, traditional healers, or others. There are tremendous differences among and within countries, and a program to promote early detection must be tailored to each country's unique situation.
In developing countries including Arab countries breast cancer is one of the most common cancers found in women. Even though breast cancer incidence is lower in Arab developing countries than in western countries, Arabic women are more likely to be diagnosed at an earlier age than the women in western countries.
A descriptive study was undertaken to investigate the type of breast cancer, lymph node involvement, side of breast and, region and age distribution of breast cancer patients registered in the National Oncology Centre in Yemen.
From September 2004 to December 2010, 2654 women across Yemen diagnosed with breast cancer were registered in the National Oncology Centre for treatment. Between the years 2004 and 2010, breast cancer represented 22% of all cancers registered in women. Seventy-one per cent of the women were aged 50 or younger at the time of diagnosis. The most common age group affected was women aged 41-50 years, with (35%) of cases occurring in this age. Invasive ductal carcinoma was the most common pathology (76%) and 79% of the patients had lymph node involvement at the time of diagnosis. Approximately 2% had bilateral disease and the frequency of left (44%) and right breast cancer (42%) were similar.
This study has shown that breast cancer is a disease of young women in Yemen. The majority of women presented with lymph node involvement. Hence efforts are needed to increase breast cancer awareness in Yemen for early detection at all age groups, and to target women living in areas that have lower access to health care services.
Despite recent evidence that fails to detect a benefit in surgical and local recurrence outcomes in those who receive optimal surgery and adjuvant systemic and radiotherapy, magnetic resonance imaging (MRI) is still being employed. We review the recent literature to clarify the role in the use of MRI in early breast cancer. A literature search using the Medline and Ovid databases was conducted between 2004 and 2011 using the terms "magnetic resonance imaging' and 'early breast cancer'. Only articles with clinical trials published in English in adult humans with available abstracts were included. Articles on high-risk women, response to neoadjuvant therapy, advanced breast cancer, the occult primary, the contralateral breast and technical articles were excluded. Articles examining the role of MRI in the staging of early breast cancer were retained. Over 260 articles regarding breast MRI have been published in the last 5 years. Additional foci may be found in 16% of patients but the impact on the extent of surgery and local recurrence rate is yet to be defined. Certain sub-groups who may benefit include those with invasive lobular carcinoma and mammographically dense breasts and those for consideration of partial breast irradiation. With standard adjuvant radiotherapy, there is no benefit in routine MRI with respect surgical extent and local recurrence. Should MRI be used, pre-operative biopsy to confirm additional disease must be undertaken prior to a change in surgical extent of resection. However, MRI may be useful in the evaluation of those who can be considered for partial breast irradiation. Centres undertaking breast MRI must have MRI-biopsy capabilities and constantly audit the reporting of MRI with correlation to the final pathology.
Few data are available on the effect of previous benign breast surgery on screening mammography accuracy. We determined whether sensitivity of screening mammography and tumor characteristics are different for women with and without previous benign breast surgery. We included a consecutive series of 317,398 screening mammograms of women screened between 1997 and 2008. During 2-year follow-up, clinical data, breast imaging, biopsy and surgery reports were collected from women with screen-detected or interval breast cancers. Screening sensitivity, tumor biology and tumor stages were compared between 168 women with breast cancer and prior ipsilateral benign breast surgery and 2,039 women with breast cancer but without previous ipsilateral, benign breast surgery. The sensitivity of screening mammography was significantly lower for women with prior surgery [64.3% (108/168) versus 73.4% (1,496/2,039), p = 0.01]. The concomitant increased interval cancer risk remained significant after logistic regression adjustment for age and breast density (OR = 1.5, 95% CI: 1.1-2.1). Comparing screen-detected cancers in women with and without prior breast surgery, no significant differences in estrogen receptor status (p = 0.56), mitotic activity (p = 0.17), proportions of large (T2+) tumors (p = 0.6) or lymph node positive tumors (p = 0.4) were found. Also for interval cancers, no differences were found in estrogen receptor status (p = 0.41), mitotic activity (p = 0.39), proportions of large tumors (p = 0.9) and lymph node positive tumors (p = 0.5) between women with and without prior breast surgery. We conclude that sensitivity of screening mammography is significantly lower in women with previous benign breast surgery than without, but tumor characteristics are comparable both for screen detected cancers and interval cancers.
After 20 years of screening for breast and prostate cancer, several observations can be made. First, the incidence of these cancers increased after the introduction of screening but has never returned to prescreening levels. Second, the increase in the relative fraction of early stage cancers has increased. Third, the incidence of regional cancers has not decreased at a commensurate rate. One possible explanation is that screening may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality. To reduce morbidity and mortality from prostate cancer and breast cancer, new approaches for screening, early detection, and prevention for both diseases should be considered.
A model for breast cancer screening has been developed. When the appropriate screening policy is specified, the model reproduces the detection rates and the incidence of interval cancers as observed in the recent screening projects in Utrecht and Nijmegen, the Netherlands. The model-predicted mortality rate reduction is in accordance with the results of the Kopparberg/Ostergötland randomized trial in Sweden. Key parameters of the model are the duration of the preclinical stages and the sensitivity of mammography. The average duration is approximately 2 years at age 40 and increases to approximately 5 years at age 70. The sensitivity is high (approximately 95%) for tumors larger than 1 cm. The model is used in the prospective evaluation of effects and costs of various screening policies.
To determine the positive predictive value (PPV) of low-cost screening mammography according to age and family history of breast cancer.
Cross-sectional.
Six counties in northern California.
A total of 31,814 women aged 30 years and older referred for mammography to the University of California, San Francisco, Mobile Mammography Screening Program from April 18, 1985, through November 20, 1992.
Breast cancer risk profile, two standard mammographic views per breast, and follow-up of abnormal screening examinations.
Although women aged 50 years or older constituted only 38.3% of all women who received first-screening mammography, 74% of breast cancers were detected in this group. Ten cancers were diagnosed per 1000 first-screening examinations in women aged 50 years or older, with 14.8 diagnostic procedures per cancer diagnosed compared with two cancers per 1000 screening examinations and 48.3 diagnostic tests per cancer diagnosed in women younger than 50 years. The PPV of first-screening mammography (number of breast cancers detected per abnormal examination) increased with age: .03 for those aged 30 to 39 years; .04 for those aged 40 to 49; .09 for those aged 50 to 59; .17 for those aged 60 to 69; and .19 for those aged 70 years or older (chi 2 for trend, P < .001). Women aged 50 to 59 years had a higher PPV for first-screening mammography than women aged 40 to 49 years (.09 vs. .04; P = .004), and women with a family history of breast cancer had higher PPVs compared with women without history (40 to 49 years of age, .13 vs .04, P = .01; and 50 to 59 years of age, .22 vs .09, P = .01).
Five times as many cancers per 1000 first-screening mammographic examinations were diagnosed in women aged 50 years or older compared with women aged less than 50 years. The highest PPVs for mammography were in women aged 50 years or older and in women aged 40 years or older with a family history of breast cancer. Efforts to promote screening mammography should focus on women in these groups, in whom the majority of breast cancers occur and for whom mammography has the highest PPVs.
The relevance of detection of ductal carcinoma in situ (DCIS) in a breast cancer screening programme, and the extent of overdiagnosis of non-progressive lesions, remains controversial. It was the purpose of this paper to estimate the incidence of non-progressive, 'overdiagnosed' DCIS. We defined non-progressive DCIS (DCIS(0)) as DCIS which could not have progressed to invasive disease if left untreated. Progressive DCIS (DCIS(1)) was defined as DCIS which has the propensity to progress to invasive disease. We fitted a Markov process model of the incidence of progressive and non-progressive DCIS, the transition of the former to preclinical invasive disease and the subsequent progression to clinical symptomatic cancer. We used data from the Swedish Two-County Trial and from service screening programmes in the UK, Netherlands, Australia and the USA to estimate the incidence of progressive and non-progressive DCIS, and the detection rates of each at the first and subsequent screening. Average incidence of non-progressive DCIS was 1.11 per 100000 per year. Average incidence of progressive DCIS was 2.1 per 1000 per year. At prevalence screen, 37% of DCIS cases were estimated to be non-progressive. A woman attending prevalence screen has a 19 times greater chance of having a progressive DCIS or an invasive tumour diagnosed than of having a non-progressive DCIS diagnosed. At incidence screen, only 4% of DCIS cases were estimated to be non-progressive. A woman attending an incidence screen has a 166 times higher probability of having a progressive DCIS or invasive lesion diagnosed than of having a non-progressive DCIS diagnosed. There is an element of overdiagnosis of DCIS in breast cancer screening, but the phenomenon is small in both relative and absolute terms.