This is an interesting question Subhojit.

In developed countries most of the efforts are put on improving the technology for an early detection of the disease (e.g. X-ray mammography, digital breast tomosynthesis, breast ultrasound) as well as designing new protocols in breast screening programmes (e.g. personalised programmes based on family history or breast density), assuming that these technologies are already available to screen the target population.

However, as you mentioned, LMIC might not be able to provide the appropriate technology to their population. Thus alternative (and probably less effective) techniques are followed as you well described (CBE and BSE). These can be used to detect some symptoms of breast lesions but I imagine that by the time the breast lesion is noticeable, the lesion is well developed.

So it would be interesting to put more effort to investigate cheaper (as well as accurate) breast cancer detection techniques to be introduced in screening programmes of LMICs.

Let's see what other colleagues has to say.

If you rule out mammography as screening, due to high cost(?) that leaves you with manual means which are low sensitivity and low specificity measures.

In young females with dense breast mammography is not a good option, but ultrasound might help. The question is whether ultrasound is available or is it considered even more high cost than mammography?

You can perhaps define high risk groups such as women with family history of breast cancer especially at early age, family history of ovarian cancer and perhaps those can be screened with ultrasound, not just CBE.

So, defining specific groups that need more attention can be better than stay with CBE to all.

For most CBE, for the high risk group both CBE and breast ultrasound. Of course MRI is much more sensitive, but as you say there is a problem with low resources.

I would suggest to strictly follow Global Summit Early Detection panel suggestions for the countries with low or medium level resources, published in Breast J (Anderson BO, Braun S, Lim S, et al. Breast J 2003; 9:S51-9). The main panel recommendation about breast cancer screening program is implementation of such effort within centralized cancer facilities firstly, in which the best practice breast cancer diagnosis and treatment is available. This centralized screening can serve as a pilot program for the future one, which could cover entire population, giving the opportunity for an insight into possible problems and to raise the consciousness of the screening importance in population.

Unfortunately, we started organized mammographic screening program at national level 7 years ago, facing many problems (low screening invitation response rate, not established quality control programs, different surgical procedures in different centers, and many more), with disappointingly bad screening success evaluation results after two implemented screening rounds.

Considering your particular problems (younger age at presentation with subsequent dense breast tissue), I would recommend CBE in combination with mammography as a pilot program in few centers fistly, with future modifications based on the achived results.

Yes, but the problem with CBE+ mammography in young women is that due to the dense breast tissue you can miss findings with mammography.

In my experience, the early detection of breast cancer has to start with breast awareness by women themselves, with the main focus being to educate women themselves about the signs and symptoms of breast cancer. This can be enhanced by the training of women in self examination by specialist nurses aided by web-based information and videos. Many of these can be found on www.breasthealthuk.com. During a ten year period, the average tumour size for non-screen detected breast cancers presenting to the Nottingham Breast Unit dropped by approximately 10mm diameter as a result of breast awareness campaigns. This can all be done at low cost via the internet or primary health care and together with some of the suggestions made already by our colleagues, could help to reduce the number of advances breast cancers presenting in LMICs. For patients who do require breast screening, mammography remains the only proven technology that can reduce breast cancer mortality.

There is an interesting article of M. Baum: The Marmot report: accepting the poisoned chalice in the British Journal of Cancer (2013) 2198-2199.

The author writes '... It is exceptionally difficult to calcutlate the benefit-to-harm ratios based on all the developments in the past 25 years ..., but my crude estimate is that for 10 000 women invited for screening, 3-4 breast cancer deaths are avoided, but along the way 120 to 140 cases will be overdiagnosed. ...I crudely estimate that an additional 1 - 3 deaths might be expected from other causes for every breast cancer death avoided. ... It is even possible that my worst estimate is too optimistic ... .'

Perhaps less (screening) may be more (safety).

I am familiar with the British point of view, but I disagree.

I would also add that doing nothing will mean that what was will be and maybe even worse because some cancers are rising in incidence.

Screening means early detection. I agree that more has to be done to refine the screening procedures, obtain more specific result and hence reduce the false positives, but I disagree with the notion that less is more. In colorectal cancer one can actually prevent the cancer if one removes polyps that have a malignant transformation potential. If mammography yields to many "false alarms" then we should deal with making the project better, achieve higher expertise in interpreting the mammography, perform it at the appropriate age, and perform other screening procedures for women at higher risk, where procedures for screening are needed at earlier age, such as breast MRI for carriers of BRCA mutations.

Hello, Yes there is a way that may help. I have had some success using a protocol here in the U.S. The issue would be how to fund a project like this.

Dr. Lembeck

This reminds me to the other screening story (prostate cancer) ending in ... doing less.

The quotation of M. Baum (see above) reads with explanations:

'... It is exceptionally difficult to calculate the benefit-to-harm ratios based on all the developments in the past 25 years ..., but my crude estimate is that for 10 000 women invited for screening, 3-4 breast cancer deaths are avoided, but along the way 120 to 140 cases will be overdiagnosed. Four-fifths of these women would receive radiotherapy and would be at an increased risk of dying of ischemic heart disease and lung cancer. Knowing the background risks and multiplying these by the factors 1.27 and 1.78 gives us increases of 2.0% for lung cancer and 1.33% for myocardial infarction. Adding that to all-cause-mortality rates, I crudely estimate that an additional 1 - 3 deaths might be expected from other causes for every breast cancer death avoided (Baum 2013). ... It is even possible that my worst estimate is too optimistic because of two papers I overlooked in the past that describe the risk of stroke following radiotherapy to the breast (Nilsson et al., 2005; 2009) and one very recent letter to the N Engl J Med on the early risk of cardiovascular deaths from the act of surgery alone, amongst patients with cancer (Voskoboynik et al., 2012). '

Baum dislikes mammography and thinks it even raises risks for lung cancer and heart disease. And he refers to mortality as his endpoint. I am not certain about the validity of such calculations. And suppose he dislikes mammography, has he any other suggestion? Women die from breast cancer if not treated and even if treated some die. It is not flu that can be left alone(mind you, even flu can be dangerous in many instances).Therefore the conclusion is wrong. If mammography is not helpful, does he have any alternative suggestions? No, he thinks less is more.... PSA is not a specific marker for prostate cancer, and yes, I would definitely not screen the 75+ age group. But, are there other more specific markers?(Yes, there are). Do we need to limit the group we screen? Yes we are. In the age of personalized medicine, when one understands there are differences and genetic polymorphisms affecting not only the chance to develop disease, but also affecting the response to specific medications, diet etc etc. one needs to think also about a more selective screening and a screening adjusted to various subpopulations comprising the general population. But to do nothing and wait to put out the fire? Ridiculous.

High resolution thermography may be a way to go, it is non-invasive...http://www.ncbi.nlm.nih.gov/pubmed/23941007

Unfortunately , countries with limited resources has to rely for the time being on extensive health education programs, and frequent clinical evaluation by the medical and paramedical staff. This may provide a capture for stage I-II in many instances and we have seen it work. It is a crude method for this era, but it is what is currently available.

Self Breast Examination followed by Clinical Breast Examination and confirmation by FNAC is ideal and less expensive approach for early diagnosis of breast cancer in low and middle income countries. Similarly IEC also play important role in increasing the awareness as well as change in attitude of women to access Public/State health care services also contribute to address the underling problem from such areas.

Thank you all for your interesting replies. The gist that I am catching from your answers is that the only way to go in LMICs is to increase awareness of women and get them to do their BSE, have some kind of risk assessment measure in place (that applies to even countries which are contemplating a reduction in mammography coz apparently women in some populations are getting screened too much!) and then have CBE/ultrasound/FNAC or even some kind of centralized mammography facilities for women with highest risk.

But your responses also underline the need for a cheaper screening method for breast cancer screening than mammography or to make mammography itself cheaper.

Also, we need to think of better protocols for breast cancer screening in LMICs vis-a-vis pre- vs. post-menopausal women since the incidence of BC in pre-menopausal women is much higher in LMICs.

Considering that most of cancer occurs at younger stage in dense breast should be useful to diffuse the correct use of ultrasound not only between radiologist but also between surgeons in order to evaluate the women better than with clinical visit. At this stage we cannot offer nothing because mammography is unable to give diagnosis.

Enzo Durante Full Professor of General Surgery, International Breast Ultrasound School Secretary

please read our paper in JNCI (Okonkwo) on cost-effectiveness of BC screening in India, or my editorial "do LMICs suffer from debates on BC screening in european countries?"

I am quite optimistic that there are cost-effective options in those countries too

CBE is one way that is commonly used in our set up. Mammogram is available but not accessible due to cost implications. As quoted above, most of those who are affected by breast cancer do present late leaving no other option but palliative care.

LMICs have a challenge of accessing screening facilities and minimal information is also available to those leaving in remote areas.

Like Dr Durante ,I advice the US, because of it is a much cheaper method comparing to mammography.LMIC countries can use US as a breast screening method.Not only breast surgeons,even educated nurses may use US as a preliminary evaluation .Then suspected cases may be refered to the radiologist in centers.My proposal has three reasons :1-US is a cheaper method comparing to mammography .2-it does not cause radiation hazards to the breast.3-patients with breast cancer in LMIC countries are mostly in premenauposal age.It means they have a low-sensitivity mammographic evaluation.

It is well known that BSE does not provide overall survival survival,so it means

nothing except increased awareness(maybe rather a fear ! )

I agree with the 3 reasons of Dr Kayar but disagree with the proposal of "educated nurses". Breast US is a very demanding technique and dangerous if not really very expert; but if, at moment, the majority of cancers in this area is T2 we may consider the opportunity, in terms of cost, to educate specialised nurses. Enzo Durante

Clinical breast examination (CBE ) is the only feasible option at present for low and middle income countries. CBE combined with mammography would be a better option but mammography due cost and manpower consideration will not be an option for LMICs. Breast self examination can create awareness among community which will later demand for CBE or further investigations.

Dear Asthana,

In China,sonography has been accepted as a favorable screening method like suggested by Wang et al ( Asian Pacific J Cancer Prev 2013:14:2277) .The author say:

"There is a trend in China that ultrasonography is becoming widely used for breast cancer screening because it is a relatively simple, convenient and cost-effective imaging method. Therefore, it is specifically suitable for breast cancer screening in rural areas in China."

Ishida T etal report a big trial comparing efficacy of US and mammography(about 36 tousand women in each group).(Trial's name:J-START)

These news support that sonography will be a good alternative for breast screening in low-middle income countries ,especially below 45 year old.

Great

But sonography is yet to be tested in Indian community based setting . This could be come out to be a good alternative or a parallel test to mammography keeping in view the high detection rate in dense tissue and in small lymph node negative lesions. But on the other hand high false positive rates , high quality training and monitoring etc could be a problem in resource limited setting . Also important to conduct clinical trial in low resource countries like India to study various aspect like Feasibility of incorporating the test for screening, acceptability running cost per screen positive ,training needs etc

Mobile digital mammography equipment and centralized radiology suite is probably the most easy to organize and cost/benefit effective in LMICs. However it is a usually political problem, not clinical.

Shahla Masood has written an interesting paper about breast cancer in countries with limited resources: https://www.researchgate.net/publication/47498295_The_Current_Status_of_Breast_CancerAmong_Resource-Limited_Countries?ev=prf_pub

Article The Current Status of Breast CancerAmong Resource-Limited Countries

Detection of breast cancer in in low- and middle-income countries is easy for them through some alternate ways that is like Accupressure.

Dear All, I thank you all for your opinions. Your ideas added a lot to a review I have been working on. The review is now published in the World Journal of Clinical Oncology. The citation is: Dey S. Preventing breast cancer in LMICs via screening and/or early detection: the real and the surreal. World J Clin Oncol 2014; 5(3): 509-519.

I have included the fact in the methodology that I had asked a related question on Researchgate and used opinions expressed here as pointers to obtain more information for the review. 

This is a really challenging problem. While the community based screening methods are limited, CBE and BSE alone are not proved to be effective in screening programs, mammography could not be recommended for all women. The critical point of our approach is risk assessment by which we can concentrate our screening programs on the moderate to high risk groups. An international collaborative research group in BCAC has been working on the polygenic risk score via analysis of more than 100 SNPs. However, it is hard to consider its feasibility in low and middle income countries. We must look for alternatives.

I think the reasonable option is to screen women over the age 50 with mammography. Where a family history of breast cancer exists, mammography should be done at an earlier age from 40 onwards. Unfortunately, genetic analysis for women with family history of breast cancer would not be readily available in low income countries, as well as modalities such as breast MRI, which can be an option for screening of BRCA positive young women, where the breast tissue is dense and mammography would not reveal small tumors.