“Breast Cancer Detection Under Budget Constraints”; Mammography Screening in Low- and Middle-Income Countries

By Marilys Corbex

The editorial in the last issue of the UICC Global News Alert (the International Union Against Cancer newsletter) is about the use (and abuse) of mammography screening in low- and middle-income countries, which presents an important lesson for advocates working with breast cancer in the Middle East.

The article reflects the growing conviction in the scientific and expert community that low- and middle-income countries should avoid engaging mammography screening too quickly as this consumes a lot of resources without benefiting many women. It also explains that advocates should be careful about pressuring their ministries of health for mammography screening as it can be counter productive to their cause. Instead, advocates should advocate for better treatment and effective early diagnosis that is readily accessible to all women of the country.

The editorial (below), plus other interesting related topics, is available at: http://www.uicc-community.org/templates/ccc/images/GNA_March%202009.pdf

Breast Cancer Detection Under Budget Constraints

By Paola Pisani, Senior Epidemiologist, Oxford University, and Joe Harford, PhD, Director, Office of International Affairs, NCI, Bethesda.

In developed countries, the debate regarding the benefits and harms due to possible overtreatment of indolent tumours discovered by mass screening via mammography continues. The health care infrastructure required for the management of suspicious or abnormal mammograms and for the treatment of breast cancer is generally present in these countries and is taken for granted in discussions.

However, the situation is different in low- and middle-income countries where breast cancer incidence is lower and where the requisite infrastructure for breast health is often suboptimal. In these settings, governments, health providers and advocacy groups struggle to develop sustainable strategic plans to control the disease, which is often the most common cancer in women, although it occurs at a lower rate than in Western countries.

These plans often focus on the introduction of mammography in emulation of early detection and screening programs that exist in more developed countries. There is no question that early detection can have a profound and positive impact on breast cancer outcomes as shown by falling mortality rates—the chief measure of efficacy. However, by focusing exclusively on introducing the detection test, health systems in low- and middle-income countries often fail to ask whether they are really ready to deal adequately with what is found through the new screening program.

Improvements in breast cancer outcomes in the United States and Western Europe began before the introduction of mass screening of asymptomatic women. In these venues, breast cancer awareness grew together with the development of comprehensive health systems that made quality care accessible to the population at large, raising expectations and trust and, eventually, demand. Breast cancer mortality began to fall in the 1960s and 1970s, in generations of young women who used health services for contraception, safer pregnancies and provision of healthcare for their children. At this time, breast cancer incidence was already increasing and state-of-the-art treatment relied largely on surgery and radiotherapy (chemotherapy and tamoxifen were to come later).

In the 1990s, mortality rates began to fall in women of all ages before all those eligible were able to receive a mammogram. The improvement in outcomes caused by the early (prescreening) movement can be attributed to the systems set up, as part of the screening policy, to manage the disease—systems that provided quality diagnosis and treatment to all breast cancer patients, most of whom still presented with overt symptoms of the disease (e.g., a palpable mass). Programs for screening asymptomatic women were implemented in an environment that already had an enhanced capacity to diagnose and treat breast cancer effectively.

In many low- and middle-income countries, breast cancer diagnosis and treatment are usually of low quality, or access to quality care is restricted to those who can afford to pay for it. In many poorer countries, only a small subpopulation of women gets state-of the-art breast health care. The introduction of mass mammography in the absence of a health care system capable of dealing with the suspicious and abnormal mammograms that are inevitable is a classic case of “cart before the horse”. Without generalised access to diagnostic and treatment services, low- and middle-income countries will see neither the early benefits of screening observed in the West nor the late ones that follow 10 years of regular screening.

In those societies where breast cancer awareness is raised, stigma is reduced and barriers to adequate diagnosis and treatment are removed, near-term improvements in breast cancer outcomes are likely to mimic those seen in the West. Health administrators in low- and middle-income countries have every reason to invest in delivering effective care to the population at large rather than investing in mammography screening, which will have a lower yield than in the West. Good management of early—yet symptomatic— tumours produces short-term, measurable reductions in mortality. Success of these programs aimed at reducing mortality and suffering will encourage funding and participation of the population. The consideration of more sophisticated and expensive programs to screen asymptomatic women is not today’s highest priority.