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Early Detection: pros ad cons of different methodologies: education alone, BE/BSE, mammography. Anthony B. Miller Professor Emeritus, Dalla Lana School of Public Health, University of Toronto, Canada. The problem. In LMI countries, breast cancer is usually diagnosed at an advanced stage

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Early detection pros ad cons of different methodologies education alone be bse mammography l.jpg

Early Detection: pros ad cons of different methodologies: education alone, BE/BSE, mammography

Anthony B. Miller

Professor Emeritus, Dalla Lana School of Public Health, University of Toronto,

Canada


The problem l.jpg
The problem education alone, BE/BSE, mammography

  • In LMI countries, breast cancer is usually diagnosed at an advanced stage

  • The majority of breast cancers are diagnosed in women under the age of 50

  • Mammography screening is less effective in women under age 50, and the technical and personnel requirements for population-based mammography screening are very substantial.


Early detection l.jpg
Early detection education alone, BE/BSE, mammography

  • Public and professional education

  • Professional education

  • Breast self examination

  • Clinical breast examination

  • Mammography

  • Adequate facilities for diagnosis


Iarc working group 2002 l.jpg
IARC Working Group, 2002 education alone, BE/BSE, mammography

Reduction in risk of death from breast cancer by mammography screening:

  • Women aged 40–49: 12%

  • Women aged 50–69: 25%


The uk trial of mammography among women age 39 41 l.jpg
The UK trial of mammography among women age 39-41 education alone, BE/BSE, mammography

  • 160,921 women randomised, 1: 2, intervention : control

  • Mammography annually for 7 years in intervention arm

  • 478 breast cancers diagnosed in intervention arm (8% excess), 809 in control


The uk trial of mammography among women age 39 416 l.jpg
The UK trial of mammography among women age 39-41 education alone, BE/BSE, mammography

Ratio of breast cancer deaths at mean follow-up of 10.7 years in intervention arm relative to the control:

0.83 (95% CI 0.66-1.04)


Iarc working group 20027 l.jpg
IARC Working Group, 2002 education alone, BE/BSE, mammography

There is inadequate evidence for the efficacy of screening women by clinical breast examination in reducing mortality from breast cancer.

There is inadequate evidence for the efficacy of screening women by breast self-examination in reducing mortality from breast cancer.


Canadian national breast screening study cnbss 2 l.jpg
Canadian National Breast Screening Study (CNBSS)-2 education alone, BE/BSE, mammography

  • 39,405 women age 50-59 randomized to:

    • Annual two-view mammography + physical examination (CBE) + BSE (MP)

    • Annual physical examination (CBE) + BSE only (PO)

  • 5 or 4 screens and 11-16 years follow-up


Occurrence of invasive breast cancers in cnbss 2 l.jpg
Occurrence of Invasive Breast Cancers in CNBSS-2 education alone, BE/BSE, mammography

MP PO

Screen detected 267 148

Interval cancers 50 88

Incident cancers 305 374

Total 622 610

[Total in situ 71 16]


Cnbss 2 deaths from breast cancer 11 16 years follow up l.jpg
CNBSS-2 Deaths from breast cancer, 11-16 years follow-up education alone, BE/BSE, mammography

MP PO

Women years (103) 216 216

Breast cancer deaths 107 105

Rate/10,000 4.95 4.86

Rate ratio (95% CI) 1.02 (0.78, 1.33)


Model based analysis of cnbss 2 rijnsberger et al 2005 l.jpg
Model based analysis of CNBSS 2 education alone, BE/BSE, mammography(Rijnsberger et al, 2005)

  • Mammography resulted in a 16-36% reduction in breast cancer mortality

  • The breast examinations resulted in a 20% reduction in breast cancer mortality, in comparison to no screening.


Cost effectiveness of screening in india okonkwo et al 2008 l.jpg
Cost–effectiveness of Screening in India education alone, BE/BSE, mammography(Okonkwo et al, 2008)

Programme Cost, per Yr Life saved

Biennial CBE $ 1341

age 40-60

Biennial mammography $ 3468

Age 40-60


Explanations for trends l.jpg
Explanations for trends education alone, BE/BSE, mammography

  • Timing of recent fall compatible with improvements in therapy

  • Timing and lack of effect in some countries is not compatible with an effect of mammography screening

  • Lack of fall prior to 1990 suggests that early detection is not effective in the absence of effective treatment


Who s recommendations l.jpg
WHO’s Recommendations education alone, BE/BSE, mammography

  • Evaluate importance of breast cancer

  • Evaluate available resources

  • Ensure availability of Early diagnosis

  • Ensure availability of therapy

  • Introduce early detection based upon evidence

  • If insufficient evidence-base, introduce screening as demonstration project first


Cairo breast screening trial l.jpg
Cairo Breast Screening Trial education alone, BE/BSE, mammography

Principal investigator: Dr Salwa Boulos

Statistician: Dr Moysen Gadallah

Senior Surgeon: Dr Sherif Neguib

Oncologist: Dr A Youssef

Pathologist: Dr EA Essam

Consultants: A Costa, N Mittra, AB Miller

Funding: The Challenge Fund


Principal objectives of the trial l.jpg
Principal Objectives of the trial education alone, BE/BSE, mammography

  • To determine whether breast examinations

    combined with the teaching of breast self-examination (CBE+BSE), performed once a year by trained health professionals, reduces the cumulative incidence of advanced (stage 3 or worse) breast cancer.

    2. To determine whether CBE+BSE reduces mortality from breast cancer.


Criteria of eligibility l.jpg
Criteria of Eligibility education alone, BE/BSE, mammography

  • Women age 40-64

  • No personal history of breast cancer,

  • Resident in the study area,

  • Not enrolled in any other breast screening program

  • Consent has been obtained


Reasons for starting at age 40 l.jpg
Reasons for starting at age 40 education alone, BE/BSE, mammography

  • The incidence of breast cancer is lower in women age 35-39 than 40-44

  • More women age 35-39 have to be examined to find a case of breast cancer than women age 40-44

  • The costs will be lower, and the screening tests more productive, if we restrict the age range


Breast cancer incidence rates per 100 000 l.jpg
Breast cancer incidence rates education alone, BE/BSE, mammography(per 100,000)

Age Canada Egypt Casablanca

35-39 51.8 63.6 50.3

40-44 107.6 96.7 95.1

45-49 162.9 144.9 109.1

50-54 199.4 171.5 107.2

55-59 229.0 181.2 116.8

60-64 285.5 144.2 96.7


Number of women to be examined to find one case of breast cancer l.jpg
Number of women to be examined, to find one case of breast cancer

Age Canada Egypt Casablanca

35-39 1930 1572 1988

40-44 929 1034 1051

45-49 614 690 917

50-54 502 583 933

55-59 437 552 856

60-64 350 693 1034


Recruitment and registration l.jpg
Recruitment and registration cancer

Areas were identified with easy access to the designated breast diagnosis centre. These contained the homes of over 10,000 women, of whom about 5,000 were the target age group (40-64).

Visits were performed by trained social workers to these homes in a systematic manner, aided by maps.


Recruitment and registration 2 l.jpg
Recruitment and registration -2 cancer

All women age 40-64 identified were registered, their ID information recorded, and interviewed using a breast cancer risk factor questionnaire.

Health information on breast cancer was provided, and they were told where to attend if they have a problem with their breasts.


Randomisation after pilot study l.jpg
Randomisation cancer(after Pilot study)

Group (cluster) - defined by sub-area (social worker).

All women in designated sub-areas were invited to attend the designated primary health centre, staffed by young female doctors, carefully trained in CBE+BSE.


Process for screening l.jpg
Process for screening cancer

CBE performed and BSE taught

Those deemed abnormal referred to the diagnosis centre

At diagnosis centre, women re-examined by study surgeon

Those confirmed abnormal receive mammography, and if needed ultrasound and FNA


Results l.jpg
Results cancer

Population compliance at PHC for screening:

Pilot study (initial) 60%

Group A 83%

Area 2 91%

Re-screening 73%

Area 3 83%


Results 2 l.jpg
Results - 2 cancer

Number found with abnormalities (percent attended for diagnosis):

Pilot study 291 (82%)

Group A 63 (83%)

Area 2 88 (88%)

Rescreening 56 (93%)

Area 3 114 (78%)


Results 3 l.jpg
Results - 3 cancer

Breast cancer detection CBE screening:

Pilot study 8 per 1,000

Re-screening 2 per 1,000

Area 2 6 per 1,000

Re-screening 3 per 1,000

Area 3 5 per 1,000


Preliminary results on staging l.jpg
Preliminary results on staging cancer

Screen Control

Stage 1 30% 8%

Stage II 43% 18%

Stage III 20% 44%

Stage IV 7%* 30%

*5 cases were detected in the prevalence round


Conclusions l.jpg
Conclusions cancer

The approach is feasible, and is being replicated in other centres: Sana’a, Khartoum, Yazd

The projects are providing evidence that earlier stage at diagnosis can be achieved by CBE screening

Other EMRO countries should consider such projects as an alternative to mammography screening


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