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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Anthony B. Miller
Professor Emeritus, Dalla Lana School of Public Health, University of Toronto,
Reduction in risk of death from breast cancer by mammography screening:
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)
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.
Screen detected 267 148
Interval cancers 50 88
Incident cancers 305 374
Total 622 610
[Total in situ 71 16]
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)
Programme Cost, per Yr Life saved
Biennial CBE $ 1341
Biennial mammography $ 3468
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
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.
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
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
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.
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.
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.
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
Population compliance at PHC for screening:
Pilot study (initial) 60%
Group A 83%
Area 2 91%
Area 3 83%
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%)
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
Stage 1 30% 8%
Stage II 43% 18%
Stage III 20% 44%
Stage IV 7%* 30%
*5 cases were detected in the prevalence round
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