Short report: Limited effectiveness of screening mammography in addition to clinical breast examination by trained nurse midwives in rural Jakarta, Indonesia

Abstract

Low-and middle-income countries (LMICs) are undergoing an increase in incidence of breast cancer, but have inadequate resources to implement mammographic screening. Clinical breast examination (CBE) has been suggested as an alternative to mammography in these settings. We compared the results of CBE screening by 47 midwives and 15 trained lay health workers to results of independently performed mammographic screening in an unscreened population of 1,179 women in Jakarta, Indonesia. Two hundred and eight-nine (24.5%) of the screened women had a suspicious finding on CBE and/or mammography. Sixty-nine (23.9%) of these women had both an abnormal CBE and mammogram; 98 (33.9%) had an abnormal CBE, but a normal mammogram; and 122 (42.2%) had a normal CBE and an abnormal mammogram. Fourteen breast cancers were diagnosed. Of these, 13 were identified by both mammogram and CBE. One breast cancer was identified from an abnormal mammogram, but had a normal CBE. One hundred and sixty-seven (14.2%) of the CBEs required additional work-up to diagnose 13 of the 14 cancers detected by mammography. In comparison, 191 (16.2%) of mammograms required additional workup to diagnose the 14 cancers. Unfortunately, only 42.8% of the women diagnosed with cancer returned for treatment. In an unscreened population in LMICs such as Indonesia, CBE is nearly as effective as mammography in detecting prevalent breast cancers. However identifying and overcoming barriers to appropriate treatment of women who are identified as having breast cancer are essential to the success of any screening program.Breast cancer is the most common cancer among women, with an estimated global incidence of 1.38 million new cancer cases diagnosed in 2008 (23% of all cancers). Breast cancer accounted for 14% of the total cancer deaths in 2008. 1 Mortality rates for breast cancer have been decreasing in the United States and many other western countries over the past 25 years, due to improved treatment and early detection via mammography, which has been shown to increase treatment options and survival, reducing breast cancer mortality by 20-30% in screened women over 50 years old. 2 In contrast, many low-and middle-income countries (LMICs) are experiencing increases in breast-cancer incidence, attributed in part to increases in life-expectancy, changes in reproductive patterns, and increasing rates of obesity. 3 Many have inadequate resources for early detection and treatment programs, leading to diagnosis at advanced stages, and thus disproportionately low 5-year survival rates, ranging from 40-60% in LMICs, compared to over 80% in developed countries. 4

Breast Cancer in Sub-Saharan Africa: Challenges and Opportunities to Reduce Mortality

“…These issues led to early termination of the study [53]. A study of CBE and mammography in Indonesia similarly demonstrated low rates of follow-up among women actually diagnosed with cancer, with only 42.8% of those returning for treatment [54]. A report of a breast cancer awareness and screening campaign in the Democratic Republic of Congo (DRC) reported that 73% of women found to have a palpable mass never followed up for further evaluation; although not emphasized in the article, it seems that women had to pay for most of their subsequent evaluation, which presumably presented a significant barrier to follow-up as well as treatment of cancers detected [55].…”

Global Cancer Consortiums: Moving from Consensus to Practice

“…The study found that in this unscreened population of 1,179 women in which 14 cancers were found, 13 were found on clinical breast examination, confirming that screening mammography adds little to cancer detection in previously unscreened LMIC populations like that of Indonesia. 53 Scaling capacity is envisaged by future pilot or demonstration projects to validate the effect of an intervention then scaling up according to resource availability. 54 This resource stratification model for guideline development has been successfully used in a diverse spectrum of countries around the world.…”

Nursing’s Potential to Address the Growing Cancer Burden in Low- and Middle-Income Countries

“…29-31 In promoting general breast health awareness, nurses are a well-suited professional group to destigmatize disease within their respective communities. 11 Nurses in LMICs knowledgeable about breast health and with skills in clinical breast examination can contribute to reaching the goal of downstaging the presentation of breast cancer in these countries.…”