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

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

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  1. 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

  2. The problem • 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.

  3. Early detection • Public and professional education • Professional education • Breast self examination • Clinical breast examination • Mammography • Adequate facilities for diagnosis

  4. IARC Working Group, 2002 Reduction in risk of death from breast cancer by mammography screening: • Women aged 40–49: 12% • Women aged 50–69: 25%

  5. The UK trial of mammography among women age 39-41 • 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

  6. The UK trial of mammography among women age 39-41 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)

  7. IARC Working Group, 2002 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.

  8. Canadian National Breast Screening Study (CNBSS)-2 • 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

  9. Occurrence of Invasive Breast Cancers in CNBSS-2 MP PO Screen detected 267 148 Interval cancers 50 88 Incident cancers 305 374 Total 622 610 [Total in situ 71 16]

  10. CNBSS-2 Deaths from breast cancer, 11-16 years follow-up 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)

  11. Model based analysis of CNBSS 2 (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.

  12. Cost–effectiveness of Screening in India (Okonkwo et al, 2008) Programme Cost, per Yr Life saved Biennial CBE $ 1341 age 40-60 Biennial mammography $ 3468 Age 40-60

  13. Explanations for trends • 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

  14. WHO’s Recommendations • 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

  15. Cairo Breast Screening Trial 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

  16. Principal Objectives of the trial • 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.

  17. Criteria of Eligibility • 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

  18. Reasons for starting at age 40 • 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

  19. Breast cancer incidence rates (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

  20. 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

  21. Recruitment and registration 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.

  22. Recruitment and registration -2 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.

  23. Randomisation (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.

  24. Process for screening 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

  25. Results Population compliance at PHC for screening: Pilot study (initial) 60% Group A 83% Area 2 91% Re-screening 73% Area 3 83%

  26. Results - 2 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%)

  27. Results - 3 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

  28. Preliminary results on staging 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

  29. Conclusions 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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