Mammography Alternative Saves Lives in Low-to-Middle Income Countries

Clinical breast examination can lead to breast cancer diagnosis at a younger age and nearly one-third fewer disease-associated deaths in women over age 50 who live in low- or middle-income countries.

Mammography is the long-standing breast cancer screening tool in developed countries, but it is not always easily available in areas with fewer resources. Not only can cost and complexity be obstacles, but most women in these countries are also younger than 50 – the age group for which mammography is known to be less effective.

But, breast cancer rates are rising worldwide, particularly in low-to-middle income countries, and the women living there need access to effective breast cancer screening. Consequently, a team of researchers from India, led by Rajendra A. Badwe, MBBS, director and head of the surgical oncology division at Tata Memorial Center, tested whether clinical breast examination could be an acceptable fill-in for mammography.

The team’s results, published Feb. 24 in The BMJ, were encouraging.

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“Our study suggests that implementation of population screening by clinical breast examination in low-to-middle income countries is feasible,” the researchers said, “provided that adequate training of screening providers, careful monitoring, and quality of performance are assured.”

For this study, the investigators analyzed 20 years of data (May 1998 to March 2019) from 151,538 women between the ages of 35 and 64. These women, who had no history of breast cancer, lived in 20 geographically distinct clusters in Mumbai, and they were randomly divided into 10 screening and 10 control groups.

A trained female primary healthcare provider conducted four rounds of clinical breast examinations on the 75,360 women in the screening group. Providers followed these women through five rounds of active surveillance every two years, as well as provided cancer awareness along the same schedule. In the control group, however, 76,178 women underwent one round of cancer awareness followed by eight rounds of active surveillance every two years.

Based on the team’s data analysis, they identified some significant advantages for using clinical breast examination with women over age 50. Women in the screening group were diagnosed at an earlier age than those in the control groups – age 55 versus age 57, respectively. In addition, a lower percentage of women developed stage III or stage IV breast cancer – 37 percent and 47 percent, respectively.

When it came to changes in breast cancer mortality between the screening and control groups, the team identified a non-significant reduction across women of all ages – 21 versus 25 deaths per 100,000 person years. However, the drop in deaths in the screening group became much more apparent when they analyzed women by age. For women over age 50, implementing clinical breast examination reduced these deaths by 30 percent (25 versus 35 deaths per 100,000 person years). They saw no mortality reduction in women under age 50.

For all causes of mortality, the team said they pinpointed a non-statistically significant 5-percent drop when comparing the screening and control groups.

Overall, the team said their longitudinal study showed that clinical breast exam can be an effective replacement for mammography with women above age 50 who do not have access the traditional screening test.

“These results indicate that clinical breast examination conducted every two years by primary health workers significantly down-staged breast cancer at diagnosis,” the team said. “Clinical breast examination should be considered for breast cancer screening in low- and middle-income countries.”

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