Breast cancer screening in developing countries.

Diagnosing breast cancer early and efficiently is a critical component of any strategy aimed at decreasing breast cancer mortality in developing countries. In this chapter, I evaluate the evidence behind screening strategies and its controversies. The effect of breast-cancer screening has never been formally evaluated in developing countries, and data from the major screening trials need to be viewed in this context. Screening asymptomatic women by means of breast self-examination, clinical examination or mammography can play a significant role in decreasing breast-cancer mortality in developing countries. Major programmes should not be implemented, however, until adequate diagnostic and therapeutic facilities are in place. The most fundamental interventions in early detection, diagnosis, surgery, radiation therapy, and drug therapy must be integrated, organised and resourced appropriately within existing healthcare structures.

Evaluation of efficacy of self breast examination for breast cancer prevention: a cost effective screening tool.

Breast cancer is the most prevalent neoplasm among females and every year the number of associated deaths increases so that there is a dire need for implementation of cancer screening and early detection. A survey conducted by various locally organised cancer registries indicated breast cancer to be the most prevalent cancer among females and the second most common cause of cancer deaths among Pakistani women. Since Pakistani females do not generally engage in screening practices we argue that nurses and lady health workers should team up to educate women for the possible early detection of cancer using Self Breast Examination as a screening tool. In this paper, we attempt to evaluate the primary efficacy of self breast examination as an early and cost effective cancer screening measure, and to discuss the relation of community health nurses as well as the lady health workers to education of females of low income countries such as Pakistan to possibly lower the cancer burden.

Cost-effectiveness of a systematic training programme in breast self-examination.

Breast self-examination (BSE) appears to be an effective method for earlier detection of breast cancer. The provision of specialized training programmes in BSE may increase the awareness of breast cancer as well as improve the practice of BSE. This study assessed the cost-effectiveness of a BSE programme that a Danish health authority is considering implementing. A model was developed that related the cost of training (of a specified target group) to the anticipated effects of the training. These anticipated effects included increased knowledge of BSE, more routine use of BSE, fewer cases diagnosed with breast cancer where the tumour is larger than 20 mm and fewer cases where the cancer has spread to lymph nodes. The model was calibrated with data synthesized from the literature, own survey data and local expert guess. In the baseline scenario, the incremental cost per person with better knowledge of BSE was estimated to be 106 euro (2002 price level), the cost per person who begins to undertake BSE to be 180 euro, and the cost per person who correctly applies the technique to be 142 euro. The cost per avoided cancer with spreading to lymph nodes was estimated to be 15 410 euro and the cost of avoiding a cancer tumour larger than 20 mm to be 16 318 euro. Sensitivity analysis showed that these cost-effectiveness ratios varied with different assumptions for the effects of BSE training.

Early detection of breast cancer in industrially developing countries.

Although the incidence of breast cancer is lower in industrially developing countries than in developed ones, half the global toll of breast cancer is in developing countries. As in the West, the incidence of breast cancer is rising in developing countries, and strategies for controlling breast cancer need to be defined taking into account the prevailing socio-economic realities. Mammography is unlikely to be a cost-effective approach to early detection. Because most breast cancers in developing countries occur in women below the age of 50, mammography is also likely to be less effective. The success of breast self-examination (BSE) requires strong motivation and the recognition that breast cancer is a potential hazard. Both these requirements are unlikely to be met in developing countries and, consequently, compliance will be low and BSE will not be performed properly. Nevertheless, the teaching of BSE may be used as a medium for increasing awareness about breast cancer. Physical examination (PE) of the breast conducted by female health workers is likely to be the most appropriate approach to early detection in developing countries. To be cost-effective, PE should be integrated into already existing health care programmes which reach women in their homes. The effectiveness of PE in the early detection of breast cancer has been underestimated, and evidence is reviewed which suggests that it may be a simple and inexpensive alternative to mammography screening even in developing countries.

Cost-effectiveness of two nurse-led programs to teach breast self-examination.

The cost-effectiveness of breast cancer screening that includes breast self-examination (BSE) has not been investigated, in part because the costs and effects of programs to teach BSE are not well known. I used data from a randomized, controlled trial and national surveys to compare the benefit, cost, and cost-effectiveness of two one-year, nurse-led programs to teach BSE in a medical practice setting. One program (Mammacare, or MAM) used manufactured silicone models to develop tactile skills; the other program (Traditional, or TRAD) stressed knowledge and examination techniques. I defined benefit as the marginal one-year increase in the number of women in an "average" adult primary care office practice who performed competent and frequent BSE. I defined cost as the marginal increase in the resources used to teach BSE and in the resources used as a result of performing BSE. Cost-effectiveness equaled the cost per competent, frequent BSE examiner added. The "average" practice was derived based on estimates from national surveys of physicians and medical practices. The MAM program's benefit was fivefold greater than the TRAD program's; its total cost was more than threefold greater; and its cost per competent, frequent examiner added was 32% lower. Yet, regardless of the program, one year following teaching only 15%-28% of women were competent, frequent performers. Cost-effectiveness was sensitive to the definition of benefit. Cost-effectiveness was also sensitive to some costs, but generally these sensitivities did not alter the relative cost-effectiveness of the two programs. The cost of teaching BSE was substantial. Benefit, cost, and cost-effectiveness varied by program.(ABSTRACT TRUNCATED AT 250 WORDS)