Early Breast cancer detection at mass level; what can be done in developing countries?

Breast cancer is the most common cancer and second leading cause of cancer death in women around the world[1]. In Indian women, breast cancer is the second most common cancer, next only to carcinoma cervix. But in many urban areas in India, the breast cancer has recently emerged as the leading cancer in women [2].Breast cancer constitutes about 19-34% of all cancer cases among women in India [3,4,5]. Age adjusted incidence of breast cancer in India varies from 16 to 25 per lac population and approximately 80,000 new cases of breast cancer are diagnosed every year.[6]. With the rapid urbanization and changing lifestyle, the numbers are likely to increase further.
Early diagnosis and prompt treatment are paramount to improving the outcome of breast cancer. In India, early breast cancer constitutes about 30% [7] and locally advanced breast cancer constitutes about 50-70% of the breast cancer load. [8]. Accordingly, the proportional mortality rates in our country are much higher compared to North America where majority of cases present in early stages. The incidence to mortality ratio in North America is 0.25 compared to 0.48 in India [9]. Similarly, 5-year survival of over 70% in North America and western Europe is much higher than less than 48 % in India [10,11] and less than 10% in other developing countries [12].
There are many barriers to early diagnosis and treatment in India and other developing countries. First, women are not able to detect a lump in their breast early. Second, even after discovering a painless lump, they fail to understand its cancerous nature or prevalent notion of incurable nature of cancer prevents them from reporting to a healthcare facility early. This fact is supported by various studies in India and other developing countries which show that 79-98% of the women surveyed don't know that a painless lump in a breast can be cancer [14,15]and more than 75% of women link painful lumps and pain in the breast to cancer.[13]. Third, access to healthcare facility is limited in rural areas where majority of population lives. Last, conservative socio-cultural milieu prevents a woman from approaching male health care personnel for early check-up. The relative contribution of each of these factors is a matter of speculation.
 To facilitate early identification of  a lump in the breast, there are 3 available modalities; BSE(breast self examination), CBE (clinical breast Examination) and mammography. Both Mammography and CBE are effective in decreasing mortality due to breast cancer[16-21] Recommending mammography as a regular screening test on mass scale in India is impractical because of the astronomical costs involved in developing the requisite infrastructure and manpower. Moreover, the burden of breast cancer in developing countries is more in younger age group[3] in which the efficacy of mammography to detect breast cancer is questionable[22]. Similarly regular CBE on mass scale is logistically difficult due to scarcity of trained health personnel and socio-religious taboos regarding clinical breast examination [23,24].
BSE is a simple and inexpensive tool and can be performed by women themselves. Some studies have shown that practicing BSE helps to detect breast cancer lumps of smaller sizes [25-29] and leads to early diagnosis of breast cancer [25-34]but this does not translate in to reduction in mortality from breast cancer[35-37]. Presently, there is insufficient evidence to recommend for or against the teaching of BSE [38]. Conversely, BSE increases the number of physician visits for the evaluation of benign breast lesions and leads to higher rates of benign breast biopsies[35-37]. Also, proper technique of BSE is expensive to teach and difficult to perform[39-43]. Hence, the status of BSE as a screening modality on mass scale is debatable [35,44,45]. Furthermore, even in women performing BSE regularly, many early detected tumors are found incidentally and not during self examination[46-49]. Thus conventional screening tools are impracticable in developing countries highlighting the need for novel approaches.
 Prevalent misconceptions of pain associated with any cancerous breast lump and incurability of cancer are unaddressed issues in developing countries. Creating awareness on mass scale about these facts that any lump in the breast even a painless one can be cancer as well as curability of early diagnosed breast cancer is the need of the hour.  This strategy is relatively easy, inexpensive and practicable in resource restricted countries till standard screening tools are universally available, affordable  and accessible to masses.
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