early detection programs for
Dr Marilys Corbex
WHO Eastern Mediterranean Regional Office
Estimated cancer incidences in the EM region
Relative incidence of breast and cervical
cancers in the EM region
Incidence (crude rates per 100 000) of breast and cervix cancer in the EMR
new cases/100 000
Effect of early detection
From the early 70ies to the late
90ies treatments have only
improved slightly survival in U.S.
The main improvement come from
Early detection programs
1. Who to target ?
2. With which tools (screening tests) ?
3. Which kind of organization ?
4. Why to monitor the program ? (quality
Who to target ?
1. Who to target ?
Age is the major risk factor of Breast cancer.
Target population has to be defined according to age pyramid and age specific incidence of
the country, taking into account available resources.
Age Range Risk of BC
30 to 39 1 in 227 Jordan 1996-2001
incidence per 100 000
40 to 49 1 in 67 US SEER 1999-2001
50 to 59 1 in 36
60 to 69 1 in 26
(US-SEER estimates) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
derived from MECC monography 2006 data
Figure: Age Specific incidence Rates for breast cancer
from Tanta population registry, Amman population
registry and US SEER
High risk groups ?
Nb of 1st degree relatives with BC
1 vs none 2
2 vs none 3-5
First child age >30 vs <20 2-3
Breast feeding none vs 4 children 2.5
Menarche <11 vs >15 1.5
Number of child none vs 3 1.5
Which tools ?
Breast cancer screening tests
• Breast self examination (BSE)
• Clinical breast examination (CBE)
• Electrical impedance imaging
• Magnetic resonance imaging
• Positron emission tomography (PET)
• Digital mammography
• Sensitivity: The proportion of all those
with disease that the test correctly
identifies as positive.
• Specificity: The proportion of all those
without disease (normal) that the test
correctly identifies as negative.
• From 53% to 92% in western countries*
• Low in pre-menopausal women (from
44% to 76 % in women <50*)
• From 82% to 98% in western countries*
Mammography requires quality control
Continuous Training and Monitoring,
*IARC handbook of cancer prevention
Breast Self Examination
low* (<17%) low*
Randomized trials of BSE:
The Russian federation / WHO study
(Semiglazov et al. 2003)
193 000 women aged 40 to 64 (begun in 1985)
More BC death in the BSE group than the
The Shangai study (Thomas et al. 2002)
267 040 women aged 31 to 66 (begun in 1990)
No difference in mortality between BSE and
*IARC handbook of cancer prevention
BSE: a deceiving screening tool
• No effect on mortality by breast cancer
• High programmatic cost (training, reinforcement, management of
• For women: time consuming (training), adverse psychological
• Potential harmful effect (delayed presentation).
However “Breast awareness” cannot be overemphasized.
Women do not have to worry about BSE procedure but have to be
breast aware and ready to report anything suspicious to a
Clinical Breast Examination
Sensitivity (western countries)
• From 40% to 70%* # in western countries
• From 85% to 95%* in western countries
Low cost technique
Performable by non medical staff
Efficiency for screening is under evaluation (No RT results to date)
Duffy et Al. BHGI 2006: Modelisations suggest that the benefit of CBE is
a little more than half of the benefit of Mammography
*IARC handbook of cancer prevention, #BHGI guidelines
Which kind of program ?
If resources are low, choose carefully:
• The target population (cost effectiveness)
• The method for early detection (cheap)
• But also the organisation of the program
Early detection methods
• Screening aim at identifying the disease before
symptoms appears by applying a test to the population
The effective application of the tests to the right
population is critical.
• Clinical downstaging: aims at identifying the disease
through its very first symptoms.
Clinical downstaging programs relies on education of
health care providers and women as well as on efficient
referral and diagnosis procedures.
2. Clinical downstaging
2. Education of population at risk (poster,
pamphlet, presentation, medias, special
1. Education of Heath staff (training sessions)
4. Rapid diagnostic and treatment
Clinical downstaging in Sarawak
Population (2000) = 2.07 million
HDI = 0.805
Experience of downstaging in Sarawak,
Percentage of patients presented at late stage
for NPC, breast and cervix in DRO, SGH (1991-1999)
250 N breast
% late breast 70
% late NPC
percentage of late stage
number of patients
% late cervix 60
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percentage of late stage presentation for breast cancer was reduced
by half over 4 years.
Training Programme – 2 days
Students: health staff from 18 district hospitals of Sarawak
77 male/female nurses team from rural clinics (PHC)
Teachers: 1 coordinator, 1 clinical-oncologist, (1 ENT doctor),
1 gynecologist and 6 female and male nurses
Reasons for success
1. Increased awareness about cancer in the public & the
2. Increased interaction between the health professionals
and population (above all, in remote area)
3. Better organization: Improved referral (referral by
4. low cost : 10 000 $ (Poster, pamphlet, teaching material
+ travels of the training team, no salary cost)
Organization of programs
1. Write the plan, assess the tools needed (HR, posters, etc)
2. Obtain good statistics of the “before situation”
3. Pilot study in a small region/population (possibly comparing
4. Ensure a disciplined action
5. Obtain good statistic of the “after situation”. Ensure a fair
Planning Action Evaluation
Why to monitor the program ?
So many opportunities to go wrong…
• Reach more the women are lower risk (young) than the women at
high risk (old)
• Screen too much some groups saturate screening facilities
• Create anxiety saturate screening facilities with benign breast
• Low quality of screening tests (Mxm, CBE). False negative and false
• Poor follow up of positive women
• Poor access to treatment facilities diagnostic without treatment !
• Neglect the acceptance of the program (“Philippines effect”) in
women and men screening without diagnostic !
ALL THESE NEED TO BE MONITORED
The Philippine study
Outcome of screening by clinical examination of the breast in a trial in the Philippines.
Pisani et al. Int J Cancer. 2006
Objective: to assess whether mass screening by CBE is feasible in an urban
population of a low-income country, and its efficacy in reducing BC mortality.
151,168 women were interviewed and offered CBE, 92% accepted.
• 2.5 % (3479) were detected positive for a lump and referred for diagnosis.
• Of these only 35% completed diagnostic follow-up, whereas 42.4% actively
refused further investigation even with home visits, and 22.5% were not traced.
• This behaviour was not due to logisitic or economic barriers.
• In U.S. receipt of an abnormal mammography result is associated with
considerable psychiatric morbidity.
Conclusions: in this relatively well-educated population, cultural and logistic
barriers to seeking diagnosis and treatment persist and need to be addressed
before any screening programme is introduced.
clinical downstaging project
1- downstaging program targeted group
- education of PHC all PHC staff
2 days workshop
- education of the population
door to door visits women 35-65
women meetings (CBE) women 35-65
“men” awareness all population
2- barriers study BC cases
- socio / psycho / economic barriers
to early diagnosis and treatment
The Fakous project
Barrier study: Effect of the program on barriers (risk factors)
Barrier study: « risk factors » of late presentation
early BC late BC
Problems for early detection programs
in the EM region
• Lack of knowledge about the socio-cultural barriers existing in the
population. These may need behavioural interventions.
• Information and programs reach better the women at lower risk
• Misconception in the medical community (high risk groups, target
population, risk factors, etc)
• “technomania” (digital mammography…)
• Barriers inherent to the health system.
• Proper structures for diagnosis and treatment (available, affordable)
• No evaluation of cost and benefit of fighting breast cancer against
competing health needs
• Lack of 1/ planning, 2/ organisation, 3/ monitoring, quality control
Planification and quality control
Suba et al. Cervical cancer
prevention for all the world’s
women: genuine promise resides in
skilled quality management rather
than novel screening approaches.
In press 2007
• Careful planning: if you fail to plan, you plan to fail
• Importance of quality management:
• political and sociological obstacle to performance measurement
• Program leaders and staff need to be sensitized to quality and evaluation
Literature for Breast cancer
• Anderson et al. 2006. Breast cancer in limited-resource countries: an
overview of the Breast Health Global Initiative 2005 guidelines.
• Pisani et al. 2006. Outcome of screening by clinical examination of the
breast in a trial in the Philippines.
• Miller AB. 2005. Screening for breast cancer -is there an alternative to
• Semiglazov et al. 2003. Results of a prospective randomized investigation
[Russia (St.Petersburg)/WHO] to evaluate the significance of self-
examination for the early detection of breast cancer
• Anderson et al. 2003. Overview of breast health care guidelines for
countries with limited resources.
• Hackshaw & Paul. 2003. Breast self-examination and death from breast
cancer: a meta-analysis.
• Etzioni et al. 2003. The case for early detection.
Raising • Thomas et al. 2002. Randomized trial of breast self-examination in
awareness Shanghai: final results.
options • Mittra et al. 2000. Is clinical breast examination an acceptable alternative
to mammographic screening?
• Pinotti et al. 1993. Breast cancer control programme in developing