DISEASE-SPECIFIC CANCER CONTROL
102 CANCER CONTROL 2014
principles of early diagnosis and referral and competent
treatment described above, managed to reduce breast cancer
late presentation from 60% to 35% in less than 5 years49, so
most women were then being diagnosed with early
potentially curable breast cancers. So the experience of many
high-income countries in Europe and Australia of falling
breast cancer-specific mortality is being replicated in a
middle-income Asian country and emphasizes the
importance of educating women to be "breast aware" so that
they detect changes in their breasts early. They must be
educated to visit a health care professional as soon as any
breast abnormality is found and there must be a system of
referral for diagnosis and competent surgical and adjuvant
therapy treatment.
The recommended adjuvant therapy by the EBCTCG of
anthracycline chemotherapy and tamoxifen endocrine
therapy is now very cheap and almost equal in effectiveness
to much more expensive chemotherapy with taxanes and
endocrine therapy with aromatase inhibitors.50,51
Conclusions
Unfortunately and tragically, population-based
mammographic screening in higher income countries has not
lived up to the promise of the RCT which began half a century
ago and concluded with the AGE RCT for women aged less
than 50 years in the mid-1990s.24 It is now likely that in a
number of high-income countries population-based
mammographic screening is causing considerably more harm
than good.
For low- and middle-income countries, education
programmes that make women breast aware, together with
the removal of financial or cultural barriers to access to a
health care system which can competently manage women
who present with breast abnormalities is the optimal
approach.52 However, it is critical that a system of affordable
and competent primary health care, which can offer CBE and
refers women with abnormalities for further diagnosis and
treatment are in place before women are educated to try and
detect breast cancer early. Raising women's awareness about
breast cancer would only make them anxious and reduce
their quality of life, unless there is a health care system that
can competently follow up on any breast abnormalities that
are discovered and diagnose and treat them competently;
adjuvant therapy is a critical component.
Although the benefits of early diagnosis (down-staging)
programmes have had little study, and their effect on breast
cancer has not yet been comprehensively assessed, WHO
recommends this approach as the minimal breast cancer
early detection intervention in low resources settings.53
WHO guidelines state that "A cancer screening programme is
a far more costly and complex undertaking than a downstaging programme.
Therefore, where resources are limited,
and where the majority of cases are diagnosed in late stages,
down-staging of the most frequent cancers, linked to
appropriate treatment, is likely to be the best option to
reduce premature deaths and suffering due to cancer."
There is a caveat to following this advice without a careful
analysis of resources for breast cancer control. "A major
potential hazard of a population early diagnosis programme is
overloading primary and secondary health care facilities with
women with breast complaints, given that up to 95% of
breast symptoms reported by women may not be cancer. In
this regard, the content and the quality of the breast
awareness messages delivered to the public are critical".1
Professor Robert Burton, MBBS, BMedSci, PhD, MD, BA, FRACS,
FRACP, FAFPHM currently works at the Department of
Epidemiology and Preventive. Medicine at Monash University,
Australia.
Professor Robin Bell is a medical epidemiologist with over 30
years experience working in women's health. She is the Deputy
Director of the Women's Health Program within the School of
Public Health and Preventive Medicine at Monash University,
Australia.
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