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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.

References

1. Corbex M, Burton R, Sancho-Garnier H. Breast cancer early detection methods for low

and middle income countries, a review of the evidence. Breast 2012;21(4):428-34.

2. Burton R, Corbex M, Yip C-H. Early detection of cancer in Asia. In: Miller A, editor.

Epidemiological studies in cancer prevention and screening. New York: Springer Science

Business-Media, 2013.

3. International Agency for Research on Cancer. Breast Cancer Screening. Lyon, 2002.

4. International Agency for Research on Cancer. IARC Handbooks of Cancer Prevention

Lyon, France, 2004.

5. Towler B, Irwig L, Glasziou P, Kewenter J, Weller D, Silagy C. A systematic review of the

effects of screening for colorectal cancer using the faecal occult blood test, hemoccult.

BMJ 1998;317(7158):559-65.

6. World Health Organization. Entre Nous The European Magazine for Sexual and

Reproductive Health: WHO Regional Office for Europe, 2007.

7. Sankaranarayanan R, Esmy PO, Rajkumar R, Muwonge R, Swaminathan R,

Shanthakumari S, et al. Effect of visual screening on cervical cancer incidence and

mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet 2007;370(9585):398-

406.

8. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, Budukh AM, et al.

HPV screening for cervical cancer in rural India. The New England journal of medicine

2009;360(14):1385-94.

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