Clinical breast examination (CBE) by trained health workers can detect breast cancer early and reduce mortality by 30 percent finds a new study published by the Tata Memorial Hospital (TMH), Mumbai.
The first of its kind study was conducted over a period of 20 years and shows clinical breast examination (CBE) to be as effective as mammography in early diagnosis and reduction of deaths from breast cancer.
These findings are particularly significant as they present an alternative to mammography in low and middle-income countries including India.
What Prompted the Study?
To answer this question, Dr C S Pramesh, Director of Tata Memorial Hospital (TMH), Mumbai, takes us back around 25 years into the past.
“In the late 90s, we would have a lot of women come in with breast cancer to the hospital, and their survival rate was very low. This was because they would only come in at a much later stage, when it was too late to do much,” he says.
Due to late detection in advanced stages, more than half the global deaths from breast cancer occur in low and middle-income countries.
In the case of cancer, early detection is key. In the west early detection of breast cancer was facilitated by mammography, something that was still new back then and not very feasible for us.”Dr C S Pramesh
This study, the brainchild of Dr Indraneel Mittra, Professor Emeritus, Department of Surgical Oncology Tata Memorial Centre, was conceptualised to find an alternative to mammography that could help detect breast cancer at an early stage and would, subsequently bring down mortality.
“Even today mammography has its limitations in a country like ours. It is very expensive and complex, requires expert radiologists, and mammography training isn't very feasible,” Dr Pramesh explains. “It also causes radiation hazards and a degree of discomfort.”
The Study, and Why It's Important
The findings of the study are based on 20 years of data from 1,51,538 women aged 35-64 with no history of breast cancer who were living in 20 geographically distinct clusters in Mumbai, India.
Women in the screening arm received four rounds of CBE conducted by trained female primary health workers and cancer awareness information every two years, followed by eight rounds of active surveillance by way of home visits every two years.
Women in the control group received one round of cancer awareness followed by eight rounds of active surveillance every two years.
Breast cancer was detected at an earlier age in the screening arm than in the control arm, with a significant reduction in the proportion of women with more advanced (stage III or IV) disease (37% v 47%) - known as downstaging.
“At the end of 20 years, the study found an overall 15% reduction in breast cancer deaths, and a significant 30% reduction in mortality in women over 50,” says Dr C S Pramesh.
When asked about the reason for the difference, Dr Pramesh explains that any kind of breast cancer intervention is more effective in women over 50 as the cancer is more easily recognisable then. Mortality from breast cancer, too, is higher past that age.
“Our study also showed that those below 50 could also benefit to the same extent provided they regularly attended all four rounds of screening. So younger women may choose to have regular Clinical Breast Examination instead of mammography.”Professor Indraneel Mittra, Professor Emeritus, Department of Surgical Oncology Tata Memorial Centre
“This study is particularly significant because it's the first and largest of its kind,” says Dr Pramesh. “The findings present CBE as a feasible, low cost, and easier alternative to mammography, that could be of immense help in India as well as in other countries.”
“The potential benefit from Clinical Breast Examination was unknown before our study,” adds Professor Mittra.
“It is also a landmark study as it may trigger a global debate about mammography. Mammography also reduces deaths from breast cancer to the same degree as we found with Clinical Breast Examination (30%), but it has major drawbacks in the form of overdiagnosis.”
“Nearly 30% of “cancers” detected by mammography are detected unnecessarily, because these small so called “cancers” are not life threatening and are harmless. Yet, once detected, women have to undergo surgery, radiotherapy and/or chemotherapy.”Professor Indraneel Mittra
Professor Mittra also points out that Clinical Breast Examination cannot be done by any doctor. “In our study, it was done by trained female health workers. If Clinical Breast Examination becomes a national policy, then a special cadre of trained female health workers will have to be created.”
“Until that time, breast cancer specialist surgeons should be capable of doing a proper Clinical Breast Examination.”
When asked what he hopes will come out of these findings, he says, “my hope is that these results will prompt the Indian Government to implement breast screening by Clinical Breast Examination as a national health policy. I also hope that other middle and low-income countries will do the same.”