Elsevier

The Breast

Volume 16, Issue 2, April 2007, Pages 113-119
The Breast

REVIEW
How relevant is breast cancer screening in the Asia/Pacific region?

https://doi.org/10.1016/j.breast.2006.08.005Get rights and content

Summary

Nationwide breast cancer screening with mammography is well-established in many western countries. Many studies have shown its benefit in mortality reduction. However, breast cancer screening in Asia has been slow to implement, as it was perceived that the breast cancer incidence was low and the parenchyma of Asian women was difficult to assess mammographically. With changing disease patterns, breast cancer is now one of the most common cancers amongst women in Asia. Breast cancer screening has become an important and relevant health problem. However, apart from biological differences between western and Asian women, cultural and economic considerations need to be addressed. This paper looks at the various issues pertaining to the feasibility and relevance of population-based screening in the Asia/Pacific region.

Introduction

Breast cancer is the most common female cancer and one of the leading causes of death among women internationally.1, 2, 3 Although worldwide figures show a rising incidence, mortality rates have been kept stable or low in many western populations.1, 4 Some authors have attributed this to their population-based screening programmes.4, 5 However, this is not the case in many of the developing countries in the Asia/Pacific region. It was perceived that breast cancer incidence was low and the parenchyma of Asian women difficult to assess mammographically.6

With changing disease patterns, breast cancer is also now one of the most common cancers amongst Asian women.1, 2, 3 However, many women still present with locally advanced or metastatic breast cancer resulting in poor survival figures. This paper aims to look at the social, cultural and economic issues on the acceptance and implementation of a population-screening programme in the countries in the Asia/Pacific region.

Europe and North America have a high incidence of breast cancer. Several trials have shown that mammographic screening for breast cancer is successful in identifying breast cancer at an early stage.7, 8, 9, 10, 11, 12, 13, 14 A 24% average reduction in mortality has been reported from screening women above 50 years of age.8 Randomised trials tend to underestimate the benefit to the individual woman due to non-attendance in the study arm and mammography contamination in the control group. Tabar et al.8 has suggested that the breast cancer mortality reduction for the individual woman may be as high as 63% (beyond randomised trials). Some trials have also indicated a survival benefit for women aged 40–49 years.15, 16, 17 Early-stage breast cancers are more amenable to breast conservation surgery, sparing women a mastectomy with no reduction in long-term survival.18, 19, 20

Successes have been reported from major nationwide breast screening programmes. For instance, the National Health Service Breast Screening Programme screened almost 1.8 million women in the UK in the year 2004/2005 with a cancer detection rate of 8 per 1000, 20% being due to non-invasive carcinoma. The 5-year survival for invasive cancers detected in 1999/2000 was 96.5%.21 Similar results were reported in New South Wales, Australia, showing a 32% reduction in breast cancer mortality.22

Section snippets

Breast cancer incidence

In the 1980s, the incidence of breast cancer in Europe and North America was comparatively higher than that in Asia.23 Although the incidence of breast cancer in Asia was lower than that in the western world, it has been steadily increasing over the years (Fig. 1).1, 2, 4, 14, 23, 24, 25, 26, 27, 28, 29, 30, 31

Breast cancer is currently one of the most common cancers in many of the developing and developed countries in Asia. Unfortunately, many Asian women present breast cancer at a more

Mortality and survival rates

The survival rates and mortality rates of breast cancer in many developing Asian countries are often lacking or unreliable due to poor patient follow-up and inadequate systems of cancer and death registry. However, there has been a gradual increase in mortality in Japan, Singapore and India.4, 37, 38 Overall 5-year survival rates for breast cancer vary greatly from 81% in Taiwan to 42% in Bangalore, India.37, 39 The advanced stage disease on presentation was believed to account for the poor

Mammography

Asian women with their smaller breast volume and relatively dense parenchyma were considered unsuitable for screening mammography because the films were difficult to interpret, resulting in lower sensitivity for detecting abnormalities. Maskarinec et al.6 studied the differences in mammographic densities in Japanese, Chinese, Caucasians and native Hawaiians. They found that the unadjusted mean dense area was 15% smaller in Japanese and Chinese women but the percentage of the breast occupied by

Breast cancer screening in Asia

Mammogram screening for breast cancer is routine practice in many western countries. In Asia, there have been conflicting results of screening efforts. However, most studies in the region have also shown that mammographic screening is superior to clinical examination.43, 44, 45

In Hong Kong, Chan et al.46 studied 13,033 women who underwent screening by breast examination and two-view mammography and reported an overall cancer detection rate of 4.94 per 1000 women aged 40–70 years. Leung et al.47

Attitudes and acceptance

Several studies of migrant Asians to western countries have reported an under utilisation of cancer screening services because of language, cultural and economic barriers.50, 51, 52, 53, 54 There is generally a low level of knowledge and misconceptions about breast cancer and screening.

In the Singapore breast screening project, 64,473 women were invited to a free screening mammogram for breast cancer. The response rate was only 41.7%. These respondents were women who were working, in the higher

Implementation of a screening programme in the Asia Pacific region

The implementation of a screening programme is no easy task. Careful planning and adequate facilities, manpower and resources are essential. A dedicated multidisciplinary panel of specialists is needed for quality assurance. Facilities and expertise to do further assessment must also be available.

Role of the family physician

The family physician is often the first doctor the woman consults for general medical ailments. She builds a rapport and friendship with the physician and is therefore more comfortable and more amenable to advice.59 This puts the family physician in an ideal position to inform and educate the woman with regard to health checks and screening mammograms.60, 61 However, he or she should not only be prepared to deal with truly positive abnormal mammograms, but also false-positive and -negative ones

Conclusion

The incidence of breast cancer has been rising and is now one of the most common cancers among women in Asia. Breast cancer screening has become an important health issue. The positive results of breast cancer screening in the west suggests that population screening would be beneficial in Asia/Pacific countries with a high incidence of breast cancer.

However, economic, logistic and cultural barriers are obstacles to a successful programme. Public education to debunk myths and misconceptions is

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