Can Breast Self-examination and Clinical Breast Examination Along With Increasing Breast Awareness Facilitate Earlier Detection of Breast Cancer in Populations With Advanced Stages at Diagnosis?

Abstract

Breast cancer is the most common form of cancer among women worldwide. Early detection is central to improving disease outcomes. Three main screening methods – mammography, breast self-examination (BSE), and clinical breast examination (CBE) – have been developed and tested in Western nations. There is ongoing debate regarding the efficacy of BSE and CBE in terms of mortality reduction, and a number of international organizations no longer recommend them as screening methods. In technically less developed countries, however, where women are usually diagnosed with breast cancer at advanced stages and younger ages, the benefits of BSE and CBE might outweigh the harm and facilitate early detection of breast cancer. This paper reviews the history of BSE and CBE and discusses their value as early detection methods. It can contribute to informed decision-making by health policy-makers and clinicians who are involved in breast cancer screening in the developing world to improve women’s well-being.

Introduction

Breast neoplasm is the most frequently reported malignancy among women globally, accounting for 24.2% of all female cancers in 2018.¹ In Saudi Arabia, as elsewhere, breast cancer is of concern. However, breast cancer behaves differently among Saudi women, with a median age at diagnosis of 50 years² in comparison with 62 years among women in the United States (US).³ This means that one-half of breast cancer cases among Saudi women are diagnosed at 50 years of age or younger. In fact, the most recent report from the Ministry of Health in Saudi Arabia revealed that nearly 19% of new breast cancer cases were recorded among women younger than 40 years, compared with only 4% for US women (Figure 1). This trend towards younger age in Saudi Arabia has also been reported in other studies.^4,5

In addition, in the Ministry report, Saudi women are commonly diagnosed at advanced stages of disease (57.3% are regional or distant metastatic breast cancers) in contrast to 37% in US women, as shown in Figure 2. A similar stage distribution has been observed among Saudi women in the literature.^2,5, 6, 7

In this context, it is important to understand the stages and the link between stage at diagnosis and breast cancer outcomes, such as survival, in order to highlight the importance of early diagnosis. If the breast cancer is detected when it is confined to its area of origin, this is referred to as localized. If the tumor has spread to another part of the body, it is referred to as regional or distant.³ The 5-year survival for localized breast cancer is 98.7%.³

Thus, the earlier breast cancer is detected, the better the outcome. However, it worth mentioning that some breast cancers that are detected at very early stages, such as ductal carcinoma in situ, are non-life-threatening and may have more harms than benefits. Data from the US showed that 31.6% of all screen-detected breast cancer was ductal carcinoma in situ.⁸ It has been argued that one possible drawback associated with early detection of these small cancer is what known as “overdiagnosis”.⁹ Overdiagnosis is the detection of breast cancer that would not cause any harm to a woman in her lifetime and that would not have progressed or otherwise been diagnosed in the absence of screening.¹⁰ Overdiagnosis is seen as the most concerning harm associated with screening as it might lead to physical, psychological, or economic harm to a woman as result of overtreatment and additional screening.¹¹ However, the true estimates of overdiagnosis vary across the studies (5% to more than 50%) largely owing to differences in measurement method, populations,¹² and some limitations related to study analyses.¹³ This variance has resulted in considerable concerns in regards to the true magnitude of overdiagnosis.¹² These concerns arise from the fact that adequate follow-up time (comparing screened with unscreened women) is required to provide the best estimates of overdiagnosis.¹² A recent independent analysis suggested that 19% is the best current estimate of overdiagnosis associated with mammography screening.¹²

There are 3 common techniques for breast cancer screening and early detection.¹⁴ The first and most universally accepted is mammography, which is the only stand-alone breast screening modality. The other 2 are breast self-examination (BSE) and clinical breast examination (CBE), which can play important supplemental roles in early cancer detection and overall breast health care.14, 15, 16

Mammography is associated with a reduction in mortality and in the rate of presentation at advanced stages. Among Austrian women aged 40 to 49 years, mammography accounted for a 17% drop in the risk of diagnosis at advanced stages.¹⁷ Recently, the Korean National Cancer Screening Program estimated that screening could result in a 59% reduction in advanced stage diagnosis.¹⁸ However, women’s participation in screening is critically important to achieve the desired outcomes, with a 70% participation rate recommended by the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis.¹⁹

Unfortunately, in Saudi Arabia, mammography screening is opportunistic in nature, and women’s engagement in screening practices is poor.²⁰ Recent data from the World Health Survey Plus showed that, among women aged 40 to 75 years, only 5% have had a mammogram²¹ in Saudi Arabia compared with 72.1% in the United Kingdom (UK).²² It should be noted that few studies on mammography screening and no randomized controlled trials (RCTs) on its efficacy have been conducted in Saudi Arabia. A 7-year longitudinal study in Riyadh (2007-2013) found that only 0.8% of women presented for screening among the targeted age group.²³ Similar rates were reported in other major cities, with 17.99% in Al-Qaseem over 3 years and 15% in Dammam over 5 years.²³

In the absence of organized screening programs, early detection is more likely to result from concerns expressed by women at the time they present with a symptom, during routine health care, or from CBE.¹⁴ If women do not practice BSE (owing to lack of knowledge of the BSE technique or understanding of its benefits), do not undergo CBE, or do not go for mammography screening, they are more likely to be diagnosed at advanced stages of breast cancer compared with women who adhere to breast screening recommendations.²⁴ It has been suggested that, in populations where women are diagnosed with breast cancer at an advanced stage, it would probably be cost-effective to teach BSE and to screen by CBE to improve breast cancer outcomes.²⁵ Thus, BSE and CBE may play an important role in facilitating early detection in Saudi Arabia.

Against this background, this paper explains the differences between screening and detection, reviews the literature on BSE and CBE and the debate around their role in facilitating early detection of breast cancer, and discusses recent developments in BSE and CBE. The main aim is to present information that can assist policy-makers, government officials, and health planners in the development and implementation of a screening program that meets population needs and maximizes women’s well-being in this part of the world.^16,26