A cluster randomized,controlled trial of breast and cervix cancer screening in Mumbai,India: methodology and interim results after three rounds of screening

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster‐randomized, controlled, screening‐trial for cervix and breast cancer using trained primary health workers to provide health‐education, visual‐inspection of cervix (with 4% acetic acid‐VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2‐year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever‐screened and never‐screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health‐seeking behavior for gynecological and breast‐related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.     

Krebsfrüherkennung

Scientific evidence for the effectiveness of early detection and screening in cancer has been established in randomized clinical trials for three malignancies: cervix, breast, and colon cancer. In cervix cancer incidence and mortality can be reduced. In breast and colon cancer early detection and screening can only reduce mortality. The German guidelines currently in use for cancer screening have adapted these results. Some of the United States guidelines are less restrictive, leading to an increased incidence of some tumor entities such as prostate cancer. The clinical significance still needs to be established. The theoretical potential for reducing cancer mortality by screening measures is estimated to be 3–6%. However, it is to be expected that improvements in detection methods and better organization of screening program structures will increase the proportion of lives saved by screening measures.     

Effects of Tamoxifen on the Cervix and Uterus in Women with Breast Cancer: Experience with Iranian Patients and a Literature Review

Objective: Invasive breast cancer is the most common malignancy in women. Due to the declining mortalityrate that is partly attributable to the use of screening mammography and effective adjuvant therapy, morewomen survive their breast cancers. The aim of this study was to evaluate the effects of tamoxifen on the genitaltract with particular attention to the uterus and cervix. Methods: We investigated the relationship betweentamoxifen and cervical or uterine cancer in Iran, reviewing all the studies performed by the Vali-Asr GynecologyOncology Clinic in Tehran. In addition, the available data on Medline from 1980 until 2009 were reviewed.Results: A total of 182 articles showed associations with gynecologic malignancies. Although as many as 121refered to links between the drug and endometrial abnormalities (polyps or cancers), 55 articles studied therelationship with changes of pap smears, four of which indicated isolated cervical metastasis followed tamoxifenuse in patients with breast cancer. Conclusion: In spite of the significant relationship between tamoxifen andendometrial cancers, cervix is rarely involved in breast cancer patients. However, vaginal bleeding or abnormalvaginal discharge has been reported in all cases before the diagnosis was made. To rule out genital tract malignancy,it is necessary, therefore, to have an annual pelvic exam, pap smear and early endometrial with endocervicalcurettage for tamoxifen users following a breast cancer in those with abnormal uterine bleeding or persistentvaginal discharge.     

Cervical Cancer Prevention and Early Detection; The Role of Nurse and Midwives

Worldwide 31% of cancers in women are in the breast or uterine cervix. Cancer of the uterine cervix is one of the ‍leading causes of cancer death among women. The estimated new cancer cervix cases per year is 500.000 of which ‍79% occur in the developing countries, where it is consistently the leading cancer and there are in excess of 233.000 ‍deaths from the disease. The major risk factors for cervical cancer include early age at first intercourse, multiple ‍sexual partners, low socioeconomic status, HSV, HPV infection, cigarette smoking and extended use of oral ‍contraceptives. Well organized and applied public education and mass screening programmes can substantially ‍reduce the mortality from cervical cancer and the incidence of invasive disease in the population. Women who are ‍health conscious are more likely to have used screening services (mammogram, pap-smear test) and performed ‍breast-self examination and genital hygiene. There are both opportunities and burdens for nurses and midwives ‍working in primary health care settings. This is a prime example of a role of public education in cancer prevention ‍with reference to population-based cancer screening programs. ‍     

Role of early diagnosis and screening; biomarkers

Currently there is evidence to support the inclusion of screening for breast and cervix cancer in programs for cancer control. Breast cancer programs have an important impact in women over the age of 50, but increasingly there are suggestions that, at least in the early years, there are no benefits for women age 40 to 49, and even that mortality from breast cancer may be increased. Cervix cancer programs can have a major impact if appropriately organized. There is no justification at present to recommend screening for colorectal cancer. Screening can be expected to have only a minor influence on reduction in cancer mortality by the year 2000. Biomarkers may be of value as indicators of risk or indicators of disease. Some have been proposed for the former, such as mammographic parenchymal patterns and breast cancer risk. There are good theoretical reasons for not incorporating them in screening programs, as the program sensitivity will decrease, even if the program specificity increases. Biomarkers as indicators of disease may be valuable when the marker is linked to the etiologic agent for the disease, providing that valid screening tests can be developed for the marker, or could be a biological indicator of the presence of disease, such as a monoclonal antibody, specific to the cancer. Examples include markers for hepatitis B virus (HBV) infection and liver cancer screening, and potentially in the future, markers for human papillomavirus (HPV) infection and cervix cancer screening. Specific monoclonal antibodies to cancer utilizable in screening are being sought, but are not yet available for use. One example under evaluation is the CA 125 monoclonal for ovarian cancer.     

Combined Screening of Cervical Cancer,Breast Cancer and Reproductive Tract Infections in Rural China

Objectives: To investigate the current prevalence and knowledge of cervical cancer, breast cancer andreproductive tract infections (RTIs) in rural Chinese women, and to explore the acceptance and feasibility ofimplementing a combined screening program in rural China. Methods: A population-based, cross-sectionalstudy was conducted among women aged 30 to 59 years old in Xiangyuan County, Shanxi Province from 2009 to2010. Socio-demographic characteristics, knowledge of cervical cancer, breast cancer and RTIs, and the attitudetoward single or combined screening were collected by an interview questionnaire. Each participant receiveda clinical examination of the cervix, breast and reproductive tract. Examinations included visual inspection,mammography, laboratory tests and pathological diagnosis. Results: A total of 1,530 women were enrolled inthis study. The prevalence of cervical precancerous lesions, suspicious breast cancer, suspicious benign breastdisease and RTIs was 1.4%, 0.2%, 14.0% and 54.3%, respectively. Cervicitis, trichomonas vaginitis, and bacterialvaginitis were the three most common RTIs among our participants. Television, radio broadcast, and publiceducation during screening were the major source of healthcare knowledge in rural China. Moreover 99.7%of women expressed great interest in participating in a combined screening project. The affordable limit forcombined screening project was only 50 RMB for more than half of the rural women. Conclusion: A combinedscreening program would be more effective and popular than single disease screening projects, while appropriateaccompanied education and a co-pay model for its successful implementation need to be explored, especially inlow-resource settings.     

Screening for cancer of the head and neck: if not now, when?

There is as yet no evidence to support population screening for oral cancer, although the mouth is easy to examine, and the disease is common in certain parts of the world and/or subsegments of the population. Oral cancer screening programs have been carried out on several hundred thousands of individuals in developing countries (mostly India and Cuba) and several thousands in developed countries (mostly the U.S.A., U.K. and Italy). Especially in developed countries, lesions of the pharynx and larynx were also searched for. Substantial portions of individuals with suspicious lesions (around 10%), mostly leukoplakia, could be identified, but major difficulties were found in targeting highest-risk individuals and referring them to a specialised centre, when necessary. When oral inspection was repeated, relatively high incidence of oral cancer, after removal of prevalent cases, suggested a rather short sojourn time for preclinical cancer (in the order of one year). Oral cancer screening programmes would be greatly facilitated by screening tests able to anticipate the detection of a preclinical phase, compared to visual inspection, thus allowing screening intervals to be prolonged. Finally, even if dysplastic lesions of the oral cavity were better recognised and understood (e.g. as for intraepithelial lesions of the cervix uteri), surgical control of the disease would be harder than for the uterus, breast, or colon-rectum.     

Comparisons of interval breast cancers with other breast cancers detected through mass screening and in outpatient clinics in Japan

In a nation-wide collaborative study on mass screening for breast cancer, we collected 152 cases of interval breast cancer diagnosed at 35 hospitals or clinics distributed throughout Japan. The definition of interval breast cancer used in the present study is "breast cancer cases which were diagnosed as having 'no malignant findings' in a previous screening for breast cancer but subsequently diagnosed as 'breast cancer' at a hospital or medical clinic within two years of the previous screening." The clinical stages and prognoses of these interval cancer were analyzed and compared with those of other breast cancers detected through mass screening and in outpatient clinics. In the clinical staging of interval breast cancer, Tis (non infiltrating cancer) accounted for only 2.1%, compared to 8.0% in cases detected through mass screening. At stage I 43.4% were interval breast cancers compared to 32.9% breast cancers detected through mass screening and 25.4% diagnosed in outpatient clinics. The stage differences between interval breast cancers and breast cancers detected through mass screening were not statistically significant. Five-year survival rates were 85.6% for interval breast cancers, 91.7% for breast cancers detected through mass screening and 84.7% for breast cancers diagnosed in outpatient clinics. Ten-year survival rates were 75.9, 80.5 and 78.1%, respectively, suggesting the interval breast cancer cases to show a similar prognosis to that of breast cancer cases diagnosed in outpatient clinics. The differences in five- and 10-year survival rates among the three groups were not statistically significant. From the present study we were not able to confirm the general belief of interval cancer being more aggressive in nature and showing a poorer prognosis than cancer detected through periodic screening. The reasons for this are discussed.     

Awareness of Cancer Screening During Treatment of Patients with Renal Failure: A Physician Survey in Turkey

Background: Today, survival rate of patients with chronic renal failure/hemodialysis has increased so thatchronic illnesses are more likely to occur. Cancer is the main cause of morbidity and mortality in such patients.Aim: In this study, physician attitudes were examined about cancer screening in patients with renal failure.Materials and Methods: This study was done by face to face questionnaire in the 27th National NephrologyCongress to determine if the physicians dealing with chronic renal failure, hemodialysis or renal transplantedpatients, recommend cancer screening or not and the methods of screening for cervix, prostate, breast and coloncancer. Results: One hundred and fifty six physicians were included in the survey. A total of 105 (67%) participantswere male and the age of responders was 48±9 years. About 29% were specialists in nephrology, 28% internalmedicine, and 5% were other areas of expertise. Some 48% of participants were hemodialysis certified generalpractitioners. Patients were grouped as compensated chronic renal failure, hemodialysis or renal transplanted.Of the 156 responders, 128 (82%) physicians recommended breast cancer screening and the most recommendedsubgroup was hemodialysis patients (15%). The most preferred methods of screening were combinations ofmammography, self breast examination and physicianbreast examination. 112 (72%) physicians recommendedcervix cancer screening, and the most preferred method of screening was pap-smear. Colon cancer screeningwas recommended by 102 (65%) physicians and prostate screening by 109 (70%) physicians. The most preferredmethods of screening were fecal occult blood test and PSA plus rectal digital test, respectively. Conclusions: Itis not obvious whether cancer screening in renal failure patients is different from the rest of society. There isa variety of screening methods. An answer can be found to these questions as a result of studies by a commonfollow-up protocol and cooperation of nephrologists and oncologists.     

Status of implementation and organization of cancer screening in The European Union Member States—Summary results from the second European screening report

The second report on the implementation status of cancer screening in European Union (EU) was published in 2017. The report described the implementation status, protocols and organization (updated till 2016) and invitation coverage (for index year 2013) of breast, cervical and colorectal cancer screening in the EU. Experts in screening programme monitoring (N = 80) from the EU Member States having access to requisite information in their respective countries provided data on breast, cervical and colorectal cancer screening through online questionnaires. Data was collected for screening performed in the framework of publicly mandated programmes only. Filled in questionnaires were received from 26 Member States for all three sites and from one Member State for breast cancer only. Substantial improvement in screening implementation using population‐based approach was documented. Among the age‐eligible women, 94.7% were residents of Member States implementing or planning population‐based breast cancer screening in 2016, compared to 91.6% in 2007. The corresponding figures for cervical cancer screening were 72.3 and 51.3% in 2016 and 2007, respectively. Most significant improvement was documented for colorectal cancer screening with roll‐out ongoing or completed in 17 Member States in 2016, compared to only five in 2007. So the access to population‐based screening increased to 72.4% of the age‐eligible populations in 2016 as opposed to only 42.6% in 2007. The invitation coverage was highly variable, ranging from 0.2–111% for breast cancer, 7.6–105% for cervical cancer and 1.8–127% for colorectal cancer in the target populations. In spite of the considerable progress, much work remains to be done to achieve optimal effectiveness. Continued monitoring, regular feedbacks and periodic reporting are needed to ensure the desired impacts of the programmes.     

Time Trend in Breast and Cervix Cancer of Women in India, (1990-2003)

The Indian Council of Medical Research (ICMR) started a National Cancer Registry Programme (NCRP)in the year 1982 with the main objective of generating reliable data on the magnitude and pattern of cancer inIndia. There are about 20 Population Based Cancer Registries (PBCR) which are currently functioning underthe network of NCRP. The present paper aims to provide the time trends in the incidence of breast and cervixcancer among females of India. The incidence data collected by Bangalore, Barshi, Bhopal, Chennai, Delhi andMumbai over the period 1990 to 2003 formed the sources of data. In the year 1990, cervix was the leading site ofcancer followed by breast cancer in the registries of Bangalore (23.0% vs. 15.9%), Bhopal (23.2% vs. 21.4%),Chennai (28.9% vs. 17.7%) and Delhi (21.6% vs. 20.3%), while in Mumbai breast was the leading site of cancer(24.1% vs. 16.0%). By the years 2000-3, the scenario had changed and breast had overtaken as the leading siteof cancer in all the registries except in Barshi (16.9% vs. 36.8%). The time trend analysis for these sites suggesteda significant decreasing trend in the case of cervix in Bangalore and Delhi registries, while the registries ofBhopal, Chennai and Mumbai did not show any significant changes. However, in the case of breast cancer, asignificant increasing trend was observed in Bhopal, Chennai and Delhi registries with Bangalore and Mumbairegistries demonstrating no such significant changes. Histopathologic confirmation for both malignancies wasfound to be more than 80% in these registries. It is concluded that in India the cervix cancer rates are decreasingwhile breast cancer is on the increase.     

Awareness of breast and cervical cancer risk factors and screening behaviours among nurses in rural region of Turkey

Breast and cervical cancer are the most common causes of cancer mortality among women worldwide, but actually they are largely preventable diseases. There is limited data on breast and cervical cancer knowledge, screening practices and attitudes of nurses in Turkey. A self-administered questionnaire was used to investigate the knowledge and attitude of nurses on risk factors of the breast and cervical cancer as well as screening programmes such as breast self-examination (BSE), clinical breast examination, mammography (MMG) and papanicolaou (pap) smear test. In total, 125 out of 160 nurses participated in the study (overall response rate was 80.6%). The risk factors and symptoms of breast cancer was generally well known, except for early menarche (23.2%) and late menopause (28.8%). For cervical cancer, the correct risk factors mostly indicated by the nurses were early age at first sexual intercourse (56%), smoking (76%), multiple sexual partners (71.2%). As for screening methods, it was believed that BSE was a beneficial method to identify the early breast changes (84.8%) and MMG was able to detect the cancer without a palpable mass (57.6%). Little was known about the fact that women should begin cervical cancer screening approximately 3 years after the onset of sexual intercourse (23.2%) and if repeated pap smear test were normal, it could be done every 2–3 years. Most of the nurses considered that MMG decreases the mortality in breast cancer (65.6%) and also believed that pap smear test decreases the mortality in cervical cancer (75.2%). Despite high level of knowledge of breast cancer risk factors, symptoms and screening methods, inadequate knowledge of cervical cancer screening method were found among nurses.     

110例乳腺间期癌的临床病理特征分析

目的 分析顺义区三轮乳腺癌筛查中110例间期癌患者的临床及病理特征。方法 将顺义区历年乳腺癌发病个案信息与北京市妇幼保健网络信息系统中适龄女性乳腺癌筛查数据进行关联,查询乳腺间期癌患者。将间期癌患者与同时期在我院乳腺中心就诊的乳腺癌患者进行特征比较。结果与门诊收治的原发性乳腺癌相比,间期癌患者年龄偏小、超声肿物较小,差异均有统计学意义（P＜0.05）。与病灶大小相近的门诊收治的乳腺癌患者相比,真正间期癌X线检查恶性钙化和浸润性导管癌的比例均较高,差异均有统计学意义（P＜0.05）。间期癌患者在乳腺癌筛查中转诊X线检查比例很低（0.91%）,而110例间期癌确诊时有103例接受了乳腺X线检查,其中53例（48.2%）存在恶性钙化表现。结论 乳腺癌筛查中,年龄偏小的女性更易发生间期癌。由于间期癌患者中接近50%在诊断时存在X线下恶性钙化表现,因而若在以超声检查为主的乳腺癌筛查过程中结合乳腺X线检查,或许可以避免部分间期癌的发生。     

Analysis of Predictors of Breast Cancer Screening among Japanese Women using Nationally Representative Survey Data, 2001–2013

Objective: Predictors of participation in breast cancer screening in recent years or the trend of participation rate by predictors over the years has not been investigated in Japan. In this study, we investigated predictors for participation in breast cancer screening and analyzed the trend of participation rate depending on the predictors using nationally representative survey data in Japan. Methods: The data of “Comprehensive Survey of Living Conditions” in Japan from 2001 to 2013 were used. Participation in breast cancer screening was used as an outcome. Next, as explanatory variables, we used age group, marital status, living arrangements, educational level, household income, employment status, smoking status, regular outpatient visit status, and self-rated health status. Then, the participation rate for breast cancer screening was calculated for each of the factors over the years. In addition, multivariate logistic regression analysis was conducted to analyze the association between each factor and the participation rate using data from 2010 and 2013. Results: We found that non-married women, women with lower educational level, women with low household income, self-employed or unemployed women, smokers, and women with low self-rated health status were significantly less likely to participate in breast cancer screening. Conversely, the participation rate increased for all predictor groups from 2001 to 2013, and the increase in the participation rate for never-married women was particularly evident compared with the other marital statuses. However, significant differences in the participation rate for breast cancer screening existed depending on marital status, household income, employment status, and smoking status throughout the analyzed years. Conclusion: Our findings suggest that further recommendations for breast cancer screening are particularly needed among women of low socioeconomic status and those who are self-employed or unemployed to increase the participation rate in Japan.     

Determinants of Breast Cancer Screening Practice among Women in Indonesia: A Nationwide Study

Background: Breast cancer remains the leading cause of death for women globally, including in Indonesia. Breast cancer screening plays a vital role in reducing deaths caused by breast cancer. However, breast cancer screening rate is still low and studies on determinants for breast cancer screening is limited in Indonesia. This study aimed to identify the determinants of breast cancer screening among women in Indonesia. Methods: This population-based study was conducted among 827 women who lived in either rural and urban areas, using a stratified sampling design where were based on province and locality combinations. Data were analysed using a binary logistic regression model to assess the associations between independent and dependent variables. Results: As many as 827 women with an average age of 29.91 (± 11.14) years old participated in this study. The overall breast cancer screening among women was 18.74%. Knowledge of breast cancer risk factors, signs, and symptoms (adj.OR = 1.75, 95%CI: 1.20 – 2.56), age of 35 to 39 years old (adj.OR. = 1.52, 95% CI: 1.02 – 2.26), and household income of ≥6,000,000 IDR (≥457 USD) (adj.OR. = 5.19, 95%CI: 1.43–18.84) were associated with breast cancer screening attendance. In contrast, Christian women had a significantly lower breast cancer screening rate that women from other religions (adj. OR. = 0.45, 95%CI: 0.24 – 0.85). Conclusion: The overall breast cancer screening attendance was poor among Indonesian women population. Age, household income, religion, and knowledge of breast cancer risk factors were identified as the determinant factors for breast cancer screening.     

Decreased rates of advanced breast cancer due to mammography screening in The Netherlands

The effect of the implementation of the Dutch breast cancer screening programme during 1990-1997 on the incidence rates of breast cancer, particularly advanced breast cancer, was analysed according to stage at diagnosis in seven regions, where no screening took place before 1990. The Netherlands Cancer Registry provided detailed data on breast cancer incidence in 1989-1997 by tumour stage, age and region. Annual age-adjusted incidence rates of all breast cancers and advanced cancers, defined as large tumours T2+ with lymph node and/or distant metastases, were compared with rates in 1989. In general, breast cancer incidence rose strongly in the early 1990s, especially in the age category 50-69 years (estimated annual percentage change (EAPC) 4.25; 95% CI 1.70, 6.86). The increase was mainly due to the increase in small T1 cancers and ductal carcinoma in situ. However, in women aged 50-69, advanced cancer incidence rates showed a significant decline by 12.1% in 1997 compared with 1989 (EAPC -2.14, 95% CI -3.47, -0.80), followed by a breast cancer mortality reduction of similar size after approximately 2 years. We confirm that breast cancer screening initially leads to a temporary strong increase in the breast cancer incidence, which is followed by a significant decrease in advanced diseases in the women invited for screening. It is evident that breast cancer screening contributes to a reduction in advanced breast cancers and breast cancer mortality.