|Year : 2014 | Volume
| Issue : 1 | Page : 14-18
Breast cancer screening in a resource poor setting: A preliminary report
Kenneth N. Ozoilo1, Michael A. Misauno1, Ogoamaka Chukwuogo2, Janefrances U. Ozoilo3, Emmanuel O. Ojo1, Ahmed A. Yakubu4
1 Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
2 Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
3 Department of Community Medicine, Jos University Teaching Hospital, Jos, Nigeria
4 Department of Surgery, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
|Date of Web Publication||15-May-2014|
Dr. Kenneth N. Ozoilo
Department of Surgery, Jos University Teaching Hospital, Jos, Plateau State
Source of Support: None, Conflict of Interest: None
Background: Breast cancer is a leading cause of death among Nigerian women. Patients typically present late with advanced and aggressive diseases from a younger age. Cure for breast cancer is only possible when the disease is discovered early and breast cancer screening greatly increases the chances of early detection. We present the results of a breast cancer screening program at the Taimako Breast and Cervical Cancer Screening Centre, Lafia, Nigeria.
Methodology: This is a prospective study of subjects who presented to our breast cancer screening centre between May 2009 and April 2010. A community mobilization and awareness campaign was mounted 3 months before screening began. A structured questionnaire was administered on each subject to elicit demographic data and risk factors. Each had a clinical breast examination. Those 35 years and above had a mammography while those below 35 years had breast ultrasound scan. Where a lump was discovered, it was subjected to tissue biopsy and histology.
Results: Two thousand and ninety five subjects were seen over the one year period. Mean age was 34 + 12 years. Mean age at menarche was at 14.3 + 1.7 years, mean parity was 3.6 +2.6. Two thousand and thirty six subjects (97.2%) had some knowledge about breast cancer, 1,269 (60.5%) had no formal education, 881(42.1%) were petty traders while 501(23.9%) were full time housewives. Four hundred and seventy (22.4%) had a positive family history of breast disease, 437 (20.9%) had history of use of oral contraceptives, and 9 (0.4%) had a previous breast biopsy. Four hundred and sixty one (22.0%) complained of breast discomfort, 184 (8.8%) complained of breast lumps, but only 95 (4.6%) of them had lump on clinical breast examination, while a further 8 (0.4%) lumps were found on breast imaging. One thousand nine hundred (90.7%) had normal breast screening results, 166 (7.9%) had benign breast diseases and 29 (1.4%) had breast cancer.
Conclusion: Knowledge about breast cancer was high because of prior campaigns and should be encouraged. Proportion of subjects with breast cancer is low even though many complained of breast lumps on presentation. Majority of the lumps were found at clinical breast examination while mammogram had a very low yield. A treatment arm needs to be incorporated into the screening program to demonstrate survival benefit.
Keywords: Breast cancer, poverty, screening
|How to cite this article:|
Ozoilo KN, Misauno MA, Chukwuogo O, Ozoilo JU, Ojo EO, Yakubu AA. Breast cancer screening in a resource poor setting: A preliminary report. J Med Trop 2014;16:14-8
|How to cite this URL:|
Ozoilo KN, Misauno MA, Chukwuogo O, Ozoilo JU, Ojo EO, Yakubu AA. Breast cancer screening in a resource poor setting: A preliminary report. J Med Trop [serial online] 2014 [cited 2022 May 17];16:14-8. Available from: https://www.jmedtropics.org/text.asp?2014/16/1/14/132569
| Introduction|| |
Breast cancer is the most common malignant disorder afflicting women worldwide and is the leading cause of death among them.  The incidence of breast cancer is generally higher in developed countries than in developing countries.  There is a general increase in the incidence of breast cancer globally, and this is more marked in societies that previously enjoyed a low incidence such as Nigeria.  Certain peculiarities of the disease among women of Negroid origin generally have become apparent. Among these populations, it occurs at a much younger age group, tends to run a more aggressive course and often presents late. This peculiarity is true for both African and African-American women.  Breast cancer is only curable when detected early and early detection is made possible by screening programs. The marked reduction in breast cancer mortality in recent decades in the developed world is attributable to the existence of breast cancer screening programs. , Such programs are not widely available in Nigeria. We present the preliminary results of one such effort from the Taimako Breast and Cervical Cancer Screening Centre in Lafia, North-Central Nigeria.
| Methodology|| |
Study design and setting
This was a study of women seen at the Taimako Breast and Cervical Cancer Screening Centre Lafia, Nasarawa State of Nigeria. Consecutive subjects who presented for breast cancer screening between May 2009 and April 2010 were studied. It was conducted at the Taimako Breast and Cervical Cancer Screening Centre, Lafia, Nasarawa state, North Central Nigeria. This program is the initiative of the wife of the former governor of Nasarawa state.
Subjects included in this study were women who presented to our center following an initial community mobilization and sensitization on breast cancer. The mobilization was carried out at the community level in each of the three senatorial districts of the state. It took the form of breast cancer awareness talks and was carried out 3 months before the commencement of screening. Consent was obtained from the subjects to participate in the study and ethical clearance was obtained from the Jos University Teaching Hospital Health Research and Ethics Committee.
All women who presented to the screening center had a structured questionnaire administered on them to obtain demographic information. Each of them subsequently had a clinical breast examination (CBE). Irrespective of CBE findings, they were further investigated. Those below 35 years of age had ultrasound examination of the breast done while those 35 years and above had mammography. Where a lump was found, whether by clinical breast examination, ultrasound or mammography, it was subjected to biopsy. All specimens were subjected to histology. Patients with a diagnosis of breast cancer or other breast diseases requiring further treatment were referred to the state specialist hospital.
All informations gathered were entered into a questionnaire on the Epi Info 3.5.1 software and analyzed using simple percentages.
| Results|| |
A total of two thousand and ninety-five subjects presented to our breast cancer screening center over the 1 year period. All were females. The ages ranged from 12 to 90 years with a mean age of 34 + 12 years. Two thousand and thirty-six (97.2%) of them had some knowledge about breast cancer. Educationally, 1269 (60.5%) had no formal education while 352 (16.8%) had tertiary education [Table 1]. Eight hundred and eighty-one (42.1%) were petty traders, 501 (23.9%) were full time housewives while 324 (15.5%) were civil servants [Table 2].
Four hundred and seventy (22.4%) had a positive family history of breast disease while 9 (0.4%) had a previous breast biopsy. Three hundred and eighty-five (18.4%) of them were post-menopausal while 1682 (80.3%) were premenopausal. Four hundred and thirty-seven (20.9%) had a history of use of oral contraceptives while 1657 (79.1%) did not. The mean parity was 3.6 + 2.6, while the mean age at menarche was 14.3 + 1.7 years.
One thousand four hundred and five subjects (67.1%) did not have any complaints, 461 (22.0%) presented with breast discomfort and 184 (8.8%) complained of breast lumps [Table 3]. One thousand nine hundred and fifty-four subjects (93.3%) had normal clinical breast examination, 96 (4.6%) had palpable lumps and 37 (1.8%) had other abnormalities on clinical breast examination. One thousand two hundred and ninety-three (61.7%) had breast ultrasound scan. Of these, ultrasound detected lumps in 32 (2.5%), cysts in 21 (1.6%) and was normal in 1193 (92.3%). Of the 32 lumps seen on USS, 6 (18.8%) were not previously detected by CBE. Mammography was done in 808 (38.6%). It revealed a lump in 32 subjects (4.0%) and was normal in 776 (96.0%). Of the lumps found on mammography, two were not previously obvious on CBE (6.3%), the rest (93.7%) having been.
A total of 104 lumps were detected (4.9%). Tissue biopsy was done in 95 subjects (4.6%), 9 (0.4%) defaulted. Sixty-six (69.5%) of these had a benign histology while 29 (31.5%) were malignant. All cysts found on ultrasound scanning were aspirated, none had malignant features and no cytology was done. Overall, 1900 (90.7%) subjects had normal breast screening results, 166 (7.9%) had benign breast diseases and 29 (1.4%) had breast cancer. None of the lumps that were only detected by USS or mammogram proved malignant.
| Discussion|| |
Of the 2095 subjects screened for breast cancer in this study, 29 were diagnosed with the disease (1.4%). Several factors may account for this apparent low yield. It may reflect the known fact that breast cancer incidence is generally low in African populations compared to white populations. Several studies have established that black women have a lower lifetime risk for breast cancer than their Caucasian counterparts.  It may also reflect the infancy of the screening program. It is likely that as the program progresses, more cases would be diagnosed.
The proportion of subjects who had prior knowledge about breast cancer was quite high (97.2%). Awareness of breast cancer is low generally in the African population. , This is particularly so in rural communities but also in urban settings. A survey of school teachers in Lagos, Nigeria found that 85% of the respondents had awareness about breast cancer  but only 53% knew that a breast lump was a significant symptom. Misauno and coworkers in Jos, found that even though the awareness for breast self examination among a cohort of final year medical students was high, the actual practice was poor.  Our finding shows a direct positive impact of the campaigns mounted prior to the commencement of the screening program and obviously influenced decision of the subjects to present. Studies have shown a positive correlation between breast cancer awareness and screening practices of women. ,,
Majority of our respondents, 60.9% had no formal education while 76.5% were not gainfully employed. This reflects the social and economic disadvantage of women in our society generally. This low socio-economic status has implications on breast cancer screening and treatment, and is a major determinant of awareness.  Ignorance of breast cancer is prevalent in societies with low socio-economic status. When there is awareness, it hinders utilization of screening tools even when these are available and free as in ours. For the same reason, women may not seek treatment early in the course of breast cancer. This disadvantage coupled with a biologic behavior that makes tumors in blacks more aggressive, of earlier onset and hormone receptor negative places women in our environment at a greater risk of dying from the disease.  These women would therefore benefit maximally from the advantage of early detection that screening offers. The apparent low yield/low incidence in the population should translate into greater cost effectiveness in overall breast cancer care in our society. Unfortunately, our screening program though free, is not complemented by a treatment arm. It is unlikely there that the women diagnosed with breast cancer will be able to afford treatment given their low socio-economic status.
Some of the known risk factors for breast cancer traditionally include early menarche and late menopause, nulli-parity, a positive family history and use of oral contraceptives.  Few of our subjects had these usual risk factors for breast cancer. Although 22.7% had a positive family history of breast diseases, it is unlikely that many of these were cancers. Many of them do not utilize hospital services so it was not possible to ascertain whether these were malignant or not. 20.9% had a history of oral contraceptive use, while only 0.4% had a previous breast biopsy. All previous biopsies were for benign disease. The mean age at menarche was 14.3 years while mean parity was 3.6 + 2.6, both higher than those of developed countries. In our study the mean age of respondents was 34 + 12 years while 18.6% of our subjects were post-menopausal reflecting a younger population. None of the risk factors showed a statistically significant association with breast cancer. This negative association with breast cancer risk factors may well explain the low yield of breast cancer in our study and thus support the notion of a generally low prevalence of the disease in our society.
Although majority of our subjects had no complaints, close to one quarter presented with breast discomfort. Again, even though 184 subjects complained of breast lumps, only 104 were actually found to have lumps after the assessment. Of that figure, nine did not turn up for the biopsy procedure, presumably out of fear of being diagnosed with cancer. Of all the subjects with lumps, only 29 (27.9%) actually had cancer. This is a very small percentage, (1.4%) of the total number of women examined. While this is an indication of the considerable anxiety associated with breast cancer among our women, our results should be of comfort because the vast majority of patients who were present for screening (98.6%) from our study actually do not have breast cancer. This anxiety is the tip of the iceberg concerning the psychological barriers to breast cancer diagnosis and management. An international conference of breast cancer survivor-advocates and advocates in 2005 identified several barriers to breast cancer advocacy.  These include personal fear at being diagnosed with breast cancer, beliefs and taboos which hinder awareness programs and treatment, and wrong perceptions about breast cancer. This may also be compounded by feelings of shame among family, a pervasive attitude of fatalism and a general feeling that cancer is not for one.  Such behaviors are particularly common among devout women of most religions and all the more prevalent in resource challenged environments like ours. Unfortunately, such fears only reinforce a vicious cycle of late presentation, necessitating mutilating and often futile treatment, resulting in death and increased dread for the disease, denial, and late presentation. A screening program such as ours is perhaps the first step toward breaking this vicious cycle through early detection with improved prospects for cure.
Of the modalities used in the breast cancer screening process, clinical breast examination had the most yield - 96 of the 104 lumps were found on CBE. This is in agreement with studies which show that CBE is a very effective screening tool for breast cancer in the community particularly in resource challenged areas.  Its yield is further enhanced when clinicians spend more time per examination and adopt a thorough, systematic technique.  Ultrasound confirmed 24 of the lumps found on CBE and identified six new lumps. Mammogram had the least yield confirming 30 of the lumps found on CBE and revealing only two new ones. We concede that various factors influence the diagnostic yield of the mammogram, ranging from the technical competence of the radiographer to the skill and experience of the interpreting radiologist, and the pathological type and behavior of the tumor. , We may have missed the subtle mammographic changes associated with non-palpable breast lesions as a result of such inexperience, given that ours was a new program. Expertise notwithstanding, conventional mammography is also limited by a decreased sensitivity in women with mammographically dense breasts  such as obtains in the younger population in our study. In our study, CBE had the most yields for detecting breast cancer. Studies comparing the relative yields of the mammogram versus the clinical breast examination indicates a much higher yield when both modalities are combined, but this is only true in older women; , our women are younger. Only magnetic resonance imaging of the breast has been shown to have consistently superior yield to all other modalities for all tumor types.  Against this background, we observe that we are unable to, on the strength of our findings, justify the huge resources expended in the acquisition and maintenance of a mammography unit in our setting. In contrast, ultrasound is cheap to acquire and maintain, easy to use, well tolerated, does not involve exposure to radiation and is widely available. It is handicapped by the operator dependence and the inability to detect micro-calcifications, but in combination with clinical breast examination has increased yield for detecting early breast cancer. 
The absence of a treatment arm is a major handicap of our breast cancer screening program. It is a truism of preventive medicine that a screening program cannot be justified in the absence of treatment availability. Those patients in whom breast cancer was diagnosed were referred to the nearby specialist hospital for treatment. In the absence of health insurance or free treatment for breast cancer in our society, it is doubtful that many of those diagnosed with cancer actually accessed treatment, given that most of them fall within the low socio-economic levels. It is therefore impossible to assess the impact of screening on outcome or demonstrate any survival benefit in these patients. It is our hope that partners will come in to complement our screening program with a treatment arm in order to demonstrate the survival benefits of breast cancer screening which have long since been established.
| Conclusions/Recommendations|| |
There is no doubt that breast cancer screening aids early detection of breast cancer, and there is no doubt that early tumors are more amenable to cure than advanced ones. Our results are modest and reflect the handicaps of our program. The apparent high awareness among our subjects was obviously due to the previous campaigns mounted. Our yield of breast cancer cannot be said to represent the true incidence of the disease in the locality since we only studied those subjects who presented to our facility. We recommend that more breast cancer screening centers should be set up across the country. Screening could start with simple measures such as awareness campaigns, teaching of breast self examination, clinical breast examination, ultrasound scans and biopsy where necessary. The absence of a mammography unit should not be an impediment to a screening program in our environment. We counsel that such dear funds are probably more wisely expended providing a treatment scheme for diagnosed cases of breast cancer, rather than acquiring one, unless it is a luxury that can truly be afforded.
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[Table 1], [Table 2], [Table 3]
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