In resource-poor settings where universal screening for breast cancer using mammography is not a viable option, regular clinical breast examination could be an equally effective screening tool in reducing the incidence of advanced stage breast cancers and breast cancer mortality, a recent study by the Regional Cancer Centre here has found.

Women should be encouraged to undergo regular clinical examination for better chances of early detection of breast cancer, doctors at RCC pointed out.

The preliminary results in the first round (after three years) of a seven-year community-based trial, conducted by RCC in Thiruvananthapuram district, involving nearly 1,20,000 women to evaluate the effect of regular clinical breast examination has shown that early stage diagnosis of breast cancer was 58 per cent in the screened or intervention group against 39 per cent in the control group.

Similarly, Lymph node- negative cases were more in the screened population (50% vs. 43% in the control group) and the rate of breast conservative surgery was also more in the screened population (18% vs 5%).

The age-standardised incidence rate for early stage breast cancer (stage II A or lower ) was 18.8 per 100,000 women in the intervention group against 8.1 per 100,000 in the control group. The preliminary results of the study, being conducted by the Regional Cancer Centre, with the support of the International Agency for Research on Cancer and WHO, has been published in the August 2011 issue of the Journal of the National Cancer Institute

The community-based trial was being carried out since January 1, 2006, in 13 panchayats in Chirayinkeezh block. It involved screening nearly120,000 women between 30 and 69 years of age to evaluate the effects of clinical breast examination once every three years and then following them up for seven years.

The trial also involved an intervention package including awareness creation, early screening and diagnosis and treatment in the early stages for better outcome.

"The results of the first round (after three years of the study) indicated that out of the 50,366 women who underwent clinical breast examination, 2,880 were detected with suspicious findings which warranted further investigations and 30 were detected with breast cancer," K. Ramdas, the Medical Superintendent of RCC and one of the principal investigators of the trial said.

Even though countries like Singapore has introduced mammography as a standard tool for early breast cancer screening and has reported substantial reduction in mortality, it is not an affordable proposition in the State’s settings. But through regular clinical breast examination, palpable lumps can be identified and treated early.

Researchers disappointed

In the trial, about five per cent of women could be picked up, who had early cancer lesions. But researchers were also disappointed that despite their best efforts, only less than half the women who were screened and referred for further investigations, actually went back to RCC for tests.

"Less than 20 per cent women in the lymph node-negative breast cancer stage or early stage of breast cancer came back for treatment. Lumps of one cm size (very early stage ) detected through clinical examination can be fully treated and breast cancer mortality reduced considerably," Dr. Ramdas said.

The trial was all about teaching women to do breast self examination for identifying any small lumps or nodes. Health workers thus visited women in their homes with a small prosthesis to teach them to feel for lumps. Once in three years, they would visit the women and a doctor would conduct clinical breast examination. For suspected cases which required confirmatory tests, mammogram, fine needle aspiration cytology (biopsy) and ultrasound scans were offered free of cost.

For cases detected as positive, RCC sponsored basic cancer treatment up to Rs. 20,000.

Many women were fearful about undergoing confirmatory diagnostic tests because they had little support from their spouses and for many others, the difficulty in reaching the RCC and other family commitments may delay the treatment. Dr. Ramdas said that many patients who had confirmatory diagnosis did not come back for treatment because they had no means of continuing treatment.

Cancers cases go up

Cancer incidence among women in urban Thiruvananthapuram has been going up. IARC estimates that the incidence of breast cancer in Thiruvananthapuram district could be `moderately high’ at 65 per 100,000 among women in the 30 to 69 years group.

The annual incidence of breast cancer in the State has gone up from 17.4 per 100,000 in 1991 to the current rate of 32 per 100,000 in 2010. The number of new patients who registered for breast cancer treatment at the RCC in 2008 was 1,600. In 2007, this figure was 1,200. And shockingly, about 20 per cent of these cases were women who were below 35 years.

Since the past two years, RCC, has been joining the global breast cancer awareness movement by observing October as the Breast Cancer Awareness Month. Apart from awareness classes, women above 30 years can register themselves for free clinical examination all of this month.

The response to the programme has been tremendous and this year, more women, who have had breast cancer reported in the family, had come in for screening, RCC sources said.