Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal.

BACKGROUND: The aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature. METHODS: We searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review. RESULTS: Fifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was < 1/1000 to 3.3/1000 and 3.3/100 to 56/1000 for CBE and mammography screening respectively. There was a lot of heterogeneity in CBE methods, target age for screening and no clear documentation of screening interval. Cost-effective analyses showed that CBE screening linked to comprehensive cancer care is most cost effective. There was limited discussion of the ethics of screening, including the possible harms of screening in the absence of linkage to care. The gap between conducting good screening program and the appropriate follow-up with diagnosis and treatment remains one of the major challenges of screening in SSA. DISCUSSION: There is insufficient real-world data to support the systematic implementation of national breast cancer screening in SSA. Further research is needed to answer important questions about screening, and national and international partnerships are needed to ensure that appropriate diagnostic and treatment modalities are available to patients who screen positive.

Recommendations on prevention and screening for breast cancer in Hong Kong.

In Hong Kong, breast cancer is the most common cancer among women and poses a significant health care burden. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) was set up in 2002 by the Cancer Coordinating Committee to review and assess local and international scientific evidence, and to formulate recommendations for cancer prevention and screening. After considering the local epidemiology, emerging scientific evidence, and local and overseas screening practices, the CEWG concluded that it was unclear whether population-based breast cancer screening did more harm than good in local asymptomatic women at average risk. The CEWG considers that there is insufficient evidence to recommend for or against population-based mammography screening for such individuals. Women who consider breast cancer screening should be adequately informed about the benefits and harms. The CEWG recommends that all women adopt primary preventive measures, be breast aware, and seek timely medical attention for suspicious symptoms. For women at high risk of breast cancer, such as carriers of confirmed BRCA1/2 deleterious mutations and those with a family history of breast cancer, the CEWG recommends that they seek doctor's advice for annual mammography screening and the age at which the process should commence. Additional annual screening by magnetic resonance imaging is recommended for confirmed BRCA1/2 mutation carriers or women who have undergone radiation therapy to the chest between the age of 10 and 30 years. Women at moderate risk of breast cancer should discuss with doctors the pros and cons of breast cancer screening before making an informed decision about mammography screening every 2 to 3 years.

Screening mammograms in Alzheimer's disease patients.

Very little guidance exists to help clinicians and families decide whether mammograms are useful in elderly women with Alzheimer's Disease (AD). We present a case of a patient with moderate AD who had a positive mammogram and discuss the dilemma faced by the family and clinician in deciding what was best to do for the patient. In this case, the family opted for breast conserving surgery (BCS) followed by palliative care which brought up the question of whether screening was appropriate with this treatment goal in mind. We reviewed the literature on AD and breast cancer screening and summarize these findings in our discussion.

[Methods to increase participation in cancer screening programmes]. / Metodi per aumentare la partecipazione ai programmi di screening oncologici.

OBJECTIVE: to synthesize scientific evidences about methods to increase cervical, breast and colorectal cancer screening participation. METHODS: a multidisciplinary working group has been set up to define the scope of the report and to conduct the evaluation. The scope and the final evaluation have been submitted to a stakeholder committee, including the Ministry of Health, the National Screening Observatory, regional screening program coordinators, scientific societies, and Lega Italiana Lotta ai Tumori, for comments and integrations. A systematic review of the principal biomedical and social literature databases was conducted to identify experimental and observational studies, updating the existing review by Jepson and coll. (Health Technol Assess. 2000;4(14):i-vii, 1-133). RESULTS: 5900 have been identified, 900 relevant for the topic.Among those, 148 reported quantitative information on intervention efficacy, other 90 came from the previous review. Organised screening programmes, based on invitation letter or on GP involvement,were consistently effective in increasing participation compared to spontaneous screening. Interventions are classified according to their target: individual, community, test simplification, health operators, health service organization. The report presents meta-analyses on efficacy, analyses of cost-effectiveness, impact on organisation and social inequality, and ethical and legal issues, of all the intervention reported in the literature. CONCLUSIONS: there are several interventions consistently effective in any context, some of them have minimal impact on costs and health service resources.

Informed choice requires information about both benefits and harms.

A study found that women participating in mammography screening were content with the programme and the paternalistic invitations that directly encourage participation and include a pre-specified time of appointment. We argue that this merely reflects that the information presented to the invited women is seriously biased in favour of participation. Women are not informed about the major harms of screening, and the decision to attend has already been made for them by a public authority. This short-circuits informed decision-making and the legislation on informed consent, and violates the autonomy of the women. Screening invitations must present both benefits and harms in a balanced fashion, and should offer, not encourage, participation. It should be stated clearly that the choice not to participate is as sensible as the choice to do so. To allow this to happen, the responsibility for the screening programmes must be separated from the responsibility for the information material.

Challenges of informed choice in organised screening.

CONTEXT: Despite much research on informed choice and the individuals' autonomy in organised medical screening, little is known about the individuals' decision-making process as expressed in their own words. OBJECTIVES: To explore the decision-making process among women invited to a mammography screening programme. SETTING: Women living in the counties of Sør- and Nord-Trøndelag, Norway, invited to the first round of the Norwegian Breast Cancer Screening Program (NBCSP) in 2003. METHODS: Qualitative methods based on eight semistructured focus-group interviews with a total of 69 women aged 50-69 years. RESULTS: The decision to attend mammography screening was not based on the information in the invitation letter and leaflet provided by the NBCSP. They perceived the invitation letter with a prescheduled appointment as if a decision for mammography had already been made. This was experienced as an aid in overcoming the postponements that easily occur in daily lives. The invitation to mammography screening was embraced as an indication of a responsible welfare state, "like a mother taking care." CONCLUSION: In a welfare state where governmental institutions are trusted, mass screening for disease is acknowledged by screening participants as a valued expression of paternalism. Trust, gratitude, and convenience were more important factors than information about benefits, harms, and risks when the women made their decisions to attend screening. These elements should be included in the ethical debates on informed choice in preventive medicine.

Breast cancer screening.

Cass R. Sunstein's 2016 book The Ethics of Influence: Government in the Age of Behavioral Science provides an extremely informative introduction to the science and ethics of the exercise of "influence" over others. As a longtime physician employed in both the public and private sectors, I now recognize that most of my formal training has been in the hard sciences, with little, if any, training in the appropriate influence of the decision-making processes of my patients and/or other health care professionals in institutional settings. Breast cancer screening is an excellent example of the conflicts of modern medicine, highlighting our collective inability to effectively "nudge" others in the pursuit of health and/or organizational effectiveness and efficiency. Using the framework of Sunstein's ethical values of welfare, autonomy, dignity, and self-government, I discuss many of the conflicting issues in a nationwide breast cancer screening program and the effects of these issues on client nudging to determine whether mammography screening is ethical.

Commentary on duty of candour and cancer screening.

English law mandates a duty of candour (DOC) for all healthcare providers. They must be open and honest when something goes wrong with care causing harm. Providers must apologize to those affected and investigate what happened. Screening is not 100% accurate and false positive and false negative results are inevitable. Guidance on DOC assists providers to judge when something has gone wrong in screening and the DOC legislation applies. DOC guidance helps distinguish such incidents from harms that are an expected and inevitable consequence of the imperfections of screening tests. For breast cancer screening the classification of interval cancers has been updated to take account of DOC. This guidance on DOC and classification of prior films of those presenting with interval cancers has relevance to other areas of diagnostic imaging. Review of prior examinations after a significant diagnosis has been made may reveal a previously overlooked abnormality.

Neighborhood-level socioeconomic predictors of nonadherence to mammography screening guidelines.

As neighborhood context is increasingly recognized as an important predictor of health outcomes and health behaviors, this analysis sought to determine the relationship between neighborhood-level socioeconomic status (SES) and regular mammography screening behavior. One thousand four hundred fifty-one women ages 40 to 79 years who obtained an "index" screening mammogram at one of five urban hospitals in Connecticut between October 1996 and January 1998 were enrolled in this prospective study. The logistic regression analysis includes the 1,229 women [484 African-American (39%) and 745 White (61%)] who completed telephone interviews at baseline and follow-up (average 29.4 months later) and for whom the study outcome, nonadherence to age-specific mammography screening guidelines, was ascertained. Neighborhood-level SES was determined using 1990 census tract information. Neighborhood-level SES variables (quartiles) were associated with nonadherence for African-American women [neighborhood-level education and composite socioeconomic position index (SEP Index)] and White women (neighborhood-level crowding and neighborhood-level assets). Using race-specific categorizations reflective of individual-level SES distributions, the SEP Index and neighborhood-level education were associated with nonadherence to mammography screening guidelines for African-American women (marginally significant for White women), independent of individual-level SES and other known predictors of mammography screening use [African-American women: SEP Index odds ratio (OR), 3.55; 95% confidence interval (95% CI), 1.33-9.51; neighborhood-level education OR, 3.21; 95% CI, 1.25-8.26; White women: SEP Index OR, 2.13; 95% CI, 0.97-4.67; neighborhood-level education OR, 2.31; 95% CI, 0.93-5.76]. The results of this analysis underscore the importance of examining neighborhood social context as well as individual factors in the study of mammography screening behavior.

Patient Care, Communication, and Safety in the Mammography Suite.

Producing high-quality mammograms requires excellent technical skills along with exemplary communication. Mammographers must be able to address differences in patients' mental states, body habitus, and physical ability to obtain an optimal examination. In addition, every mammographer must practice consistently with patient safety, care, and satisfaction in mind. This article discusses verbal and nonverbal communication strategies, barriers to communication, and the care and safety of patients in the mammography suite who present special challenges.

Mammography screening. Benefits, harms, and informed choice.

The rationale for breast cancer screening with mammography is deceptively simple: catch it early and reduce mortality from the disease and the need for mastectomies. But breast cancer is a complex problem, and complex problems rarely have simple solutions. Breast screening brings forward the time of diagnosis only slightly compared to the lifetime of a tumour, and screen-detected tumours have a size where metastases are possible. A key question is if screening can prevent metastases, and if the screen-detected tumours are small enough to allow breast conserving surgery rather than mastectomy. A mortality reduction can never justify a medical intervention in its own right, but must be weighed against the harms. Overdiagnosis is the most important harm of breast screening, but has gained wider recognition only in recent years. Screening leads to the detection and treatment of breast cancers that would otherwise never have been detected because they grow very slowly or not at all and would not have been detected in the woman's lifetime in the absence of screening. Screening therefore turns women into cancer patients unnecessarily, with life-long physical and psychological harms. The debate about the justification of breast screening is therefore not a simple question of whether screening reduces breast cancer mortality. This dissertation quantifies the primary benefits and harms of screening mammography. Denmark has an unscreened "control group" because only two geographical regions offered screening over a long time-period, which is unique in an international context. This was used to study breast cancer mortality, overdiagnosis, and the use of mastectomies. Also, a systematic review of overdiagnosis in five other countries allowed us to show that about half of the screen-detected breast cancers are overdiagnosed. An effect on breast cancer mortality is doubtful in today's setting, and overdiagnosis causes an increase in the use of mastectomies. These findings are discussed in the context of tumour biology and stage at diagnosis. The information provided to women in invitations and on the Internet exaggerates benefits, participation is directly recommended, and the harms are downplayed or left out, despite agreement that the objective is informed choice. This raises an ethical discussion concerning autonomy versus paternalism, and the difficulty in weighing benefits against harms. Finally, financial, political, and professional conflicts of interest are discussed, as well as health economics.