Self-breast examination for breast cancer screening: The Indian story

Breast cancer (BC) is the second most common cancer worldwide, with a rising incidence, specifically in low- and middle-income countries (LMICs).[1] It accounts for 19%–34% of all cancer cases in India.[2] In Mumbai, BC incidence has risen by around 40% between 1992 and 2016.[3] Out of the 685,000 BC-related deaths every year, over 90,000 occur in India, making it the leading cause of cancer-related death in the country.[2] The increasing mortality can be attributed to a number of cultural and logistic issues. Firstly, there is a lack of a robust national screening program. Most screening camps are dedicated to cervical cancer and hence, BC screening becomes an opportunistic event. Secondly, lack of effective primary health centers necessitates visits to tertiary health care centers, which becomes an inconvenience. Thirdly, there is a deficit of awareness and education. Many asymptomatic women consider it unnecessary to test for the disease even if the procedures are free of cost and convenient. Even if knowledge prevails, the fear of loss of the affected breast and stigma of rejection contributes to the fatalistic attitude and ignorance of these women.[3] Mammography is the chief diagnostic screening modality for BC. It has a sensitivity of only 62%–68% and are ineffective in women with dense breast tissues and women aged below 35. The scarcity of mammograms in the rural sector leads to delayed diagnosis and treatment. Almost 70% of all breast cancer cases present in the advanced stages, when oncological treatment options are limited.[3] Ultrasound scan (USS) is more sensitive and effective in women aged below 35, but warrants a radiologist's interpretation. However, the radiologist/patient ratio can be as worse as 1:100000 in the rural setting.[3] Furthermore, USS machines cannot be used as a community-based screening tool courtesy the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 that aims to prevent female feticide. Although the International Agency for Research on Cancer (IARC) has introduced clinician-independent portable ultrasound devices which cause less discomfort, their efficacy is still under investigation. Mitra et al.[3] from Tata Memorial Hospital, Mumbai observed for over 20 years that BC was identified at an earlier age among those who participated in screening. Participants underwent four rounds of Clinical Breast Examination (CBE) and cancer awareness every two years followed by five rounds of active surveillance every two years. The control group received only one round of cancer awareness followed by eight rounds of active surveillance every two years. The various tests were conducted by trained female primary health workers via home visits. There was a marked decrease in late presentations. A 15% reduction was noted in the screening group as compared to the control group. The relative reduction in mortality was 30% in women aged 50 or older. The overall reduction in the all-cause mortality was 5%.[3] Hence, CBE proved highly effective in down-staging BC at diagnosis, and thus was recommended as the screening procedure of choice in LMICs. Self-Breast Examination (SBE) can be seen as a minimally expensive and invasive screening modality for early detection. According to Mitra et al.,[3] SBE is a less useful strategy as it may not be feasible to ensure women perform it well. However, in a country with two-thirds of the population in the rural setting and the demanding doctor-patient ratio, there is an unmet need for implementation of education programs to highlight benefits of SBE in view of timely BC diagnosis. Their significant impact is shown by a study by Parchuri et al.[4] that involved SBE training of around 5000 women in Hyderabad from 2018 to 2019. Visual aids and short videos were distributed across 19 health camps and participants were medically supervised. In total, 93% of the women completed SBE successfully. One hundred sixty-five new cases were reported, out of which 76 demonstrated proven malignancy. Prusty et al.[5] used Information, Education and Communication (IEC) modules on SBE and BC. This health education–based intervention was catered to around 400 women aged between 18 and 55 years of lower socioeconomic communities in Mumbai. It resulted in a drastic improvement of SBE practice rates from 3% to 65%. In a similar quasi-experimental, pre- and post-intervention study conducted among 260 women aged 20–60 years in rural Tamil Nadu, Nisha et al.[6] noted a 70% and 60% increase in knowledge and practice rates concerning SBE, respectively. The Canadian National Breast Screening Study (NBSS) was a multicenter, randomized, controlled trial with a case–control study design. Cases involved women who died of breast cancer or with distant metastases. Quality of SBE using objective assessment was documented and Odds Ratio (OR) concerning the same was evaluated. Results showed that proficient SBE practice can reduce the risk of death from BC.[7] Community outreach programs can play a key role in increasing the acceptance of screening procedures. During Breast Cancer Awareness Month in October 2021, Avon, the international beauty brand collaborated with the Indian Cancer Society (ICS). They came up with a one-year project focusing on examination, diagnosis, and awareness regarding breast cancer. They introduced #InYourBreastInterest to help people ask questions, raise issues and have a healthy, consolidated platform to discuss this heavily stigmatized condition. They also introduced an augmented reality (AR) filter called “Crown of Hope” to remind women to perform SBE.[8] Health belief models elaborate the significance of preventive behaviors which can lead to lower incidence rates. In August 2020, the global soap brand, Lux, launched The Soap with a Lump campaign in collaboration with the ICS. The soaps were shaped with an evident lump. The intention was to remind women to perform SBE for any unusual lumps while washing themselves in the bath. It is easy, convenient and can be done in the privacy of their homes. These soaps were distributed at various screening camps in Maharashtra along with pamphlets on the consequences of neglected breast lumps. Even younger women were cautioned about breast abnormalities. This initiative by Unilever and Wunderman Thompson aimed at detecting breast cancer at its onset.[9] On 7 November 2020, National Cancer Awareness Day in India, the ICS launched a national campaign called “#BreastCancerBhavishya” by creating a micro-site with 12 zodiac signs. Each zodiac gave information about the horoscope, thus increasing readership. They concluded by cautioning about SBE and early screening for BC.[10] On 8 March 2021, International Women's Day, fashion brand Marks & Spencer partnered with Women's Cancer Initiative, Tata Memorial Hospital to launched the Straps that Remind campaign. They distributed, free of cost, an innovative set of transparent bra straps with messages written in thermochromic ink. This reminded women to indulge in SBE and educated them about how early detection of breast cancer is crucial in deciding the prognosis. It provided a personal and effective tool.[11] A reliable screening program is expected to be widely acceptable, highly affordable, and particularly efficacious. SBE is enough to detect breast cancer in its infancy and contribute towards a significant decline in mortality rates. It should thus be considered as the most apt screening tool in LMICs like India.

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