Determinants of Compliance to Breast Cancer Screening and Referral in Low Socio-Economic Regions of Urban India

Breast Cancer Screening Awareness and Associated Factors Among Saudi Females: A Cross-Sectional Study in Jeddah, Saudi Arabia (2024)

BACKGROUND

Breast cancer (BC) represents a major health concern for women globally, including those in Saudi Arabia. Awareness and early detection through screening practices are vital measures in improving BC outcomes.

OBJECTIVE

This study aims to assess the awareness and associated factors of BC screening among Saudi females in Jeddah, Saudi Arabia.

METHODS

A cross-sectional study was conducted in 2024 among Saudi females aged 18 and above, residing in Jeddah. Data was collected using a structured questionnaire that included sections on demographic characteristics, Breast Cancer Awareness Measure (Breast CAM), knowledge, and factors influencing participation in screening programs. The collected data was analyzed using IBM SPSS Statistics.

RESULTS

The study, consisting of 454 participants, found that half of them rarely or never checked their breasts and many were not confident about noticing any changes in their breasts. There was a strong awareness of the Ministry of Health's (MOH) BC screening program, but most were uncertain about the age at which screenings should start and end. Only a small percentage reported receiving an invitation for breast screening and an even smaller percentage have participated in the screening. Significant associations were found between higher awareness of BC signs, a monthly family income of over 20,000, and being medically free (p-value <0.05).

CONCLUSION

The study found a significant gap in BC awareness and screening practices among females in Jeddah, Saudi Arabia. This underlines the importance of targeted health education and awareness programs, as well as accessible and affordable screening services, to improve early detection and outcomes for BC.

Menstrual and reproductive factors associated with risk of breast cancer among Indian women: a cross sectional study from National Family Health Survey, 2019-21

BACKGROUND

The breast cancer is common cancer in women globally. The risk of breast cancer is strongly associated with women's menstrual and reproductive factors that have been established in different countries. Therefore present study was aim to explore the association between menstrual and reproductive factors and the risk of breast cancer screening in Indian women.

METHODS

The present study data has been used fifth round of the National Family Health Survey (NFHS-V) with 724,115 women in aged 15-49 in 2019-21. The self-reported ever screened of breast cancer for women aged 30-49 was the main outcome variable of the study. Logistic regression models were used to estimate odds ratios and 95% confidence intervals for breast cancer by menstrual and reproductive factors adjusted for potential confounders.

RESULTS

Late menarche (OR = 2.20, 95% CI: 1.48-3.28), irregular menstrual cycle (OR = 1.29, 95% CI: 1.08-3.53)), delay age at first birth (OR = 1.93, 95% CI: 1.11-3.04) and contraceptive pill used (OR = 1.11, 95% CI: 0.74-2.10) were significantly associated to increases the uptake of screening breast cancer. While, a higher number of birth (OR = 0.52, 95% CI: 0.10-1.03), and long duration of breast-feeding practice (OR = 0.75, 95% CI: 0.63-0.91) were reduced to participate for screening breast cancer.

CONCLUSION

The results of the study confirm the role of menstrual and reproductive factors in breast cancer in Indian women. Therefore, our findings are imperative for developing breast cancer prevention strategies and better preparedness. Creating awareness and providing knowledge on cancer could be key strategies for the reduction of breast cancer in Indian reproductive age group women.

Breast Cancer in India: Screening, Detection, and Management

Breast cancer is the most common cancer in urban Indian women and the second most common cancer in all Indian women. The epidemiology as well as biology of this cancer seems to be different in the Indian subcontinent when compared with the West. The lack of population-based breast cancer screening programs and delay in seeking a medical consult due to financial and social reasons, including lack of awareness and fear related to a cancer diagnosis, results in delayed diagnosis.

Treatment-seeking behaviour among 15-49-year-olds with self-reported heart disease, cancer, chronic respiratory disease, and diabetes: a national cross-sectional study in India

BACKGROUND

Eighty per cent of India´s non-communicable disease (NCD) mortality is due to four conditions: heart disease, cancer, chronic respiratory disease, and diabetes, which are primarily cause-amenable through treatment. Based on Andersen's behavioural model of health services use, the current study aimed to identify the predisposing, enabling, and need factors associated with treatment-seeking status among people self-reporting the four main NCDs in India.

METHODS

Cross-sectional study using secondary data. Usual residents aged 15-49 who self-reported cancer (n = 1 056), chronic respiratory disease (n = 10 534), diabetes (n = 13 501), and/or heart disease (n = 5 861) during the fifth National Family and Health Survey (NFHS-5), 2019-21, were included. Treatment-seeking status was modelled separately for each disease using survey-adjusted multivariable logistic regression.

RESULTS

3.9% of India´s 15-49-year-old population self-reported ≥ 1 of the four main NCDs (0.1% cancer, 1.4% chronic respiratory disease, 2% diabetes, 0.8% heart disease). The percentage that had sought treatment for their condition(s) was 82%, 68%, 76%, and 74%, respectively. Greater age and having ≥ 1 of the NCDs were associated with greater odds of seeking disease-specific treatment. People in the middle or lower wealth quintiles had lower odds of seeking care than the wealthiest 20% for all conditions. Women with diabetes or chronic respiratory disease had greater odds of seeking disease-specific treatment than men. Muslims, the unmarried, and those with health insurance had greater odds of seeking cancer treatment than Hindus, the married, and the uninsured.

CONCLUSION

Predisposing, enabling, and need factors are associated with treatment-seeking status among people reporting the four major NCDs in India, suggesting that multiple processes inform the decision to seek disease-specific care among aware cases. Successfully encouraging and enabling as many people as possible who knowingly live with major NCDs to seek treatment is likely contingent on a multi-pronged approach to healthcare policy-making. The need to improve treatment uptake through accessible healthcare is further underscored by the fact that one-fifth (cancer) to one-third (chronic respiratory disease) of 15-49-year-olds reporting a major NCD have never sought treatment despite being aware of their condition.

Training health workers in clinical breast examination for early detection of breast cancer in low- and middle-income countries

BACKGROUND

Most women living in low- and middle-income countries (LMICs) present with advanced-stage breast cancer. Limitations of poor serviceable health systems, restricted access to treatment facilities, and lack of breast cancer screening programmes all likely contribute to the late presentation of women with breast cancer living in these countries. Women are diagnosed with advanced disease and frequently do not complete their care due to a number of factors, including financial reasons as health expenditure is largely out of pocket resulting in financial toxicity; health system failures, such as missing services or health worker lack of awareness on common signs and symptoms of cancer; and sociocultural barriers, such as stigma and use of alternative therapies. Clinical breast examination (CBE) is an inexpensive early detection technique for breast cancer in women with palpable breast masses. Training health workers from LMICs to conduct CBE has the potential to improve the quality of the technique and the ability of health workers to detect breast cancers early.

OBJECTIVES

To assess whether training in CBE affects the ability of health workers in LMICs to detect early breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Registry, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, and ClinicalTrials.gov up to 17 July 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including individual and cluster-RCTs), quasi-experimental studies and controlled before-and-after studies if they fulfilled the eligibility criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, and extracted data, assessed risk of bias, and assessed the certainty of the evidence using the GRADE approach. We performed statistical analysis using Review Manager software and presented the main findings of the review in a summary of findings table.

MAIN RESULTS

We included four RCTs that screened a total population of 947,190 women for breast cancer, out of which 593 breast cancers were diagnosed. All included studies were cluster-RCTs; two were conducted in India, one in the Philippines, and one in Rwanda. Health workers trained to perform CBE in the included studies were primary health workers, nurses, midwives, and community health workers. Three of the four included studies reported on the primary outcome (breast cancer stage at the time of presentation). Amongst secondary outcomes, included studies reported CBE coverage, follow-up, accuracy of health worker-performed CBE, and breast cancer mortality. None of the included studies reported knowledge attitude practice (KAP) outcomes and cost-effectiveness. Three studies reported diagnosis of breast cancer at early stage (at stage 0+I+II), suggesting that training health workers in CBE may increase the number of women detected with breast cancer at an early stage compared to the non-training group (45% detected versus 31% detected; risk ratio (RR) 1.44, 95% confidence interval (CI) 1.01 to 2.06; three studies; 593 participants; I2 = 0%; low-certainty evidence). Three studies reported diagnosis at late stage (III+IV) suggesting that training health workers in CBE may slightly reduce the number of women detected with breast cancer at late stage compared to the non-training group (13% detected versus 42%, RR 0.58, 95% CI 0.36 to 0.94; three studies; 593 participants; I2 = 52%; low-certainty evidence). Regarding secondary outcomes, two studies reported breast cancer mortality, implying that the evidence is uncertain for the impact on breast cancer mortality (RR 0.88, 95% CI 0.24 to 3.26; two studies; 355 participants; I2 = 68%; very low-certainty evidence). Due to the study heterogeneity, we could not conduct meta-analysis for accuracy of health worker-performed CBE, CBE coverage, and completion of follow-up, and therefore reported narratively using the 'Synthesis without meta-analysis' (SWiM) guideline. Sensitivity of health worker-performed CBE was reported to be 53.2% and 51.7%; while specificity was reported to be 100% and 94.3% respectively in two included studies (very low-certainty evidence). One trial reported CBE coverage with a mean adherence of 67.07% for the first four screening rounds (low-certainty evidence). One trial reported follow-up suggesting that compliance rates for diagnostic confirmation following a positive CBE were 68.29%, 71.20%, 78.84% and 79.98% during the respective first four rounds of screening in the intervention group compared to 90.88%, 82.96%, 79.56% and 80.39% during the respective four rounds of screening in the control group.

AUTHORS' CONCLUSIONS

Our review findings suggest some benefit of training health workers from LMICs in CBE on early detection of breast cancer. However, the evidence regarding mortality, accuracy of health worker-performed CBE, and completion of follow up is uncertain and requires further evaluation.

Factors associated with the uptake of clinical breast examination among women of reproductive age in Lesotho: analysis of a national survey

BACKGROUND

In low-resource settings with weak health systems, the WHO recommends clinical breast examination (CBE) as the most cost-effective breast screening modality for women. Evidence shows that biennial CBE leads to significant downstaging of breast cancer in all women. Breast cancer is the second most common cancer among women in Lesotho with a weaker healthcare system and a low breast cancer screening rate. This study investigated the prevalence and factors associated with the uptake of CBE among women of reproductive age in Lesotho.

METHODS

This study used cross-sectional data from the 2014 Lesotho Demographic and Health Survey. A sample of 6584 reproductive-age women was included in this study. We conducted both descriptive and multivariable logistic regression analyses. The study results were presented in frequencies, percentages, and adjusted odds ratios (aOR) with their corresponding confidence intervals (CIs).

RESULTS

The prevalence of CBE uptake was 9.73% (95% CI: 8.91, 10.61). Women who were covered by health insurance (aOR = 2.31, 95% CI [1.37, 3.88]), those who were pregnant (aOR = 2.34, 95% CI [1.64, 3.35]), those who had one to three children (aOR = 1.81, 95% CI [1.29,2.52]), and women who frequently read newspapers or magazines (aOR = 1.33, 95% CI [1.02,1.72]) were more likely to undergo CBE than their counterparts. Women who were aware of breast cancer (aOR = 2.54, 95% CI [1.63,3.97]), those who have ever had breast self-examination (BSE) within the last 12 months prior to the study (aOR = 5.30, 95% CI [4.35,6.46]), and those who visited the health facility in the last 12 months prior to the study (aOR = 1.57, 95% CI [1.27,1.95]) were also more likely to undergo CBE than their counterparts. Women residing in the Qacha's-nek region (aOR = 0.42, 95% CI [0.26,0.67]) were less likely to undergo CBE than those in the Botha-bothe region.

CONCLUSION

The study found a low prevalence of CBE uptake among reproductive-age women in Lesotho. Factors associated with CBE uptake include health insurance coverage, being pregnant, those who had one to three children, exposure to media, breast cancer awareness, ever had BSE, and those who visited a health facility. To increase CBE uptake, these factors should be considered when designing cancer screening interventions and policies in order to help reduce the burden of breast cancer in Lesotho.

Acceptance of artificial intelligence (AI)-based screening for breast health in urban slums of central Karnataka, India - SWOC analysis

Background

Artificial intelligence-based imaging is a low-cost, radiation-free solution for the breast imaging process that uses infrared radiation emitted by the body. This is a novel procedure that, when feasible, could be a better solution, particularly in underprivileged communities having low access to breast health care.

Aims

To assess the acceptance and explore challenges for an artificial intelligence-based screening solution for breast health among the urban slum population.

Settings and Design

A mixed-method study was conducted in urban slums of central Karnataka, India.

Material and Methods

The study was carried out for a period of two years in 2019-21 among women in the reproductive age group in urban slums of central Karnataka to understand the acceptance of an artificial intelligence-based imaging solution for screening breast health. In-depth interviews were conducted to identify the strength, weaknesses, opportunities, and challenges (SWOC) screening for breast health.

Statistical Analysis Used

Quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) v16.0, and for qualitative data, manual descriptive content analysis was carried out, and the sub-themes were generated.

Results

A total of 768 women accessed the thermalytix ® breast imaging services, the majority of them in the age group 31-40 years (35%), belonging to the Muslim religion (68.5%) with a mean monthly family income of Rs. 11,950.67/- SWOC analysis identified reduced cost for the screening services and involvement of female self-help groups (SHGs) as strengths. Weaknesses included poor breast health awareness among women and the stigma associated with breast cancer.

Conclusions

Artificial intelligence-based screening is a feasible solution for breast health in low-income, low health access areas like urban slums. Engagement of the local community and active involvement of the health system is of paramount importance for the sustainability of any novel strategy.

Determinants of Compliance for Breast and Cervical Cancers Screening among Female Police Personnel of Mumbai, India—A Cross-Sectional Study

Introduction Women working in police force have unique and vital role to play in law enforcement. Although these women have established a secured place for themselves in the police force, they are exposed to several behavioral and health risks apart from job stress. All these can have potentially serious consequences on their well-being.

Objectives To determine the compliance to breast and uterine cervical cancers screening and identify predictors of participation in breast and cervical cancers screening among women police personnel.

Materials and Methods This is a cross-sectional study conducted among the Mumbai police personnel during the period 2019 to 2021. All women working for Mumbai police work force in 12 zones were invited to participate in the study. Temporary clinics for screening were set up in different police stations and eligible participants were enrolled after obtaining written informed consent. This was followed by sociodemographic and risk factor assessment, health education program, screening for common cancers conducted by trained primary health workers (breast by clinical breast examination and uterine cervix by visual inspection with 5% acetic acid). Screen positives were referred according to predefined referral criteria for further investigations and management.

Results A total of 3,017 police women were contacted, among them, 2,629 (87.14%) were eligible for screening, 2,609 (99.24%) participated in health education, and 1,839 (69.95%) complied for breast or cervical cancer screening. Further, compliance for screening of breast and uterine cervix were 1,837 (91.67%) and 1,297 (64.72%). A total of 256 (13.94%) and 217 (11.81%) police women were screen positives for breast and cervical cancers. According to multivariate logistic regression analysis, women younger than 50 years, those who were not married or were widowed or separated, postmenopausal women, and those who did not have shift duties had higher compliance for breast and cervix cancers screening.

Conclusion Good participation for breast and cervical cancers screening was seen among the women police personnel. This study has demonstrated that awareness and screening by simple low-cost methods for breast and cervical cancers screening is easily implementable and can be replicated among the women police force in different states of India.

Intersectional social-economic inequalities in breast cancer screening in India: analysis of the National Family Health Survey

Background

Breast cancer incidence rates are increasing in developing countries including India. With 1.3 million new cases of cancer been diagnosed annually, breast cancer is the most common women’s cancer in India. India’s National Family Health Survey (NFHS-4) data 2015–2016 shows that only 9.8% of women between the ages of 15 and 49 had ever undergone breast examination (BE). Further, access to screening and treatment is unequally distributed, with inequalities by socio-economic status. It is unclear, however, if socio-economic inequalities in breast examination are similar across population subgroups.

Methods

We compared BE coverage in population sub-groups categorised by place of residence, religion, caste/tribal groups, education levels, age, marital status, and employment status in their intersection with economic status in India. We analysed data for 699,686 women aged 15–49 using the NFHS-4 data set conducted during 2015–2016. Descriptive (mean, standard errors, and confidence intervals) of women undergoing BE disaggregated by dimensions of inequality (education, caste/tribal groups, religion, place of residence) and their intersections with wealth were computed with national weights using STATA 12. Chi-square tests were performed to assess the association between socio-demographic factors and breast screening. Additionally, the World Health Organisation’s Health Equity Assessment Toolkit Plus was used to compute summary measures of inequality: Slope index for inequality (SII) and Relative Concentration Indices (RCI) for each intersecting dimension.

Results

BE coverage was concentrated among wealthier groups regardless of other intersecting population subgroups. Wealth-related inequalities in BE coverage were most pronounced among Christians (SII; 20.6, 95% CI: 18.5–22.7), married (SII; 14.1, 95% CI: 13.8–14.4), employed (SII: 14.6, 95%CI: 13.9, 15.3), and rural women (SII; 10.8, 95% CI: 10.5–11.1). Overall, relative summary measures (RCI) were consistent with our absolute summary measures (SII).

Conclusions

Breast examination coverage in India is concentrated among wealthier populations across population groups defined by place of residence, religion, age, employment, and marital status. Apart from this national analysis, subnational analyses may also help identify strategies for programme rollout and ensure equity in women’s cancer screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01464-5.

Community health workers and early detection of breast cancer in low-income and middle-income countries: a systematic scoping review of the literature

Background

Breast cancer is the leading cause of female mortality in low-income and middle-income countries (LMICs). Early detection of breast cancer, either through screening or early diagnosis initiatives, led by community health workers (CHWs) has been proposed as a potential way to address the unjustly high mortality rates. We therefore document: (1) where and how CHWs are currently deployed in this role; (2) how CHWs are trained, including the content, duration and outcomes of training; and (3) the evidence on costs associated with deploying CHWs in breast cancer early detection.

Methods

We conducted a systematic scoping review and searched eight major databases, as well as the grey literature. We included original studies focusing on the role of CHWs to assist in breast cancer early detection in a country defined as a LMIC according to the World Bank.

Findings

16 eligible studies were identified. Several roles were identified for CHWs including awareness raising and community education (n=13); history taking (n=7); performing clinical breast examination (n=9); making onward referrals (n=7); and assisting in patient navigation and follow-up (n=4). Details surrounding training programmes were poorly reported and no studies provided a formal cost analysis.

Conclusions

Despite the relative paucity of studies addressing the role of CHWs in breast cancer early detection, as well as the heterogeneity of existing studies, evidence suggests that CHWs can play a number of important roles in breast cancer early detection initiatives in LMICs. However, if they are to realise their full potential, they must be appropriately supported within the wider health system.

Prognostic Factors Associated with Curing in Patients with Breast Cancer: A Joint Frailty Model

Background:

Recurrent event data arise frequently in longitudinal medical studies. In many situations, there are a large portion of patients without any recurrences, manifesting the “zero-inflated” nature of the data. Moreover, there often exists a terminal event which may be correlated with the recurrent events. The goal of this study is to extend the application of joint frailty model to identify the prognostic factors associated with curing in patients with breast cancer.

Methods:

As a prospective study, medical records of women who had been attended to Cancer Research Center, Shahid Beheshti University of Medical Sciences from January 1998 to February 2016 were reviewed. Finally, after an initial review of medical records, 711 patients were included in the study and analyzed. A checklist that included items drawn from the demographic background of patients was provided in the study. Two joint frailty models for zero-inflated recurrent events, combining a logistic model for “structural zero” status (Yes/No) and a joint frailty proportional hazards model for recurrent and terminal event times were performed to identify factors associated with BCS.

Results:

The mean age of patients was 38.2 years. The numbers of subjects with 1, 2, 3, and 4 recurrent events were 392, 207, 97, and 15, respectively. The median follow-up time was 6.87 years. There were 137 (19.2%) deaths from cancer during the follow-up. Among the 574 patients who were censored, 418 had no tumor recurrence. Thus, there may exist a large portion of “cured” subjects. We can see that the radiation (OR = 6.02, CI = (3.87, 8.61)) and tumor size interaction with radiation (OR = 1.065, CI = (1.002–1.26)) were significant in the cure model (P < 0.05) which means that patients with smaller tumor sizes were more likely to be cured by radiation therapy.

Conclusions:

Our proposed models can help investigators to evaluate which treatment will result in a higher fraction of cured subjects. This is usually an important research question in biomedical studies.

Social determinants of mammography screening among women aged 50 to 59, Peru 2015

Breast cancer (BC) screening could reduce its mortality; however, its access is influenced by societal forces. Our objective is to identify the social determinants associated with mammography screening (MS) in women aged 50 to 59 in Peru. In this cross-sectional analysis of the Peruvian Demographic Health Survey, 2015, MS within the past two years was evaluated through self-report. Prevalence for MS was 21.9% [95% CI: 18.9 to 25.1]. The average age was 54 years (s.d.: 2.5). The higher the socioeconomic status, the higher the prevalence of screening (3.2% vs 41.4% in extreme quintiles, p < .001). In the adjusted models, higher socioeconomic status (PR: 5.81, 95% CI: 2.28 to 14.79), higher education level (PR: 2.03, 95% CI: 1.30 a 3,15) and having health insurance from the Ministry of Health (PR: 2.21, 95% CI: 1.28 to 3.82) and EsSalud (PR: 4.37, 95% CI: 2.67 to 7.15), were positively associated with MS. Social inequalities in screening access exist and might translate into inequalities in cancer morbidity and mortality. The Peruvian government urgently needs to improve screening rates in these vulnerable populations.

Barriers to Cancer Screening Uptake in Women: A Qualitative Study from Tamil Nadu, India

BACKGROUND

The uptake for cancer screening has been consistently poor in India despite the efforts of nation-wide screening programs. Understanding the barriers and enablers among community women would aid in increasing the proportion of cancer screening uptake.

METHODS

Nineteen key informants including community women, service providers and a cancer survivor were interviewed using a semi-structured interview guide. Interviews were recorded and transcribed by the interviewers. Manual descriptive thematic analysis was conducted using deductive approach. Codes were given and extracted into categories which were later grouped to form themes.

RESULTS

The mean age of participants was 38 years. Among the participants, 38.9% and 16.7% underwent breast and cervical cancer screening respectively. The psychosocial factors were the major barriers for screening uptake such as fear of screening procedure and fear of being diagnosed with cancer. The other factors include lack of awareness, cultural beliefs, in addition to financial difficulties and health care system-related factors. Change in government policies to conduct mandatory screening programs, incentivization and creating awareness were reported as enablers for increasing the screening uptake among women.

CONCLUSION

Psychosocial factors, the major barriers for screening uptake in women have remained unchanged over the years. Increasing awareness campaigns, usage of decision-making aids and changes in government policies are crucial for improving the rate of uptake and successful implementation of national screening programs.

Smokeless tobacco use and oral neoplasia among urban Indian women

OBJECTIVES

Oral cavity cancers are fourth most common cancers among Indian women. The objectives were to create cancer awareness (CA) and screen tobacco-using women for oral cavity cancers.

MATERIALS AND METHODS

A community-based CA and screening programme was conducted among women in Mumbai, India. The tobacco-using women participated in CA and oral cavity screening by oral visual inspection (OVI). All screen-positive women were referred to nodal hospital and assisted for diagnostic confirmation and treatment completion.

RESULTS

Twelve slum clusters comprising of 138,383 population and 13,492 tobacco-using women have been covered. Among them, 11,895 (88.2%) participated in CA and 11,768 (87.2%) in OVI. A total of 377 (3.2%) women were screened positive, 275 (72.9%) complied with referral and 207 oral precancers [173 leukoplakia, 9 erythroplakia, 3 erythroleukoplakia and 41 sub-mucus fibrosis (SMF) including 35 women with multiple precancers] and 7 oral cancers were diagnosed. The detection rate of oral precancerous lesions and oral cancers was 17.6 and 0.6 per 1,000 screened women. Thirty-five women had multiple oral precancerous lesions. The results of multivariate analysis indicate dose-response relationship between tobacco use and risk of oral precancers.

CONCLUSION

Good participation rates (>85%) for cancer awareness and OVI were seen among urban slum women in India. Many oral precancer and cancer cases were detected and were managed at the nodal hospital.