Breast cancer is the top cancer in women both in the developed and the developing world.

The incidence of breast cancer is increasing in the developing world due to increase life expectancy, increase urbanization and adoption of western lifestyles. There are about 1.38 million new cases and 458 000 deaths from breast cancer each year.

 Although breast cancer is thought to be a disease of the developed world, almost 50% of breast cancer cases and 58% of deaths occur in less developed countries. 

In most of the developing regions the incidence rates are below 40 per 100,000. The lowest incidence rates are found in most African countries but here breast cancer incidence rates are also increasing.

The low survival rates in less developed countries can be explained mainly by the lack of early detection programmes, resulting in a high proportion of women presenting with late-stage disease, as well as by the lack of adequate diagnosis and treatment facilities.

Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages.

Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.

Limited resource settings with weak health systems where breast cancer incidence is relatively low and the majority of women are diagnosed in late stages have the option to implement early diagnosis programmes based on awareness of early signs and symptoms and prompt referral to diagnosis and treatment.

So far, the only breast cancer screening method that has proved to be effective is mammography screening. Mammography screening is very costly and is cost-effective and feasible in countries with good health infrastructure that can afford a long-term organized population-based screening programmes. 

 

Breast Cancer Risk Factors.

Several risk factors for breast cancer have been well documented. However, for the majority of women presenting with breast cancer it is not possible to identify specific risk factors.

A familial history of breast cancer increases the risk by a factor of two or three. Reproductive factors associated with prolonged exposure to endogenous estrogens, such as early menarche, late menopause, late age at first childbirth are among the most important risk factors for breast cancer. Exogenous hormones also exert a higher risk for breast cancer. Oral contraceptive and hormone replacement therapy users are at higher risk than non-users. 

 

Breastfeeding has a protective effect.

21% of all breast cancer deaths worldwide are attributable to alcohol use, overweight and obesity, and physical inactivity. This proportion was higher in high-income countries (27%), and the most important contributor was overweight and obesity. In low- and middle-income countries, the proportion of breast cancers attributable to these risk factors was 18%, and physical inactivity was the most important determinant (10%).

The differences in breast cancer incidence between developed and developing countries can partly be explained by dietary effects combined with later first childbirth, lower parity, and shorter breastfeeding. The increasing adoption of Western life-style in low- and middle-income countries is an important determinant in the increase of breast cancer incidence in these countries.

 

 Signs and Symptoms. 

Signs and Symptoms of breast cancer may include: a breast lump or thickening that feels different from the surrounding tissue ,change in the size, shape or appearance of a breast, changes to the skin over the breast, such as dimpling, a newly inverted nipple ,peeling, scaling, crusting or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin and redness or pitting of the skin over your breast, like the skin of an orange.

 

Breast Cancer Control.

Comprehensive cancer control involves prevention, early detection, diagnosis, treatment, rehabilitation and palliative care.

Raising general public awareness on the breast cancer problem and the mechanisms to control as well as advocating for appropriate policies and programmes are key strategies of population-based breast cancer control. Many low and middle-income countries face now a double burden of breast and cervical cancer which represent top cancer killers in women of over 30 years old. These countries need to implement combined strategies that address both public health problems in an effective and efficient way.

 

Prevention

Control of specific modifiable breast cancer risk factors as well as effective integrated prevention of non-communicable diseases which promotes healthy diet, physical activity and control of alcohol intake, overweight and obesity, could eventually have an impact in reducing the incidence of breast cancer in the long term. 

Combination hormone therapy may increase the risk of breast cancer .To reduce the risk of breast cancer, use the lowest dose of hormone therapy possible for the shortest amount of time.

 

Preventive Medications (Chemoprevention)

Estrogen-blocking medications, such as selective estrogen receptor modulators and aromatase inhibitors, reduce the risk of breast cancer in women with a high risk of the disease.

These medications carry a risk of side effects, so Doctors reserve these medications for women who have a very high risk of breast cancer. 

 

Preventive Surgery

Women with a very high risk of breast cancer may choose to have their healthy breasts surgically removed (Prophylactic Mastectomy). They may also choose to have their healthy ovaries removed (Prophylactic Oophorectomy) to reduce the risk of both breast cancer and ovarian cancer.

 

Early Detection

Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries. Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.

 

There are two early detection methods: Early diagnosis or awareness of early signs and symptoms in symptomatic populations in order to facilitate diagnosis and early treatment, and screening that is the systematic application of a screening test in a presumably asymptomatic population. It aims to identify individuals with an abnormality suggestive of cancer.

A screening programme is a far more complex undertaking than an early diagnosis programme. (WHO, 2007).

Targeting the wrong age group, such as, younger women with low risk of breast cancer, could cause a lower number of breast cancers found per woman screened and therefore reduce its cost-effectiveness. 

 

Early Diagnosis

Early diagnosis remains an important early detection strategy, particularly in low- and middle-income countries where the diseases is diagnosed in late stages and resources are very limited. There are some evidence that this strategy can produce "down staging" (increasing in proportion of breast cancers detected at an early stage) of the disease to stages that are more amenable to curative treatment.

 

Mammography Screening

Mammography screening is the only screening method that has proven to be effective. Although there is evidence that organized population-based mammography screening programmes can reduce breast cancer mortality by around 20% in the screened group versus the unscreened group across all age groups. 

In general, there appears to be a narrow balance of benefits compared with harms, particularly in younger and older women. There is uncertainty about the magnitude of the harms – particularly overdiagnosis and overtreatment. Mammography screening is very complex and resource intensive.

 

Breast Self -Examination (BSE)

There is no evidence on the effect of screening through Breast Self-Examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommended for raising awareness among women at risk rather than as a screening method.

 

Clinical Breast Examination (CBE)

Research is underway to evaluate CBE as a low-cost approach to breast cancer screening that can work in less affluent countries. Promising preliminary results show that the age-standardized incidence rate for advanced-stage breast cancer is lower in the screened group compared to the unscreened group.

Other Diagnostic Procedures includes; breast ultrasound, fine needle biopsy for histology. A biopsy is the only definitive way to make a diagnosis of breast cancer.