Utility of augmented breast self-examination as an education and screening tool in Rural India for early detection of breast cancer

INTRODUCTION

In India cervical cancer is the leading cause of the women malignancies followed by breast. Breast cancer contributes 19-34%, the percentages vary according to the region.^1-4 The reasons for this variability are many including but not limited to lifestyle, lack of awareness and other cultural reasons. High number of patients (approximately 69%) with breast cancers presenting in locally advanced or metastatic setting up front due to lack of awareness or proper structured screening methodology.

BSE is easy, cost effective and proven way for early detection.^4-7 Early detection of BC by population-based screening programs would be a potentially useful approach for controlling the disease and reducing mortality.⁸ Periodical mammograms, CBE and monthly BSE is crucial to detect BC at an early stage.^10,11 With recent technical advances, which are simple to use, we used indigenously developed devise for aBSE and thought of exploring the feasibility of the same and compare with conventional BSE and CBE.⁹ Despite the benefits associated with BSE, few women regularly perform it and many do not even know how to perform it. There is also evidence that women are more likely to perform BSE effectively when taught by physicians or a nurse.^12-14

The purpose of this screening program was to train women for BSE in health camps and feasibility and comparison study of aBSE versus BSE versus CBE in Rural Indian women.

METHODS

As a part of the mass screening and community outreach clinics of various hospitals and NGOs significant data was collected and the same was compiled. Standardized AV tools (15 minutes duration) were prepared and used to educate the volunteers followed by a question answer section to elicit the understanding with 20:1 random check. For BSE and a BSE we did a verification for the understanding and adoption of techniques as per instruction manual. The participants were observed and supervised by trained personal during the process followed by CBE. The results BSE, aBSE and CBE were documented.

RESULTS

We trained 7214 women over 3 years period for BSE across 48 camps between 2018-2020. The detailed split was given in the Figure 1 for the demographics. Upon evaluation 93.8% of women understood accurately. However after validation check it was felt necessary to retrain 18% as per their perception. aBSE was done for 1085 (15% approximately) subjects. Comparison was done between the aBSC and CBE for the population and we could conclude that aBSE could detect 92.6% of all the lumps identified by CBE, which is much better than 68% of BSE. There are 23.4% more suspicious lumps were unearthed after aBSE after conventional BSE. Of all the camps we could detect 356 new lumps among participants, which were referred for mammographic evaluation at medical centers and malignancies were detected in 142 participants, which indicates high impact of such training programs in Rural India.

DISCUSSION

BSE provides an inexpensive method for early detection of breast tumors, thus knowledge and consistent practice could protect women from severe morbidity and mortality due to breast cancer. Several studies have been done, confirming the importance of awareness about breast cancer and screening methods.^2-6

This modified and advanced screening program was done as multiple pilot projects to assess the practice of BSE after training as well the impact on the early detection. In view of the vast population of India residing in rural region and the structure of the primary healthcare system we chose the rural camps to implement the protocol. For this, we trained various sectors of healthcare practitioners who were instrumental in providing proper education and creating awareness on BSE.

Various factors including education, culture, lack of time shortage of self-confidence, fear of possible cancer and various other myths stand as significant barriers for the widespread implementation of the BSE though it helps immensely in the early detection of breast cancer. This was compounded by awkwardness of self-breast handing, forgetfulness, negative socio-cultural perception about breast cancer and poorly structured support system after diagnosis.

This program brought out a feasibility and process for the early detection of breast cancer patients and emphasized the immense need for a public health education program to inculcate the practice of BSE among women to minimize the fear, denial, myths and misconceptions. We could also feel the importance of community and family involvement especially parents and spouse, which lead better facilitation of understanding of BSE as well as aBSE.

Considering the substantial role that can be played by BSE in low resource settings, there is an urgent need for interventions to implement and reinforce BSE and aBSE in the existing cancer awareness and screening programs.

We could sense that the simple tools and empowering Anganwadi workers shall go long way in bridging gap of application-knowledge and empower with less erroneous and more objective screening method. Though we agreed that the screening of breast cancer doesn’t stop at BSE, it definitely was the first positive step towards more confirmative steps like mammogram and also shall prioritize, who should seek immediate medical attention (especially those with aBSC suggested lumps). This triaging shall help to prorate the mammograms-especially in resource constrained nations like India. Advanced tools like aBSE can surely boost the existing screening modalities to next level.

CONCLUSION

BSE and aBSE are quite useful in clinical detection of lump and simple technique of aBSE is easy to implement and educating them yielded very satisfactory results. With detection rate of 1.9%, which is quite high especially in the rural areas where medical facilities are poor, we feel that aBSE can be adopted in large scale and is well accepted among rural women and can improve on conventional BSE and is comparable with CBE.

ACKNOWLEDGEMENTS

We gratefully acknowledge all the doctors, volunteers, NGOs, who selflessly participated in the largest camps to educate and screen the breast cancer screening initiative.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Vaddeboina N, Attili S, Peri S, Sunkavalli C, Dilip P. Feasibility and comparison study of augmented breast self-examination vs. conventional breast self-examination rural Indian women for early detection-results of POC study. Euro Breast Cancer Confer. 2020.
2. 2. Somdatta P, Baridalyne N. Awareness of breast cancer in women of an urban resettlement colony. Indian J Cancer. 2008;45(4):149-53.
3. 3. Globocon data 2021. Global cancer Observatory, WHO Internatioanl agency for research on Cancer. https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. Accessed on 01 May 2021.
4. 4. Chatergee P. A study to assess the effectiveness of planned teaching programme on the knowledge of GNM students regarding breast cancer and breast self-examination and the ability of GNM students to perform breast self-examination. Nurs J India. 2002;9:3.
5. 5. Sreedharan J, Muttappallymyalil J, Venkatramana M, Thomas M. Breast self-examination: knowledge and practice among nurses in United Arab Emirates. Asian Pac J Cancer Prev. 2010;11(3):651-4.
6. 6. Mahmoodi HM, Montazeri A, Jarvandi S, Ebrahimi M, Haghighat S, Harirchi I. Breast selfexamination: knowledge, attitudes, and practices among female health care workers in Tehran, Iran. Breast J. 2002;8(4):222-5.
7. 7. Secginli S, Nahcivan NO. Factors associated with breast cancer screening behaviors in a sample of Turkish women: a questionnaire survey. Int J Nurs Stud. 2006;43(2):161-71.
8. 8. Abu Awwad D, Hossain SZ, Mackey M, Brennan P, Adam S. Optimising Awareness and Knowledge of Breast Cancer Screening for Nurses Through Train- the-Trainer Workshops. J Cancer Educ. 2021.
9. 9. Breast light information. https://www.breastlightsouthafrica.co.za/. Accessed on 01 May 2021.
10. 10. Du¨ndar EP, Ozmen D, Ozturk B, Haspolat G, Akyildiz F, Coban S, et al. The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey. BMC Cancer. 2006;6:43.
11. 11. Ozturk M, Engin VS, Kisioglu AN, Yilmazer G. Effects of education on knowledge and attitude of breast self-examination among 25+ years old women. East J Med. 2000;5(1):13-7.
12. 12. Petro-Nustas W, Mikhail BI. Factors associated with breast selfexamination among Jordanian women. Public Health Nurs. 2002;19(4):263-71.
13. 13. Abu Awwad D, Hossain SZ, Mackey M, Brennan P, Adam S. Exploring the role of healthcare organisations in increasing women's participation in breast-screening in the United Arab Emirates. J Cancer Educ. 2020.
14. 14. O'Mahony M, Comber H, Fitzgerald T, Corrigan MA, Fitzgerald E, Grunfeld EA, Flynn MG, Hegarty J. Interventions for raising breast cancer awareness in women. Cochrane Database Syst Rev. 2017;2(2):CD011396.