|Year : 2019 | Volume
| Issue : 4 | Page : 229-231
Is it feasible to develop and implement a successful regional breast cancer screening program in India?
Lavandan Jegatheeswaran1, Payal Haria1, Byung Choi1, Thin Kyi Phyu Naing2, Ed Babu1, Arunmoy Chakravorty3
1 Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, England, UK
2 University of Nottingham School of Medicine, Nottingham, England, UK
3 Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, England, UK; Honorary International Professor, AHERF, New Delhi, India
|Date of Submission||29-Oct-2019|
|Date of Acceptance||30-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Consultant Oncoplastic Breast Surgeon, The Hillingdon Hospital NHS Foundation Trust, London, England
Source of Support: None, Conflict of Interest: None
Breast cancer is now one of the most prevalent cancers in Indian cities and certain rural areas. India lacks a dedicated breast cancer screening program. This review explores the barriers to the successful implementation of breast cancer screening in India and aims to offer plausible pathways in potentially making this initiative a reality.
Keywords: Artificial intelligence, breast cancer, breast screening
|How to cite this article:|
Jegatheeswaran L, Haria P, Choi B, Phyu Naing TK, Babu E, Chakravorty A. Is it feasible to develop and implement a successful regional breast cancer screening program in India?. Apollo Med 2019;16:229-31
|How to cite this URL:|
Jegatheeswaran L, Haria P, Choi B, Phyu Naing TK, Babu E, Chakravorty A. Is it feasible to develop and implement a successful regional breast cancer screening program in India?. Apollo Med [serial online] 2019 [cited 2020 Jan 18];16:229-31. Available from: http://www.apollomedicine.org/text.asp?2019/16/4/229/272831
As of July 2019, India's population stands at 1,366,418,000, thus making it the second-most populous country in the world. Under the tax-financed public system, all citizens of India are entitled to free health-care services; however, due to the large bottlenecks in the access of public health care, it is estimated that almost 70% of Indian citizens deviate toward private care., The World Bank estimated the total health expenditures in India from March 2015 to March 2016 as 3.66% of Gross Domestic Product (GDP). The Indian government expenditure on health care at the same time amounted to 0.93% of GDP. Given that the target threshold for the percentage GDP as total health-care expenditure lies at 5% for all United Nations member states, as a part of the sustainable development goals to achieve universal health-care coverage by 2030, it is apparent that India's commitment needs to improve., In order to achieve universal health coverage, there are key areas that the Indian government should consider focusing their health-care expenditure on, including implementing national screening programs for prevalent diseases and conditions and improving access to health care.
One such prevalent condition is breast cancer, which has overtaken the incidence rates of cervical cancer and is now the most prevalent cancer in most Indian cities and some rural areas. Studies have shown that women in India are less likely to develop breast cancer than women in western countries. This is likely due to the nature of Indian society, where risk factors for breast cancer, i.e., increased estrogen exposure such as late or absent full-term pregnancy and short or absent length of breastfeeding are less frequent than in Western societies. Despite this, breast cancer figures are still estimated to be between 19% and 34% of all cancer cases in women in India. It is also interesting to note that breast cancer tends to affect Indian women, on average, almost a decade earlier when compared to their western counterparts., The implementation of breast cancer screening programs has been proven to be hugely effective in western countries, with breast cancer-related mortality in the UK estimated to have decreased by 20% since the birth of its national screening program in 1988. However, no such equivalent screening mechanism exists in India, and the purpose of this review is to identify a plausible way of introducing such an initiative to this country.
There are a multitude of factors affecting the successful implementation of a nationwide breast cancer screening program in India. Firstly, the lack of breast cancer awareness and education. Breast cancer awareness programs, if present, tend to be concentrated in urban areas, with their efficacy influenced by contributing secondary social factors such as illiteracy and the existence of various myths in Indian society relaying an unrealistic fear and stigmatization of the disease.
Another key factor is the lack of medical professionals in the public health sector. The World Health Organization (WHO) recommends the doctor to population ratio to be 1:1000; however, India's public health-care system is at 1:1674. A huge understaffing in all roles in health care within the public sector, and the stark divide in the proportion of doctors working in rural areas and urban areas contributes to the unequal distribution of access to health care across India. In India, where a paternalistic approach often governs a patient–doctor relationship, in that advice and parting of education given during a consultation is greatly trusted, one can begin to see the detrimental effect that unequal and sparsity of services can have.
A difficulty in the self-diagnosis of breast cancer is that it most commonly presents as a painless lump, which to the layperson may go undetected or ignored. Consequently, this lack of awareness and education results in patients presenting to a health-care provider when the cancer has reached an advanced stage, either when it has become invasive or metastatic. This is in huge contrast to cervical cancer diagnosis in India, in which the presenting symptoms of the disease are less insidious as that in breast cancer; thus, health-care staff can respond appropriately with just opportunistic screening.
Screening for breast cancer usually involves a combination of breast self-examination and mammography. In the UK, if an abnormality is identified on mammography, then further targeted investigations such as ultrasound and core needle biopsy are used to identify the exact nature of the abnormality. However, anecdotally, concerns are present over the limited feasibility of a breast cancer screening program involving mammography and ultrasound due to the financial implications associated with it. A lack of quality assurance and trained professionals who can interpret the mammograms locally likely exists and therefore a need to outsource imaging interpretation.
These factors, alongside the absence of a nationwide breast cancer screening program, may explain why almost 70% of those diagnosed with breast cancer, present at an advanced stage, and thus the high mortality associated with breast cancer in India.
As such, the key to a successful implementation of a national breast cancer screening program is dependent on the barriers to health care being effectively addressed.,
Despite there being a high unawareness of breast cancer in Indian society as a whole, it has been shown that education by health professionals, not just doctors, can raise awareness, early detection, and improvement of breast cancer survival.,, As awareness grows, more communities should be encouraged to actively participate in educating their population and actively promote women to breast self-examination on a regular basis, perhaps through the means of community volunteers, to relieve the burden of the lack of access to healthcare faced in rural and remote areas of India. One such project was trialed in the Kannur district in Kerala, where a team of 8200 volunteers visited the homes of just over 1 million women aged over 30 years to provide breast cancer education. The trial was proven to be successful with 93% screened using a symptom risk factor checklist, and of the breast cancer cases confirmed, 61% of these cancers were in the early stages with these women remaining disease-free at the 3 years of follow-up. However, for an initiative like this to be successful on a national scale, a combination of encouraging community participation with local self-government and the engagement of the health-care system is required to help the sustainability of the project.
As discussed, many women in India are still afraid of the stigmatism attached to a cancer diagnosis. This fear may delay or prevent them from presenting to healthcare services., The need for a holistic approach to a nationalized screening program with a strong focus on education and counseling by medical professionals, volunteers, and the greater community has been shown to improve adherence to screening programs and treatment. In addition, the involvement of major charities supporting cancer patients will also help reduce the stigma and fear that a diagnosis of breast cancer may bring. For example, in the UK, Cancer Research UK, a charity whose focus is to support its cancer patients as well as fund innovative research is hugely successful. Breast cancer charities in India do exist, for example, “The Pink Initiative” and “BCPBF,” however, these charities only cover small parts of India; due to the challenges of funding and the vast geographical size of the country. Nevertheless, despite their small reach, they exhibit a positive influence in the areas that they operate in, and may prove to be a useful tool in the successful implementation of a nationwide screening program.
Affordability of such an initiative is potentially the biggest factor in preventing its success. The affordability of health-care directly relates to the late presentation of breast cancer in lower-income citizens. The rapid improvements in digital infrastructure that India has seen in recent years, alongside the rise of artificial intelligence (AI) and deep machine learning may be key in keeping the cost of health-care down. This may prove particularly useful in enabling rural communities to participate in screening programs. Telemedicine is not a new concept to India; however, it may be useful as a tool to expand screening programs to rural communities., Outreach clinics, as part of a public–private health-care partnership, could be created in which mammography performed in rural areas can be sent digitally to tertiary centers in urban areas, where specialists can analyze the images and determine who requires further symptomatic screening. This method will enable quality assurance in rural health care. A similar set up has been running successfully since 2007 at a regional private tertiary center in Delhi, whereby outreach mammography clinics in Haryana and Rajasthan transfer images taken to Delhi and patients with abnormal scans are informed and seen at the regional private hospital for further investigations. Maximizing this approach across other states may be crucial in making this breast cancer screening initiative a reality. The rise of AI and deep machine learning proves to be an exciting development, as this can improve the efficiency of which mammograms are analyzed and reported on. The benefit of deep machine learning is that the more mammograms the computer is exposed to, the more accurate its detection of lesions become, thus a continuous improvement in quality assurance., Although AI is still in its infancy and its accuracy is unreliable, it may be essential for countries such as India in obtaining universal health coverage in the future. Utilizing the potential of telemedicine and moving one step further would be to introduce a mandatory multidisciplinary team approach to take advantage and integrate the opinions of a number of professionals across the country from various disciplines into the care of individual patients. This has been shown to improve coordination, consistency, and cost-effectiveness.
Increasing government expenditure on public health care is crucial to improve access to health care for Indian citizens, in particular, those who are at higher risk of entering crippling medical expenditure.,, The Modi's government new National Health Protection Scheme (termed Ayushman Bharat), designed to provide free health care to an estimated 500 million Indian citizens, is a step in the right direction. The need for free comprehensive health care and free access to essential drugs and diagnostic services, identified in this scheme, would reduce the financial burden on the citizens of India. Furthermore, the proposition of increasing medical colleges and government hospitals should in theory improve access to health care. Although expected to cost an estimated 110 billion INR each year, this pushes India to reach the 5% of GDP threshold recommended by the WHO, which should allow India to make an equity in health and achieve universal health coverage.,,
In conclusion, the path to the successful implementation of a nationwide breast cancer screening program in India is difficult but not impossible. Renewed focus on health care by the current Modi government, the adoption of digital technology into health care and the emphasis of education and holistic approaches, could aid in tackling the issue of affordability of health care and alleviate the obstacles that currently exist on the way to building an effective breast cancer screening program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects2019, Online Edition. United Nations, Department of Economic and Social Affairs, Population Division; 2019.
Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011;377:505-15.
Government of India. Annual Report to the People on Health. New Delhi: Ministry of Health and Family Welfare; 2010.
World Health Organization and International Bank for Reconstruction and Development (The World Bank). Domestic general government health expenditure (%of GDP). Washington, D.C: The World Bank; 2017.
World Health Organization (WHO) and International Bank for Reconstruction and Development (The World Bank). Tracking Universal Health Coverage: 2017 Global Monitoring Report. Washington, D.C: The World Bank; 2017.
Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L, et al.
Towards achievement of universal health care in India by 2020: A call to action. Lancet 2011;377:760-8.
Indian Council of Medical Research. Summary of Specific Sites of Cancer: BREAST (ICD-10: C50) – Females. National Cancer Registry Project. Indian Council of Medical Research; 2010.
Agarwal G, Pradeep PV, Aggarwal V, Yip CH, Cheung PS. Spectrum of breast cancer in Asian women. World J Surg 2007;31:1031-40.
Somdatta P, Baridalyne N. Awareness of breast cancer in women of an urban resettlement colony. Indian J Cancer 2008;45:149-53.
] [Full text]
Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: An independent review. Lancet 2012;380:1778-86.
Agarwal G, Ramakant P. Breast cancer care in India: The current scenario and the challenges for the future. Breast Care (Basel) 2008;3:21-7.
Kasthuri A. Challenges to healthcare in India – The five A's. Indian J Community Med 2018;43:141-3.
] [Full text]
Shrivastava SR, Shrivastava PS, Ramasamy J. Self breast examination: A tool for early diagnosis of breast cancer. Am J Public Health Res 2013;6:135-9.
Parambil NA, Philip S, Tripathy JP, Philip PM, Duraisamy K, Balasubramanian S. Community engaged breast cancer screening program in Kannur district, Kerala, India: A ray of hope for early diagnosis and treatment. Indian J Cancer 2019;56:222-7.
] [Full text]
Shulman LN, Willett W, Sievers A, Knaul FM. Breast cancer in developing countries: Opportunities for improved survival. J Oncol 2010;2010:1-6.
Singh S, Shrivastava JP, Dwivedi A. Breast cancer screening existence in India: A nonexisting reality. Indian J Med Paediatr Oncol 2015;36:207-9.
] [Full text]
Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: An analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan 2012;27:288-300.
Dasgupta A, Deb S. Telemedicine: A new horizon in public health in India. Indian J Community Med 2008;33:3-8.
] [Full text]
Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand? J Family Med Prim Care 2019;8:1872-6.
] [Full text]
Pisano ED, Hendrick RE, Yaffe MJ, Baum JK, Acharyya S, Cormack JB, et al.
Diagnostic accuracy of digital versus film mammography: Exploratory analysis of selected population subgroups in DMIST. Radiology 2008;246:376-83.
Panda PS, Bhatia V. Role of artificial intelligence (AI) in public health. Indian J Community Fam Med 2018;4:60-2. [Full text]
Mendelson EB. Artificial intelligence in breast imaging: Potentials and limitations. AJR Am J Roentgenol 2019;212:293-9.
Government of India. National Health Accounts Estimates for India (2013-14), National Health Systems Resource (NHSRC) Centre, Ministry of Health and Family Welfare, Government of India: New Delhi: Government of India; 2016.
Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: Are they effective in the UK? Lancet Oncol 2006;7:935-43.
Sharma S. Health Care for India's 500 Million: The Promise of the National Health Protection Scheme. Harvard Public Health Review; 2018. p. 18.