Radiology Fighting Breast Cancer in Developed Nations and Limited-Resource Countries
Breast cancer is the most common cause of cancer among women in the world with 1.1 million new cases and about 411,000 deaths each year. The key to curing breast cancer is early detection and diagnosis when the tumors are still very small. This early diagnosis depends on radiology’s screening of women through breast imaging. Such screening is most effective in the form of mammograms, which is a special type of X-ray image that is uniquely designed for breast tissues, and is recommended for women (of average risk) on a yearly basis over the age of forty years old.
Specially trained radiologists interpret these mammograms and identify the cases needing biopsy and treatment. Ultrasound, which is imaging created from sound-waves on a viewing monitor, has also been shown to be useful in detecting breast cancers, especially in younger women when the breast tissue is dense, and for characterizing palpable nodules. Multiple studies have shown that breast cancer screening with mammograms decreases the risk of
death by 20-35% (NEJM, 2003). Nevertheless, in developed countries where health care resources are more accessible, alarming data in 2007 uncovered a decline in the number of women receiving mammograms. For example, survey data from 2000-2005 showed a 6.3% drop among women ages 50-64, which is the most beneficial age range to be receiving mammograms.
Different explanations include a changing psychological perception of risk and the drop in number of radiology facilities available for mammogram screenings. A troubling trend has been the 6% drop in the number of radiologists interpreting mammograms, a 5% drop in the number of mammogram facilities, and a 3% drop in the number of technologists who manage the imaging equipment, according to the Government Accountability Office (GAO) from 2001-2004.
In developing nations having limited health care resources, breast cancer has been rising at up to 5% per year and women usually present at much later stages with larger tumors that have already spread, often due to lack of health care resources, limited screening programs, and inadequate education of the public. Although guidelines have been distributed to doctors about the appropriate methods to screen these populations, the World Health Organization (WHO) has argued that the guidelines are based on optimal health care resources in developed nations and that these guidelines have limited usefulness in resource-constrained regions of the world. For example, the American Cancer Society recommends yearly mammogram screening for breast cancer in women over the age of 40 with average risk factors, but the WHO argues that this recommendation is of limited utility in countries having no access to mammography facilities and insufficient numbers of skilled radiologists for mammogram interpretations.
RAD-AID supports the Breast Health Global Initiative (BHGI), which was co-sponsored by the Fred Hutchinson Cancer Research Center and the Susan G. Komen Breast Cancer Foundation to develop evidenced-based, economically viable, and culturally-adapted guidelines for breast cancer screening and treatment in developing regions of the world. For example, mammograms in developed countries are the first-line method of screening and ultrasound is considered a supplementary tool for most cases. However, in limited-resource regions, ultrasound is considered by the BHGI to be the first line imaging resource because, (1) ultrasound can be used for a wider variety of radiology-imaging versus mammograms being only useful for breast imaging, and (2) mammography equipment involves more complex expensive maintenance.
Nevertheless, the fact remains that the use of ultrasound as a primary screening tool is not optimal, and women of the third world should ideally receive better care. As resources improve, third world health care systems should aim to offer mammograms in the same way that developed countries offer mammograms as a first-line screening method. As a result, the BGHI Global Summit in 2005 generated stratified approaches to screening and treatment of breast cancer based on resource availability, and RAD-AID is committed to implementing these recommendations.
One opportunity on the horizon for improved breast cancer screening is digital imaging. Similar to regular cameras, the world has transitioned from regular film and printed images to digital images that are seen on computer screens and transmitted as electronic files. As of 2005, about 10.4% of mammograms in the US were digital with significant growth ahead. Research has shown that film-based and digital mammograms have approximately the same diagnostic capability. Digital mammography provides a new tool for bringing better breast cancer screening to resource-scarce environments because the images (1) can be obtained via portable equipment, (2) the images do not need to be printed, and (3) the images can be sent electronically to radiologists all over the world for interpretation.
There is much work to do in solving the breast cancer public health challenge both in developed and developing nations of the world. In developed nations, RAD-AID works to improve the use and quality of mammogram screening. In developing nations, RAD-AID aims to advance the Breast Health Global Initiative and spearhead the WHO’s recommendation to improve breast cancer screening and meet the health needs of women in limited-resource areas of the world.