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 TC CNS PIN WIRE CUTTER 7" ORTHOPEDIC SURGICAL INST US $64.99
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 Coated Vaginal Speculum Large Gynecology Surgical Inst US $27.99
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 Castroviejo Calipers Angled 3.5" Dental Surgical Inst US $23.99
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 Kevorkian Biopsy Punch Forceps Gynecology Surgical Inst US $67.99
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 Extracting Forceps# 3FS Dental Veterinary Surgical Inst US $8.99
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 Extracting Forceps# 101 Dental Veterinary Surgical inst US $7.99
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 BECKMAN-Weitlaner Retractor 9" 3x4 Sharp Surgical Inst US $47.99
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 Coated Vaginal Speculum Large Gynecology Surgical Inst US $27.99
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 TUBE OCCLUDING CLAMPS 5.5" Surgical Ob/ Gyn Inst US $1.99
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 Dental Elevators # EA Surgical Dental Veterinary inst US $4.99
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 Diamond Molar Rasporatory 7" Veterinary Surgical Inst US $4.99
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 Burke Biopsy Punch Forceps Gynecology Surgical Inst US $67.99
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Surgical Inst
Surgical Instrument counting and organizational system
Early Breast cancer detection at mass level; what can be done in developing countries?
Breast cancer is the most common cancer and second leading cause of cancer death in women around the world[1]. In Indian women, breast cancer is the second most common cancer, next only to carcinoma cervix. But in many urban areas in India, the breast cancer has recently emerged as the leading cancer in women [2].Breast cancer constitutes about 19-34% of all cancer cases among women in India [3,4,5]. Age adjusted incidence of breast cancer in India varies from 16 to 25 per lac population and approximately 80,000 new cases of breast cancer are diagnosed every year.[6]. With the rapid urbanization and changing lifestyle, the numbers are likely to increase further.
Early diagnosis and prompt treatment are paramount to improving the outcome of breast cancer. In India, early breast cancer constitutes about 30% [7] and locally advanced breast cancer constitutes about 50-70% of the breast cancer load. [8]. Accordingly, the proportional mortality rates in our country are much higher compared to North America where majority of cases present in early stages. The incidence to mortality ratio in North America is 0.25 compared to 0.48 in India [9]. Similarly, 5-year survival of over 70% in North America and western Europe is much higher than less than 48 % in India [10,11] and less than 10% in other developing countries [12].
There are many barriers to early diagnosis and treatment in India and other developing countries. First, women are not able to detect a lump in their breast early. Second, even after discovering a painless lump, they fail to understand its cancerous nature or prevalent notion of incurable nature of cancer prevents them from reporting to a healthcare facility early. This fact is supported by various studies in India and other developing countries which show that 79-98% of the women surveyed don't know that a painless lump in a breast can be cancer [14,15]and more than 75% of women link painful lumps and pain in the breast to cancer.[13]. Third, access to healthcare facility is limited in rural areas where majority of population lives. Last, conservative socio-cultural milieu prevents a woman from approaching male health care personnel for early check-up. The relative contribution of each of these factors is a matter of speculation.
To facilitate early identification of a lump in the breast, there are 3 available modalities; BSE(breast self examination), CBE (clinical breast Examination) and mammography. Both Mammography and CBE are effective in decreasing mortality due to breast cancer[16-21] Recommending mammography as a regular screening test on mass scale in India is impractical because of the astronomical costs involved in developing the requisite infrastructure and manpower. Moreover, the burden of breast cancer in developing countries is more in younger age group[3] in which the efficacy of mammography to detect breast cancer is questionable[22]. Similarly regular CBE on mass scale is logistically difficult due to scarcity of trained health personnel and socio-religious taboos regarding clinical breast examination [23,24].
BSE is a simple and inexpensive tool and can be performed by women themselves. Some studies have shown that practicing BSE helps to detect breast cancer lumps of smaller sizes [25-29] and leads to early diagnosis of breast cancer [25-34]but this does not translate in to reduction in mortality from breast cancer[35-37]. Presently, there is insufficient evidence to recommend for or against the teaching of BSE [38]. Conversely, BSE increases the number of physician visits for the evaluation of benign breast lesions and leads to higher rates of benign breast biopsies[35-37]. Also, proper technique of BSE is expensive to teach and difficult to perform[39-43]. Hence, the status of BSE as a screening modality on mass scale is debatable [35,44,45]. Furthermore, even in women performing BSE regularly, many early detected tumors are found incidentally and not during self examination[46-49]. Thus conventional screening tools are impracticable in developing countries highlighting the need for novel approaches.
Prevalent misconceptions of pain associated with any cancerous breast lump and incurability of cancer are unaddressed issues in developing countries. Creating awareness on mass scale about these facts that any lump in the breast even a painless one can be cancer as well as curability of early diagnosed breast cancer is the need of the hour. This strategy is relatively easy, inexpensive and practicable in resource restricted countries till standard screening tools are universally available, affordable and accessible to masses.
References
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- Indian Council of Medical Research. National Cancer Registry Programme of India - an Overview. NCRP: Bangalore; 2002
- National Cancer Registry Programme. Consolidated report of the population based cancer registries1990-1996. New Delhi: Indian Council of Medical Research; 2001
- National Cancer Registry Programme. Ten year consolidated report of the hospital based cancer registries 1984-1993. An assessment of the burden and care of cancer patients. New Delhi: Indian Council of Medical Research; 2001
- National Cancer Registry Programme. Consolidated report of the population based cancer registries1990-1996. Supplement: Year-wise tabulation of incident cancers and rates by site and gender. New Delhi: Indian Council of Medical Research; 2001
- Nair MK, Sankaranarayanan R, Nair KS, Amma NS, Varghese C, Padmakumari G, et al. Overall survival from breast cancer in Kerala, India, in relation to Menstrual, Reproductive, and Clinical factors. Cancer 1993;71:1791-6
- Nandakumar A, Anantha N, Venugopal TC, Sankaranarayanan R, Thimmasetty K, Dhar M. Survival in breast cancer: A population-based study in Bangalore, India. Int J Cancer 1995;60:593-6.
- Chopra R. The Indian scene. J Clin Oncol 2001;19:106S-11S
- Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA Cancer J Clin 1999;49:33-64
- Goel AK, Seenu V, Shukla NK, Raina V. Breast cancer presentation at a regional cancer center. Natl Med J India 1995;8:6-9
- Gajalakshmi CK, Shanta V, Swaminathan R, Sankaranarayanan R, Black RJ. A population-based survival study on female breast cancer in Madras, India. Br J Cancer 1997;75:771-5
- Okobia MN, Osime U.Clinicopathological study of carcinoma of breast in Benin city. Afr J Reprod Health 2001;5(2)56-62
- Odusanya OO, Tayo OO. Breast cancer knowledge, attitudes and practice among nurses in Lagos, Nigeria. Acta Oncol 2001;40(7):844-848
- Okabia MN, Bunker CH, Okonofua FE, Osime U. Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross sectional study. Wor J Surg Onco 2006;4:11-20
- Oluwatosin OA, Oladepo O.Knowledge of breast cancer and its early detection measures among rural women in Akinyele local government area, Ibadan, Nigeria. BMC Cancer 2006; 6: 271
- Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. JAMA 1995;273:149–54
- Wells MJ. Mammography and the politics of randomized controlled trials. Br Med J 1998;317:1224-1230
- Smart CR, Hendrick RE, Rutledge JH 3d, Smith RA. Benefit of mammography screening in women ages 40 to 49 years. Current evidence from randomized controlled trials. Cancer 1995;75:1619-26 (published erratum appears in Cancer 1995;75).
- Tabar L, Fagerberg G, Chen HH, Duffy SW, Smart CR, Gad A, et al. Efficacy of breast cancer screening by age. New results from the Swedish Two-county Trial. Cancer 1995;75:2507-17
- Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50–59 years. J Natl Cancer Inst 2000;92:1490–9
- Maxwell AE, Bastani R, Warda US. Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States. Amer J Prev Med 2000;18:62–68.
- Maxwell AE, Bastani R, Warda US. Misconceptions and mammography use among Filipino-and Korean-American women. Ethnc and Dis. 1998;8:377–384
- Owen WL, Hoge AG, Asal NR, Anderson PL Jr, Cucchiara AJ. Self-examination of the breast: use and effectiveness. South Med J 1985;78:1170–3.
- Smith EM, Francis AM, Polissar L. The effect of breast self-exam practices and physician examinations on extent of disease at diagnosis. Prev Med 1980;9:409–17
- McPherson CP, Swenson KK, Jolitz G, Murray CL Survival of women ages 40–49 years with breast carcinoma according to method of detection. Cancer 1997;79:1923–32
- Smith EM, Burns TL. The effects of breast self-examination in a population-based cancer registry. Cancer 1985;55:432–7
- Koibuchi Y, Iino Y, Takei H, Maemura M, Horiguchi J, Yokoe T, et al. The effect of mass screening by physical examination combined with regular breast self-examination on clinical stage and course of Japanese women with breast cancer. Oncol Rep 1998;5:151–5
- Gould-Martin K, Paganini-Hill A, Casagrande C, Mack T, Ross RK. Behavioral and biological determinants of surgical stage of breast cancer. Prev Med 1982;11:429–40
- Greenwald P, Nasca PC, Lawrence CE, Horton J, McGarrah RP, Gabriele T, et al. Estimated effect of breast self-examination and routine physician examinations on breast-cancer mortality. N Engl J Med 1978;299:271–3.
- Kuroishi T, Tominaga S, Ota J, Horino T, Taguchi T, Ishida T, et al. The effect of breast self-examination on early detection and survival. Jpn J Cancer Res 1992;83:344–50
- Philip J, Harris WG, Flaherty C, Joslin CA, Rustage JH, Wijesinghe DP. Breast self-examination: clinical results from a population-based prospective study. Br J Cancer 1984;50:7–12
- Auvinen A, Elovainio L, Hakama M. Breast self-examination and survival from breast cancer: a prospective follow-up study. Breast Cancer Res Treat 1996;38:161–8.
- Thomas DB, Gao DL, Ray RM, Wang WW, Allison CJ, Chen FL, et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst 2002;94:1445–57
- Semiglazov VF, Moiseyenko VM, Manikhas AG, Protsenko SA, Kharikova RS, Ivanov VG, et al. Role of breast self-examination in early detection of breast cancer: Russia/WHO prospective randomized trial in St. Petersburg. Cancer Strategy 1999;1:145–51
- Semiglazov VF, Moiseyenko VM, Bavli JL, Migmanova NS, Seleznyov NK, Popova RT, et al. The role of breast self-examination in early breast cancer detection (results of the 5-years USSR/WHO randomized study in Leningrad). Eur J Epidemiol 1992;8:498–502
- U.S. Preventive Services Task Force. Screening for breast cancer: recommendations and rationale. Ann Intern Med 2002;137:344–6
- O'Malley MS. Cost-effectiveness of two nurse-led programs to teach breast self-examination. Am J Prev Med 1993;9:139–45
- Campbell HS, McBean M, Mandin H, Bryant H. Teaching medical students how to perform a clinical breast examination. Acad Med 1994;69:993–5
- Fletcher SW, O'Malley MS, Earp JL, Morgan TM, Lin S, Degnan D. How best to teach women breast self-examination. A randomized controlled trial. Ann Intern Med 1990;112:772–9
- Campbell HS, Fletcher SW, Pilgrim CA, Morgan TM, Lin S. Improving physicians' and nurses' clinical breast examination: a randomized controlled trial. Am J Prev Med 1991;7:1–8
- Pilgrim C, Lannon C, Harris RP, Cogburn W, Fletcher SW. Improving clinical breast examination training in a medical school: a randomized controlled trial. J Gen Intern Med 1993;8:685–8
- Harris R, Kinsinger LS. Routinely Teaching Breast Self-Examination is Dead. What Does This Mean? J Nat Can Inst 2002; 94(19): 1420-1421
- World Health Organisation- Guidelines 2007. Screening for Breast Cancer
- Auvinen A, Elovainio L, Hakama M. Breast self-examination and survival from breast cancer: a prospective follow up study. Breast Cancer Res Treat 1996;38(2):161-8
- Miller AB, Baines CJ, To T, Wall C. Canadian National Breast Screening Study: 2. Breast cancer detection and death rates among women aged 50–59 years. CMAJ 1992;147:1477-88
- McPherson CP, Swenson KK, Jolitz G, Murray CL. Survival of women ages 40–49 years with breast carcinoma according to method of detection. Cancer 1997;79:1923-32
- Huguley CM, Brown RL, Greenberg RS, Clark WS. Breast self-examination and survival from breast cancer. Cancer 1988;62:1389-96
About the Author
Senior Surgeon & Internationally renowned Doctor
Department of Surgery, Fortis Super-specialty Hospital
Mohali (Chandigarh), Punjab
India
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