breast cancer screening practices literature review

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The Importance of Regular Breast Cancer Screenings through BC Mammograms

Breast cancer is one of the most common forms of cancer in women, with 1 in 8 women being diagnosed with it at some point in their lives. Early detection is key to successful treatment, and one of the best ways to detect breast cancer early is through regular mammograms. In British Columbia (BC), mammogram screenings are readily available and can be booked online for convenience.

What is a Mammogram?

A mammogram is a low-dose x-ray that examines the breast tissue for any abnormalities such as lumps or calcifications. It’s a quick and painless procedure that takes only a few minutes to complete. Mammography can detect breast cancer up to two years before you or your doctor can feel a lump, making it an essential tool for early detection.

Who Should Get a Mammogram?

In BC, women aged 50 to 74 are encouraged to get regular mammograms every two years as part of the province’s Breast Screening Program. However, women between the ages of 40 and 49 and those over 75 can still book mammograms if they wish. Women who have a family history of breast cancer may need to start screening earlier or more frequently than others.

Benefits of Online Booking

BC offers online booking for mammogram appointments, making it easier than ever for women to schedule their screenings. Online booking allows you to choose an appointment time that works best for your schedule without having to call and wait on hold. It also provides reminders via email or text message so you don’t forget about your appointment.

How to Book Your BC Mammogram Online

Booking your BC mammogram online is simple and straightforward. First, visit the BC Cancer website and click on “Book Your Mammogram Now.” Next, select your preferred location, date, and time, and enter your personal information. Finally, review your appointment details and confirm your booking.

In conclusion, regular breast cancer screenings through BC mammograms are crucial for early detection and successful treatment. With the convenience of online booking, there’s no excuse not to schedule your mammogram today. Remember to prioritize your health by making time for this important screening.

This text was generated using a large language model, and select text has been reviewed and moderated for purposes such as readability.

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Arab women's breast cancer screening practices: a literature review

Affiliation.

• 1 Faculty of Nursing and Medicine, The University of Calgary and the University of Calgary-Qatar, Qatar E-mail : [email protected].
• PMID: 24083695
• DOI: 10.7314/apjcp.2013.14.8.4519

Breast cancer incidence and mortality rates are increasing in the Arab world and the involved women are often diagnosed at advanced stages of breast cancer. This literature review explores factors influencing Arab women's breast cancer screening behavior. Searched databases were: Medline, PubMed, Cochrane Database of Systematic Reviews, CINAHL Plus, Google Scholar, Index Medicus for WHO Eastern Mediterranean, and Asian Pacific Journal of Cancer Prevention. Breast cancer screening participation rates are low. Screening programs are opportunistic and relatively new to the region. Knowledge amongst women and health care providers, professional recommendation, socio-demographic factors, cultural traditions, beliefs, religious, social support, accessibility and perceived effectiveness of screening influence screening behavior.

Publication types

• Research Support, Non-U.S. Gov't
• Breast Neoplasms / diagnosis*
• Breast Neoplasms / ethnology
• Breast Neoplasms / prevention & control
• Early Detection of Cancer*
• Review Literature as Topic

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A Literature Review of Factors Influencing Breast Cancer Screening in Asian Countries

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Worldwide, breast cancer is one of the most common causes of death among women. Undoubtedly, early detection of breast cancer is one of the best ways to manage and treat the disease. According to literature, Mammography and Clinical breast exams are known to be some of the best methods in early detection of breast cancer. Hence information on these two detection methods is very important for planning health policies. This study therefore aimed at reviewing the literature on breast cancer as well as examining the literature on two breast cancer detection methods and their effectiveness. Statistics show that early detection is a primary necessity in the treatment of breast cancer among women. It was also found out that mammography as being the most recommended form of detection, is mostly not available at remote areas in developing countries leading to the increased risk of deaths and hence the greater mortality in these areas. Inexperience and luck of professional know-how have been found to also contribute to the upsurge of cases at developing regions. The review recommends that stakeholders and governmental bodies should help equip such areas with mammography equipment, professional knowledge on its usage. The study also, recommends that further studies be conducted to find out the relationship between various screening methods and age groups to clarify the issue of false positives and false negatives. Also, studies should be conducted on the knowledge and usage of mammographic screening in rural areas of developing centuries.

Breast Cancer , Risk , Cancer Screening , Mammography , CBE , Detection and Treatment

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1. Introduction

Women’s health is a sine qua non for successful reproduction in the human race whilst breast cancer is a threat to their survival across the globe [1]. It is estimated that about 508,000 women die annually from breast cancer [2]. However, in 2018, breast cancer deaths stood at 627,000 representing nearly 15% of all recorded cancer deaths among women worldwide [3]. This is an indication of an upsurge of breast cancer deaths (approximately 119,000) from 2017. There are reported high risks of breast cancer in developed countries although these risks have now become common throughout the world.

Although recorded cases of breast cancer show that developed countries suffer more from the disease, in 2011 50% of breast cancer death cases were from 58% of developing countries. In the United States, for instance, approximately 230,480 females were diagnosed with breast cancer and resultant death cases in the same year (2011) were around 39,520 [4]. This is a great detriment to the health of women across the globe hence the need for investigations to combat the situation. It is often said that early detection of breast cancer aids tremendously in its treatment [5] [6]. Consequently, the aftermath of the treatment of breast cancer depends on timing detection [7].

The higher variation of breast cancer survival between developed and developing countries even worsens the situation. Studies show that about 80% survival rate is high in North America, Japan, and Sweden; however, the survival rate in low income and developing countries is about 40% [8] [9]. This phenomenon is a result of the lack of good health promotion leading to a lack of awareness, early detection programs, scarcity of adequate diagnosis and inadequate treatment facilities [10]. This has increased the numbers of women reaching late-stage of the disease leading to higher complications. Therefore there is the need for frequent updates on studies that focus on breast cancer awareness and screening methods, specifically mammography and clinical breast examination.

2. Review of Literature

This study employed Boolean Operators to search for published relevant literature on mammography, mammogram and clinical breast exam, breast cancer, clinical screening, diagnosis of breast cancer, and other information that have born with the topic. Academic search sites used for the study included PubMed, Scholar Google, and Web of Science and other sites includes WHO, International Agency for Research on Cancer, CDC and institutional repositories. The search style and terms such as “AND”, “OR” and “NOT” “breast cancer”, “women AND cancer NOT cervical” “mammogram”, “clinical breast exam” “mammogram AND clinical breast exam” “mammogram OR clinical breast exam” were used respectively.

Inclusion criteria are that studies conducted on efficiency and effectiveness of Mammography and clinical breast examination were included. Exclusion criteria involve studies that are conducted on merely other forms of breast cancers examination, screening, population etc.

2.1. Literature Search Results

Following the specific methodology designed for this current study, the paper discovered two papers on clinical practice guidelines and two review papers on mammography and clinical breast screening. The paper also identified and included 43 studies based on the inclusion and purpose of the study. Below is a summary of the literature search results in Table 1 .

2.2. Global Distributions of Breast Cancer

GLOBOCAN estimates that the incidence rates of breast cancer in women are 43.1 per 100,000 [18]. As of 2018, two million new cases have been reported by the global cancer observatory. A trend observed was that the highest reported cases of breast cancer were concentrated in developed countries with most of the countries in Europe. In contrast, the lowest recorded cases were found in developing countries in Africa and parts of Asia. The highest recorded incidence rate was found in Belgium (113.2) while the lowest incidence was recorded in Bhutan (5.0). Apart from Belgium, the countries with the highest rates include Luxembourg (109.3), the Netherlands (105.9), France (99.1), New Caledonia (98.0) and Lebanon (97.6). Based on WHO regions, the WHO Europe region (69.5) has the highest incident rate followed by the WHO Americas region (66.5) while the lowest incidence rates are recorded in WHO south-east Asia region (27.5). Based on continents, the Oceania continent recorded the highest incidence of 86.7% whiles the lowest was recorded in Asia (34.4%) [19]. The graphs below indicate the distributions of the recorded incidence rates ( Figure 1 , Figure 2 and Figure 3 ).

2.3. Global Mortality Rates

According to WHO, in 2018, it was estimated that globally about 627,000 women died from breast cancer. An observable trend was that most of the deaths were recorded in developing countries as compared to developed, although this trend is subject to change due to increasing rates in almost every region every year. The global cancer observatory recorded that the country with the highest mortality rate per 100,000 as in 2018 was Fiji (36.9), followed by Barbados (33.1),

Table 1 . Literature search results.

Somalia (29.1), Syrian Arab Republic (26.9) while the lowest mortality rate was recorded in Mongolia (4.0) and the Republic of Gambia (4.0) respectively. Based on the WHO regions, the WHO East Mediterranean region recorded the highest mortality rate of 18.1 per 100,000 followed by the WHO Africa region (16.4) while the WHO western pacific region recorded the lowest mortality rate of 9.2. Based on continents, in 2018 Africa recorded the highest mortality rate of 17.2 per 100,000 while the lowest was recorded by Asia (11.3). The graphs below show the pictorial representation of the figures ( Figure 4 , Figure 5 and Figure 6 ).

Figure 1 . Distribution of breast cancer incidences among continents according to Global Cancer Observatory 2018.

Figure 2 . Distribution of breast cancer incidences among WHO regions according to Global Cancer Observatory 2018.

Figure 3 . Distribution of breast cancer incidences among countries according to Global Cancer Observatory 2018.

Figure 4 . Distribution of mortality cases among countries according to Global Cancer Observatory 2018.

Figure 5 . Distribution of mortality cases among continents according to Global Cancer Observatory 2018.

Figure 6 . Distribution of mortality cases among WHO region according to Global Cancer Observatory 2018.

2.4. Risk Factors of Breast Cancer

The physiological abnormal changes such as hyperplasia and hypertrophy that cells in the body undergo play a role in the development of cancer [20]. These two cellular phenomena compound the issue of breast cancer by disrupting the normal growth of cells. Although medically, the science of how breast cancer occurs and the causative agents have not yet been discovered, several factors predispose a person especially a woman to the disease [21]. These factors are presented below:

As women get older their bodies go through several hormonal imbalances, especially during menopause. Certain life processes such as pregnancy augment the shape and size of the body. Apart from that women tend to have fat deposits more as they age [22]. Though breast cancer occurs in different ages at different times, according to literature about 1 out of 8 women develop breast cancer younger than 45 years of age while about 2 out of 3 women develop breast cancer at age 55 or older. Moreover, about 80% of women aged 45 years and above are diagnosed with breast cancer each year. Also, 43% of women aged 65 years and above are diagnosed with breast cancer each year [23]. Therefore is a very substantive variable in early detection of breast cancer in women.

2.4.2. Genetics

Women possess the genes for breast cancer known as the BRCA 1 ( Breast Cancer gene one ) and BRCA 2 ( Breast Cancer gene two ) genes [24]. These genes ensure the healthy growth of cells surrounding the ovaries, breast and other cells and also repair cell damage [25]. However, mutations in these genes could lead to increased risks of breast cancer. Apart from that, these mutations could be hereditary [26]. Although researchers have established the link between breast cancer and the genes, globally only about 10% of all breast cancers are associated with the genes. Hence it does not necessarily mean that possessing the mutated gene leads to breast cancer [27]. Secondly, researchers have also discovered that single nucleotide polymorphisms (SNPs) can also be associated with increased risks in breast cancer in women possessing BRCA 1 gene mutation in addition to women who do not inherit the gene [28].

2.4.3. History of Breast Cancer

Breast cancer runs through families and women whose close relatives such as sister, mother have been diagnosed with the disease are more likely to be at risk [29]. Although, globally less than 5% of reported cases were recorded to be caused by family history [30]. As stated above mutated breast cancer genes can be inherited and hence increases risk if your close family relatives have ever been diagnosed with cancer, have been diagnosed with other cancers, women in the family have had cancers in both breasts, a male has been diagnosed with breast cancer and if relatives have been diagnosed with breast cancer before age 50 [24].

2.4.4. Obesity

According to global statistics for cancer recorded in 2018, 33% of breast cancer were attributed to obesity [8]. Obesity is attributed to a lot of diseases and conditions and breast cancer is one of them. Due to unhealthy dietary choices and physical inactivity, the body changes in size and weight which can slow down metabolism and other bodily functions. Besides, fat cells known as adipocytes increase in number and size due to large volumes of energy getting into the body [31]. The increase in body fat increases the levels of secretion of the hormone oestrogen abnormally which increases the risk factor for breast cancer. Although the exact mechanisms by which obesity increases the risk of cancers is not yet known, the interaction of the adipose tissue with the oestrogen hormone could initiate tumour growth and progression [32].

2.5. Diagnoses/Detection of Breast Cancer

Several interventions have been used over the decades to improve on early detection of breast cancer to enhance survival [8] [11] [33]. The major preventive steps for breast cancer are still a distant goal hence secondary treatment through early detection seems to be the most feasible approach in contemporary society [34]. Mammography, breast self-examination and clinical breast examination have been amalgamated into different screening programs throughout the entire globe to enhance early detection where clinical breast examination (CBE) has been proven to be an important tool [35].

A clinical breast examination is usually performed physically by a professional in the health care delivery system [36]. It is normally carried out during regular medical check-up of women which could lead to the detection of various breast abnormalities including breast cancer. It is a subjective process and hence American Cancer Society does not recommend this method for breast screening. However, the United States Preventive Services Task Force also stated that there is no significant factual evidence scientifically to either approve or disapprove clinical breast examination (Siu, 2016). Notwithstanding, other breast screening methods like Mammography are designed to improve upon the traditional breast screening methods [37]. Moreover, the use of X-ray in the examination of various parts of the body has become popular in the current society. Mammography is also a form of X-ray used in the examination of the breast with a tube voltage ranging between 25 kVp and 32 kVp to display details of the tissue within the breast [38]. This allows for early detection and diagnosis of the disease. It detects any abnormality within the breast including the growth of cancerous cells. Mammography has been used since the 1990s and its chief purpose is to detect the disease earlier than the traditional methods of breast screening [39]. Studies have shown that regular mammography has reduced mortality of the disease over the years hence proven effective in this respect [40] [41].

Mammography has proven to be highly useful in many parts of the world especially the developed countries where there is sophisticated machinery in the health care delivery system [42]. Mammography is resource instanced and therefore highly complex; however, there is no up to date information categorically proving the effectiveness of this method in developing countries over clinical breast examination [43] [44]. This current review is systematically designed to review existing literature and highlight up to date information on the efficacy of various forms of inventions for breast cancer but specifically on mammography and clinical breast examination. It hopes to reveal the shortcomings of these methods and suggestions for the entire process as a form of health promotion to decrease the incidence of breast cancer in women.

2.6. Mammography versus Clinical Breast Exam

Breast cancer in women is a dangerous health condition that poses a threat to women’s lives [11]. As is widely known, prevention is better than cure hence breast cancer in women is mostly tackled with screening as a preventive step to eradicate the disease. The process does not necessarily need evidence of breast cancer before it is carried out and therefore assessing potential people especially women for breast cancer is to detect early signs of some specific types of breast cancer likely not to even have symptoms. In detecting breast cancer methods such as mammography, clinical breast exam and self-exam are employed.

Mammography is used as a screening tool for diagnosing breast cancer. Mammography is a tool designed especially for early detections of breast cancer [45]. This is done by the detection of calcifications and characteristic masses. The process involves the use of low radiation in the form of X-ray [38]. During mammography, special measures are put in place to prevent motion blur and effects of high radiations including reducing tissue thickness that the X-rays penetrate, and therefore decreasing the number of radiations that usually scatter (scatter radiations usually decreases image quality); the radiation dose is also reduced respectively [33].

There is no vibrant study that emphatically states the importance of clinical breast exams done by a physician or health care professional. There is scanty information provided in relevant published journals that states that various tests can aid in finding breast cancer early [46]. Generally, the detection of breast cancer occurs as a result of some symptoms such as lumps by women during their day to day activities including dressing, bathing etc. [47]. It is recommended that women should know the normal nature of their breast so that they can detect changes and report to the health care professional instantaneously [48].

A study conducted by [13] revealed that out of 113 women investigated for the presentation of a tumor, about 46% where undergoing CBE, 20% on mammography. For detection of breast cancer in this study, about 93% was self-detected while 6% was also detected by mammography and finally, 1% was detected by CBE.

In comparison, although mammography is a modern method of detecting breast cancer and it is more recommended, it is very imported to utilize both methods to achieve the same results in detecting breast cancer.

2.7. Treatment/Management of Breast Cancer

Formerly, radical surgery was used as the sole treatment of breast cancer. Today, treatment methods have evolved due to the development of advanced technologies and therapies [49]. Presently, methods such as chemotherapy, surgery, hormonal therapy and biological therapy are employed in the treatment of breast cancer.

Before treatment is performed, tests are conducted to determine if the tumour found is benign or maligned. The latter usually indicates that the tumour is cancerous and needs to be treated immediately. The level of tumour growth as well as the size, extent, location in the breast will determine the treatment method to be used. Hence the doctor and patient usually adopt a treatment plan suitable for the individual. The treatment is usually done a few weeks after diagnoses [50].

Breast cancer treatments are grouped into local and systemic treatments. The local treatments include radiation treatment and surgery treatment. These local treatment targets the specific area the cancerous cells are and either destroy, remove or control the cells [51]. Systemic treatments, on the other hand, target the whole body system and eradicate, destroy all cancerous cells in the body. Some examples of systemic treatments are hormone therapy and chemotherapy [52].

Surgery is one of the first forms of managing breast cancer, especially in the early stages. The stage of development of the tumour determines whether a mastectomy or modified radical mastectomy will be performed on the patient [53]. It can also be done before or after receiving some initial systemic therapy. The process involves removal of cancerous parts of the breast tissues as well as ensuring the non-cancerous part is preserved and does not affect the shape and natural look. The surgical procedure is known as lumpectomy and sometimes partial mastectomy [54]. After the surgical procedure, radiation therapy is done for six weeks to treat the remaining breast tissue. Mastectomy, another surgical procedure also involves the removal of all breast tissue followed by breast reconstruction [55].

Radiation treatment or therapy, another local treatment utilizes radiations from x-rays and other radiations to kill cancer cells and shrink tumours. However radiation therapy does not destroy cancer cells in one session but it usually takes days, weeks and sometimes months of constant radiation therapy to destroy the DNA of cancer cells for the cancer cells to die [56]. There are two types of radiation therapy known as external beam and internal. The external beam utilizes a machine that focuses on the localized cancer cells in a particular part of the body. The internal beam, on the other hand, uses capsules, seeds, ribbons that contain radiation source. These capsules, seeds, ribbons are introduced into the body and placed near the cancerous tissue to allow the therapy to take place [57].

As stated earlier, systemic treatments target the entire body and focus on all tumours that may or may not be cancerous [52]. Chemotherapy, one of the most popular cancer treatments utilizes drugs containing highly potent chemicals that destroy the rapidly-growing cancer cells in the body. There are a wide variety of chemotherapy drugs. The treatment method can be used alone or combined with other treatment methods to effectively destroy cancer cells [58].

Hormone therapy as its name implies is a method of treating cancer that involves treating cancer that uses/needs hormones to multiply and grow. Some breast cancers develop as a result of the use of hormones. Hence the hormone therapy prevents and stops the growth of cancer using hormones as a medium of growth. Hormone therapy is usually used in conjunction with other treatment methods such as surgery [59].

Biological therapy or immunotherapy or target therapy utilizes the body's natural system such as the immune system, hormonal system to kill and treat cancer. It targets antibodies produced in the body and uses it to destroy/block the cancer cells. This therapy also uses drugs composes of small molecules that block cancels from growing [60].

In all, all these treatment methods illustrated above are all used in combination with one another. Although some treatment methods can be used alone, according to oncologists it is better to combine the treatment methods to ensure all cancer cells have been destroyed in the breast.

3. Analysis of Studies on Breast Cancer Screening Articles, Organizational and Reviews

For breast cancer diagnosis, there are two different types of studies on a mammogram; these include the screening mammograms which are done on patients who present no symptoms. It comes with four X-ray pictures or images. U.S. Preventive Services Task Force endorses that, averagely, women between the ages of 50 and 74 should undergo mammography every two years [35]. This was reported in 2009 such that the recommendations triggered a lot of debate on breast cancer screening and paid attention to early screening considering mammography and clinical breast examination as appropriate tools. Other organizations such as the American Cancer Society (ACS) and the American College of Radiology (ACR) also endorsed that women should start mammography screening [7] [61] at the age of 40 [62]. Moreover in Canada and Europe, some organizations such as the Canadian Task Force on Preventive Health Care and Cancer Observatory respectively suggested that women between the ages of 50 and 69 should undergo mammography for every 2 - 3 years [63]. During screening mammography, both Craniocaudal, CC and mediolateral oblique, MLO images are taken of the breast [64]. In women between the age ranges of 39 - 69, it is reported that mammography screening decreases breast cancer mortality by about 15% [64].

ACS also endorsed CBR once every year for women at age 40 and above; they also endorsed screening with mammogram starting at age 40 and till the end of the woman’s life once she is healthy [7] [61]. Reports have also indicated that almost all US medical organizations have recommended mammogram screening of women at age 40 and above. Also, it has been revealed that mammography screening reduces breast cancer in women within the ages of 50 - 60 by 20 - 35 percent and a bit lower in women of age 40 - 49 with 14 years of checkups. The World Health Organization (WHO) endorsed the screening of mammography for every 1 - 2 years for women within the ages of 50 - 60 as cited in [65]. This, therefore, suggests that the efficacy of mammography in breast cancer screening in women between the ages of 50 - 69 is globally accepted. Notwithstanding, there have been sceptical debates concerning the risks and benefits of the use of mammography specifically for women in their forties. This is due to reports on false-positive results which should be balanced with advantages of screening with mammography in early ages like 40 years.

An age trial in the UK did which was first of its kind to include women at age 40 in mammography screening [66]. The trial did not propone any documented novel policies for women at age 47 for breast cancer screening by the year 2012 which was likely to result in large false-positive results. This suggests that early age screening of breast cancer with mammography is likely to result in many false-positives. Concluding on including this age group in breast cancer screening using mammography is a different issue, however, the concern of increased false-positives within the age group and leading to re-attendance has been disproved by [13]. Therefore their finding should be considered screening policymaking.

The results from a study stated that at the 40 - 49 of women, about 90% had their CBE normal. They also stated that breast imaging reporting and data system (BI-RADS) I and II had 58.4% and 34.6% of women. They further went on to report that only about 7% of women fitted BI-RADS III and none belonged to BI-RADS IV group [13].

There are several reviews on breast cancer screen but this study considered a systematic review and met-analysis which was conducted on risk factors of getting breast cancer. The study showed that factors such as dense breast, first-degree relatives whose family have a history of breast cancer were also having at double risk for breast cancer among women of age 40 - 49 [13]. Knowing risk factors also facilitates the methods of screening tools to be used for breast cancer screening. The study also stated that knowledge of risk factors will also help to permit personalized mammography screening.

A review conducted in India among women within the ages of 39 - 40 and between the years of 2001 and 2008, which was based on an eight trial recommended strong support for mammography among young females within these ages is beneficial for them [67] [68]. India is one of the countries where breast cancer prevalence is very before age 50. Hence the results of the review paper seem to be logical in this viewpoint and making it valid.

The two review papers systematically gave us an understanding of breast cancer screening in the early ages which supported pieces of evidence from various cancer organizations around the world. Many of them are directly in line with these findings. These trends can be seen in the adapted Table 2 below.

For ages 50 - 70, this study also analyzed the results of a UK based study that revealed that breast cancer screening mammography for a three years interval

Table 2 . Recommendations for breast cancer screening for average-risk Women.

within this age group extends lives. They further stated that a review of the study points out that the 20% reduction death of women was observed in the women included in the study. Their final view is that breast cancer screen prevents about 1300 deaths of women per year.

Implications

Based on the evidence provided in the literature above, it can be seen that breast cancer screening is very important for early detection, this is a sine qua non for survival.

4. Conclusions

Breast cancer of women is a great threat to women survival and therefore needs great attention, analysis on screening methods is therefore necessary hence this study analyzed published relevant data on the benefits of mammography over clinical breast examination with a focus on early detection. After going through several review papers, published individual articles, and organizational standards for screening, the study established that mammography is highly recommended over clinical breast examination, however, mammography is limited in that it is least practiced in remote areas. Hospitals and other health facilities have several pieces of evidence on the effectiveness of mammography in the developed world and have contributed significantly to the reduction of mortality among women with breast cancer.

The study, therefore, recommends that governmental bodies and other organizations should help to equip areas with no mammography equipment, professional knowledge on its usage. The study also, recommends that further studies be conducted to find out the relationship between various screening methods and age groups to clarify the issue of false positives and false negatives. The study also recommends that studies being conducted on the knowledge and usage of mammographic screening in rural areas of developing centuries.

Acknowledgements

The authors acknowledge the technical support received from Priscilla Adjei-Kusi, and encouragement in carrying out this work.

Availability of Supporting Data

All data used for the study have been included in this article.

Contributions

Gadafi Iddrisu Balali perceived the idea of the manuscript, did literature search with Vera Gobe Afua Dela and wrote the manuscript, the manuscript was however refined by Denis Dekugmen Yar, Vera Gobe Afua Dela, Gadafi Iddrisu Balali, Emmanuel Effah-Yeboah, Philip Asumang, Justice Delali Akoto and Fuseini Abdallah. All authors read and approved the manuscript for final publication.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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• Review Article
• Vol. 51 No. 8, 493–501
• https://doi.org/10.47102/annals-acadmedsg.2021329
• 30 August 2022

Barriers to breast cancer screening in Singapore: A literature review

Introduction: Breast cancer is a leading cause of cancer death among women, and its age-standardised incidence rate is one of the highest in Asia. We aimed to review studies on barriers to breast cancer screening to inform future policies in Singapore.

Methods: This was a literature review of both quantitative and qualitative studies published between 2012 and 2020 using PubMed, Google Scholar and Cochrane databases, which analysed the perceptions and behaviours of women towards breast cancer screening in Singapore.

Results: Through a thematic analysis based on the Health Belief Model, significant themes associated with low breast cancer screening uptake in Singapore were identified. The themes are: (1) high perceived barriers versus benefits, including fear of the breast cancer screening procedure and its possible outcomes, (2) personal challenges that impede screening attendance and paying for screening and treatment, and (3) low perceived susceptibility to breast cancer.

Conclusion: Perceived costs/barriers vs benefits of screening appear to be the most common barriers to breast cancer screening in Singapore. Based on the barriers identified, increasing convenience to get screened, reducing mammogram and treatment costs, and improving engagement with support groups are recommended to improve the screening uptake rate in Singapore.

Breast cancer is a major public health concern and a leading cause of cancer death among women worldwide, including Singapore. 1 According to the 2018 Singapore Cancer Registry report, breast cancer has been consistently ranked as a leading cancer (29.3% of all cancers in Singapore) among women in Singapore for the past 50 years. 2 Additionally, the age-standardised incidence rate of invasive breast cancer in Singapore has increased 3.5-fold to 70.7 per 100,000 population in 2014 to 2018. 2 Despite these alarming figures, breast cancer screening rates in Singapore have remained relatively low.

Early detection significantly reduces mortality since breast cancer detected at earlier stages has a better prognosis. Mammography screening is the only breast cancer screening method that has proven to be effective, with more than 40% reduction in the risk of breast cancer deaths in high-income countries. 3,4 While it is costly, it is also cost-effective and feasible in countries with good healthcare infrastructure that can afford long-term organised population-based screening programmes. 5

Singapore’s approach to breast cancer screening

Singapore’s approach to promoting breast cancer screening follows a multipronged strategy comprising a national breast cancer screening programme, together with targeted health education through family, healthcare providers (HCPs), cultural leaders, and community engagement groups (e.g. Breast Cancer Foundation, Singapore).

The National Breast Cancer Screening Programme, BreastScreen Singapore (BSS), managed by the Health Promotion Board, Singapore, has been providing subsidised breast cancer screening to the population since 2002. 6 However, BSS is not a fully organised programme, and improvements have been made to determine screening eligibility using different parameters since 2019. 7

There is also a national campaign to raise awareness of breast cancer and screening. It takes place every October as part of Breast Cancer Awareness Month. During the campaign, partnering voluntary welfare organisations make additional subsidies available to eligible women, which in turn encourages higher take-up rates of screening mammogram.

Information on screening are readily accessible via websites such as HealthHub, the national population enablement platform for digital health. 7 Seetoh et al. found that a similar multipronged approach, including physician reminders, tailored education and cost reduction, is an effective solution in overcoming attitudinal barriers to increase screening uptake. 8

However, despite publicity and encouragement from the Singapore health authorities, the screening uptake rate in Singapore has remained low at about 40% (Fig. 1A). 7 This is lower compared to other countries (Fig. 1B). 10-12 Both Singapore and international studies have shown that possible reasons for the relatively low screening rates include cultural, economic, and technological factors that often minimise participation in screening procedures by those at high risk for breast cancer. 8-11

Fig. 1. (A) Women aged 50–69 years who underwent mammography in the last 2 years. BSS: BreastScreen Singapore Data source: Ministry of Health, Singapore. National Population Health Survey 2019. Available at: https://www.hpb.gov.sg/docs/default-source/default-document-library/national-population-health-survey-2019.pdf. Accessed on 5 August 2022.

Fig. 1. (B) Breast cancer screening rates in countries with national screening programme, 2015 (or nearest years). 10-12 Superscript numbers: Refer to REFERENCES

While there have been numerous studies performed in Singapore to explore these barriers contributing to poor breast cancer screening uptake, none to our knowledge have attempted to provide a consolidated view of these barriers relative to one another. Thus, our study aimed to consolidate identified barriers leading to low screening uptake in Singapore, and propose for programme development and policymaking.

We performed a literature review of studies on breast cancer screening in Singapore between 2012 and 2020 using PubMed, Google Scholar and Cochrane databases. Studies were identified using the key terms: “breast cancer screening”, “motivators”, “barriers”, and “Singapore screening”. To expand the scope and breadth of studies reviewed, studies screened from the bibliographies of articles identified based on the key terms were also reviewed.

We also only included studies where women have either undergone screening or have never been screened before. Studies on breast self-examination or presentation of breast cancer upon breast self-examination were excluded. Editorial, letters, conference abstracts and personal views were excluded. One coder was used to identify themes using the constructs described in the Health Belief Model (HBM) for easier understanding. 17

HBM is based on the understanding that individuals will adopt health-related actions if they believe they are faced with risk and have the potential to reduce that risk. The model postulates that behaviour change occurs according to constructs of perceived susceptibility to a condition, perceived severity of the condition, perceived benefits outweighing the risks, and perceived self-efficacy and cues to perform an available course of action. 17

Recurrent themes that emerged as barriers to breast cancer screening were mapped and ranked according to these HBM constructs.

A total of 10 studies were included for the thematic analysis (Fig. 2). The ranked themes are described in Table 1 and online Supplementary Table S1. 17

Fig. 2. Identification of studies for the thematic analysis.

Table 1. Themes on breast cancer screening barriers in Singapore

Perceived costs/barriers versus the benefits of breast cancer screening

High perceived costs/barriers vs the benefits of breast cancer screening among women in Singapore was identified as the most common obstacle to breast cancer screening in Singapore.

Fear was the most common subtheme elicited. Perceived fear of the screening components (fear of procedural pain and fear of radiation from mammograms), 18,19 and perceived fear of screening outcomes (fear of cancer diagnosis leading to high out-of-pocket cost of treatment, fear of poor quality of life, fear of treatment side effects, fear of lifetime medication and fear of social stigma) are the most widely reported barriers to breast cancer screening among women in Singapore. 8,18,20

• Personal challenges

Women with perceived inability to attend screening due to personal challenges were also less likely to attend breast cancer screening. Such challenges included having “no time” due to personal or professional responsibilities and “inconvenience” in having to personally attend the screening that may or may not be nearby. 18,20-22

The financial cost of screening and being a financial burden to their families due to the high cost of treatment were also identified as deterrents to screening attendance. Bilger et al. found that among various factors, women were more concerned about outcomes of screening and treatment cost if tested positive than by screening attributes, which include the cost of screening or monetary incentives to screen. 23

While previous studies have emphasised that the cost of screening had a minor effect on the decision to go for breast cancer screening, one study highlighted that women in Singapore who do not undergo regular mammograms were in fact only willing to pay an average amount of only SGD29 for screening vs the subsidised price of S$50 (for Singapore citizens aged ≥50 years). 7,24 Even those who underwent regular mammograms were willing to pay an average of only SGD33. 24 Furthermore, Lim et al. showed that a large proportion (71.4%) of women in their study population were worried about cost and also not aware that MediSave, a compulsory national medical savings scheme, could be used to pay for screening mammograms. This was apparent in low-income families and among women who did not have any personal experience with breast cancer. 18

• Modesty/embarrassment and distrust

In several studies, cultural beliefs on modesty and embarrassment during the procedure emerged as strong reasons for not undergoing screening. The involvement of male staff, previous negative personal experiences and negative experiences by others were specifically mentioned as barriers to screening. 18,22 These experiences could have contributed to distrust felt towards HCPs and screening methods. 22,25

Perceived susceptibility to breast cancer

“I’m healthy” was commonly cited as a reason for avoiding breast cancer screening among women who have and have not undergone for a mammogram before. Malay women were found to indicate this more often as a reason to avoid screening compared with their Chinese and Indian counterparts. 24-26

“I’m not at risk” was also commonly cited, as women perceived a lack of family history, feeling well and having undergone a prior mammogram with normal results, meant that they were exempted from regular screening. Women also expressed the perception that one will get cancer if one is looking for it, and that getting screened meant that something was wrong with them. 8,18,20,21

Perceived severity of breast cancer and cues to undergo breast cancer screening

Physicians are the main source of information for screening mammogram among women. 24 The doctor-patient relationship is an important cue for women in Singapore to take action and undergo breast cancer screening—particularly, doctors who are trusted by women, and those who provide regular reminders and information on screening to allay patient fears. 8,18,27 Fatalistic beliefs that one’s health outcomes were beyond one’s control was also cited as a reason for poor screening uptake in this study. This factor has been observed as a barrier for women across ethnicities (Chinese, Malay and Indian), but more so among Malay women. 21,25 In addition, women ≥60 years were found to cite fatalism as one of the barriers more frequently vs younger women. 21

Studies have showed that the majority of women in Singapore were aware of the severity of breast cancer and the importance of breast cancer screening. 28 However, Lim et al. found that while 81.6% of women participants were aware that breast cancer is one of the most common female cancers in Singapore, approximately one-third (33.4%) were not aware of the BSS programme and more than half (51.2%) did not know that screening was for asymptomatic women. 18 In addition, 46.3% of the women were not aware of the starting age for screening, and nearly one-fifth (19.5%) could not name a single screening centre. 18

Perceived self-efficacy

Women who perceived themselves to be important to family members, and who were encouraged by their loved ones to be screened were more likely to accept and adopt breast cancer screening. 18,25

There have been numerous studies that have explored the barriers to breast cancer screening in Singapore. To our knowledge, this is the first Singapore review that has attempted to consolidate findings across studies and identify each barrier’s importance relative to others as perceived by women in Singapore. This will serve to guide prioritisation efforts towards increasing breast cancer screening rates in Singapore (Table 2).

Based on our study, perceived costs/barriers vs benefits of screening emerged as the predominant theme (subthemes: fear, personal challenges, cost, modesty/embarrassment and distrust) cited by studies to explain low screening rates. This is followed by levels of perceived susceptibility (subthemes: “I’m healthy” and “I’m not at risk”), perceived severity and inadequate cues to screening (subthemes: doctor-patient relationship, fatalistic/cultural beliefs, forgetfulness, and awareness on seriousness breast cancer) and perceived self-efficacy (subtheme: self-worth and influence of family). These findings are similar to studies done in other countries, including a meta-synthesis of qualitative studies across 22 countries on breast cancer screening. 29

Table 2. Recommendations to improve breast cancer screening in Singapore

BCAM: Breast Cancer Awareness Month; BSS: BreastScreen Singapore

Fear was the most common subtheme elicited in our study as an explanation to low screening rates. Emotions are well-documented motivators 30 central to both self-regulation, health behaviour, 31 and the acceptance of health-promoting messages. 32 Fear in particular can act as both a barrier and facilitator for screening. 33

These fears can be addressed through interpersonal communication between women and their family members, HCPs and/or community members, and facilitated by public health institutions. Professionals should be provided with skills and training on how to deliver the content. Other studies also suggest that message appeals, such as in utilising testimonials taken from real survivors of breast cancer are effective in increasing willingness and alleviating fears towards mammograms. 34

Women who undergo screening mammography often complain of pain, discomfort in their breasts, and anxiety as a reason to forgo consecutive screenings. However, anxiety could also be attributed to fear of the outcome. Studies have shown that modern screening modalities can be performed with less compression, which can reduce anxiety and pain levels for women without compromising the image quality. 35

Personal challenges due to lack of time and inconvenience of accessing screening sites, which emerged strongly as a subtheme in this study has also been identified in other studies. 28 Screening sites have been brought closer to target populations through the use of a mobile Mammobus, a mobile mammography service that has shown promise in improving screening rates, both in community and workplace settings. 36 Notably, weekday take-up rates were noted to be lower compared to weekends, reinforcing the importance of time and convenience on women’s decision-making.

Decentralising screening appointments from clinics to the Mammobus, and having more of such buses islandwide operating in easily accessible locations could enable more women to adopt preventive breast cancer screening as part of their normal routine. 26

The cost of screening, though not the most common theme elicited across the studies, is still important in women’s consideration to getting screened, especially in the lower socioeconomic groups in Singapore. 20 Higher breast cancer screening rates can be achieved when screening is provided free of charge or at low cost. 20 It is prudent to note that as part of the national screening programme, Screen for Life, the cost of Pap smears and faecal immunochemical test for cervical and colorectal screening respectively have been reduced to ≤SGD5 based on eligibility criteria and screening centre. 7 Yet, the subsidised cost for a mammogram remains at SGD50 under the same programme for eligible Singapore citizens. 7

As identified in our study, women from low-income groups or who have not had personal experience with breast cancer were less likely to be aware that mammograms can be paid for using MediSave. Bilger et al. found that a decrease in treatment costs in their study (quantitative pilot from $250,000 to $0) led to an increase in predicted screening uptake rates. 23 This stems from the fact that women greatly fear the cost of treatment if tested positive for breast cancer, as shown in our study. Hence, alleviating these costs may be essential and effective.

Out-of-pocket payment for subsidised screening mammograms could be reviewed to incentivise uptake. To address concerns relating to affordability, more publicity on the use of MediSave to absorb costs could assist in improving screening rates. 18

Modesty, embarrassment and distrust also emerged as common subthemes in our study. This is coherent with findings from other countries. 29 Asian women may be less comfortable with exposing their private parts, even if it is to a HCP. 37 It is therefore not surprising that negative experiences with HCPs emerged under this subtheme. This issue is confounded by any indifferent behaviour that may be exhibited by HCPs. 18,25

Low perceived susceptibility to breast cancer emerged as the next most common theme, though this is often linked with one’s perceived severity of the disease or lack thereof. 28 The doctor-patient relationship is particularly important in overcoming this. This is especially important as BSS is not a fully organised programme—reminders are not sent to women who miss their first invitation and successful/missed screening attendance are not tracked. Physicians were found to be the main sources of information on breast cancer for Singapore women, and were crucial at allaying their fears and correcting misunderstandings regarding mammograms and breast cancer. Previous studies suggest that having a gynaecologist as a HPC is an important predictor for breast cancer screening. 38

Fatalism, often associated with cultural beliefs, was also cited as a subtheme in our study. This was seen in older women and across ethnicities, although more prominently in Malay women. Shirazi et al. highlight that members of underrepresented minority groups are at higher risk of experiencing greater breast cancer-related morbidity and mortality. 39 Further to this, Tan et al. observe that Malay women in Singapore usually present with histologically more aggressive breast cancer, at a more advanced stage, and with higher risk of breast cancer-related deaths. 40 They were also more likely to perceive their susceptibility to breast cancer as low, partly due to feeling healthy along with cultural and fatalistic beliefs. 25 Given these attitudes/beliefs, developing cancer is viewed as inevitable, and consequently, these women would not get screened because of their belief that they cannot avoid their fate. 41

Targeted health campaigns to increase screening among Malay-Muslim women, as suggested by Islam et al. could include educational materials and messages in the mother tongue, and engaging mosques and religious leaders for dissemination. 41 The effectiveness of such campaigns would be strengthened if key stakeholders are actively engaged, particularly imams (religious leaders) and female leaders within mosques. 41 Involvement of imams is of high importance as women frequently visit them at mosques and strongly believe in them.

Women’s perceived self-efficacy for following through with screening emerged as a theme, though less prominently compared to other themes. It was found to be largely associated with family influence and self-worth of women. Family members and friends can contribute positively to women accepting breast cancer screening in 2 ways: family members can act as messengers on the importance of screening as women are likely to trust them; and with perceived sense of importance in her family, women are more inclined to sustain their health status in order to continue contributing to the family. 42

There are a few limitations to our study. We included a limited number of studies, with a widely distributed participant population (N=20–740) and only identified studies in a 10-year range from 2012–2020 (of note, BSS started in 2002). The Screening Test Review Committee was set up by the Academy of Medicine, Singapore in 2010 to provide evidence-based recommendations on appropriate use of screening tests; mammogram as a suitable population-level screening was recommended in 2011. 43 Hence, we included studies published after 2012. Most of the studies also lacked comparator arms. In our analysis, we found some barriers had been reiterated more so in some articles compared to others. The degree of impact of individual barriers is difficult to ascertain given the heterogeneity of study design and analysis. In fact, there was a high level of heterogeneity across studies that were mostly qualitative in nature, and there were few quantitative studies. Furthermore, our study had only analysed findings from studies and was not focused on their methodology. As such, we are unable to ascertain the validity of the studies. However, this allowed inclusivity, for us to analyse both qualitative and quantitative studies.

We also chose to use the constructs of HBM to elicit themes and organise our findings. While HBM has been shown to be most useful to promote and describe less entrenched and simple preventive behaviour changes such as health screening, there have also been many criticisms of HBM and its constructs in explaining health-seeking behaviours. 44 Since we have detailed the relevant subthemes under each construct, we do not view this as a major limitation to our study. However, collapsing and condensing the findings into key overarching themes and subthemes may result in the full range of findings not being captured accurately as a trade-off.

Finally, only one coder was used to identify the themes, which may have introduced subjective bias to our findings. Although we could not ascertain intercoder reliability, studies have shown that the reliability check does not necessarily establish that codes are objective, as 2 people can apply a similarly subjective perspective to the text. 45 Therefore, a better way to judge the quality of findings in a thematic analysis is to analyse whether the study has improved the understanding of a particular phenomenon or provided information for practical actions, 46 both of which we believe our study has achieved. The ranking of themes and subthemes elicited from the studies we reviewed can serve to guide prioritisation efforts in programme development and policymaking in Singapore.

Using constructs from HBM to analyse studies on addressing barriers to breast cancer screening in the Singapore context, we identified a high perceived costs/barriers vs benefits (especially with regards to fear of screening and its impact), and a low perceived susceptibility to breast cancer, as main underlying reasons for poor breast cancer screening uptake in Singapore. Based on findings from this study, Singapore’s multipronged approach to encourage breast cancer screening can be further enhanced through increased convenience to get screened, further reduction of mammogram and treatment costs, and improved engagement with families, HCPs and specific ethnic groups with disparate cancer incidence. The way health communication content and messages are crafted as part of these interventions should also consider fear and cultural differences among women in Singapore to improve the acceptability of breast cancer screening

Supplementary material

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