Clinical breast examination (CBE) training for health workers compared with no training for early detection of breast cancer in LMICs

Patient or population: health workers

Settings: community settings in LMICs 

Intervention: CBE training for health workers

Comparison: standard of care (no CBE training for health works)

Breast cancer stage at the time of presentation: defined as the proportion of women with breast cancer diagnosed at early stage (stage 0, I, II)

Time of outcome assessment: 3 years to 20 years

Method of measurement: CBE

RR 1.44 (1.01 to 2.06)

593 participants (3 studies) out of a total of 947,190 women screened in 4 studies 

⊕⊕⊝⊝ Low^a,b

Breast cancer stage at the time of presentation: defined as the proportion of women with breast cancer diagnosed at late stage (stage III, IV)

Time of outcome assessment: 3 years to 20 years

Method of measurement: CBE

RR 0.58 (0.36 to 0.94)

593 participants (3 studies) out of a total of 947,190 women screened in 4 studies 

⊕⊕⊝⊝ Low^a,b

Accuracy of health worker‐performed CBE

Time of outcome assessment: 2 years to 20 years

Method of measurement: Sensitivity, specificity and positive predictive value

‐

2 studies

⊕⊝⊝⊝ Very low^a,c,d

The outcome could not be pooled. The sensitivity ranged between 51.7% (Sankaranarayanan 2011) to 53.2% (Pisani 2006); the specificity ranged between 94.3% (Sankaranarayanan 2011) to 100% (Pisani 2006) ; and the positive predictive value ranged between 1% (Sankaranarayanan 2011) to 1.2% (Pisani 2006).

CBE coverage

Time of outcome assessment: 20 years

Method of measurement: active surveillance

‐

1 study

⊕⊕⊕⊝ Moderate^a

One study (Mittra 2021) reported mean adherence to the 4 screening rounds to be 67.07%.

Completion of follow‐up: defined as the proportion of women who completed follow‐up after screening and CBE and advice to complete follow‐up

Time of outcome assessment: 20 years

Method of measurement: active surveillance

‐

1 study

⊕⊕⊕⊝ Moderate^a

One study (Mittra 2021) reported follow‐up defined as the proportion of women who completed follow‐up after screening and CBE and suggested that compliance rates for diagnostic confirmation following a positive CBE were 68.29%, 71.20%, 78.84%, and 79.98% during the 1st, 2nd, 3rd and 4th rounds of screening in the intervention group compared to 90.88%, 82.96%, 79.56% and 80.39% during the respective 4 rounds of screening in the control group.

Breast cancer mortality: defined as deaths among women who received a diagnosis of breast cancer

Time of outcome assessment: 3 years to 20 years

Method of measurement: death registration offices, hospital records, and house visits

RR 0.88 (0.24 to 3.26)

355 participants (2 studies)

⊕⊝⊝⊝

Very low^{a,e, f}

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CBE: clinical breast examination; CI: confidence interval; LMIC: low‐ and middle‐income country; RR: risk ratio.

GRADE Working Group grades of evidence
High certainty: further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: we are very uncertain about the estimate.