Description of the condition

The worldwide incidence of breast cancer increased by 3.1% annually between 1980 and 2010 (Forouzanfar 2011) and an estimated 1.677 million new cases were reported in 2012 (Ferlay 2015). This represents 25% of all reported cancer cases (Ferlay 2015). According to the International Agency for Research on Cancer (IARC) GLOBOCAN 2012 database, incidence rates of breast cancer are lower in low‐ and middle‐income countries (LMICs) than in high‐income countries, but both overall incidence (number of cases) and age‐specific incidence appear to be rising in LMICs. A modelling study obtained registry data on the incidence of breast and cervical cancer spanning a period of 30 years (1980 to 2010) and covering 187 countries, and reported that twice as many cases of breast cancer occurred in individuals aged 15 to 49 years in developing countries than occurred in the same population in the developed world (Forouzanfar 2011). This may be attributed to population growth, increasing life expectancy and a relative decrease in the burden of infectious diseases, or it may be the result of changes in lifestyle‐related risk factors due to urbanisation and economic development (Torre 2015). As an example, women in Africa have a lower incidence of breast cancer than women in developed countries (age‐standardised rate (ASR) of 36 vs 74) but a higher mortality rate (ASR of 17 vs 15). Deaths attributed to breast cancer were reported to be higher in LMICs than in more developed countries, with 324,000 versus 198,000 reported deaths, respectively (Ferlay 2015). One reason for this could be the advanced stage of disease at presentation. A study from Kenya reported that more than 60% of women with breast cancer received the diagnosis at disease stage III or IV (Sayed 2014). Similarly, almost 50% of women from four major hospitals in India presented with stage III and IV disease (Agarwal 2008), as was the case in a review and registry analysis of breast cancer trends in six Arab countries for which data regarding tumour stage were available (Saghir 2007). As cited by Saghir 2007, data from the National Cancer Institute of Cairo showed breast cancer stages III and IV to be around 80% to 90%. Similarly, most women from the four‐hospital study in India (Agarwal 2008) presented with stage IIIB (35%), stage IIIA (27%) and stage IV (8% to 10%) disease, and only very few women (approximately 5%) presented with stage I disease. This late presentation of breast cancer may reflect lack of awareness about breast cancer among women and, in particular, little or no knowledge about early symptoms and signs and available screening and treatment options.

Various barriers at individual and community levels coupled with poorly functional health systems are likely contributing factors. Limited access to cancer screening and treatment facilities in remote areas, where most of the population of LMICs resides, may also contribute to late presentation of breast cancer. In addition, no national or population‐based screening programmes for breast cancer are available in most LMICs, where mammography is too costly to implement and sustain. In addition, limited evidence is available on the role of mammography in reducing breast cancer mortality among women between 40 and 50 years of age (Lauby‐Secretan 2015) ‐ the age groups within which most cancers in LMICs are diagnosed (Knaul 2012). Even among health workers, knowledge and clinical skills related to screening, diagnosis and treatment of breast cancer are limited. As an example, survey results from Nigeria report that among 393 female health workers (102 doctors, 254 nurses and 37 radiographers, laboratory scientists and pharmacists), 55% of respondents had overall poor knowledge of breast cancer risk factors and furthermore, of the female respondents eligible for breast cancer screening only 3.1% had ever had a screening mammogram done (Akhigbe 2009). Clinical breast examination (CBE) is an inexpensive early detection technique for breast cancer for which sufficient evidence shows downstaging of disease at presentation (Lauby‐Secretan 2015). However, health workers in LMICs may be inadequately trained to perform good quality CBEs and therefore are likely to dismiss breast complaints and to miss early disease, compounding the problem of late presentation. Although there is inadequate evidence to show that CBE reduces mortality from breast cancer (Lauby‐Secretan 2015), the important issue in LMICs is early detection of breast cancer, rather than the search for subcentimetre tumours through screening mammography (Dey 2014). This review aims to explore different training methods/programmes in CBE for various groups of health workers and to determine whether training in CBE improves the quality of the technique and the ability of health workers to detect breast cancers early.

Description of the intervention

Screening and early detection of breast cancer can provide maximum beneficial impact in lowering morbidity and mortality due to breast cancer (Dey 2014). It has been reported that between 1990 and 1998, an estimated 6.4% of the 21% decrease in mortality from breast cancer among women between 55 and 69 years of age in the United Kingdom was directly attributable to screening (Blanks 2000). The most widely adopted method of screening for breast cancer remains mammography. However, in most developing countries, constrained health infrastructure combined with limited trained personnel makes high‐quality population‐based mammographic screening programmes too costly to implement and sustain (Dey 2014). In LMICs, many breast cancers are diagnosed in women younger than 54 years of age (Knaul 2012), whose breasts are denser (Heng 2004), thus limiting the accuracy of mammographic diagnosis. The level of awareness among women of the utility of mammography as a screening tool for breast cancer is limited (Alharbi 2011; Obajimi 2013), and those who have heard of the tool often cite financial challenges as a limiting factor in accessing the service. As an example, in Ghana, a Knowledge Attitude and Practice (KAP) study suggested that 33.5% of respondents did not know of the existence of mammography services, and of those who were aware of such services, 27% cited financial reasons for not accessing mammography (Opoku 2012). American Cancer Society (ACS) guidelines (Smith 2013), which were recently updated (Oeffinger 2015), now state that CBE is currently not recommended in settings where mammography is available, but it is likely that CBE provides significantly greater benefit in settings where mammography is not available. It is noteworthy that most women in LMICs have neither regular general health exams nor access to good quality mammography, thus their only contact for a breast complaint might be a health worker within the community. Although the utility of CBE as a breast cancer screening and early detection tool has been mired in controversy (Larkin 2001), it is possible that CBE is being performed by health workers who have not been adequately trained in the correct technique. Training health workers in CBE and using these trained personnel to implement early detection programmes for breast cancer may provide the only opportunity for women in LMICs to undergo regular breast examination for early detection of breast cancer.

CBE is a systematic method that involves physical examination of the breast by a health worker (NCB Dictionary). Its main purpose is to detect breast abnormalities for onward referral to the next level of care. Various techniques can be used to train diverse groups of health workers in CBE. The main considerations for a standard CBE include clinical history, visual inspection, palpation and interpretation and reporting of findings (Saslow 2004). Some techniques such as using silicone breast models and adopting objective structured clinical examination training tools have been reported to increase the sensitivity of the tool (Saslow 2004). Task shifting involves training community health workers (CHWs) in CBE by using role modelling to empower them to detect breast cancer at an earlier disease stage (Wadler 2011). A competency‐based training programme for primary care physicians and nurses in breast health care that combines technical knowledge, skills and behaviours has been proposed to circumvent the shortage of specialist personnel in LMICs (Harford 2008). Training community nurses to implement a combination of breast self‐examination (BSE) and CBE was shown to downstage breast cancer presentation in the Cairo Breast Screening Trial (Miller 2008). Interim results from a cluster‐randomised controlled trial showed that training primary health workers for a specified duration of time in CBE, on the basis of the modified Canadian Breast Screening protocol, and implementing the CBE programme as provided by trained healthcare personnel resulted in downstaging of breast cancer presentation (Mittra 2010). Preliminary results of another randomised controlled trial (RCT) from India show that upon completion of a structured three‐week training programme in CBE that targeted female health workers with a tertiary level of education, a significant number of early breast cancers were detected in the intervention arm when compared with the control arm (Sankaranarayanan 2011). This contrasts with results from four Canadian organised breast cancer screening programmes, which showed that use of trained health workers in CBE contributed little to early detection of breast cancer (Bancej 2003). Similarly, a trial in the Philippines (Pisani 2006) failed to demonstrate any benefit for downstaging of breast cancer after nurses were trained in CBE. This is one important reason for the controversy surrounding CBE in LMICs. In particular, the sensitivity of CBEs performed by nurses is low, supporting our premise that the quality of CBE performed may be an issue.

How the intervention might work

The Breast Health Global Initiative (BHGI), established in 2002, is an international health alliance that develops evidence‐based and resource‐sensitive guidelines for screening, early detection, diagnosis and treatment of breast cancer in LMICs. According to its recommended guidelines for breast cancer, screening should be adopted within the local context and should take into account available resources, with a view towards encouraging incremental improvements ultimately leading to an ideal healthcare delivery system (Smith 2006; Yip 2008). This would offer a more sustainable approach for early detection of breast cancer in LMICs.

Breast self‐awareness (BSA) education and CBE may be important techniques for early detection of breast cancer in the LMIC setting. Given that a large proportion of disease is diagnosed at late stages (Dey 2014), care providers have a great opportunity to make a difference in breast cancer mortality through earlier detection of palpable masses, which can be attained by training a broad group of health workers working within communities, including nurses and CHWs.

CBE remains a viable option for detection of breast cancer at an early stage, when the disease is potentially curable. CBE is a simple procedure that can be performed by a health worker at any level of a healthcare facility, and, if appropriately performed, it can detect lumps when they are still small and can contribute to early detection and probably reduced morbidity and mortality from breast cancer. In addition, health workers can be trained in screening CBE or evaluation of breast masses. Screening or evaluation could take place in facilities or in patients’ homes, as was demonstrated in a pilot study from Sudan (Abuidris 2013). Performance of a CBE also provides an opportunity for the health worker to educate women on breast self‐awareness and breast health care (Farid 2014). The CBE programme can be integrated into existing training programmes for community heath workers, such as Visual Inspection by Acetic Acid (VIA) for cervical cancer screening, as has been described in a Malaysian trial (Devi 2007). The CBE method can be used as an opportunistic early detection tool by a trained health worker when women present at a health facility for other problems, or it can be included as a component of population‐based screening and early detection programmes through integration into existing women's reproductive health programmes (Farid 2014). Through refresher training of CHWs in CBE, the programme can become a sustainable low‐cost model for embedding early detection of breast cancer into LMICs (Wadler 2011).

Why it is important to do this review

Any improvement in breast cancer outcomes requires creating awareness, providing access to early detection, making an accurate diagnosis, referring patients appropriately and maintaining the proper standard of treatment. Training health workers in CBE for early detection of breast cancer is an important concept for promoting breast health. It has the potential to promote early detection of breast cancer in the developing world, where mammography is limited and inaccessible for most women. Although controversy surrounds the utility of CBE as a mass breast screening tool (Larkin 2001), with large RCTs in China and Russia (Kösters 2003; Thomas 1997) showing no benefit for mortality from breast cancer when BSE or CBE is performed in isolation, evidence showing the efficacy of training health workers in CBE as an early detection tool in the developing world is limited. An RCT from the Philippines (Pisani 2006) that studied clinical outcomes of CBE performed by trained nurses had to be abandoned owing to participant non‐compliance with follow‐up and treatment guidelines. This RCT reported that despite training of nurses, both inexperience of the health worker and breast cancer beliefs and behaviours at the individual level contributed to the low sensitivity (53.2%) of the programme, and that these concerns must be addressed before future screening programmes are implemented.

Work from other health disciplines on the effectiveness of training health workers to improve care has been previously published. A recently updated Cochrane review of in‐service neonatal emergency care courses for nurses (Opiyo 2015) reported that although evidence of the effectiveness of training for neonatal mortality was inconclusive, the two trials included in the review provided evidence of moderate certainty indicating that newborn resuscitation training compared with usual care improved provider performance of appropriate resuscitation (trained 66% vs usual care 27%, risk ratio 2.45, 95% confidence interval 1.75 to 3.42). In addition, evidence of moderate quality suggested that training of nurses reduced inappropriate resuscitation and in the short term improved healthcare professionals' treatment of seriously ill babies (Opiyo 2015).

Within the context of knowledge, experience and recommendations from global practitioners, it is recognised that community engagement is key to strengthening interventions that improve health outcomes. In particular, community‐based interventions have been recognised as playing an important role in improving maternal, newborn and child health (Rifkin 2014). Community‐based health workers are “strategically placed to facilitate community participation and stimulate critical thinking; and they act as a catalyst to social action to address the social and cultural determinants of poor health” (Perry 2009). Training CHWs and other health workers in CBE for early detection of breast cancer can therefore provide a sustainable model in the LMIC setting, where existing health infrastructure and resources are overwhelmed by management of diseases of infective origin. A review of breast cancer control in South Africa (Wadler 2011) recommended that, on the basis of low cost and minimal skills training, CBE can be implemented in an LMIC setting by training CHWs and by integrating breast health care into existing primary healthcare programmes. However, the authors admit that the pragmatic success of implementing trained CHW breast screening activities requires good quality evidence derived from RCTs.