Breast cancer in women

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Why. cancer of the breast is the leading cause of cancer deaths in women in many developing countries, as well as in most developed countries .early detection can significantly improve the chances of survival (Stanley et al., 1987)as well as quality of life, making far less radical therapy necessary. current use of lumpectomy rather than mastectomy in many cases makes treatment more acceptable than in previous years.
Who and how .the USPSTF (1989) recommends annual clinical examination of the breasts in women aged 35 and older with a family history of premenopausal breast cancer in a first-degree relative, and of all women aged 40 and over. They recommend mammohraphy every 1-2years in the high –risk group, and every 1-2 years for all women aged 50-75. The Canadian task force recommended an annual clinical examination and mannography for all women between the ages of 50 and 59 and only an annual clinical examination for those aged 40 to 49 (CTF, 1986;Morrison, 1986).the WHO collaborating centre in the Netherlands supported recommendations that all women aged 50-70 in that country should be screened with mammography every two years, with mobile units providing examination in some areas (habbema, 1990). There is still controversy in developed countries about the cost-effectiveness of mass mammography in various age groups (van der maas et al ,. 1989). It is clear that mass mammography (estimated cost US$50-100 per mammogram) as an initial screen will be beyond the means of developing countries for the immediate future, some alternative approaches are outlined below.
Screening for breast cancer should first be targeted to women aged 50 and over, with coverage of younger women being gradually phased in once older women are adequately covered (CTF, 1986;Morrison, 1986;Stanley et al., 1987;USPSTF, 1989).the best approach would be annual physical examination by a trained professional, together with mammography (miller, 1989).where mammography cannot be performed on all women over 50, frequent clinical examination by a trained professional, with mammography for suspected cases, may be the best option, though it is as yet an untested technique and one that is not highly sensitive or specific (Pavlov &semiglazov,1981).
Where mammography cannot be performed for all women at high risk, a worthwhile alternative may be public education to promote self-examination by all women over the age of 20,with more intensive screening , if possible, for women of 50 and over and those with a family history of breast cancer (Stanley et al., 1987). Large-scale prospective controlled studies of self –examination of breasts as an intial screening technique were initiated under the auspices of WHO in 1985 in what was then the USSR, and in 1989 in what was then the german democratic republic; preliminary reports indicate it feasibility (semiglazov &moissenko, 1987; WHO ,1989c)and early data on its effects are expected in the near future.
In 1990,koroltchouk et al . stated all three main elements public education, early detection and locally available treatment must be part of a breast cancer control program. These program elements can be delivered through existing health care infrastructures at almost any stage of development, given that there is a serious commitment of current resources. The use of perhaps nonoptimal  but realistic available technology and the application of current knowledge would allow the extension of cre to many patients who now die without diagnosis , treatment, and palliation.
Resource levels required.low for screening by self-examination but the technique  further  validation, medium for clinical examination , high for mammography or biopsy; high for surgery and chemotherapy; very high for radiation therapy.
Recommendation on use of screening . uncertain, owing to inadequate evidence in the accuracy of the available screening tests that would be affordable on a population wide basis in ddeveloping countries. Routine mammography for women aged 50 or over appears to be quite accurate, but is beyond the resources of most developing countries at present; the capacity to perform it should have high priority as a goal for the future . women should be made more aware of breast cancer and encouraged to practice self – referral for suspicious lumps or skin changes.

Research priority. Validation of low-cost, accurate methods of screening and early detection .

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