thesis on breast cancer screening

• Conclusions
• Article Information

Evidence reviews for the USPSTF use an analytic framework to visually display the key questions that the review will address in order to allow the USPSTF to evaluate the effectiveness and safety of a preventative service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line indicates a health outcome that immediately follows an intermediate outcome. For additional details see the US Preventive Services Task Force Procedure Manual. 13

Reasons for exclusion: Design: Study did not use an included design. Outcomes: Study did not have relevant outcomes or had incomplete outcomes. Comparator: Study used an excluded comparator. Intervention: Study used an excluded intervention/screening approach. Population: Study was not conducted in an average-risk population. Timing: Study only reported first (prevalence) round screening follow-up. Publication type: Study was published in non–English-language or only available in an abstract. Quality: Study did not meet criteria for fair or good quality. Setting: Study was not conducted in a setting relevant to US practice. KQ indicates key question.

DBT indicates digital breast tomosynthesis; DM, digital mammography; and RR, relative risk.

a From random-effects restricted maximum likelihood model.

eMethods. Literature Search Strategies for Primary Literature

eTable 1. Inclusion and Exclusion Criteria

eTable 2. Quality Assessment Criteria

eTable 3. Included Studies and Their Ancillary Publications

eTable 4. Screen-Detected DCIS Diagnosed in Studies Comparing Digital Breast Tomosynthesis and Digital Mammography

eFigure 1. Pooled Analysis of Screen-Detected Invasive Cancers Diagnosed in Trials Comparing Digital Breast Tomosynthesis and Digital Mammography

eFigure 2. Pooled Analysis of Interval Cancers Diagnosed in Trials Comparing Digital Breast Tomosynthesis and Digital Mammography

eFigure 3. Cumulative Probability of False-Positive Biopsy in One NSRI Using BCSC Data Comparing Annual vs Biennial Screening with DBT or DM

eFigure 4. Cumulative Probability of False-Positive Recall in One NSRI Using BCSC Data Comparing Annual vs Biennial Screening with DBT or DM

eFigure 5. Cumulative Probability of False-Positive Recall or Biopsy in One NSRI Using BCSC Data Comparing Annual vs Biennial Screening with DBT or DM, among Women with Extremely Dense Breasts

• USPSTF Recommendation: Screening for Breast Cancer JAMA US Preventive Services Task Force April 30, 2024 This 2024 Recommendation Statement from the US Preventive Services Task Force recommends biennial screening mammography for women aged 40 to 74 years (B recommendation) and concludes that evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years or older (I statement) and of screening using ultrasonography or MRI in women with dense breasts on a negative mammogram (I statement). US Preventive Services Task Force; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; John B. Wong, MD; Michael J. Barry, MD; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Marie Krousel-Wood, MD, MSPH; Sei Lee, MD, MAS; Li Li, MD, PhD, MPH; Carol M. Mangione, MD, MSPH; Goutham Rao, MD; John M. Ruiz, PhD; James J. Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; Sarah Wiehe, MD, MPH
• USPSTF Report: Collaborative Modeling to Compare Breast Cancer Screening Strategies JAMA US Preventive Services Task Force April 30, 2024 This modeling study uses Cancer Intervention and Surveillance Modeling Network models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses to estimate outcomes of various mammography screening strategies. Amy Trentham-Dietz, PhD, MS; Christina Hunter Chapman, MD, MS; Jinani Jayasekera, PhD, MS; Kathryn P. Lowry, MD; Brandy M. Heckman-Stoddard, PhD, MPH; John M. Hampton, MS; Jennifer L. Caswell-Jin, MD; Ronald E. Gangnon, PhD; Ying Lu, PhD, MS; Hui Huang, MS; Sarah Stein, PhD; Liyang Sun, MS; Eugenio J. Gil Quessep, MS; Yuanliang Yang, MS; Yifan Lu, BASc; Juhee Song, PhD; Diego F. Muñoz, PhD; Yisheng Li, PhD, MS; Allison W. Kurian, MD, MSc; Karla Kerlikowske, MD; Ellen S. O’Meara, PhD; Brian L. Sprague, PhD; Anna N. A. Tosteson, ScD; Eric J. Feuer, PhD; Donald Berry, PhD; Sylvia K. Plevritis, PhD; Xuelin Huang, PhD; Harry J. de Koning, MD, PhD; Nicolien T. van Ravesteyn, PhD; Sandra J. Lee, ScD; Oguzhan Alagoz, PhD, MS; Clyde B. Schechter, MD, MA; Natasha K. Stout, PhD; Diana L. Miglioretti, PhD, ScM; Jeanne S. Mandelblatt, MD, MPH
• Toward More Equitable Breast Cancer Outcomes JAMA Editorial April 30, 2024 Joann G. Elmore, MD, MPH; Christoph I. Lee, MD, MS
• Screening for Breast Cancer JAMA JAMA Patient Page April 30, 2024 In this JAMA Patient Page, the US Preventive Services Task Force provides a guide to screening for breast cancer. US Preventive Services Task Force
• When Is It Best to Begin Mammograms, and How Often? JAMA Medical News & Perspectives May 3, 2024 This Medical News story discusses new USPSTF recommendations about the timing of screening mammograms. Rita Rubin, MA
• New Recommendations for Breast Cancer Screening—In Pursuit of Health Equity JAMA Network Open Editorial April 30, 2024 Lydia E. Pace, MD, MPH; Nancy L. Keating, MD, MPH
• USPSTF Breast Cancer Screening Guidelines Do Not Go Far Enough JAMA Oncology Editorial April 30, 2024 Wendie A. Berg, MD, PhD

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Henderson JT , Webber EM , Weyrich MS , Miller M , Melnikow J. Screening for Breast Cancer : Evidence Report and Systematic Review for the US Preventive Services Task Force . JAMA. Published online April 30, 2024. doi:10.1001/jama.2023.25844

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Screening for Breast Cancer : Evidence Report and Systematic Review for the US Preventive Services Task Force

• 1 Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Portland, Oregon
• 2 University of California Davis Center for Healthcare Policy and Research, Sacramento
• Editorial Toward More Equitable Breast Cancer Outcomes Joann G. Elmore, MD, MPH; Christoph I. Lee, MD, MS JAMA
• Editorial New Recommendations for Breast Cancer Screening—In Pursuit of Health Equity Lydia E. Pace, MD, MPH; Nancy L. Keating, MD, MPH JAMA Network Open
• Editorial USPSTF Breast Cancer Screening Guidelines Do Not Go Far Enough Wendie A. Berg, MD, PhD JAMA Oncology
• US Preventive Services Task Force USPSTF Recommendation: Screening for Breast Cancer US Preventive Services Task Force; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; John B. Wong, MD; Michael J. Barry, MD; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Marie Krousel-Wood, MD, MSPH; Sei Lee, MD, MAS; Li Li, MD, PhD, MPH; Carol M. Mangione, MD, MSPH; Goutham Rao, MD; John M. Ruiz, PhD; James J. Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; Sarah Wiehe, MD, MPH JAMA
• US Preventive Services Task Force USPSTF Report: Collaborative Modeling to Compare Breast Cancer Screening Strategies Amy Trentham-Dietz, PhD, MS; Christina Hunter Chapman, MD, MS; Jinani Jayasekera, PhD, MS; Kathryn P. Lowry, MD; Brandy M. Heckman-Stoddard, PhD, MPH; John M. Hampton, MS; Jennifer L. Caswell-Jin, MD; Ronald E. Gangnon, PhD; Ying Lu, PhD, MS; Hui Huang, MS; Sarah Stein, PhD; Liyang Sun, MS; Eugenio J. Gil Quessep, MS; Yuanliang Yang, MS; Yifan Lu, BASc; Juhee Song, PhD; Diego F. Muñoz, PhD; Yisheng Li, PhD, MS; Allison W. Kurian, MD, MSc; Karla Kerlikowske, MD; Ellen S. O’Meara, PhD; Brian L. Sprague, PhD; Anna N. A. Tosteson, ScD; Eric J. Feuer, PhD; Donald Berry, PhD; Sylvia K. Plevritis, PhD; Xuelin Huang, PhD; Harry J. de Koning, MD, PhD; Nicolien T. van Ravesteyn, PhD; Sandra J. Lee, ScD; Oguzhan Alagoz, PhD, MS; Clyde B. Schechter, MD, MA; Natasha K. Stout, PhD; Diana L. Miglioretti, PhD, ScM; Jeanne S. Mandelblatt, MD, MPH JAMA
• JAMA Patient Page Screening for Breast Cancer US Preventive Services Task Force JAMA
• Medical News & Perspectives When Is It Best to Begin Mammograms, and How Often? Rita Rubin, MA JAMA

Importance   Breast cancer is a leading cause of cancer mortality for US women. Trials have established that screening mammography can reduce mortality risk, but optimal screening ages, intervals, and modalities for population screening guidelines remain unclear.

Objective   To review studies comparing different breast cancer screening strategies for the US Preventive Services Task Force.

Data Sources   MEDLINE, Cochrane Library through August 22, 2022; literature surveillance through March 2024.

Study Selection   English-language publications; randomized clinical trials and nonrandomized studies comparing screening strategies; expanded criteria for screening harms.

Data Extraction and Synthesis   Two reviewers independently assessed study eligibility and quality; data extracted from fair- and good-quality studies.

Main Outcomes and Measures   Mortality, morbidity, progression to advanced cancer, interval cancers, screening harms.

Results   Seven randomized clinical trials and 13 nonrandomized studies were included; 2 nonrandomized studies reported mortality outcomes. A nonrandomized trial emulation study estimated no mortality difference for screening beyond age 74 years (adjusted hazard ratio, 1.00 [95% CI, 0.83 to 1.19]). Advanced cancer detection did not differ following annual or biennial screening intervals in a nonrandomized study. Three trials compared digital breast tomosynthesis (DBT) mammography screening with digital mammography alone. With DBT, more invasive cancers were detected at the first screening round than with digital mammography, but there were no statistically significant differences in interval cancers (pooled relative risk, 0.87 [95% CI, 0.64-1.17]; 3 studies [n = 130 196]; I 2  = 0%). Risk of advanced cancer (stage II or higher) at the subsequent screening round was not statistically significant for DBT vs digital mammography in the individual trials. Limited evidence from trials and nonrandomized studies suggested lower recall rates with DBT. An RCT randomizing individuals with dense breasts to invitations for supplemental screening with magnetic resonance imaging reported reduced interval cancer risk (relative risk, 0.47 [95% CI, 0.29-0.77]) and additional false-positive recalls and biopsy results with the intervention; no longer-term advanced breast cancer incidence or morbidity and mortality outcomes were available. One RCT and 1 nonrandomized study of supplemental ultrasound screening reported additional false-positives and no differences in interval cancers.

Conclusions and Relevance   Evidence comparing the effectiveness of different breast cancer screening strategies is inconclusive because key studies have not yet been completed and few studies have reported the stage shift or mortality outcomes necessary to assess relative benefits.

Breast cancer is the second leading cause of cancer mortality for US women, despite a steady overall decline in breast-cancer mortality rates over the past 20 years. 1 The average age-adjusted rate for the years 2016-2020 was 19.6 per 100 000, with an estimated 43 170 deaths in 2023. 1 , 2 The majority of cases occur between the ages of 55 and 74 years, 1 and incidence is highest among women ages 70 to 74 (468.2 per 100 000). 3 Non-Hispanic White women have the highest breast cancer incidence, 4 but mortality is 40% higher for non-Hispanic Black women (27.6 per 100 000) compared with White women (19.7 per 100 000); non-Hispanic Black women experience lower 5-year survival regardless of the cancer subtype or stage at the time of detection. 1 , 5 - 7

Previous reviews of breast cancer screening effectiveness established the benefits and harms of mammography based primarily on large, long-term trials. 8 , 9 In 2016, the US Preventive Services Task Force (USPSTF) recommended screening for breast cancer in women starting at age 50 years every 2 years continuing through age 74 years (B recommendation) and that screening from ages 40 to 49 years should be based on clinical discussions of patient preferences and individual breast cancer risk (C recommendation). 10 This comparative effectiveness systematic review of breast cancer screening strategies was conducted concurrently with a separate decision modeling study. 11 Both informed the USPSTF updated breast cancer screening recommendations. 12

This review addressed 3 key questions (KQs) on the comparative effectiveness and harms of different screening strategies ( Figure 1 ). Methodological details including study selection, a list of excluded studies, detailed study-level results for all outcomes and for specific subpopulations, and contextual observations are available in the full evidence report. 14

Studies included in the 2016 USPSTF reviews 8 , 9 , 15 , 16 were evaluated for inclusion with eligibility criteria for the current review. In addition, database searches for relevant studies published between January 2014 and August 22, 2022, were conducted in MEDLINE, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews (eMethods in the Supplement ). Reference lists of other systematic reviews were searched to identify additional relevant studies. ClinicalTrials.gov was searched for relevant ongoing trials. Ongoing surveillance to identify newly published studies was conducted through March 2024 to identify major studies published in the interim. Two new nonrandomized studies were identified 17 , 18 and are not further discussed, as they would not change interpretation of the review findings or conclusions.

Two independent reviewers screened titles, abstracts, and relevant full-text articles to ensure consistency with a priori inclusion and exclusion criteria (eTable 1 in the Supplement ). We included English-language studies of asymptomatic screening populations not at high risk for breast cancer. The eligible population for this review is adult females (sex assigned at birth). For consistency with the underlying evidence, the term “women” is used throughout this report; however, cancer registries and studies of breast cancer generally infer gender based on physiology and medical history rather than measuring self-reported gender. Included studies compared mammography screening modalities (mammography with or without digital breast tomosynthesis [DBT]), different screening strategies with respect to interval, age to start, age to stop, or supplemental screening strategies using ultrasound or magnetic resonance imaging (MRI) with mammography.

For KQ1, randomized clinical trials (RCTs) or nonrandomized studies of interventions with contemporaneous comparison groups that reported breast cancer morbidity, mortality, all-cause mortality, or quality of life were included. For KQ2, the primary outcome of interest was progression to advanced breast cancer, defined for this review as stage IIB or higher, which encompasses tumors with local lymph node involvement or distant metastases. 19 Study-defined advanced breast cancer outcomes were used when this outcome was not reported (eg, stage II or higher). Invasive breast cancer detection outcomes from multiple screening rounds can indicate whether a screening modality or strategy reduces the risk of advanced cancer by detecting early cancers that would otherwise have progressed (stage shift), thereby potentially reducing breast cancer morbidity and mortality. 20 - 23

For KQ3, RCTs and nonrandomized studies of interventions reporting adverse events, including psychological harms, radiation exposure, and interval invasive cancers (incident or missed due to false-negative screening) were included, regardless of the number of screening rounds reported. False-positive recall, false-positive biopsy recommendation, and false-positive biopsy rates (individuals who underwent a biopsy for a benign lesion) were obtained from included RCTs and from nonrandomized studies reporting cumulative rates of these potential harms of screening.

Two reviewers evaluated all articles that met inclusion criteria using prespecified quality criteria (eTable 2 in the Supplement ). Discordant quality ratings were resolved through discussion and input from a third reviewer. Risk-of-bias assessment was conducted using the USPSTF-specific criteria for randomized trials 13 and an adapted tool from the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I). 24 Studies determined to be at high risk of bias were excluded. One reviewer extracted key elements of included studies into standardized evidence tables in DistillerSR (Evidence Partners) and a second reviewer checked the data for accuracy. Limited evidence on sub-KQs is available in the full report. 14 When available, reported relative risks were provided in the tables, but we calculated and reported crude effect estimates and confidence intervals when studies did not provide them. For KQ2 intermediate detection outcomes, the definition of advanced cancer reported in the studies was used for synthesis; commonly this was stage II or later. Comparisons of prognostic characteristics or markers (eg, grade, tumor size, nodal involvement, receptor status) were included for comparisons as data allowed.

All quantitative analyses were conducted in Stata version 16 (StataCorp). The presence of statistical heterogeneity was assessed among pooled studies using the I 2 statistic. Where effects were sufficiently consistent and clinical and statistical heterogeneity low, random-effects meta-analyses were conducted using the restricted maximum likelihood; all tests were 2-sided, with P  < .05 indicating statistical significance.

Aggregate strength of evidence (ie, high, moderate, or low) was assessed for each KQ and comparison using the approach described in the Methods Guide for the Effectiveness and Comparative Effectiveness Reviews, 25 based on consistency, precision, publication bias, and study quality.

Investigators reviewed 10 378 unique citations and 419 full-text articles for all KQs ( Figure 2 ). Twenty studies reported in 45 publications were included. 26 - 45 A full list of included studies by KQ is located in eTable 3 in the Supplement .

Key Question 1. What is the comparative effectiveness of different mammography-based breast cancer screening strategies (eg, by modality, interval, initiation and stopping age, use of supplemental imaging, or personalization based on risk factors) on breast cancer morbidity and mortality?

Two nonrandomized studies reported on the association of different screening programs with breast cancer morbidity and mortality. One study was designed to compare different ages to stop screening 30 and another compared annual and triennial screening intervals. 41

A fair-quality observational study (n = 1 058 013) on age to stop screening used an emulated trial methodology to analyze a random sample of US Medicare A and B claims data for enrollees aged 70 to 84 years (1999 to 2008), eligible for breast cancer screening, and with at least a 10-year estimated life expectancy. The study estimated the effect of stopping screening at ages 70, 75, and 80 years compared with continued annual screening. 30 , 46 Continuation of screening between the ages of 70 and 74 years was associated with reduced mortality risk based on survival analysis (hazard ratio, 0.78 [95% CI, 0.63 to 0.95]), but the absolute difference in the risk of death for the age group was small and the confidence interval included null (1.0 fewer deaths per 1000 screened [95% CI, −2.3 to 0.1]). These results indicate a difference in the cumulative incidence curves that approached a difference in the mortality risk for the age group. Conversely, continued screening vs no screening from ages 75 to 84 years did not result in statistically significant differences in the absolute risk of breast cancer mortality (0.07 fewer deaths per 1000 [95% CI, –0.93 to 1.3]) or the cumulative mortality incidence (hazard ratio, 1.00 [95% CI, 0.83 to 1.19]).

A fair-quality nonrandomized clinical study (n = 14 765) conducted in Finland during the years 1985 to 1995 assigned participants aged 40 to 49 years to annual or triennial screening invitations by alternating birth year. 41 The study reported no difference in breast cancer mortality: 20.3 deaths per 100 000 person-years with annual screening invitations and 17.9 deaths per 100 000 person-years with triennial screening invitations (relative risk [RR], 1.14 [95% CI, 0.59-1.27]).

Key Question 2. What is the comparative effectiveness of different mammography-based breast cancer screening strategies (eg, by modality, interval, initiation and stopping age, use of supplemental imaging, or personalization based on risk factors) on the incidence of and progression to advanced breast cancer?

No eligible studies of age to start or stop screening, supplemental screening, or personalized screening were included, because no RCTs or nonrandomized studies reported more than a single round of screening comparing screening strategies. For screening interval, 1 RCT 26 and 1 nonrandomized study, 41 and for comparisons of different screening modalities (DBT vs digital mammography) 3 RCTs 27 , 33 , 42 and 2 nonrandomized studies, 34 , 44 met eligibility criteria.

Two fair-quality studies addressed the effect of screening interval on the characteristics of detected cancers. A fair-quality United Kingdom Co-ordinating Committee on Cancer Research (UKCCCR) RCT comparing screening intervals was conducted as part of the UK National Breast Screening Program. The study randomized participants aged 50 to 62 years to annual (n = 37 530) or triennial (n = 38 492) breast cancer screening during the years 1989 to 1996. 26 After 3 years of screening (1 incidence screen in the triennial screening group), a similar number of cancers (screen-detected and interval) had been diagnosed in the annual and triennial screening groups (6.26 and 5.40 per 1000 screened, respectively; RR, 1.16 [95% CI, 0.96 to 1.40]). No statistically significant differences were found in the cancer characteristics (tumor size, nodal status, histological grade) between groups over the course of the study.

A fair-quality nonrandomized study using Breast Cancer Surveillance Consortium (BCSC) registry data (1996 to 2012) 39 found the relative risk of being diagnosed with a breast cancer with less favorable prognostic characteristics (stage IIB or higher, tumor size >15 mm, or node-positive) was not statistically different for women screened biennially compared with those screened annually for any age category (40-49, 50-59, 60-69, 70-85 years).

Three fair-quality RCTs 27 , 33 , 42 reported cancer detection over 2 rounds of screening, comparing the effects of screening with DBT and digital mammography on the presence of advanced cancer at subsequent screening rounds ( Table 1 ). Participants were randomized to the DBT intervention group or the digital mammography control group at a first round of screening, followed in 2 trials by a second round of screening with digital mammography for all second-round participants (Proteus Donna, 27 RETomo 42 ) and in 1 trial with DBT for all second-round participants (To-Be 33 ). The trials used an identical screening modality for both study groups at the second round because using the same instrument is a stronger design for detection of stage shift.

The RCTs reported increased detection of invasive cancer with DBT at the first round of screening (pooled RR, 1.41 [95% CI, 1.20 to 1.64]; 3 RCTs [n = 129 492]; I 2  = 7.6%) and no statistical difference in invasive cancer at the subsequent screening (pooled RR, 0.87 [95% CI, 0.73 to 1.05]; 3 RCTs [n = 105 064]; I 2  = 0%) (eFigure 1 in the Supplement ). 27 , 33 , 42 There was no statistically significant difference in the incidence of advanced cancers at the subsequent screening round (progression of cancers not found at prior screening that would indicate stage shift) in the individual trials ( Figure 3 ). Results were inconsistent and thus not pooled for the advanced cancer, larger tumor (>20 mm), and node-positive cancer outcomes. The results for histologic grade 3 cancer at the second screening were consistent (pooled RR, 0.97 [95% CI, 0.61-1.55]; 3 RCTs [n = 105 244]; I 2  = 0%) ( Figure 3 ). Due to the small number of cases, it was not possible to assess differences in the detection of cancers lacking hormone or growth factor receptors (ie, triple-negative cancers) that have the worst prognosis among breast cancer subtypes.

Two fair-quality nonrandomized studies of interventions (NRSIs), including a US study using BCSC data, compared breast cancer detection outcomes from screening over multiple rounds (≥2) with either DBT-based mammography or digital mammography alone. 34 , 44 The findings were generally consistent with the trial results for cancer detection and stage shift.

Key Question 3. What are the comparative harms of different mammography-based breast cancer screening strategies (modality, interval, initiation age, use of supplemental imaging, or personalization based on risk factors)?

No eligible studies of age to start screening or personalized screening were identified. For age to stop screening, 1 fair-quality nonrandomized study met eligibility criteria. 30 For comparisons of potential harms associated with different screening intervals, a fair-quality RCT 26 and 2 fair-quality nonrandomized studies 39 , 41 were included. For comparisons of different screening modalities (DBT vs digital mammography), 4 RCTs (3 good- and 1 fair-quality) 27 , 31 , 33 , 42 and 7 fair-quality nonrandomized studies were included. 28 , 32 , 34 - 36 , 43 , 44

In the NRSI using an emulated trial methodology to evaluate the age to stop screening, 30 the 8-year cumulative proportion of participants with a breast cancer diagnosis was higher among those who continued annual screening from ages 70 to 84 years (5.5%) compared with those who discontinued screening (3.9%) at age 70 years. Because fewer cancers were diagnosed among those who discontinued screening, there was a lower risk of undergoing cancer treatment and experiencing related morbidity. Notably, for participants aged 75 to 84 years, screening (and treatment) were not associated with lower breast cancer mortality (see KQ1 results).

The UKCCCR trial included for KQ2 26 reported fewer interval cancers (false-negative and incident cancers) diagnosed in the annual invitation group compared with triennial screening (1.84 vs 2.70 per 1000 women screened, respectively; RR, 0.68 [95% CI, 0.50 to 0.92]). The nonrandomized clinical trial conducted in Finland included for KQ1 41 also reported interval cancers diagnosed with annual vs triennial screening and found no statistical difference in incidence ( P  = .22, data not reported). Data from 2 studies from the BCSC registry reported higher probabilities of false-positive recalls and biopsy recommendations with annual screening compared with biennial screening and no statistical difference in interval cancers in adjusted analyses. 32 , 39 , 44

Four RCTs (3 good-quality, 1 fair-quality) 27 , 31 , 33 , 42 and 7 fair-quality nonrandomized studies 28 , 32 , 34 - 36 , 43 , 44 reported outcomes related to potential screening harms associated with DBT-based screening compared with digital mammography–only screening, including interval cancer rates, round-specific and cumulative false-positive recalls and biopsies, and radiation exposure. Meta-analysis of 3 large trials did not show a statistically significant difference in rates of interval cancer after screening with DBT compared with digital mammography (pooled RR, 0.87 [95% CI, 0.64 to 1.17]; 3 RCTs [n = 130 196]; I 2  = 0%) (eFigure 2 in the Supplement ). 27 , 33 , 42

Data on interval cancers were also obtained from 7 nonrandomized studies. 28 , 32 , 34 - 36 , 43 , 44 The most recent BCSC analysis, reporting interval cancer rates across multiple screening rounds with either DBT or digital mammography, did not identify statistically significant differences in invasive or advanced interval cancers. 44

The effects of DBT screening on false-positive recall and false-positive biopsy rates varied across studies 27 , 33 , 42 and by screening round, with small or no statistical differences between study groups, not consistently favoring DBT-based mammography or digital mammography.

Evidence from 2 nonrandomized BCSC studies provided false-positive results across several screening rounds. 32 , 44 In 1 study, rates of false-positive recall and false-positive biopsy rates were lower with DBT in initial screening rounds, but differences were attenuated and not statistically significant compared with digital mammography only after additional rounds of screening ( Table 2 ). 44 The other study reported no statistical difference in 10-year cumulative false-positive biopsy recommendation rates between biennial DBT and digital mammography screening, but false-positive recall was slightly lower with DBT (eFigures 3 and 4 in the Supplement ); no differences by modality were identified for individuals with extremely dense breasts in stratified analyses (eFigure 5 in the Supplement ). 32

Four RCTs 27 , 31 , 33 , 42 and 1 NRSI 35 reported the mean, median, or relative radiation dose received in each study group at a single screening round. The 3 studies using DBT/digital mammography screening reported radiation exposure approximately 2 times higher in the intervention group compared with the digital mammography–only group. 27 , 35 , 42 Differences between study groups in radiation exposure were smaller in studies using DBT with synthetic digital mammography. 33 , 47

The Dense Tissue and Early Breast Neoplasm Screening (DENSE) trial, a good-quality RCT conducted in the Netherlands, randomized (1:4) participants aged 50 to 75 years with extremely dense breasts and negative mammography findings (2011-2015) (n = 40 373) to an invitation or no invitation for supplemental MRI screening. 45 (The RCT was not included for KQ2 because second round results in the control group were unavailable). Fifty-nine percent of those randomized to the invitation underwent an MRI examination (n = 4783). In intention-to-treat analysis, 2.2 per 1000 experienced interval breast cancer diagnoses in the supplemental screening invitation group, compared with 4.7 per 1000 screened in the digital mammography control group (RR, 0.47 [95% CI, 0.29 to 0.77]). Adverse events related to the supplemental MRI screening reported in the trial included 5 classified as serious adverse events (2 vasovagal reactions and 3 allergic reactions to the contrast agent) and 2 reports of extravasation (leaking) of the contrast agents and 1 shoulder subluxation. Twenty-seven participants (0.6% of the MRI group) reported a serious adverse event within 30 days of the MRI. Those who underwent supplemental MRI screening also experienced additional recalls (94.9 per 1000 screened), false-positive recalls (80.0 per 1000 screened), and false-positive biopsies (62.7 per 1000 screened).

A fair-quality nonrandomized study used claims data from commercially insured women (MarketScan database) aged 40 to 64 years who had received at least 1 bilateral screening breast MRI (n = 9208) or mammogram (n = 9208) between January 2017 and June 2018. 29 Following propensity score matching, those undergoing screening with MRI were more likely to have additional health care cascade events such as office visits and follow-up tests unrelated to breast conditions (adjusted difference between groups, 19.6 per 100 screened [95% CI, 8.6 to 30.7]) in the subsequent 6 months.

A fair-quality RCT, the Japan Strategic Anti-cancer Randomized Trial, randomly assigned asymptomatic women aged 40 to 49 years (2007-2011) to breast cancer screening with mammography plus handheld ultrasound (digital mammography/ultrasound) (n = 36 859) or mammography only (digital mammography) (n = 36 139). 40 The relative risk of invasive interval cancer was not statistically significantly different for digital mammography/ultrasound vs digital mammography only (RR, 0.58 [95% CI, 0.31 to 1.08]). This result differs from the statistically significant population-average effect reported in the study ( P  = .03), which included interval ductal carcinoma in situ (proportion difference, −0.05% [95% CI, −0.09 to 0]). Those undergoing ultrasound in addition to digital mammography experienced 48.0 per 1000 additional false-positive recall results compared with those assigned to digital mammography screening only.

A fair-quality nonrandomized study using data from 2 BCSC registry sites compared screening outcomes for participants receiving ultrasonography on the same day as a screening mammogram (digital mammography/ultrasound) (n = 3386, contributing 6081 screens) compared with those that received only a mammogram (digital mammography) (n = 15 176, contributing 30 062 screens). 37 However, 31% of participants had a first-degree family history of breast cancer or previous breast biopsy. There was no statistical difference in interval cancer risk (adjusted RR, 0.67 [95% CI, 0.33 to 1.37]), and rates of false-positive biopsy were twice as high for the mammography/ultrasound group (adjusted RR, 2.23 [95% CI, 1.03 to 2.58]).

Prior screening effectiveness reviews based on large trials initiated in previous decades established a statistically significant mortality benefit for mammography screening of women aged 50 to 69 years. 8 , 9 , 15 The current review considered comparative effectiveness questions on the relative benefits and harms of different screening start and stop ages, intervals, and modalities for women at average breast cancer risk. Findings are summarized in Table 3 .

The evidence was insufficient for addressing the age to start or end screening. No eligible studies comparing different ages to start screening were identified. Limited evidence from 1 nonrandomized study, using an emulated trial study design, suggested that screening beyond age 74 years may not reduce breast cancer mortality. 30

Evidence was also insufficient for evaluating the effect of screening intervals on breast cancer morbidity and mortality. Two nonrandomized studies found no difference in breast cancer outcomes. 26 , 39 Moderate evidence supported longer screening intervals (eg, biennial) to reduce the cumulative risk of false-positive recall and biopsy. The observational studies of different screening intervals compared individuals who self-selected or were referred for different screening intervals, contributing to risk of bias in the results.

Results from 3 RCTs 27 , 33 , 42 and 2 nonrandomized studies 34 , 44 provided moderate evidence that DBT-based mammography does not reduce the risk of invasive interval cancer or advanced cancer at subsequent screening rounds. Additional rounds of screening and longer follow-up are needed to fully evaluate whether DBT reduces breast cancer morbidity and mortality. Consistent with trial findings, a nonrandomized BCSC study did not find reduced risks of advanced or interval cancers with DBT. 44 Limited evidence from trials on harms of screening with DBT 27 , 33 , 42 indicated similar false-positive recall and biopsy rates. An observational BCSC study did not show differences in the 10-year cumulative false-positive biopsy rates 32 ; lower false-positive recall and biopsy with DBT screening were attenuated after several screening rounds. 44 Additional research is needed to ascertain whether DBT-based screening would reduce false-positives over a lifetime of screening.

The evidence was not adequate to evaluate the benefits and harms of supplemental MRI screening for people with dense breasts. No eligible studies were identified that provide evidence on breast cancer morbidity or mortality outcomes with supplemental MRI screening compared with mammography alone among individuals with dense breasts. The DENSE trial 45 reported fewer interval cancers with 1 round of supplemental MRI screening, but results from a second screening round are not yet published. Evidence of higher advanced cancer incidence in the mammography-only group relative to the MRI group would be needed to anticipate effects on morbidity or mortality. Supplemental MRI led to additional false-positive recalls and biopsies, and uncommon but serious adverse events were observed. 45 Two recent systematic reviews of the test performance literature reported higher cancer detection with supplemental MRI screening along with substantially increased recall and biopsy rates among individuals without cancer. 48 , 49

Lack of a standardized and reliable assessment tool for measuring breast density and density variation across the lifespan pose challenges for research into the optimal screening strategy for persons with dense breasts. 16 Research is also needed to evaluate personalized risk-based screening, based on breast cancer risk factors and personal screening preferences. The ongoing WISDOM trial and My Personalized Breast Screening study (expected completion in 2025) may help to address these research gaps. 50 , 51

Breast cancer is an active area of research, yet few longitudinal RCTs comparing different screening strategies have been conducted following completion of the major trials that established the effectiveness of mammography for reducing breast cancer mortality for women aged 50 to 69 years. This review included 6 new randomized trials, 27 , 31 , 33 , 40 , 42 , 45 4 comparing DBT with digital mammography screening 27 , 31 , 33 , 42 and 2 on supplemental screening compared with mammography alone. 40 , 45 Three of these trials are ongoing 31 , 40 , 45 and have reported preliminary results only. Observational studies were also included, but few studies were available that followed up a screening population over time to compare the health outcomes associated with different screening approaches. These studies, while potentially more representative of a screening population, have higher risk of biased results due to confounding and selection.

Changes in population health, imaging technologies, and available treatments may limit the applicability of previous studies. Recent trials included in this review were conducted outside of the US and enrolled mostly White European populations. No studies evaluated screening outcomes for racial or ethnic groups in the US that experience health inequities and higher rates of breast cancer mortality. Black women are at highest risk of breast cancer mortality, 52 with lower 5-year survival than all other race and ethnicity groups. 7 Breast cancer mortality risk also increases at younger ages for Black women compared with White women. 53 This review did not address additional factors beyond screening that contribute to breast cancer mortality inequities. 54 Rigorous research is essential to understand and identify improvements needed along the pathway from screening to treatment 55 and to address inequities in follow-up time after a positive screening result, time to diagnosis, 56 - 60 and receipt of high-quality treatment and support services. 59 , 61 , 62

Evidence comparing outcomes for different screening intervals and ages to start and stop screening was limited or absent. Trials of personalized screening based on risk and patient preferences are in progress and may address evidence gaps related to optimal screening start ages and intervals. Research is needed to better characterize potential harms of screening, including patient perspectives on experiencing false-positive screening results. Women with false-positive screening results may be less likely to return for their next scheduled mammogram, as reported in a large US health system study. 55 , 63 Rigorous studies that enroll screening populations and report advanced cancer detection, morbidity, and mortality outcomes from multiple rounds of screening are needed to overcome persistent limitations in the evidence on breast cancer screening. Multiple screening rounds are essential to determine whether a screening modality or strategy reduces the risk of advanced cancer by detecting early cancers that would otherwise have progressed (stage shift), potentially reducing breast cancer morbidity and mortality. 20 - 23 , 64

The potential benefits of risk-stratified screening strategies, including the use of supplemental screening with ultrasound or MRI, have not been fully evaluated, although some harms are evident. Longer term follow-up on existing comparative effectiveness trials, complete results from ongoing RCTs of personalized screening programs, 65 , 66 and rigorous new studies are needed to further strengthen the evidence and optimize breast cancer screening strategies.

Evidence comparing the effectiveness of different breast cancer screening strategies is inconclusive because key studies have not yet been completed and few studies have reported the stage shift or mortality outcomes necessary to assess relative benefits.

Accepted for Publication: November 23, 2023.

Published Online: April 30, 2024. doi:10.1001/jama.2023.25844

Corresponding Author: Jillian T. Henderson, PhD, MPH, Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Ave, Portland, OR 97227 ( [email protected] ).

Author Contributions: Dr Henderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical review of the manuscript for important intellectual content: Henderson, Weyrich, Miller.

Statistical analysis: Henderson.

Administrative, technical, or material support: Webber, Melnikow.

Supervision: Henderson.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded under contract number 75Q80120D00004, Task Order 75Q80121F32004, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings.

Disclaimer: The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: The authors gratefully acknowledge the following individuals for their contributions to this project: Howard Tracer, MD (AHRQ); Heidi D. Nelson, MD, MPH, MACP (Kaiser Permanente Bernard J. Tyson School of Medicine); current and former members of the USPSTF who contributed to topic deliberations; and Evidence-based Practice Center staff members Melinda Davies, MA, Jill Pope, and Leslie A. Purdue, MPH, for technical and editorial assistance at the Kaiser Permanente Center for Health Research. USPSTF members, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 5 content and methods experts (Nehmat Houssami, MBBS, MPH, Med, PhD [University of Sydney-Australia]; Patricia Ganz, MD [UCLA]; Gerald Gartlehner, MD, MPH [Cochrane Austria]; Karla Kerlikowske, MD [UC San Francisco]; Lisa Newman, MD, MPH [New York Presbyterian/Weill Cornell Medical Center]) and 4 scientific representatives from 3 federal partner organizations (Centers for Disease Control and Prevention; Office of Research on Women’s Health; National Institute on Minority Health and Health Disparities). Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA .

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Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation

• PMID: 26756588
• DOI: 10.7326/M15-0969

Background: In 2009, the U.S. Preventive Services Task Force recommended biennial mammography screening for women aged 50 to 74 years and selective screening for those aged 40 to 49 years.

Purpose: To review studies of the effectiveness of breast cancer screening in average-risk women.

Data sources: MEDLINE and Cochrane databases to 4 June 2015.

Study selection: English-language randomized, controlled trials and observational studies of screening with mammography, magnetic resonance imaging, and ultrasonography that reported breast cancer mortality, all-cause mortality, or advanced breast cancer outcomes.

Data extraction: Investigators extracted and confirmed data and dual rated study quality; discrepancies were resolved through consensus.

Data synthesis: Fair-quality evidence from a meta-analysis of mammography trials indicated relative risks (RRs) for breast cancer mortality of 0.92 for women aged 39 to 49 years (95% CI, 0.75 to 1.02) (9 trials; 3 deaths prevented per 10,000 women over 10 years); 0.86 for those aged 50 to 59 years (CI, 0.68 to 0.97) (7 trials; 8 deaths prevented per 10,000 women over 10 years); 0.67 for those aged 60 to 69 years (CI, 0.54 to 0.83) (5 trials; 21 deaths prevented per 10,000 women over 10 years); and 0.80 for those aged 70 to 74 years (CI, 0.51 to 1.28) (3 trials; 13 deaths prevented per 10,000 women over 10 years). Risk reduction was 25% to 31% for women aged 50 to 69 years in observational studies of mammography screening. All-cause mortality was not reduced with screening. Advanced breast cancer was reduced for women aged 50 years or older (RR, 0.62 [CI, 0.46 to 0.83]) (3 trials) but not those aged 39 to 49 years (RR, 0.98 [CI, 0.74 to 1.37]) (4 trials); less evidence supported this outcome.

Limitations: Most trials used imaging technologies and treatments that are now outdated, and definitions of advanced breast cancer were heterogeneous. Studies of effectiveness based on risk factors, intervals, or other modalities were unavailable or methodologically limited.

Conclusion: Breast cancer mortality is generally reduced with mammography screening, although estimates are not statistically significant at all ages and the magnitudes of effect are small. Advanced cancer is reduced with screening for women aged 50 years or older.

Primary funding source: Agency for Healthcare Research and Quality.

Publication types

• Meta-Analysis
• Research Support, N.I.H., Extramural
• Systematic Review
• Age Factors
• Breast Neoplasms / diagnostic imaging
• Breast Neoplasms / mortality*
• Breast Neoplasms / prevention & control*
• Early Detection of Cancer*
• Mammography*
• Mass Screening*
• Middle Aged
• Risk Factors
• Time Factors

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Assessment of cancer screening effectiveness in the era of screening programs

• Published: 14 September 2020
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• Hans-Olov Adami   ORCID: orcid.org/0000-0001-9592-5791 1 , 2 , 3 , 4 ,
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Whilst the benefit of detecting and removing cancer precursors in the cervix and the large bowel is unequivocally documented, the balance between benefit and harm due to screening for early detection of breast and prostate cancer remains uncertain after 30–50 years of randomized control trials (RCTs). Concomitantly, traditional RCTs become increasingly unfeasible due to low compliance, contamination of control groups, difficulties to enroll screening naïve individuals, and prohibitively high costs. Therefore, we have systematically reviewed pros and cons with alternative study designs to quantify screening effectiveness. Whilst traditional RCTs should remain gold standard whenever feasible, observational cohort and case–control studies are unlikely to provide the valid evidence needed for health policy decisions. Instead, we advocate two methodological approaches that are novel in assessment of cancer screening effectiveness. One—the difference-in-difference design, well established in health policy and public health research—has a sophisticated ecologic design which unfortunately is feasible only in few countries. Another implies that sequential RCTs become embedded whenever population-based screening programs are implemented.

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Hans-Olov Adami & Mette Kalager

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Adami, HO., Bretthauer, M. & Kalager, M. Assessment of cancer screening effectiveness in the era of screening programs. Eur J Epidemiol 35 , 891–897 (2020). https://doi.org/10.1007/s10654-020-00684-7

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Received : 19 May 2020

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DOI : https://doi.org/10.1007/s10654-020-00684-7

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• Volume 11, Issue 11
• Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis
• Article Text
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• Rebecca Mottram 1 ,
• http://orcid.org/0000-0002-6475-9417 Wendy Lynn Knerr 1 ,
• http://orcid.org/0000-0003-0506-9384 Daniel Gallacher 1 ,
• Hannah Fraser 1 ,
• Lena Al-Khudairy 1 ,
• http://orcid.org/0000-0002-4915-5092 Abimbola Ayorinde 1 ,
• Sian Williamson 1 ,
• Chidozie Nduka 1 ,
• http://orcid.org/0000-0002-8567-3081 Olalekan A Uthman 1 ,
• Samantha Johnson 2 ,
• Alexander Tsertsvadze 3 ,
• Christopher Stinton 1 ,
• http://orcid.org/0000-0002-1841-4346 Sian Taylor-Phillips 1 ,
• Aileen Clarke 1
• 1 Division of Health Sciences , Warwick Medical School, University of Warwick , Coventry , UK
• 2 University of Warwick Library , University of Warwick , Coventry , West Midlands , UK
• 3 School of Epidemiology and Public Health , University of Ottawa Faculty of Medicine , Ottawa , Ontario , Canada
• Correspondence to Aileen Clarke; aileen.clarke{at}warwick.ac.uk

Objective Attendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.

Design CINAHL, Cochrane Library, Embase, Medline, OVID, PsycINFO and Web of Science were searched for studies of any design, published January 1987–June 2019, and reporting attendance in relation to at least one patient-level factor.

Data synthesis Independent reviewers performed screening, data extraction and quality appraisal. OR and 95% CIs were calculated for attendance for each factor and random-effects meta-analysis was undertaken where possible.

Results Of 19 776 studies, 335 were assessed at full text and 66 studies (n=22 150 922) were included. Risk of bias was generally low. In meta-analysis, increased attendance was associated with higher socioeconomic status (SES) (n=11 studies; OR 1.45, 95% CI: 1.20 to 1.75); higher income (n=5 studies; OR 1.96, 95% CI: 1.68 to 2.29); home ownership (n=3 studies; OR 2.16, 95% CI: 2.08 to 2.23); being non-immigrant (n=7 studies; OR 2.23, 95% CI: 2.00 to 2.48); being married/cohabiting (n=7 studies; OR 1.86, 95% CI: 1.58 to 2.19) and medium (vs low) level of education (n=6 studies; OR 1.24, 95% CI: 1.09 to 1.41). Women with previous false-positive results were less likely to reattend (n=6 studies; OR 0.77, 95% CI: 0.68 to 0.88). There were no differences by age group or by rural versus urban residence.

Conclusions Attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Variations in service delivery, screening programmes and study populations may influence findings. Our findings are of univariable associations. Underlying causes of lower uptake such as practical, physical, psychological or financial barriers should be investigated.

Trial registration number CRD42016051597.

• breast tumours
• breast imaging
• diagnostic radiology
• public health

Data availability statement

No data are available. No new data have been created in the preparation of this report and therefore there is nothing available for access and further sharing. All queries should be submitted to the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2020-046660

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Strengths and limitations of this study

Comprehensive systematic review of all identified patient-level factors associated with attendance at routine population-based breast cancer (mammographic) screening.

Two reviewers independently conducted all study selection, data extraction and quality appraisal using Quality in Prognosis Studies.

Both observational and experimental designs were included, using control arms of quasi-experimental or randomised designs and ORs were independently recalculated using each study’s raw data.

Heterogeneity is high partly due to the large size of studies. Studies were separately meta-analysed by study design, and sensitivity analysis was conducted for one study with an extreme effect size.

Reporting of potential confounders and effect modifiers was highly variable in studies; this was partially mitigated by recategorising variables, such as education levels, to harmonise variables across studies where possible.

Introduction

Breast cancer was the most commonly diagnosed cancer worldwide in 2020, with 2.3 million cases, and the most common cause of cancer death in women. 1 Breast cancer incidence is higher in more developed countries (Europe, Australia, New Zealand and North America; 55.9 cases per 100 000 population) than in less developed countries (29.7 per 100 000), while the reverse is true of death rates (12.4 vs 15.0 per 100 000, respectively). 1 In the EU, mortality rates decreased 18.7% between the period 2005–2009 and 2019 from 16.44 to (predicted) 13.36 per 100 000. 2

Population-based mammographic screening aims to reduce breast cancer mortality. However, there has been controversy about the balance of benefits and harms of breast screening 3 and breast screening programmes have become more aware of the need for promoting informed choice. 4 5

Attendance at breast screening is not uniform among the eligible population. 6 Ross et al 7 described attendance at screening as an individual decision (behavioural) which is affected by accessibility of services (structural) and by a woman’s immediate surroundings (societal). Characteristics that have been associated with screening attendance can be grouped into a number of categories related to sociodemographic factors; health status; health behaviours; accessibility and logistics; beliefs, attitudes and knowledge; simple intention to attend and societal factors including health systems financing and organisation. 8–11

Most reviews of factors associated with breast screening attendance have focused on individual factors. 12–14 We aimed to provide a comprehensive systematic review of all identified patient-level characteristics associated with the uptake of population-based mammographic screening, to inform screening programmes of the available evidence about who does and does not attend.

Protocol and registration

The review was conducted in accordance with prespecified methods documented in the protocol registered on the 22November 2016 in the PROSPERO International Prospective Register of Systematic Reviews database ( online supplemental file A ). 15

Supplemental material

Search and information sources.

The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Embase, Medline, PsycINFO and Web of Science were searched for studies published between 1 January 1987 and 26 June 2019. The search was developed in Medline using a combination of MeSH headings and free-text terms and adapted for use in the other databases (the search strategy is available in online supplemental file B ).

Reference lists of relevant reviews were searched for potentially relevant studies. Experienced researchers with prior studies in the field were contacted to identify other potentially relevant studies that had not been identified in the searches.

Eligibility criteria

Primary studies of any design were included if they reported attendance data from routine population-based mammography screening programmes in relation to at least one patient-level factor, and were written in English between January 1987 and June 2019. Studies were excluded if they involved self-reported mammography uptake, opportunistic screening programmes, data for only a subgroup of the eligible population (eg, only women in a narrow age range, only immigrants or only rural women) or uptake data by number of invitations sent rather than number of women. Reviews, commentaries, opinions, letters, and non-empirical and qualitative studies were excluded.

Study selection and data extraction process

Pairs of reviewers screened titles and abstracts independently to identify potentially relevant studies with third reviewer cross-check. Two reviewers independently assessed full-text studies for formal inclusion/exclusion assessment against predefined eligibility criteria with third reviewer cross-check. Disagreements were resolved by a consensus between the two reviewers or by help of a third reviewer.

Data from included studies were extracted and then cross-checked by two reviewers independently. The data included the number of women who attended mammographic screening and the number invited, and data on patient characteristics, including: sociodemographic factors, such as age, marital status, educational level, race/ethnicity, immigration status and socioeconomic status (SES, which was measured in two ways, (a) with various composite indices of deprivation that included factors such as housing density, employment, education, social support, car ownership and crime prevalence, and (b) based on household income); beliefs, attitudes and socioemotional factors; health history and behaviours; logistic and accessibility factors (eg, distance from screening centre).

Risk of bias of included studies

Risk of bias (RoB) of all included studies was appraised by two independent reviewers using the Quality in Prognosis Studies (QUIPS) tool. 16 The QUIPS tool covers six RoB domains (participation, attrition, prognostic factor, confounding factors, outcome measurement and analysis and reporting), each of which includes multiple items that are judged separately. A conclusive judgement for each RoB domain is reached and expressed on a three-grade scale (high, moderate or low RoB).

Synthesis of data

We used raw attendance data to calculate unadjusted ORs for each factor. A random-effects model-based meta-analysis was conducted for an association between a factor of interest (dichotomous or more categories) and the dichotomous outcome (screening attendance) to generate Mantel-Haenszel ORs with 95% CIs, when possible. 17 Random-effects models were used to allow for heterogeneity in the effects of the factors considered to vary across the different studies.

In addition to the main meta-analyses, we conducted separate meta-analyses for (a) observational studies whose samples were made up only of women who had previously attended screening (hereafter referred to as rescreening studies) and (b) intervention studies (quasi-experimental and randomised controlled trials) that reported characteristics separately for intervention and control arms, recording only data for the control group, as their attendance would not be influenced by exposure to an intervention. We also conducted a sensitivity analysis to determine the impact of a study with an extreme effect size 18 on the meta-analysis of SES.

We summarised results narratively if there were inadequate quantitative data for meta-analysis, if variables were reported in fewer than three studies, 17 or if the data from multiple studies were highly variable and therefore could not be meaningfully pooled.

This review is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines ( online supplemental file C ). 19 All analyses were conducted in Stata V.16.

Patient and public involvement

Public contributors were involved in design and informed of ongoing progress and findings as part of the West Midlands Centres for Leadership in Applied Health Research. Results were reported back to the contributors as part of the wider dissemination activities of the relevant theme in the Centres for Leadership in Applied Health Research.

Literature search

The process of study flow and reasons for exclusion are provided in figure 1 . In brief, the searches of electronic databases identified 11 953 unique publications (after deduplication), published between January 1987 and June 2019, of which 11 618 were excluded at the level of abstract/title screening, leaving 335 records for full-text review. Of the 335 full texts, 66 unique studies reported in 67 publications were included. 18 20–87

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PRISMA flow diagram, showing the process of study flow and reasons for exclusion. The searches of electronic databases identified 11 953 unique publications (after deduplication), published between January 1987 and June 2019, of which 11 618 were excluded at the level of abstract/title screening, leaving 335 records for full-text review. Of the 335 full texts, 66 unique studies reported in 67 publications were included. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study characteristics

Characteristics of all included studies are listed in online supplemental file D . Of the 66 studies, 49 were observational (45 retrospective cohort, 2 cross-sectional and 2 case–control designs); and 17 were intervention studies (16 randomised controlled trials and 1 quasi-experimental). Sample sizes ranged from 82 to 4.8 million.

The studies were conducted in Europe (n=40), North America (n=18), Asia-Pacific (n=5) and the Middle East (n=3). The UK had the most studies (n=16) followed by the USA (n=11).

We were able to pool data from 31 observational studies (reported in 32 publications) on the attendance at screening in relation to nine factors (age, education, home ownership, immigration status, marital status, results of previous mammogram, rural/urban residence, SES and income) ( table 1 ). We were only able to pool data from three intervention studies, and only for one factor (age).

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Results of meta-analyses*

Adequate data for meta-analysis was not provided for 35 studies; although six of these studies provided adequate data to calculate ORs and CIs, and are narratively reported in table 2 . The remaining 29 studies reported data that could not be analysed. (Reasons are detailed in online supplemental file E .) In brief, 14 of the 29 studies were intervention trials, where data were not in the right format for us to use. The other 15 studies could not be analysed because uptake data were reported by health-provider characteristics rather than patient characteristics; because the paper reported percentage uptake but not sample sizes per category; or because data for different factors were not reported separately.

Likelihood of attending screening by factors not suitable for meta-analysis in observational studies

Risk of bias

RoB across studies was generally low on all domains ( figure 2 ). For study participation, 71% of studies were considered at low RoB; for attrition, 91%; for outcome measurement, 97% and for statistical analysis and reporting, 83%. For measurement of variables associated with attendance (prognostic factors), more than half (61%) of studies had a low RoB, while 23% had a high RoB, mostly due to SES being measured at the area level (eg, neighbourhood) rather than at the individual level. More than half of studies (53%) had a low RoB with regard to measuring potential confounders, with around one-quarter (27%) having a moderate risk and just over one-fifth (21%) having a high risk.

Overall summary of QUIPS risk of bias scores: risk of bias (RoB) of all included studies was appraised by two independent reviewers using the Quality in Prognosis Studies (QUIPS) tool. The QUIPS tool covers six RoB domains (participation, attrition, prognostic factor, confounding factors, outcome measurement and analysis and reporting), each of which includes multiple items that are judged separately. A conclusive judgement for each RoB domain is reached and expressed on a three-grade scale (high, moderate or low RoB). RoB across studies was generally low on all domains.

Quantitative data analysis (meta-analyses)

Table 1 presents unadjusted OR estimates with their 95% CIs of attendance at breast screening for factors that were reported in three or more studies. The analyses gave I 2 values of around 99%, meaning that there was a high level of heterogeneity, except for the analysis of homeowners versus tenants, where the I 2 value was 38.9% ( table 1 ).

We compared the odds of attending mammographic screening by the age bands most commonly eligible for national screening programmes (60―69 and 50―59). There was no significant difference by age group in meta-analyses of observational studies (n=16; OR 0.97, 95% CI: 0.88 to 1.08, p=0.631, figure 3 ) or intervention trials (n=3; OR 0.78, 95% CI: 0.47 to 1.31, p=0.354).

Meta-analyses. This figure shows comparisons of the odds of attending mammographic screening, using random-effects analysis, in observational studies by the following variables. Points to the left of the centre line (<1) suggest a lower likelihood of attending screening, while points to the right of the centre line (>1) indicate a higher likelihood of attending. Age bands: we compared the age bands most commonly eligible for national screening programmes (60―69 and 50―59); there was no significant difference by age group (n=16; OR 0.97, 95% CI: 0.88 to 1.08, p=0.631); Home ownership: we compared people who own their homes to those who are tenants or do not own their homes; the odds of attending were higher for homeowners than for tenants or non-owners (n=3; OR 2.16, 95% CI: 2.08 to 2.23, p<0.001); Immigrant status: we compared screening attendance of people born in the country in which the study took place (non-immigrants) to those born in another country (immigrants); non-immigrants were more likely to attend than immigrants (n=7; OR 2.23, 95% CI: 2.00 to 2.48, p<0.001). Marital status: we compared women who were married or cohabiting to those who were unmarried or not cohabiting: women where were married/cohabiting were more likely to attend than their unmarried/non-cohabiting counterparts (n=7; OR 1.86, 95% CI: 1.58 to 2.19, p<0.001). Reattendance; using data from studies with samples made up only of women who had previously attended mammographic screening, we compared women who had previously received a false-positive to those who had had a normal result; those with a previous false-positive result were less likely to reattend (OR 0.78, 95% CI: 0.68 to 0.88, p<0.001).

We grouped education data from six studies to approximate the United Nations Educational, Scientific and Cultural Organisation (UNESCO) three-level classification: low (≤10 years), middle (11–15 years) and high (>15 years). Compared with women with a low level of education, women with a medium level were more likely to attend (OR 1.24, 95% CI: 1.09 to 1.41, p<0.001). Results from comparisons of women with a high level of education versus low or medium levels were not statistically significant ( figure 4A ).

Meta-analyses of attendance by educational level, socioeconomic status (SES) and income. These figures show random-effects meta-analyses of screening attendance by educational level and socioeconomic status in observational studies. Points to the left of the centre line (<1) suggest a lower likelihood of attending screening, while points to the right of the centre line (>1) indicate a higher likelihood of attending. Figure 4A shows the effects of different levels of education on screening attendance. We grouped education data to approximate the United Nations Educational, Scientific and Cultural Organization (UNESCO) three-level classification: low (≤10 years), middle (11–15 years) and high (>15 years). Compared with women with a low level of education, women with a medium level were more likely to attend (OR 1.24, 95% CI: 1.09 to 1.41, p<0.001). Results from comparisons of women with a high level of education versus low or medium levels were not statistically significant ( figure 4A ). Figure 4B shows the meta-analysis of attendance by overall SES. Studies were grouped into low, medium and high categories. Women with medium or high SES were more likely to attend than those with a low SES (medium vs low SES OR 1.45, 95% CI: 1.20 to 1.75, p<0.001; high vs low SES OR 1.69, 95% CI: 1.40 to 2.05, p<0.001, figure 4B ). Figure 4C shows the meta-analysis of screening attendance by income. Studies were grouped into low, intermediate and high categories. Women with an intermediate or high income were more likely to attend than those with low income (intermediate vs low income OR 1.96, 95% CI: 1.68 to 2.29, p<0.001; high vs low OR 2.18, 95% CI: 1.86 to 2.56, p<0.001; high vs intermediate OR 1.11, 95% CI: 0.95 to 1.30, p=0.20, figure 4C ). For both income and SES, there was no significant difference between women at intermediate and high levels, indicating that there was no statistically significant dose response effect for higher SES or income.

The odds of attending mammographic screening were higher for homeowners than for tenants or non-owners (n=3; OR 2.16, 95% CI: 2.08 to 2.23, p<0.001, figure 3 ).

Meta-analysis of participants’ country of origin showed that people born in the study country (non-immigrants) were more likely to attend than immigrants (n=7; OR 2.23, 95% CI: 2.00 to 2.48, p<0.001, figure 3 ).

We meta-analysed attendance using two measures of SES. Data for overall SES from 11 studies were grouped into low, medium and high categories. Women with medium or high SES were more likely to attend than those with a low SES (medium vs low SES OR 1.45, 95% CI: 1.20 to 1.75, p<0.001; high vs low SES OR 1.69, 95% CI: 1.40 to 2.05, p<0.001, figure 4B ). One study from France (DeBorde) 18 (n=4.8 million) reported that women with a higher SES were less likely to attend than those with either a low or intermediate SES. We conducted a sensitivity analysis excluding that study, but it made very little difference to the odds of attending: women with high or medium SES were both more likely to attend compared with women of lower SES (OR 1.84, 95% CI: 1.55 to 2.17, p<0.001, and OR 1.49, 95% CI: 1.27 to 1.76, p<0.001, respectively).

Data on income from five studies were grouped into low, intermediate and high categories. Women with an intermediate or high income were more likely to attend than those with low income (intermediate vs low income OR 1.96, 95% CI: 1.68 to 2.29, p<0.001; high vs low OR 2.18, 95% CI: 1.86 to 2.56, p<0.001; high vs intermediate OR 1.11, 95% CI: 0.95 to 1.30, p=0.20, figure 4C ). For both income and SES, there was no significant difference between women at intermediate and high levels, indicating that there was no statistically significant dose response effect for higher SES or income.

Women who were married or cohabiting were more likely to attend than their unmarried or non-cohabiting counterparts (n=7; OR 1.86, 95% CI: 1.58 to 2.19, p<0.001, figure 3 ).

We analysed data separately for studies with samples made up only of women who had previously attended mammographic screening (ie, rescreening studies). Six of these studies reported data on attendance based on the results of a previous mammogram. Women who had previously received a false-positive result were less likely to attend than those with a normal result (OR 0.78, 95% CI: 0.68 to 0.88, p<0.001, figure 3 ).

There was no statistically significant difference in attendance among women living in rural compared with urban areas (n=3; OR 1.12, 95% CI: 0.76 to 1.66, p=0.557).

Narrative synthesis

Factors that could not be meta-analysed (because they were reported in fewer than three studies or could not be pooled) are reported in table 2 with ORs.

These studies include a variety of factors associated with reduced attendance clustered around sociodemographic, accessibility and logistics (living in crowded housing and being unemployed, receiving disability benefits, lack of access to a vehicle), and spoken language not English.

Associations with women’s health status, behaviours, attitudes and knowledge showed a mixed picture. There was some evidence that good general health, lack of comorbidity and not taking hormone replacement therapy (HRT) were all associated with higher attendance, but studies also reported higher attendance among women with a higher numbers of previous clinic visits, depression and heart disease. A previous negative attitude to breast screening, limiting long-term illness, schizophrenia, non-work-related stress and current smoking were associated with lower attendance.

Factors that did not show any statistical difference included body mass index and service provision factors. No difference in women’s attendance was found according to availability of general practitioners or radiologists or physician years since graduation, and there were mixed results according to distance to screening centre and diabetes.

We undertook a comprehensive review of the current evidence on patient-level factors associated with breast cancer (mammographic) screening attendance. Where appropriate, meta-analyses were performed to determine the strength of association.

Main findings

In line with other systematic reviews, we found that in general higher SES status, higher income, 14 being born in the country of residence (ie, non-immigrant) 12 and home ownership (compared with renting) predicted mammographic screening attendance. However, it appears that women with a higher SES or income were not more likely to attend than those with an intermediate level. We hypothesise that women with a higher SES may be more likely to use alternative screening services (ie, opportunistic or privately funded screening) compared with women with a low or intermediate SES, thus their attendance would not be apparent in studies using data from national screening programmes. This was suggested as a limitation by many of the included studies in this review, most notably the large study from France 18 (n=4.8 million), which was the only study to find that women with a higher SES were less likely to attend than those with either a low or intermediate SES. The authors of that study note the high levels of opportunistic screening available to women with a high SES in France. We conducted a sensitivity analysis excluding that study, but it made very little difference to the ORs for attendance.

A medium level of education was also associated with screening attendance when compared with a low level, but a higher level of education was not associated with increased attendance compared with either medium or lower levels. As with the analyses of SES, it is possible that women with the highest levels of education are more likely to use alternative screening services not reflected in data from public screening programmes.

We hypothesised that some variation in relation to education or SES might be due to changes in women’s attitudes to breast screening as a result of concerns about its overall benefits, 65 88 perhaps related to the informed-choice agenda. 4 However, we found no population screening studies investigating this.

Our results also support previous research indicating that marital status is associated with attendance at mammography, 65 88–91 with women who were married or cohabiting more likely to attend than their unmarried or non-cohabiting counterparts. Previous literature indicates lower uptake among women from minority-ethnic backgrounds. 92 93 While our data were not sufficient to meta-analyse ethnicity, we did find that immigrant women were less likely to attend screening than non-immigrants.

We did not find a significant effect of age. There was very high heterogeneity here, with individual large studies finding highly statistically significant results in both directions. We hypothesised that attendance may be higher among older women because they have been invited to breast screening for at least two decades, and attendance may have become more routine in this cohort, and possibly less likely to be affected by recent debates around the risks and benefits of screening. To explore this, we did a post-hoc analysis of the effect of age on attendance by the year of study completion. We found that older women were more likely to attend compared with younger women in more recent studies (ie, those completed since 2010), but that the opposite was true in older studies, particularly those published before 2005.

Women who received a false-positive result at a previous screening were less likely to attend than those with a normal result, confirming previous findings. 94

Strengths and limitations

This review has many strengths. The large number of studies included (n=66), involving more than 22 million women, represents a comprehensive overview of available evidence. Studies included in the meta-analysis were judged to have a low RoB on most domains and included large numbers of women. At least two reviewers were involved at all stages to reduce the risk of errors and bias. This study was undertaken from the perspective of population-based breast cancer screening programmes and we were strict in our eligibility criteria in including only those studies. Studies where the sampling frame was restricted to population subgroups (and not based on population-based screening programmes) were excluded. We also excluded studies that relied on self-reported attendance (though it is important to note that self-report is essential for some factors, such as ethnicity and attitudes to screening).

A limitation is that most studies reported cross-sectional attendance data, which included mixed groups of those who were attending for the first time and some who had previously attended. Also, we inevitably had to make choices of categories for meta-analysis which may affect meta-analytic results; where possible we used independent sources to select appropriate categorisations.

The main limitation of this review is significant between-study heterogeneity. Although we used random-effect models throughout, our results should be considered in light of this. We chose random-effects models as almost all of our analyses contained heterogeneity and it is also expected that there would be differences in attendance across the different study populations. Studies with larger sample sizes are assumed to contain the least uncertainty and are given higher weightings than smaller studies. For analyses of small numbers of studies, the random-effects analysis may struggle to correctly estimate uncertainty, but any meta-analysis performed on few studies would have its limitations, and the use of random-effects analysis maintained consistency with the other analyses.

Heterogeneity may in part be due to differences between health systems and the organisation of mammographic screening, as well as differences in the culture and attitudes of the populations served. We conducted sensitivity analysis to determine the impact of a very large study with an extreme effect size 18 on the meta-analysis of SES. For some outcomes (such as age), the heterogeneity encompasses studies with highly significant results in both directions, and here the results of the meta-analysis should be interpreted with great caution. For other variables (such as reattendance after false-positive results), the high I 2 simply reflects that there were very large studies with very small CIs, which all had point estimates of different magnitude in the same direction. Here the meta-analysis results show a consistent effect, with some disagreement between studies on the exact size of effect.

Another limitation is that we extracted univariable associations with uptake. In practice, many of the variables investigated will be highly correlated, and there will be complex interactions and confounding which we have not been able to account for. While some studies did report multivariable models, these were varied in structure, methods and variables included, so would have been difficult to combine in any meaningful way. We were therefore unable to undertake multivariable meta-regression analysis, examining the effects of individual attendance factors on overall attendance.

For the studies included in the narrative analysis, large numbers of women were also often involved, but these studies should be treated with caution as they are potentially subject to bias. The risk of confounding was found to be high in these studies using the QUIPs tool. However, confounding is inherent in the design of population-based observational and especially ecological designs.

To investigate the risk of reporting bias, we conducted funnel plots ( online supplemental file F ), which demonstrated the high level of heterogeneity present between the studies in our analyses. Age was the only analysis where the studies disagree over the direction of attendance, however the disagreement is among larger studies, suggesting this is unlikely to be associated with biased reporting and instead down to the study heterogeneity. All other analyses, while having studies which disagree on the point estimate, have agreement as to which group is more or less likely to attend mammographic screening. Overall, we are not concerned about reporting bias.

Finally, we have not included health insurance (or lack of health insurance) as a factor in the narrative analysis because of the problems of comparison between countries.

Conclusions

A wide variety of factors affect a woman’s decision to attend breast screening. Our main findings are that attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Based on our current findings, if screening programmes wish to improve equity of access to breast screening services, they should concentrate on women facing access (practical, physical, psychological and financial) barriers.

Future research in this area would also need to systematically assess the effects of interventions to reduce the impact of access barriers to screening attendance.

Deviations from study protocol

To assess RoB, the QUIPS tool was used rather than the Quality Assessment Tool; and for data synthesis, despite significant heterogeneity, meta-analysis was possible for some predictors. In addition, we clarified our inclusion criteria to include only studies with data from routine population-based mammography screening programmes in order to ensure generalisability.

Ethics statements

Patient consent for publication.

Not required.

Acknowledgments

The authors would like to thank Magdalena Skrybant, Patient and Public Involvement and Engagement Lead, Applied Research Centre West Midlands (formerly Centres for Leadership in Applied Health and Care, West Midlands) for her support in coordinating public engagement in this project.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3
• Data supplement 4
• Data supplement 5
• Data supplement 6

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Contributors RM conceived the study as part of her PhD Dissertation, and it was further refined in collaboration with AC and ST-P. AC, CS and WLK further developed the inclusion and exclusion criteria. SJ undertook database searches and AC, HF, RM, LA-K, SW and WLK reviewed titles and abstracts. Each study retained for full-text review was reviewed by RM and WLK. Discrepancies regarding inclusion and exclusion were resolved by AC and CS. RM and WLK did data extraction, and data were checked by OAU and CN. Studies were critically appraised by AA, AT, CS and WLK. Meta-analyses were conducted by DG. Thematic synthesis was done by AC, ST-P and WLK. All authors contributed to the manuscript and approved the final version. AC is the guarantor for this paper.

Funding This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands (NIHR CLAHRC WM), now recommissioned as NIHR Applied Research Collaboration West Midlands (NIHR ARC WM). RM, L A-K, ST-P, SW, HF, CS and AC were all supported by the NIHR CLAHRC WM and WLK, AA, AC and L-AK are all partly supported by the NIHR ARC WM. OAU is supported by the NIHR using Official Development Assistance (ODA) funding. ST-P is supported by an NIHR Career Development Fellowship (CDF-2016-09-018). The views expressed in this publication are those of the author(s) and not necessarily those of the UK National Health Service (NHS), the NIHR or the Department of Health and Social Care.

Competing interests RM reports personal fees from the National Institute for Health Research (NIHR) Centre for Leadership in Applied Research and Health Care (CLARHC) West Midlands during the conduct of the study. LA-K reports grants from the NIHR during the conduct of the study. ST-P reports grants from NIHR outside the submitted work. AC reports grants from the NIHR for the NIHR Applied Research Centre (ARC) West Midlands and previously from the NIHR CLARHC West Midlands, which supported her and researchers working on this project. AC also received grants from Public Health England (PHE) outside the submitted work.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Research article
• Open access
• Published: 22 October 2019

Knowledge, attitudes, and practices related to breast cancer screening among female health care professionals: a cross sectional study

• Humariya Heena   ORCID: orcid.org/0000-0002-0493-1422 1 ,
• Sajid Durrani 2 ,
• Muhammad Riaz 3 ,
• Isamme AlFayyad 1 ,
• Rabeena Tabasim 4 ,
• Gazi Parvez 5 &
• Amani Abu-Shaheen 1  

BMC Women's Health volume  19 , Article number:  122 ( 2019 ) Cite this article

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Incidence of breast cancer in the Kingdom of Saudi Arabia (KSA) has increased in recent years. Screening helps in early detection of cancer and early diagnosis and timely treatment of breast cancer lead to a better prognosis. Women in the healthcare profession can have a positive impact on the attitudes, beliefs, and practices of general public. Therefore, it is important that the healthcare workers themselves have adequate knowledge and positive attitudes. We conducted a study to assess the knowledge, attitudes, and practices related to breast cancer screening among female healthcare professionals.

A cross-sectional study was conducted on female health professional of KFMC (King Fahad Medical City). Data was collected using a pre-designed, tested, self-administered questionnaire. The questionnaire included specific sections to test the participants’ knowledge, attitude, and practices related to cervical cancer and its screening. Data analysis was done using descriptive statistics.

A total of 395 health care workers participated in this study. The mean age of the participants was 34.7 years. Participants included physicians ( n  = 63, 16.0%), nurses ( n  = 261, 66.1%), and allied health workers ( n  = 71, 18.0%). Only 6 (1.5%) participants had a good level of knowledge of breast cancer and 104 (26.8%) participants demonstrated a fair level of knowledge. Overall, 370 (93.7%), 339 (85.8%), and 368 (93.2%) participants had heard of breast self-examination, clinical breast examination, and mammography, respectively. A total of 295 (74.7%) participants reported practicing breast self-examination, 95 (24.1%) had undergone clinical breast examination, and 74 (18.7%) had ever undergone mammography.

The knowledge, attitudes, and practices related to breast cancer screening were found to be lower than expected. Active steps are required to develop educational programs for the health care staff, which might empower them to spread the knowledge and positively influence the attitudes of female patients in the hospital.

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Breast cancer is the most common cancer among women worldwide [ 1 ]. In 2018, over 2 million new cases of breast cancer were diagnosed globally accounting for 11.6% of all cancers. Breast cancer is also the most common cause of cancer-related deaths in women [ 1 ]. It is no longer prevalent only in the developed part of the world but is commonly reported in the developing countries as well. In Kingdom of Saudi Arabia incidence of breast cancer has been on the rise in recent years with number of cases increasing from 1152 per 100.000 inhabitants in 2008 to 1473 per 100.000 inhabitants in 2010, and 1826 per 100.000 inhabitants in 2014 [ 2 , 3 ]. The KSA health council 2014 cancer registry reported breast cancer to be the most common cancer in women accounting to 28.7% of all cancers while another study attributed 13.08% of all deaths to breast cancer 98% of which occurred in women and 12% in men [ 3 , 4 ].

Although there has been immense progress in the treatment of breast cancer, prognosis remains poor in developing countries including KSA [ 4 ]. An important reason for the poor prognosis could be a delay in diagnosis. When breast cancer is diagnosed at an early stage, prognosis is believed to be good with reduced morbidity and mortality [ 5 ]. Therefore, steps should be taken to ensure early detection and timely treatment. Two vital strategies for early detection include early diagnosis and screening [ 6 ]. An important aspect of early diagnosis includes increasing the awareness of early signs of cancer among physicians, nurses, other healthcare workers as well as the general population [ 7 ]. Screening, on the other hand, includes employing simple tests to identify individuals with cancer even before symptoms appear. Breast self-examination (BSE), clinical breast examination (CBE), and mammography are well recognized screening methods for breast cancer [ 6 , 7 ]. Although in recent international guidelines, which focus on developed countries, the timeframes for screening have been questioned, this may not apply to the developing countries including Saudi Arabia where the awareness is very low and patients routinely present at advanced stage of breast cancer [ 8 , 9 ].

Breast cancers in women from Arab populations have different characteristics and affected patients are at least a decade younger. Hence, the of Ministry of health in KSA guidelines in contrast to international guidelines recommend the use of screening strategies with mammography for the detection of breast cancer in women aged 40–49 years every 1 to 2 years. The indication that higher benefit on breast cancer mortality justifies a recommendation in favor of implementing breast cancer screening using mammography in this age group in this population.

Based on local cancer registry data, the incidence of breast cancer in the KSA for the age group 50–69 years is similar to the ones reported in the literature in other countries. Hence the Ministry suggests screening with mammography in women aged 50–69 years every 2 years and no screening with mammography for women aged 70–74 years, however a nationalized large scale screening program is yet to take off [ 10 ].

In KSA despite the healthcare facilities being free of cost, utilization of breast cancer screening methods, including mammography, is very low with one study reporting that out of women 50 years or older, 89% of them reported not having a clinical breast examination (CBE) and 92% of women reported never having a mammogram in the past year [ 11 ].

For effective screening and early diagnosis, adequate knowledge and awareness are of utmost importance. Women healthcare workers can bring about a significant change in the overall perspective of their female patients, regarding screening practices and positively influence their attitudes and beliefs [ 12 ]. They are also the first point of contact irrespective of their specialty of work for not only their female patients but also female relatives and friends for advice regarding breast cancer screening. Females usually feel embarrassed to talk about this issue with their male physicians. Consequently, measures are required to educate women and spread awareness. To achieve this, an important step would be to ensure that female healthcare professionals themselves possess adequate knowledge which they can transmit to their patients, relatives and acquaintances [ 13 ].

Several studies have been conducted in other developing countries to assess the knowledge and practices of breast cancer screening both in the general population as well as specifically in healthcare professionals [ 14 , 15 , 16 , 17 , 18 ]. In KSA, also several similar studies have been conducted on the general population [ 19 ]. However, the number of studies conducted on healthcare professionals in KSA have been limited. We, therefore, conducted this study to assess the knowledge, attitudes, and practices related to breast cancer screening among female healthcare professionals.

Study design and study population

A cross-sectional study was conducted on female healthcare workers (with at least 1 year of clinical experience) in 2018, including physicians, nurses, and allied health staff, at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.

Data collection

Data were collected using a pre-designed, pre-tested, and self-administered questionnaire. The questionnaire was developed from previous studies after an in depth literature review [ 14 , 15 , 16 , 17 , 18 , 20 , 21 , 22 ]. Before administering the questionnaire to the study population, the face validity of the questionnaire was ensured by a committee of experts in research methodology, obstetrics and gynecology, and oncology. A pilot study was conducted on 70 participants to ensure the clarity and reliability of the questionnaire. Cronbach’s alpha was used to evaluate the reliability which was found to be > 0.70. A trained research assistant randomly approached the subjects in each department and distributed the questionnaires. A survey cover sheet explaining the study was attached to the questionnaire for the participants to sign and complete. Complete anonymity was maintained to protect participants’ identity and to ensure confidentiality of data.

After an extensive literature search, the various survey questions were formulated and the questionnaire was divided into several sections. Some of the question were modified or deleted as per the recommendations of the expert committee since they were either off topic or not suitable for health care workers. The questionnaire included different parts.

First part elicited socio-demographic data on age, clinical experience, education, designation, department, marital status, age at marriage, number of pregnancies, number of children, history of breast cancer, and family history of breast cancer of each study participant.

Questions relating to knowledge of breast cancer were included in the second part. These questions were included under three categories: potential risk factors, signs and symptoms, and ways of screening/diagnosis of breast cancer including BSE, CBE, and mammography.

The respondents were requested to record their answers by choosing one of the three options: ‘Yes’, ‘No’, or ‘Don’t Know’. The scale was then dichotomized (Yes = 1 and No/Don’t Know = 0) and the total knowledge score for each participant was computed by adding up (maximum score of 30). The total score was then categorized as poor knowledge (score of 0–4), fair knowledge (score of 5–14), and good knowledge (score of 15–30).

Participants’ attitude regarding breast cancer was assessed in the third part by asking them to rate 10 specific statements on a 5-point Likert scale. Following 10 statements were included in the questionnaire: 1) Any woman is at risk for breast cancer; 2) Breast cancer can be prevented; 3) If I examine my breast myself, I cannot detect abnormalities in my breast; 4) There is no reason to examine my breasts; 5) If I knew the benefit of breast self-examination, I would have done it by now; 6) Women prefer female doctor for breast examination; 7) If there is no problem in the breasts, periodic breast examinations by a physician are not required; 8) Early detection methods have no effect on treatment; 9) Personal hygiene decreases breast cancer risk; 10) By early diagnosis of breast cancer, the person will have prolonged life. Participants were asked to choose one of the following options for each of the statements above: ‘strongly agree’, ‘agree’, ‘neither agree nor disagree’, ‘disagree’, or ‘strongly disagree’. For presenting results, ‘strongly agree’ and ‘agree’ were combined; similarly, ‘disagree’ and ‘strongly disagree’ were combined.

Participants’ practices were assessed through the last section asking specific questions about BSE, CBE, and mammography. Participants were asked whether they had heard of BSE, CBE, and mammography and whether they believed these tests were useful for early detection of breast cancer. Other questions under BSE enquired whether they had been taught BSE, whether they practice BSE, what age should BSE be done, how frequently should BSE be done, what is the best time to do BSE, what action must be taken when any abnormality is found in BSE, and what, according to them, are the benefits of BSE. Similarly, questions under CBE sought information on whether they had undergone CBE, how CBE is done (by whom, using what), and how often should CBE be done. Questions on mammography tested the participants’ knowledge on what age mammography should be started, how often should it be done, and whether they had undergone mammography.

Ethical considerations

An informed consent was obtained from each participant before enrolment and no compensation or incentive was paid to the participants for this study. The study was approved by the ethics committee at KFMC.

Sample size estimate

The study population was stratified according to their professions into three groups: physicians, nurses, and allied healthcare workers. To ensure appropriate representation from each group of healthcare professionals, the proportionate population sampling method in the form of 4:1:1 for nurses, physicians, and allied healthcare workers, respectively, was adopted. Hence, 260 nurses (out of 2400), 65 physicians (out of 600) and 65 allied health care workers (out of 700) were approached on a random basis from each department and the total sample size was determined to be 390.

Statistical analysis

The statistical package for social science (IBM SPSS statistics 22. Ink) was used for data analysis. Descriptive statistics (i.e., frequencies, percentages, mean [standard deviation, SD] /median [interquartile range, IQR]) were used to describe the demographic characteristics, knowledge, attitude, and practice of breast cancer screening.

Socio-demographic characteristics

A total of 420 questionnaires were distributed to the KFMC female employees of which 395 (94%) were returned and included in the analysis. The mean age (SD) of the participants was 34.7 (8.3) years. Majority of the participants were married ( n  = 239, 60.5%). Respondents included 261 (66.1%) nurses, 63 (16.0%) physicians, and 71 (18.0%) other healthcare workers including pharmacists, dieticians, technicians, health educators, physiotherapists, and therapists. Majority of the participants were bachelor’s degree holders ( n  = 272, 68.9%) and 52 (13.2%) had a postgraduate qualification. Average work experience was 10 [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ] years. Nine (2.3%) participants reported having history of breast cancer and 40 (10.1%) participants reported having a first-degree relative with history of breast cancer (Table  1 ).

Participants’ knowledge about breast Cancer

The knowledge score achieved in this study is very low; the median score of (range) = 1(0–5). When ranked in order, the 75th percentile is =5 (it means knowledge of only 5 items on the scale). Therefore, in this study, we considered a score of [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ] as fair and a score of (> = 15) as good. The total score was therefore categorized as poor knowledge (score of 0–4), fair knowledge (score of 5–14), and good knowledge (score of 15–30). About 14 to 26% of the participants responded ‘Yes’ to the following potential risk factors for breast cancer: high-fat diet, working-class women, alcohol consumption, first child at a late age, early onset of menarche, late menopause, obesity, and larger breast (Table  2 ).

For other risk factors listed in the questionnaire, less than 14% responded ‘Yes’. Under the section of signs and symptoms of breast cancer, 49 (12.4%) participants agreed that scaling/dry skin in the nipple region could be a sign of breast cancer and 40 (10.1%) participants knew that weight loss could also be a sign of breast cancer. Less than 10% of the participants responded ‘Yes’ to rest of the signs/symptoms. Similarly, a lower rate (< 10%) was observed for the methods of diagnosis of breast cancer. The median (IQR) total score of knowledge about breast cancer was 1 (0–5), and only 5 (1.3%) participants appeared to have good level of knowledge (score: 15–30), while 104 (26.3%) scored fair level knowledge (score:5–14).

Slightly higher proportion of the fair (score: 5–14) knowledge was achieved by other allied health workers 27 (38.6%) comparing to 13 (21.7%) by the physician, and 64 (24.6%) by the nurses, however, this was not significant statistically ( p  = 0.113). When compared, there was no statistically significant difference of proportions of the fair (score: 5–14) knowledge among female physicians working under different specialties at KFMC ( p  = 0.183).

Participants’ attitudes toward breast Cancer screening and self-examination

Table  3 shows the responses on the statements for attitudes toward breast cancer screening and self-examination. Only 20 (5.1%) participants believed that any woman is at risk of breast cancer and 37 (9.4%) believed that breast cancer can be prevented (Table 3 ). Also, 53.4% of the participants believed that they could not detect abnormalities in breast by self-examination.

Knowledge and practice of breast self-examination

Results for the knowledge and practice of BSE are presented in Table  4 . Overall, 370 (93.7%) participants were aware of BSE, and 358 (90.6%) agreed that it is a useful tool for early detection of breast cancer. A total of 336 (85.1%) participants had been taught about BSE and 295 (74.7%) participants reported to be practicing it. Overall, 170 (43.0%) participants chose that BSE should be started from puberty, and 91 (23.0%) chose the age of 20 years to start doing BSE. A total of 317 (80.3%) participants agreed that the best time for BSE is a week after period and 293 (74.2%) participants agreed that BSE should be done monthly. Overall, 362 (91.7%) participants agreed that BSE is a good practice.

Knowledge and practice of clinical breast examination

Results for the knowledge and practice of CBE are presented in Table  5 . A total of 345 (87.3%) participants believed that CBE is a useful tool for detection of breast cancer, but only 95 (24.1%) had undergone CBE. Also, 273 (60.0%) respondents chose that a physician should do CBE, 131 (33.2%) believed that mammography should be used in CBE, and 190 (48.1%) agreed that the examination should be conducted at an interval of 1 year.

Knowledge and use of mammography

Overall, 368 (93.2%) participants had heard about mammography. A total of 287 (72.7%) participants agreed that mammography should be started at 40 years of age and 183 (46.3%) participants believed that mammography should be done every year. Seventy-four (18.7%) participants had undergone mammography (Table  6 ). Out of these 18.7% women, 59.5% were aged above 41 years while 40.5% were either less than or equal to 41 years of age.

Under reasons for not undergoing mammography, 104 (33.2%) participants responded that they were not old enough and 75 (24.0%) didn’t believe there was any reason to undergo mammography.

Knowledge and awareness play a vital role in early detection and optimal treatment of breast cancer. The knowledge level of healthcare professionals and their attitudes towards screening methods for breast cancer are important determinants of the practice of these methods by their patients. This study was, therefore, conducted to evaluate the knowledge, attitudes, and practices of breast cancer screening in the female healthcare workers at KFMC. Our cohort demonstrated especially poor knowledge on risk factors, signs and symptoms, and methods of diagnosis. The knowledge related to breast cancer in our cohort appears to be lesser than that found in some other studies [ 20 , 21 , 22 ]. Our results for attitudes of participants towards breast cancer screening were also discouraging, which could be due to lack of knowledge in this study population.

With regard to BSE, the results appeared positive with most participants being aware of the importance of BSE. Their knowledge related to BSE was also satisfactory. Also, almost 75% of the participants reported practicing BSE. This is much higher than the rate for BSE seen in some other studies [ 19 , 20 , 23 ]. This is very encouraging indeed and also a little surprising considering the low level of knowledge and attitude in this cohort. The usefulness of breast self-examination as an appropriate method for early breast cancer detection has been debated in the recent past. Whereas, WHO states that there is no evidence of the effect of screening through BSE, although BSE can empower women and it can be used to create awareness some organizations/countries recommend against BSE altogether (e.g. Dutch guidelines), while others still promote it (ACS, Medscape). In KSA, breast self-examination role is important in regions where mammography may not be offered due to socio-cultural reasons. Besides, statistics indicate that 90% of breast lumps are discovered by women themselves. One of the aspects of screening is that women in developing country settings are more aware of the BSE as the information regarding BSE is transmitted more frequently and is readily acceptable than mammography given the specific cultural norms in KSA. Women would prefer to undergo BSE in the privacy of their homes than to reach out to health care services for mammography, which is also embarrassing and uncomfortable procedure. Also, most of the participants in our study had heard of CBE and believed that it is a useful tool. However, only quarter of the participants had undergone CBE. The results were similar for mammography as well with most being aware of mammography as a screening tool but only a few opting for it. Another important reason for the lower number of participants undergoing screening, especially mammography, could be that it is usually recommended after the age of 40 years and the average age of this cohort was younger [ 24 ]. However, the low knowledge of breast cancer is of concern and needs to be addressed. Poorly informed healthcare staff could be a concerning barrier in increasing the awareness of general population. Several other studies have been conducted in the KSA to assess the knowledge and practices of breast cancer screening [ 19 , 20 , 21 , 22 , 25 , 26 , 27 ]. The results of these studies were similar with knowledge and attitudes of women towards breast cancer screening below expectation, thus, emphasizing the need for appropriate steps to spread awareness.

As regards to the practice of screening methods, results from studies conducted in other developing countries have not been very encouraging either. An important barrier in other countries is financial constraints [ 16 , 18 , 28 ]. However, this is not a concern in the KSA where healthcare facilities are provided free of cost. Optimal utilization of these services is what needs to be targeted. Thus, proper education of the healthcare staff as well as general population appears to be the single most crucial step required.

Also, reservations that women may have about screening also need to be addressed. Recently, a study ( N  = 816) was conducted by Abdel-Aziz et al. in the Al Hassa region of KSA to evaluate the perceived barriers for breast cancer screening. They found personal fears such as fear of physicians, fear of results, and fear of hospitals as the main barriers for not practicing screening for breast cancer [ 29 ]. Being healthcare professionals themselves, such fears were understandably less commonly seen in our cohort. Knowledgeable healthcare professionals with good communication skills and well-planned educational campaigns could make a difference in helping women overcome their fears and hesitations.

In a study ( N  = 500) conducted in five primary healthcare centers in Najran, Saudi Arabia, 57% of the study participants were unaware of mammogram and BSE and 44% were unaware of CBE [ 20 ]. Thus, lack of awareness of the methods of screening was an important barrier in the general population in this region of KSA. A quarter of the patients reported not receiving CBE due to unavailability of female doctors. Although this is another important aspect that needs to be addressed however clinical breast examination as method for breast cancer screening should be used only when mammography is unavailable as per the latest recommendations of the Ministry of health in Saudi Arabia [ 20 ]. Interestingly, very few participants in our study believed that women prefer female doctors for breast examination. This could be because women may not be able to openly express this reservation to the healthcare staff and therefore healthcare workers are not aware of this fact. Also, it has been found in studies that women who have frequent contact with their physician are more likely to undergo screening further emphasizing the crucial role of healthcare staff. All this implies that some factors affect the rate of breast cancer screening in any community. These include the knowledge and attitude of the healthcare workers themselves, the educational programs for the healthcare workers and for general public, the faith of the women on their clinicians, and the extent of barriers and steps taken to overcome them [ 29 ].

One limitation of our study is that it was conducted at one center. Nevertheless, this study provides important insights on the current knowledge and practices of screening methods in female healthcare workers and emphasizes the need for educational programs for the healthcare staff at KFMC. The results also urge other hospitals in the KSA to conduct similar studies to evaluate gaps in the knowledge, attitudes, and practices in their staff. Moreover, we recommend further studies to validate the questionnaire through analysis as the questionnaire was compiled after in-depth review of several articles in the field of study and more extensive studies to be conducted to draw comparison between the differences in health care and non health care workers knowledge and attitude towards screening and practices.

Overall, the knowledge, attitudes, and practices of the staff related to breast cancer at KFMC were found to be lower than expected. However, the study population had fairly good awareness of the availability and the usefulness of the screening methods. The results from this study, conducted on women healthcare professionals at KFMC, highlight the need for well-planned and comprehensive educational programs for the hospital staff.

Although, the screening tools and resources are available and free of charge in KSA however there is lack of active educational programs and campaigns directed at healthcare workers. Hence, inadequate knowledge about methods of breast cancer screening and their benefits among them could be the reason for lower than expected results of the study. In addition, a nationalized education and screening program in the region, combined with considerations for social and cultural factors needs to be functional.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the KFMC research center through the corresponding author on reasonable request.

Abbreviations

American Cancer Society

• Breast self-examination
• Clinical breast examination

Fine Needle Aspiration Cytology

Interquartile range

King Fahad Medical City

Kingdom of Saudi Arabia,

Standard deviation

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This work was supported by Intramural Research Fund (IRF No: 050–017) by Research Center at KFMC. The funding body was not involved in the design of the study; collection, analysis, and interpretation of data; and in writing the manuscript.

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Humariya Heena, Isamme AlFayyad & Amani Abu-Shaheen

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HH conceived, designed the study and drafted the manuscript, MR, IA, RT, GP helped in data collection, questionnaire development, data interpretation, data analysis and drafting the manuscript. SD, AA revised the manuscript, providing valuable intellectual content. All authors commented on and approved the final manuscript.

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Heena, H., Durrani, S., Riaz, M. et al. Knowledge, attitudes, and practices related to breast cancer screening among female health care professionals: a cross sectional study. BMC Women's Health 19 , 122 (2019). https://doi.org/10.1186/s12905-019-0819-x

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• Published: 18 May 2024

Disparities in quality of life among patients with breast cancer based on surgical methods: a cross-sectional prospective study

• Yi Wang 1 ,
• Yibo He 1 ,
• Shiyan Wu 1 &
• Shangnao Xie 1  

Scientific Reports volume  14 , Article number:  11364 ( 2024 ) Cite this article

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• Breast cancer
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To determine the impact of breast conservation on quality of life and identify treatment-related and other demographic factors associated with post-breast cancer treatment quality of life. A prospective study was conducted on 392 women who underwent breast cancer surgery at Hangzhou Cancer Hospital from January 1, 2013, to December 31, 2022. Operable breast cancer patients who had completed all treatments except endocrine therapy were included. Patients with tumor recurrence/metastasis, bilateral or male breast cancer, and other primary malignancies were excluded. After enrollment, patients were asked to complete the BREAST-Q scale, and their pathological and medical records were reviewed. Analysis of variance was used to compare the quality of life scores among the groups. Univariate and multivariate linear regression analyses were performed to identify independent factors associated with quality of life scores in different domains. Participants completed the BREAST-Q scale at a median of 4.6 years after surgery. Quality of life scores varied based on the therapeutic strategy. Breast conservation has significant advantages over mastectomy in terms of breast satisfaction, psychosocial, and sexual well-being. Compared to oncoplastic breast-conserving surgery, mastectomy was independently associated with decreased breast satisfaction, psychosocial, and sexual well-being, while conventional breast-conserving surgery showed comparable outcomes to oncoplastic breast-conserving surgery in terms of these factors. Breast conservation leads to an improvement in quality of life compared to mastectomy. Oncoplastic breast-conserving surgery does not lead to a decrease in quality of life compared to conventional breast-conserving surgery and offers better outcomes compared to mastectomy.

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Introduction.

Breast cancer is a prevalent global malignancy 1 , and breast-conserving surgery (BCS) with adjuvant radiotherapy (RT) is a well-established treatment for early-stage breast cancer 2 , 3 . However, up to 30% of BCS recipients express dissatisfaction with their postoperative appearance, necessitating corrective interventions 4 . In the 1980s, European surgeons introduced "oncoplastic breast-conserving surgery" (OBCS), which incorporates plastic surgery techniques for post-BCS breast defect reconstruction 5 .

While OBCS offers satisfactory long-term oncological results and broadens treatment possibilities for patients who would typically undergo mastectomies 6 , it involves more extensive incisions, additional tissue manipulation, and potential flap reconstruction in comparison to conventional breast-conserving surgery (cBCS) 7 , 8 . The procedures involved in OBCS are more complex, time-consuming, and costly. Given these complexities, is it still worthwhile to pursue breast conservation by OBCS? Some researchers have proposed whether the use of OBCS should be reduced 9 .

Understanding the impact on the quality of life of breast cancer survivors is crucial given its significant influence on medical decision-making 10 , 11 . Despite the widespread utilization of OBCS to conserve the breast and enhance its aesthetics, research on its impact on quality of life is limited and complicated due to the variability of surgical approaches. Consequently, this study aimed to assess the effect of breast conservation by OBCS on the quality of life of patients with operable breast cancer treated at Hangzhou Cancer Hospital from January 1, 2013, to December 31, 2022, and to elucidate the treatment and demographic factors associated with postoperative quality of life.

Materials and methods

This prospective, cross-sectional, case–control study was conducted at a single center. The inclusion criteria were operable breast cancer patients treated at Hangzhou Cancer Hospital between January 1, 2013, and December 31, 2022, who had completed all treatments except endocrine therapy and provided participation consent. The exclusion criteria were patients with tumor recurrence/metastasis, bilateral or male breast cancer, or other primary malignancies. Participants were categorized into two groups: BCS group (cBCS with RT subgroup and OBCS with RT subgroup), and unilateral MAST group (MAST with RT subgroup and MAST without RT subgroup). This study utilized the BREAST-Q scale 12 , which includes separate modules for BCS and MAST without reconstruction. The BCS module was used for the OBCS with RT subgroup because OBCS in this study predominantly referred to oncoplastic lumpectomy/glandular remodeling. BREAST-Q assesses six distinct domains: satisfaction with breasts, psychosocial well-being, physical well-being, sexual well-being, satisfaction with overall outcome, and satisfaction with care. Due to the elapsed time between surgery and questionnaire completion in this study, the domains of satisfaction with the overall outcome and satisfaction with care were excluded. Each domain was scored on a scale from 0 to 100, with higher scores indicating an enhanced quality of life. Differences in BREAST-Q scores were categorized as small (2–3 points), moderate (4–7 points), and large (8–10 points) 13 . Patient characteristics, collected using the questionnaire, included employment status, educational level, marital status, and economic status. Patients’ medical and pathological records were reviewed to determine the disease tumor, node, and metastasis (TNM) staging 14 , erythroblastic oncogene B (ERBB2; formerly HER2/neu or HER2) status, hormone receptor status, and body mass index (BMI). Information on surgery, chemotherapy (yes/no), RT, and endocrine therapy (yes/no) was obtained using a questionnaire in conjunction with medical records. The lymphedema status (yes/no) was assessed using the questionnaire's question regarding arm swelling. This study was approved by the Ethics Committee of Hangzhou Cancer Hospital, and all participants provided written informed consent. The study was performed in accordance with the Declaration of Helsinki and followed the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) reporting guidelines.

Statistical analysis

The experimental data were statistically analyzed using SPSS (version 29.0) software, and categorical covariates were expressed as numbers (percentages). Analysis of variance (ANOVA) was used to compare quality of life scores among the different groups. Univariate and multivariate linear regression analyses were used to determine the independent factors associated with the quality of life scores in each domain. Variables with two-tailed P  ≤ 0.15 in the univariate analysis were included in the multivariate analysis model using a stepwise method to establish the final multivariate model. Differences with P  < 0.05 were considered statistically significant.

Ethics approval and consent to participate

This study was reviewed and approved by the ethics committee of Hangzhou Cancer Hospital (approval number: [hzch-2023] HS no.007). Written informed consent was obtained from every patient.

Patient enrollment

After screening, 623 eligible patients were invited, 456 provided written informed consent and completed the survey, but three were found to not meet the inclusion criteria after enrollment. After excluding 61 participants who only completed a brief questionnaire, a total of 392 patients’ data were included in the statistical analysis.

Patient, disease, and treatment characteristics

The interval between surgery and scale completion averaged 4.6 years (range: 0.33 to 9.83 years). Patient characteristics are detailed in Table 1 . Majority were married, employed, had moderate economic status (income ¥30,000–200,000 per year), and high school or higher education. At surgery, 324 (82.7%) patients had a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) within the normal range (18.5 to 23.9 kg/m 2 ), and 56 (14.3%) patients had a BMI of 24 kg/m 2 or above. Among the patients, 39 (9.9%) had stage 0 breast cancer, 154 (39.3%) had stage I breast cancer, 158 (40.3%) had stage II breast cancer, and 41 (10.5%) had stage III breast cancer. The lesions on imaging before surgery of 253 (64.5%) patients measured two centimeters or less, 134 (34.2%) two to five centimeters, and 5 (1.3%) more than five centimeters. Chemotherapy was administered to 293 (74.7%) patients, with 121(30.9%) receiving neoadjuvant chemotherapy, and 273 (69.6%) patients received hormone therapy.

Treatment details including surgery, RT, and lymphedema are presented in Table 1 . Among the patients, 88 (22.4%) underwent OBCS, 51 (13.0%) underwent cBCS, and 253 (64.5%) underwent unilateral MAST, among which 100 (25.5%) patients who underwent unilateral MAST received postoperative RT. All patients underwent axillary surgery, with 255 (65.1%) patients undergoing sentinel lymph node biopsy only and 137 (34.9%) patients undergoing axillary lymph node dissection. 61 (15.6%) patients reported having lymphedema.

BREAST-Q results by breast surgery strategy

Figure  1 illustrates unadjusted mean BREAST-Q scores by breast surgery strategy. Satisfaction with breasts, psychosocial well-being and sexual well-being were significantly different among the groups ( P  < 0.001). BCS group showed higher scores in satisfaction with breasts (61.70), psychosocial well-being (76.01), physical well-being (83.52) and sexual well-being (55.06), while the scores for MAST group is lower (satisfaction with breasts: 57.30, psychosocial well-being: 70.83, physical well-being: 82.40 and sexual well-being: 49.21).

Unadjusted BREAST-Q mean scores by breast surgery strategy. BCS: breast-conserving surgery; MAST: mastectomy.

Satisfaction with breasts

Higher scores in satisfaction with breasts correlated independently with age ≥ 60 (β = 4.662; 95% CI = 2.345 to 6.979; P  < 0.001) and patient-reported income ≥ 200,000 (β = 5.068; 95% CI = 2.781 to 7.356; P  < 0.001). Lower scores were associated with BMI ≥ 24 (β = − 2.528; 95% CI = − 4.977 to − 0.079; P  = 0.043), axillary dissection (β = − 4.875; 95% CI = − 6.704 to − 3.046; P  < 0.001) and MAST (β = − 3.927; 95% CI = − 5.741 to − 2.113; P  < 0.001) (Fig.  2 A). Patient-reported income < 30,000 and lymphedema showed significance only in univariate analysis. Other factors exhibited no significant association.

Patient and treatment factors associated with breast satisfaction ( A ), psychosocial well-being ( B ), physical well-being ( C ) and sexual well-being ( D ) scores by breast surgery strategy. MAST: mastectomy; BCS: breast-conserving surgery; BMI: body mass index; CI: confidence interval.

Psychosocial well-being

Better psychosocial well-being correlated with age ≥ 60 (β = 2.564; 95% CI = 0.163 to 4.965; P  = 0.036), patient-reported income ≥ 200,000 (β = 4.820; 95% CI = 2.496 to 7.144; P  < 0.001), and ≥ 5y from surgery (β = 2.419; 95% CI = 0.523 to 4.315; P  = 0.013). Poor psychosocial well-being was linked to age < 35 (β = − 3.892; 95% CI = − 7.715 to − 0.069; P  = 0.046), BMI ≥ 24 (β = − 3.352; 95% CI = − 5.845 to − 0.859; P  = 0.009), patient-reported income < 30,000 (β = − 4.489; 95% CI = − 7.317 to − 1.660; P  = 0.002), axillary dissection (β = − 5.898; 95% CI = − 7.739 to − 4.058; P  < 0.001) and MAST (β = − 5.157; 95% CI = − 7.032 to − 3.283; P  < 0.001) (Fig.  2 B). Chemotherapy was only significant in univariate analysis. Other variables showed no significant association.

Physical well-being

Factors associated with better physical well-being were age ≥ 60 (β = 3.594; 95% CI = 1.554 to 5.634; P  = 0.001), patient-reported income ≥ 200,000 (β = 4.541; 95% CI = 2.559 to 6.524; P  < 0.001), and ≥ 5y from surgery (β = 2.311; 95% CI = 0.714 to 3.907; P  = 0.005). Conversely, patient-reported income < 30,000 (β = − 5.924; 95% CI = − 8.351 to − 3.497; P  < 0.001), axillary dissection (β = − 2.486; 95% CI = − 4.057 to − 0.914; P  = 0.002) and lymphedema (β = − 2.185; 95% CI = − 4.275 to − 0.094; P  = 0.041) were associated with poorer physical well-being (Fig.  2 C). < 1y from surgery was only significant in univariate analysis. Other factors lacked significant association.

Sexual well-being

Multivariate analysis indicated lower sexual well-being scores with BMI ≥ 24 (β = − 2.887; 95% CI = − 4.831 to − 0.943; P  = 0.004), < 1y from surgery (β = − 3.482; 95% CI = − 5.887 to − 1.077; P  = 0.005), axillary dissection (β = − 3.002; 95% CI = − 4.437 to − 1.567; P  < 0.001), and MAST (β = − 5.650; 95% CI = − 7.114 to − 4.187; P  < 0.001). Patient-reported income ≥ 200,000 (β = 2.272; 95% CI = 0.441 to 4.104; P  = 0.015) correlated with elevated sexual well-being (Fig.  2 D). Lymphedema was significant in univariate analysis. Other variables exhibited no significant correlation.

BREAST-Q results by local therapy strategy

To assess if there were enhancements in quality of life among women who underwent OBCS, we performed similar analyses among the subgroups. Figure  3 illustrates unadjusted mean BREAST-Q scores by local therapy strategy. All four domains were significantly different ( P  < 0.05). OBCS with RT group showed highest scores in satisfaction with breasts (61.99), psychosocial well-being (76.27) and sexual well-being (55.53). cBCS with RT group yielded the highest physical well-being score (84.10). The lowest domain scores were in MAST with RT group (satisfaction with breasts: 53.11, psychosocial well-being: 65.49, physical well-being: 79.89 and sexual well-being: 46.24).

Unadjusted BREAST-Q mean scores by local therapy strategy. RT: radiotherapy; cBCS: conventional breast-conserving surgery; OBCS: oncoplastic breast-conserving surgery; MAST: mastectomy.

Multivariate analysis indicated that MAST with RT was associated with poor breast satisfaction (β = − 8.381; 95% CI = − 10.858 to − 5.905; P  < 0.001), psychosocial well-being (β = − 11.491; 95% CI = − 14.039 to − 8.943; P  < 0.001), physical well-being (β = − 3.607; 95% CI = − 5.782 to − 1.432; P  = 0.001) and sexual well-being (β = − 9.493; 95% CI = − 11.454 to − 7.533; P  < 0.001). MAST without RT was associated with decreased breast satisfaction (β = − 2.536; 95% CI = − 4.817 to − 0.255; P  = 0.029), psychosocial well-being (β = − 3.171; 95% CI = − 5.487 to − 0.855; P  = 0.007) and sexual well-being (β = − 4.739; 95% CI = − 6.530 to − 2.947; P  < 0.001). cBCS with RT was not associated with BREAST-Q scores on univariate or multivariate analysis. The statistically significant factors correlated with BREAST-Q scores were mostly consistent with the outcomes of the breast surgery models (Fig.  4 ).

Patient and treatment factors associated with breast satisfaction ( A ), psychosocial well-being ( B ), physical well-being ( C ) and sexual well-being ( D ) scores by local therapy strategy. cBCS: conventional breast-conserving surgery; OBCS: oncoplastic breast-conserving surgery; MAST: mastectomy; RT: radiotherapy; BMI: body mass index; CI: confidence interval.

The rates of BCS and breast reconstruction after mastectomy are significantly lower in China than in Western countries 15 . One contributing factor is that Chinese women typically have smaller breast sizes than women in Western countries, while presenting with larger breast tumor volumes at the time of initial diagnosis, making BCS challenging. Additionally, some Chinese patients adhere to outdated beliefs and have concerns about potential impacts on treatment outcomes or cancer recurrence associated with BCS. OBCS provides acceptable long-term oncological outcomes and has extended treatment options for patients who would traditionally be candidates for mastectomies 6 . In recent years, there has been a clear change in the emphasis of surgical oncology in China, with a growing emphasis on utilizing modern oncoplastic surgical techniques to perform more breast conserving surgeries. Given the increasing prevalence of OBCS, it is essential to examine its impact on quality of life.

In this single-center prospective study, discernible disparities in quality of life surfaced among patients with breast cancer undergoing various local treatment strategies within ten years of surgery. Patients opting for more extensive surgery, particularly when combined with RT, experienced diminished quality of life; satisfaction with breasts; and psychosocial, physical, and sexual well-being. This aligns with findings from prior studies. Engel et al.’s study 16 has shown that patients undergoing BCS reports a higher quality of life compared to those opting for mastectomy. This improvement is often linked to the conservation of the breast and the associated psychological advantages. BCS enables breast conservation, leading to enhanced body image and self-esteem. Patients undergoing BCS may experience less psychological distress and enjoy better psychosocial well-being due to breast conservation. Additionally, BCS has a lesser impact on sexual well-being in comparison to mastectomy, as it retains natural breast tissue.

This study’s findings concur with those of Otsuka et al.’s study 17 in that oncoplastic surgery improved satisfaction with breasts. However, in Otsuka et al.’s study, the quality of life score was not elevated by OBCS (major breast surgery: 154.5 ± 24.6; minor breast surgery: 159.0 ± 20.8; OBCS: 158.7 ± 14.0). Although differences exist between major breast surgery and OBCS, the difference is not pronounced. In the present study, psychosocial and sexual well-being scores were elevated compared to MAST. Additionally, patients who underwent OBCS had better physical well-being scores than those who underwent MAST with RT and equal physical well-being scores than those who underwent MAST without RT. This may be attributable to the omission of RT, reduced chemotherapy and lymphedema in the MAST without RT group. Previous studies 18 , 19 have highlighted RT, chemotherapy, and lymphedema as adverse determinants of quality of life.

Rose et al. 20 suggested that patients who underwent OBCS showed significant improvement in the “psychosocial well-being” module compared to cBCS, while no significant differences were observed between the two groups in the “physical health,” “breast satisfaction,” and “sexual health” modules. Furthermore, a meta-analysis 21 indicated improved quality of life with OBCS compared with cBCS in patients with early-stage breast cancer, with better physical and psychological well-being, higher self-esteem, and a more stable body image, leading to improved social and emotional functioning. However, the clinical studies included in the meta-analysis were predominantly small- sample studies from single centers, and the surgical approaches varied. This study identified no significant differences in any of the quality of life modules between the patients who underwent OBCS and those who underwent cBCS, which is consistent with the findings of de Oliveira-Junior et al 22 . This may be because the present study’s follow-up time was longer, and several aspects of OBCS will decline over time 23 . In our study, the tumor lesion on imaging before surgery averaged 2.11 ± 0.67 cm in OBCS subgroup, and 1.62 ± 0.52 cm in cBCS subgroup. Smaller lesions are more likely to undergo cBCS, resulting in comparable cosmetic outcomes between the two surgical groups. Moreover, the limited number of BCS patients in our study is a significant factor that limits the ability to detect differences in quality of life between OBCS and cBCS subgroups.

In addition to the type of surgery, other clinical factors such as BMI (≥ 24), income (< 30,000), < 1y from surgery, axillary dissection, and lymphedema were negatively correlated with quality of life. Identifying these risk factors can facilitate early postoperative intervention and ultimately improve the postoperative quality of life of patients with breast cancer. Age (≥ 60) and ≥ 5y from surgery were associated with enhanced quality of life. Breast cancer patients can experience significant effects from the disease itself and the ongoing adjuvant therapies, both after diagnosis and during the treatment process 24 . These are all factors that lead to decreased quality of life within 5 years, especially within 1 year, rather than ≥ 5y after surgery. Moreover, good economic status was associated with better satisfaction with breasts, and psychosocial, physical, and sexual well-being. Patients with improved financial circumstances can access higher-quality healthcare services, opt for more expensive treatment options that may improve aesthetic outcomes. The financial advantage also affords patients more opportunities for supportive care, counseling, and resources to manage the challenges of breast cancer treatment and recovery, resulting in a decrease in stress, anxiety, and depression. These enhancements can have a positive impact on patients’ self-perception, confidence, and overall satisfaction with their breast appearance, all of which are closely connected to sexual health and intimacy. Notably, other studies 25 , 26 found an association between economic status and quality of life.

This study has some limitations. It was a cross-sectional, single-time, survey-based prospective study; therefore, the baseline quality of life of patients before surgery was not recorded, which may have influenced their choice of surgical approach and postoperative quality of life. Additionally, this study did not identify patients who chose MAST due to refusal of BCS; patients who selected MAST based on personal preferences may have different quality-of-life scores. Furthermore, this study did not include patients with postmastectomy breast reconstructions, which may improve quality of life of postmastectomy patients. Finally, given that this was a single-center small-sample study, studies with larger sample sizes are required to further confirm the findings of this study. Nevertheless, patient-reported questionnaires can provide basic information on quality of life and assist in identifying potential areas requiring intervention during the patient’s survival period.

OBCS is an acceptable option for patients with larger tumors who are not suitable for cBCS because it allows them to conserve their breasts 6 . This study demonstrated that patients who had their breast conserved reported a higher quality of life compared to mastectomy patients. Despite extensive incisions, additional tissue manipulation, and potential flap reconstruction, patients who underwent OBCS did not report a lower quality of life than those who underwent cBCS. Furthermore, they experienced significantly enhanced quality of life compared with patients who underwent MAST, particularly in the domains of satisfaction with breasts, psychosocial well-being, and sexual well-being. Quality of life data should be incorporated into decision support tools to assist patients with breast cancer in selecting the surgical approach, and discussions with patients should include information regarding quality of life to ensure that they understand the long-term impacts of different surgical approaches. This is particularly crucial because most patients with breast cancer have an extended postoperative survival period. Our data can support further improvements in Chinese breast surgical care for better survival and quality of life.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to Chinese law but are available from the corresponding author on reasonable request.

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Yi Wang, Yibo He, Shiyan Wu & Shangnao Xie

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Wang, Y., He, Y., Wu, S. et al. Disparities in quality of life among patients with breast cancer based on surgical methods: a cross-sectional prospective study. Sci Rep 14 , 11364 (2024). https://doi.org/10.1038/s41598-024-62105-z

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Evaluation of knowledge, awareness and attitudes towards breast cancer risk factors and early detection among females in Bangladesh: A hospital based cross-sectional study

Nur e. alam.

1 Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh

Md. Shariful Islam

2 Department of Biology, University of Kentucky, Lexington, Kentucky, United States of America

Hedayet Ullah

Md. tarek molla, siratul kubra shifat, sumaiya akter, salma aktar, mst. mahmuda khatun.

3 Department of Biochemistry and Molecular Biology, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh

Md. Rayhan Ali

Tapon chandra sen, kamal chowdhury.

4 Department of Biology, Claflin University, Orangeburg, South Carolina, United States of America

Rehana Pervin

5 Department of Gynaecology and Obstetrics, Tangail Medical College, Tangail, Bangladesh

A. K. M. Mohiuddin

Associated data.

All relevant data are within the manuscript and its Supporting Information files.

Breast cancer (BCa) is a leading cause of mortality among women in Bangladesh. Many young women in Bangladesh have poor knowledge about breast cancer screening, including risk factors, warning signs/symptoms, diagnosis and early detection. We investigated awareness about breast cancer risk factors as a screening tool among women at the Sheikh Hasina Medical College (SHMC) of Tangail district in Bangladesh.

A cross sectional survey was conducted to collect data via a structured questionnaire from SHMC during the period of February to December 2019. A total of 1,007 participants (aged 33.47 (±12.37 years)) was considered for data analysis.

Of the 1,007 women, about 50% were knowledgeable about the risk factors. Pain in the breast was identified as the most commonly warning sign/symptom of breast cancer. Only 32.2% of respondents knew at least one breast cancer screening method. The mean knowledge was scored 3.43 ± 2.25 out of a total possible score of 8. Awareness of BCa was associated with residence, family history of breast cancer, marital, literacy and socio-economic status ( p <0.05). Only 14.7% of women who knew about BSE said they were conducting regular breast self-examination. Unmarried women (aOR: 2.971; 95% CI: 1.108–7.968) were more likely to have performed BSE compared to married women ( p <0.05).

Although most participants were aware of breast cancer; knowledge about risk factors, warning signs/symptoms, early diagnosis and detection was relatively poor. Knowledge about performing BSE was particularly low. This highlights the importance of increasing awareness about breast cancer risk factors and early detection among young women in Bangladesh.

Introduction

Breast cancer (BCa) is the most common malignancy that seems to frequently occur with the highest fatality rates in women worldwide [ 1 ]. The incidence, morbidity, and mortality rate of breast cancer has been increased in both high and low-resource settings due to the increased life expectancy, urbanization and adoption of western lifestyles [ 2 ]. According to global cancer statistics report in 2020, female breast cancer was recognized as the leading cause of global cancer incidence. It has been estimated that about 2.3 million new breast cancer cases were diagnosed, representing about 11.7% of all new cancer cases worldwide [ 3 ]. According to the World Health Organization (WHO), an estimated 685,000 females died because of breast cancer in 2020 [ 4 ].

Breast cancer becomes epidemic in South Asian countries as the incidence and mortality rate are increasing in a dramatic way. Around 588 million women over 15 years of aged face a rising breast cancer epidemic in these countries. In India, around 100,000 women with breast cancer are diagnosed annually [ 5 ] and the mortality rate was 21.5% [ 6 ]. In Pakistan 34,066 women were diagnosed in 2018 [ 7 ] and the breast cancer mortality rate was 26.76% [ 8 ].

Bangladesh is a small and the seventh (nearly 160 million people) most populous country in the world [ 9 ]. Recently, the prevalence of breast cancer increasing tremendously but there is no national central cancer registry that can provide the complete nationwide data. Therefore, the actual incidence and mortality of breast cancer is mostly unknown. However, based on cancer registry report 2015–2017 of the National Institute of Cancer Research and Hospital (NICRH), 4930 new breast cancer cases were registered during this period [ 10 ]. According to GLOBOCAN, 13,028 new breast cancer cases were diagnosed in 2020, with an age-standardized incidence rate (ASR) of 17 per 100,000 [ 11 ]. A report based on the NICRH, the mean age was 41.8 years for the breast cancer patients, maximum (> 56%) cases were among reproductive age women. This presents a higher extent of premenopausal cases and among the patients around 90% are diagnosed at stage III–IV [ 12 ]. It might be due to lower preference for the treatment compared to younger family members as only one doctor serves approximately 3,300 people in urban areas and more than 15,000 people in rural areas [ 13 ]. Another issue is the socio-cultural factors that contribute to delay in seeking treatment because of breast cancer is a topic that is not freely discussed in public. Besides, scarcity of proper knowledge, low education and ignorance among women are also the major causes behind late detection of breast cancer [ 14 ].

The knowledge of risk factors and the early detection methods of breast cancer can successfully reduce the mortality rates and improve the patients’ prognosis. In Bangladesh, Breast self-examination (BSE) could be performed as an effective way for early detection as BSE is simple, inexpensive and more importantly can be carried out by the women themselves in houses [ 15 ]. According to the Breast Health Global Initiative (BHGI) reports, if females have adequate knowledge and awareness of breast cancer self-examination (BSE), the disease could be diagnosed at an early stage as well as could be easier to manage the disease [ 16 ].

To date, knowledge about breast cancer risk factors, early diagnosis and detection methods has not been assessed among the female population in Tangail district, Bangladesh. Therefore, a hospital-based survey was carried out to explore the scenario of knowledge, awareness and treatment about breast cancer among females in Tangail district of Bangladesh.

This cross-sectional study was carried out among 1,100 women in Sheikh Hasina Medical College, Tangail, Bangladesh in the period of February 2019 to December 2019. The respondents were given an explanation of the objectives and benefits of the study. Before the interview, verbal consent was taken from the respondents according to the WHO and Bangladesh Medical Research Council (BMRC) guidelines of ethical consideration. Respondent’s right to refuse and withdraw from study any time was accepted. Confidentiality of the respondents was strictly maintained. As a part of the population-based program, the women’s knowledge, awareness and attitude levels about different aspects of BCa including risk factors, early warning signs, practicing early detection methods, and therapeutic approaches were evaluated in this study.

Respondents

Participants’ age ranged from 15–75 years with a mean of 33.47 (±12.37) years. Majority (87.8%) of them resided in villages. About 79.3% of participants were married and 73.6% had no formal/primary/secondary education. The majority (88.3%) were Muslims and 55.8% belonged to middle class families ( Table 1 ).

Literacy status: Others* include primary/secondary/no formal education.

Questionnaire content

Data were collected via a structured questionnaire for this study which was derived from the literature review of the previous peer-reviewed published studies [ 17 – 20 ]. The study questionnaire was first developed in English and translated into Bengali after which translation accuracy was verified by an independent bilingual translator.

The questionnaire was divided into four distinct sections; each one documented with appropriate heading indicating its content. First section contained sociodemographic variables such as marital status, age, literacy, living place, socio-economic status. Second section contained questions about breast cancer’s knowledge. Third and fourth section contained practice status of early detection methods and participants’ risk of breast cancer, respectively.

A knowledge score was calculated by summing the responses for each participant. They were given two points for any two correct responses for each of the four areas. These are: risk factor (such as menarche earlier than normal age, diet and diet related factors, hormones and reproductive factors, and benign breast disease) symptoms (pain in the breast, painless lump in the breast and bloody nipple discharge), early screening methods (such as breast self-examination, clinical breast examination and mammography) and were given two points for any one of the correct responses of treatment associated with breast cancer. The total score ranged between 0 and 8. A total score of 0 to 4 were categorized as insufficient knowledge and a score greater than 4 were considered as sufficient knowledge.

Cronbach’s Alpha was used to assess the reliability coefficient which is a measure of the internal consistency of the questionnaire. The Cronbach’s alpha coefficient was 0.830 for the questionnaire where the value >0.7 is considered acceptable [ 21 ].

Statistical analysis

All the data collected from the survey was entered and analyzed using Statistical packages for social sciences (SPSS) version 20 statistical software. Frequencies, percentages, tables, flow chart were used to describe study variables. Multivariable logistic regression models were generated to assess factors associated with “Performing BSE”. Adjusted odds ratios (aORs) and its 95% confidence intervals (CIs) were estimated. The following variables were adjusted for in the models: marital status, living place, education, socio-economic status and have family history of breast cancer. Collinearity was assessed using the variance inflation factor (VIF) to ensure a strong linear relationship among independent variables included in the model was not present. The goodness of fit of the model was checked using the Hosmer Lemeshow (H-L) test. One-way ANOVA was performed to assess the association between the demographic variables and participants’ overall knowledge of breast cancer. A p -value less than 0.05 was considered to be significant.

Ethical consideration

This study was conducted in accordance with the Declaration of Helsinki. Ethics approval was approved by the Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Tangail-1902, Bangladesh (Ref: MBSTU/BGE(Research project(87)/2009(106) Date:29-01-2019). Written permission was also obtained from the Department of Gynecology and Obstetrics, Sheikh Hasina Medical College, Tangail-1900, Bangladesh.

Knowledge and awareness about breast cancer and practice of early detection

All of the participants (1007) were familiar with breast cancer. Half of the participants (50%) have knowledge about risk factors of BCa. Menarche earlier than normal age, diet and diet related factors, hormones and reproductive factors, and benign breast disease were mentioned by 23.3%, 19.1%, 16.8% and 15.5% of participants, respectively ( Table 2 ). Like the risk factors, participants were also asked to list at least one symptom of breast cancer had known of or they had heard of. About 30.5% of respondents were aware of that pain in the breast was a major symptom of breast cancer. However, knowledge of other symptoms was generally poor; merely 18.4%, 17.8% and 16.7%, recognized itching, painless lump in the breast and bloody nipple discharge as signs of breast cancer ( Fig 1 ). Majority of the respondents were not aware about other signs of breast cancer like nipple retraction, discoloration of nipple skin, change in breast size, rash around one of the nipples.

About 32.2% of respondents knew of at least one method of screening for breast cancer including 19.7% knew about breast self-examination (BSE), 12.1% and 5.9% have heard of clinical breast examination (CBE) and mammography. In terms of practice or performing early detection, only 14.7% of women who knew about BSE said they performed it at least once a month. Of those who had heard of CBE and mammography, 87.7% and 91.5% had not received a clinical breast examination or never had received a mammogram ( Fig 1 ).

Participants risk for breast cancer

Family history of breast cancer was reported by 166 (16.5%) of the respondents while 7.4% reported that their first-degree relatives (mother, sister) had breast cancer. In addition, 14 (1.4%) of the women have benign breast disease and 9 (0.9%) had performed hormone replacement therapy which may lead to breast cancer ( Fig 2 ).

Factors associated with knowledge and screening of breast cancer

Table 3 presents factors that may have an impact on acquiring satisfactory knowledge about breast cancer. Among all respondents, 287 (28.5%) had sufficient knowledge of breast cancer. Out of a total possible score of 8, the mean knowledge score was poor (3.43 ± 2.254). Women with a university-level education have better knowledge scores than the women from other education levels. However, women’s knowledge score on breast cancer varied significantly by all the variables except religion ( p < 0.05).

Bold shows factors that were significant.

From the multivariable analysis, unmarried women (adjusted odds ratio [aOR]: 2.971; 95% confidence interval [CI]: 1.108–7.968) were more likely to perform BSE compared to married women. We found a significant association between performing BSE and marital status of the women ( p = 0.031). Women who had primary/secondary/no-formal education (aOR: 0.246; 95% CI: 0.075–0.806) were less likely to have performed BSE. Moreover, middle economic respondents were more likely to perform BSE compared to low and high economic respondents but there was no statistical significance found. The H–L p value for the model was 0.196 ( Table 4 ).

This hospital-based study was carried out to determine and assess the knowledge and attitude of breast cancer among females in Bangladesh. Awareness of breast cancer, knowledge, attitudes and regular practice of BSE promote early detection of breast cancer, which improves the chances of survival and better health outcomes. Very few studies have investigated knowledge about breast cancer risk factors and early detection methods among females in Bangladesh, and this is the first study conducted among the general female patients at the Sheikh Hasina Medical College and Hospital of Tangail. Our study provides useful insights to help address this knowledge gap.

In terms of associated risk factors for breast cancer, Half (50%) of the participants had knowledge about risk factors of breast cancer. About 29% of participants claimed that gender (being a woman) was a risk factor for breast cancer followed by menarche earlier than normal age as mentioned by 23.3% of participants. This finding was consistent with a study conducted in Dhaka; Bangladesh that showed 37.5% respondents were aware about breast cancer risk [ 22 ]. In contrast to ours, some previous studies reported personal and family history of breast cancer as the most widely known risk factors [ 2 , 23 – 25 ].

In this study, pain in the breast (30.5%) was reported as the major symptoms of breast cancer by women which indicated that women had inadequate knowledge about breast cancer symptoms. This is consistent with a study conducted in Toronto where 72% of Iranian immigrant women erroneously associated breast pain with early breast cancer [ 26 ]. For instance, only a small percentage of women knew that painless breast lump (17.8%) and bloody discharge in nipple (16.7%) as signs of breast cancer that was reported the major symptoms in previous studies performed in different developing countries [ 15 , 27 , 28 ]. However, in our study other signs of breast cancer like nipple retraction, discoloration of nipple skin, and change in breast size were not recognized by the majority of the women. Similar findings were reported in previous studies from Malaysia showed inadequate knowledge about nipple retraction, discoloration of nipple, breast skin retraction [ 29 , 30 ].

Our study revealed that 16.5% of the respondents had family history of breast cancer while 7.4% reported that their closest relatives (mother, sister) had breast cancer, suggesting a high perceived risk of breast cancer. This study findings were similar to other studies conducted in Bangladesh, Germany, and Saudi Arabia [ 22 , 31 , 32 ] where 10–25% had at least family members with breast cancer.

In terms of knowledge and attitudes related to breast cancer screening, about one-third of the participants (32.2%) knew about a breast cancer screening method which was lower than a study conducted in Bangladesh that reported 64.2% of participants were aware of the screening methods [ 18 ]. Only 19.7% women knew about BSE which is the easiest detection method of breast cancer. The participants who knew about BSE; they (14.7%) hardly practiced it. A recent study from Bangladesh reported that, only 2% respondents mentioned that they were regularly practicing BSE. In addition, it has been reported that, regarding the knowledge about risk factor of breast cancer, 65% respondents have no idea about the risk of breast cancer, where 32% mentioned few risk factors which have relation with breast cancer and 3% respondents did not mention anything [ 33 ]. The study findings were consistent with other studies carried out in Sri Lanka [ 34 ], Saudi Arabia [ 35 ], Nigeria [ 28 ] and Ghana [ 36 ]. In the current study, the majority of participants who had heard of CBE and mammography reported lower rates of receiving mammograms and clinical breast exams compared with other Asian studies in Turkey, Singapore, and Malaysia [ 37 – 39 ]. From this study finding, the low level of knowledge and practice of breast cancer screening may be one of the main reasons for late presentation of breast cancer among women in Bangladesh.

The results also indicated that the awareness and understanding of breast cancer is associated with educational level, residence, economic status and family history of breast cancer. Unmarried women with high education level and high annual family income tend to be more aware of breast cancer. The practice level for early detection of breast cancer was very low among women which might be due to most of them have no breast cancer symptoms [ 18 ].

This study had some limitations that should be considered. The selection of respondents in this study was based on convenience sampling; therefore, our study sample may not be representative of all female population in the Tangail district of Bangladesh. In addition, our findings cannot be generalized to all female patients of Sheikh Hasina Medical College or more widely to others hospitals elsewhere, because potential participants did not have a random chance of being selected. As the survey questionnaire based on multiple choice, it is possible that some respondents might provide socially desirable responses to some questions.

The following initiatives may be useful to prevent and minimize the breast cancer mortality in Bangladesh: Early stage of diagnosis; Using data mining technology to develop risk prediction score software and apps to visualize the risk factor score early; Performing various community campaigns; Preparing nationwide cancer registry report annually and finally Carrying out region-wise epidemiology-based study on a regular basis [ 40 ].

Though this study didn’t cover the whole country, it represents the exact scenario of Bangladeshi women. It is evident that some factors such as education, residential area, and socio-economic status are the main obstacles of being aware about breast cancer. In rural area Bangladeshi women are not getting proper formal education and diagnostic or health care facilities. Lacking of knowledge and awareness about breast cancer along with unavailable diagnostic and treatment facilities are the major reason for breast cancer-related death. This is high time to turn the table by frequently organizing educational programs on breast cancer awareness throughout rural and urban areas. Surely, awareness would lead to early detection and diagnosis, therefore, will improve the odds of survival and cure with simpler and more cost-effective treatment.

Supporting information

Acknowledgments.

The authors are grateful to all survey participants for their involvement. Special thanks to Mashfiqul Huq Chowdhury, Associate Professor, Department of Statistics, Mawlana Bhashani Science and Technology University for statistical analysis support.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

Mammogram guideline sparks debate among breast cancer experts

Dr. Cindy Lee, chief of breast imaging at Stony Brook Medicine, believes many women should have annual mammograms to screen for breast cancer. Credit: Stony Brook Medicine /Jeanne Neville

Health experts agree that mammograms can save lives, but they don’t always agree on how often women should get the breast cancer screening procedure or when they should start.

The U.S. Preventive Services Task Force , an influential panel of national experts, drew praise from advocates when it recently dropped the recommended age for most women to get mammograms to 40 from 50. But it also advised mammograms every other year instead of annually — a move that left some doctors frustrated and many patients confused.

The American Cancer Society , for example, recommends women have the option of starting annual screenings at age 40 but says they should start receiving annual mammograms at 45. 

“It’s creating a huge amount of confusion among my patients and the practicing primary care physicians sending patients to me,” said Dr. Cindy Lee, chief of breast imaging at Stony Brook Medicine.

In its recommendation, the task force said evidence showed biennial screening was a better option to balance the detection of cancers with the possible harms of false positives. Annual screenings, it pointed out, could lead to more false-positive diagnoses, possibly causing unnecessary procedures.

Sometimes a mammogram might reveal a spot or mass, prompting the need for an ultrasound, MRI or biopsy to determine whether it is benign or cancerous. When it is benign, it is considered a false positive.  Studies have shown that false positives can increase the stress level for patients and even make them less likely to return for regular mammograms.

But Long Island doctors said it's better for patients to have the knowledge there might be something in their breast, and then they can discuss options with their doctors.

Dr. Alfredo Torres, an oncologist at NY Cancer and Blood Specialists in Port Jefferson, said he always recommends annual mammograms for women at average risk who are 40 and older.

“We are seeing younger and younger patients getting breast cancer so I am not going to change from 40 and every year,” said Torres, who is also an American Cancer Society Long Island board member.

Lee said she believes the more mammograms that are performed, the more lives can be saved and noted that the possibility of a false positive result should not dissuade women.

“I don’t like to compare genders, but prostate cancer screening is notoriously full of false positives,” she said. “You don’t hear complaints about men being anxious or them wanting to cut back.”

Breast cancer is the second-most common cancer among women in the United States, according to the Centers for Disease Control and Prevention, topped only by some types of skin cancer.

More than 43,100 women died of breast cancer in 2023, according to estimates quoted by the task force. Black women are more likely to be diagnosed with later stage breast cancer and about 40% more likely to die of breast cancer when compared with white women. The highest rates of breast cancer cases overall are among non-Hispanic white women, followed by non-Hispanic Black women.

Female breast cancer rates vary around the region, with Long Island's higher than New York City and the state.

The Nassau County rate of breast cancer is 145.9 per 100,000 and Suffolk County is 139.9, according to the New York State Cancer Registry . New York City's rate is 126.1 and the state's rate is 134 per 100,000.

Mammograms — an X-ray image of the breast — are a game changer in efforts to catch these cancers early and treat them. One study reported that women who had mammograms had a 41% reduction in their risk of dying of breast cancer within 10 years and a 25% reduction in the rate of advanced breast cancers.

But there remains a debate over how often they should be given to women at average risk. The guidelines are different for women at higher risk — those with a family history of breast cancer, who test positive for genes linked to breast cancer or who had previous radiation on their chest.

The guidelines are a framework for patients to use when discussing mammograms with their doctors, said Dr. Melissa Fana, a breast surgical oncologist and NYU Langone Health’s director of women’s health for Suffolk County.

“For a woman who is truly at average risk, the determination of whether it’s every year or every two is really made in conjunction with their health care provider,” she said.

Fana said she is encouraged the task force guidelines dropped the age women should start mammograms. But she said it's key that every woman knows her lifetime risk , which includes factors ranging from age at first menstrual period to whether or not they have given birth, family history and race/ethnicity.

“I’m just afraid we will miss people,” if women only go every other year for a mammogram, said Dr. Monique De Four Jones, associate chief of labor and delivery at Katz Women’s Hospital — Long Island Jewish Medical Center in New Hyde Park. “Some people don’t like going to doctors to begin with.”

De Four Jones said going every two years can be further delayed if the women are too busy, centers are not accessible and the patient does not have insurance.

Dr. Sophia Fu, director of breast surgery at Good Samaritan University Hospital in West Islip, said having annual mammograms makes a difference.

“The reason we have done so well in the treatment of breast cancer is that we are always trying to get ahead of the curve,” she said. “There are cancers that can grow sooner than two years.”

Fana said women need to prioritize their health care and know their family history and personal risk assessment for breast cancer. Those at higher risk can get screened earlier than age 40.

“You wouldn't miss a mortgage payment,” Fana said. “You should not miss a mammogram.”

WHAT TO KNOW

• Experts have different views on when a woman should start getting a mammogram and how often she should get one.
• An influential task force recently said women should get them every other year starting at 40, but some groups think these screenings should happen every year.
• Women are advised to discuss breast health with their health care providers to determine if they have any risk factors and what kind of screening would work best for them.

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Higher LI breast cancer rates

Dr. Sophia Fu, director of breast surgery at Good Samaritan University Hospital in West Islip, said annual mammograms can make a difference. Credit: Catholic Health

Lisa joined Newsday as a staff writer in 2019. She previously worked at amNewYork, the New York Daily News and the Asbury Park Press covering politics, government and general assignment.

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About the Right to Know Campaign

At a glance.

Women with disabilities are less likely to have been screened for breast cancer within the recommended guidelines. The "Right to Know" campaign materials increase awareness of the importance of breast cancer screening among women with disabilities.

Why it's needed

Breast cancer is a major public health concern for all women, including women with disabilities. However, women with disablities are significantly less likely to have been screened within the recommended guidelines . 1 The public health community has used health communication messages and campaigns to increase breast cancer awareness and encourage women to take steps to help prevent breast cancer, yet few communication messages exist for women with disabilities.

Several studies have explored the barriers to breast cancer screening for women who have physical disabilities. 2 3 4 The barriers include:

• Thinking, "It won't happen to me"
• Focusing on other health issues
• Difficulty with positioning while getting a mammogram
• Not knowing where to go for accessible screening
• Inaccessible facilities and equipment
• Healthcare provider's knowledge and attitudes

Women with disabilities also identified the lack of health promotion messages and materials that reflect their needs as a problem and requested that CDC address this issue.

As a result of this study, CDC developed health promotion materials (e.g., print advertisements, posters, fliers, tip sheets, audio files and transcripts) to increase awareness of breast cancer among women with physical disabilities and encourage these women to get screened. Materials share the tagline "Breast Cancer Screening. The Right To Know," and feature four women with physical disabilities who have survived breast cancer .

• Courtney-Long E, Armour B, Frammartino B, Miller J. Factors associated with self-reported mammography use for women with and women without a disability. Journal of Women's Health . 2011; 20:1279-1286.
• Magasi, Susan, et al. ScreenABLE: Breast Cancer Screening among Women with Disabilities from Community Identified Challenges to Community-Based Programs. Progress in Community Health Partnerships: Research, Education, and Action , vol. 13 no. 5, 2019; p. 61-69. Project MUSE .
• Todd A, Stuifbergen A. Breast cancer screening barriers and disability. Rehabil Nurs. 2012 Mar-Apr;37(2):74-9. doi: 10.1002/RNJ.00013. Erratum in: Rehabil Nurs. 2012 Sep-Oct;37(5):266. PMID: 22434617; PMCID: PMC4521895.
• Thierry, JM (2004). Barriers to breast cancer screening among women aged 40 years and older who have physical disabilities. (Doctoral dissertation) Retrieved from https://getd.libs.uga.edu/pdfs/thierry_joann_m_200412_phd.pdf

Breast Cancer Screening — The Right to Know Campaign

What is the best age to start getting mammograms? The recommended age has lowered

Adam’s Journal

Like many employers, the Oklahoma Medical Research Foundation teams with a mobile mammography service to offer onsite breast cancer screening services to our employees.

An employee in her 20s has inquired about using the service. Of course, she could. But should she?

Dr. James Prescribes

Recently, recommendations for when women should begin regular screening for breast cancer have changed. Where guidelines had suggested waiting until age 50, the U.S. Preventive Services Task Force now counsels that women should get a mammogram every year beginning at age 40.

Not coincidentally, it is typically starting at this age — 40 — that insurance companies will pay for the procedure as a routine preventive test.

Health experts do not recommend that women under 40 who are at average risk for breast cancer undergo mammograms. That generally means that women in their 20s and 30s are too young to begin screening unless they have: (1) a known genetic mutation (like BRCA1 or BRCA2) that puts them at high risk for breast cancer; (2) an extremely strong family history of breast cancer; or (3) physical symptoms of the disease, such as a mass or other breast changes.

Young women have a low risk for breast cancer. Mammography involves radiation exposure, so the risk-benefit calculus — especially when one considers lifetime radiation exposure, a risk factor for many cancers — does not make sense for normal-risk patients under the age of 40. However, that risk-benefit calculus changes once women reach the age of 40, as about 1 in 6 breast cancers are diagnosed in this age group.

Mammograms for young women also carry a higher level of false positives. This can mean unnecessary anxiety, additional testing, and costs.

It is important that women of any age understand if they are at higher risk for breast cancer. This involves learning your family history, which could in some circumstances lead to testing for certain genetic variants like BRCA1and BRCA2.

For young women, instead of mammography, doctors suggest performing self-breast exams regularly beginning at the age of 20. These self-exams can help women know how their breasts should feel, and they will help them notice any changes.

If they do detect a lump or any abnormality, that’s the time to talk to a healthcare provider and seek a breast examination.

James is executive vice president and chief medical officer of the Oklahoma Medical Research Foundation. Cohen, a marathoner, is OMRF’s senior vice president and general counsel. Send your health questions to [email protected].

Latest recommendation by health experts lowers breast cancer screening age to help save more lives

W AUSAU, Wis. (WSAW) - Wisconsin health care experts are weighing in on the new breast cancer screening recommendations from the U.S. Preventive Services Task Force, which now advises women to begin screenings at age 40, a full decade earlier than the previous recommendation of 50.

The task force now suggests screenings starting at age 40 to catch potential cancers earlier. This significant shift reflects growing evidence that earlier detection can save lives.

“Breast cancer is a major problem. In general, most breast cancers are diagnosed by mammogram.” Dr. Niaz Haque, a physician at Aspirus Cancer Center, said.

Dr. Haque highlighted the prevalence of breast cancer, noting that approximately 300,000 women will be diagnosed this year, with about 40,000 deaths expected from the illness.

Andrea Moskal, a mother from Madison, knows firsthand the importance of early detection. She was under 40 when a mammogram revealed her cancer.

“My heart sank,” Moskal said. “Kind of all the confidence melted away, and the fear started to set in.”

Moskal’s experience underscores that breast cancer can occur at any age and that early and regular screenings are crucial.

“I (now) get scans every six months,” she said.

These frequent screenings have allowed Moskal to focus on her family and career with peace of mind. She has been cancer-free since 2021.

“You just appreciate every little thing a little bit more. Everything’s a little bit brighter,” she said.

For those at average risk, starting biennial mammograms at 40 is now the standard recommendation. However, Dr. Haque emphasized that individuals with a personal history of breast cancer or other risk factors should follow their doctor’s specific screening plan, which might involve starting as early as 21.

“Depending on your situation, you may need to start screening earlier,” Dr. Haque said.

Aspirus health experts stress the importance of personalized care and regular screenings to ensure the best outcomes in breast cancer detection and treatment.

Commentary | Women need to self advocate for their own…

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Commentary | preakness 2024: seize the grey goes wire-to-wire, outruns mystik dan in 149th running, commentary | women need to self advocate for their own breast health | guest commentary.

Cancer diagnoses among people under 50 are on the rise , particularly among women. A 2023 study published in the JAMA Network Open found that, between 2010 and 2019, diagnoses among people age 30 to 39 increased 19.4%, with breast cancer accounting for the highest number of cancer cases in younger people. The rate of late-stage breast cancer diagnoses in young women also has been climbing.

While the reasons for this are multifactorial and still not fully understood, what has become painfully clear is that women need to be proactive in taking control of their own breast health, insisting upon early detection measures that could have a profound impact on their health trajectory.

Last month, the United States Preventative Task Force (USPSTF) released a  final recommendation on breast cancer screening, calling for women at average risk to begin screening at age 40, which is a long overdue shift from their current guidelines of age 50. Yet, the recommendation falls woefully short, declining to call for annual screening, and failing to recommend additional screening for women with dense tissue and for earlier risk assessment for especially high-risk groups, such as Black women. Without annual screening, interval cancers can grow unchecked and quickly, and mammograms can miss about half of breast cancers in patients with dense tissue. These recommendations are shortsighted and must be reconsidered.

Breast cancer cannot be prevented. Yet the earlier that breast cancer is detected, the better the health outcomes. While 1 in 8 women will get diagnosed with breast cancer, not everyone is at equal risk. Individual risk factors including family history/genetics and breast density, which can present significant increased risk. Having a first-degree blood relative (mother, sister, or daughter) with breast cancer almost doubles a woman’s risk, and having two first-degree relatives with breast cancer increases her risk by about 3-fold.

It is well-documented that early detection of breast cancer saves lives; over 95% percent of women who receive an early diagnosis can see high rates of survival with treatment. Due to a range of social, economic, political, and environmental factors that contribute to an individual’s health conditions, breast cancer mortality doesn’t impact all communities in the same way.  Today, Black women are more likely to be diagnosed with an aggressive form of cancer called Triple-Negative Breast Cancer and are 41% more likely to die of breast cancer than white women, despite a lower rate of breast cancer incidence than white women.

Knowledge is power in early detection of breast cancer. It is important to do monthly self-exams and to find a doctor you trust to put you on an annual schedule of mammograms. Push for additional screening such as ultrasound or MRI, if you are at higher risk. Get informed about genetic testing for breast cancer and get tested for the BRCA (breast cancer gene) and other gene mutations that carry a higher risk for breast cancer.

As we saw in Olivia Munn’s experience, personalized risk assessments are an important tool in early diagnosis. The American College of Radiology recommends that women at particularly high risk — including Black and Ashkenazi Jewish women — get risk assessments by age 25 to determine whether a mammogram and other screening are needed before age 40 and whether genetic testing would be beneficial. Patient-facing tools such as CheckMate ( breastquiz.bremfoundation.org , a simple, no-cost, online breast health risk quiz developed by Silver Spring-based Brem Foundation to Defeat Breast Cancer — whose mission is to drive early detection of breast cancer, and where I serve as CEO — are an easy way for women to learn about their personal risk factors and help drive a more informed conversation with their provider.

Women need every tool in their toolbox to diagnose cancer as early as possible to drive better health outcomes. We also need to be empowered patients, pushing back to protect our breast health — especially if our national guidelines do not. Simply put, our lives could depend upon it.

Clare Dougherty ([email protected]) is CEO of the Brem Foundation to Defeat Breast Cancer. 

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