A year before, our hospital acquired a mammography unit, aimed at early detection of breast cancer in women. We did so at the behest of Medical Council of India (MCI) – provision of mammography is one of the several prerequisites for granting approval for MD (Radiodiagnosis) post-graduation programme. Eager to win MCI approval, we spent fortune to equip the radiology department with the equipment. The technology was partly funded by the National Cancer Control Programme, Department of Health and Family Welfare, Government of India.
The brand new machine arrived. The glitter of technology began to radiate in the department. Residents in the radiology department couldn’t conceal their joy- after all residents always drool over new technology. Women living in city, always wanting to have multiple tests performed on their body, started asking their doctors if they could have a mammogram in their annual health check up package. Hospital administrators quickly flashed the news on their institute website, quarterly news bulletin and local press. The MCI inspectors had a good luck at the machine, noted its presence in their data collection forms and went away. Everybody seems to be happy,for breast cancer evokes fear and pain and people think that new technology will reduce the misery associated with breast cancer.
Breast cancer is common- although the data available in India is not very reliable, it is estimated that one in 22 Indian females is likely to develop breast cancer during her lifetime in contrast to one in eight in America. In 2005 the BMJ reported that breast cancers had replaced cervical cancer as the leading cancer site in women in Indian cities. The World Health Organization estimates that in the year 2007 there were 1.2 million new cases of breast cancer diagnosed worldwide, 79,000 in India.
Sevagram is no exception. For example, data obtained from our hospital information system show that in the year 2008, a total of 562 women underwent either a breast biopsy or a fine needle aspiration cytology test. Breast cancer accounted for 237 discharge diagnoses (ICD-10 code C50.9) in 2007. Published data from the Atlas of Cancer Registry of India shows that in 2001-02, as high as 25% of all cancers in women in Wardha district originated in the breast.
Mammogram is a simple test- it takes just 20 minutes to obtain high-quality mammogram. The test does not hurt much, generates impressive images and can detect lumps which elude self-examination. Doctors and public naively believe that mammograms detect early stages of cancer at which time treatment is more effective than at the time of usual diagnosis.
Was the decision to buy a mammogram right? Does an early diagnosis of breast cancer by mammogram really result in longer- and better -cancer-free life?
The best way to answer the question is to look at evidence. JAMA (21 October 2009) provides an objective evidence on the utility of population based screening of women aged 50 and above with a mammogram. JAMA says:
Even in breast cancer, for which there is evidence and agreement that screening saves lives, for every breast cancer death averted, even in the age group for which screening is least controversial (age 50-70 years), 838 women must undergo screening for 6 years, generating thousands of screens, hundreds of biopsies, and many cancers treated as if they were life threatening when they are not.
What about younger women- those below 50 years of age? If these women undergo an annual mammogram for 10 years, mammography will reduce their risk of dying from breast cancer from 3.3 to 2.5 per thousand. Thus, of the 1000 women who follow the annual ritual of mammography for 10 years, only 1 of them will have her life prolonged. For every 1000 women screened, 100 – 500 (10 – 50 %) will end up with a false positive result and many women will be subjected – unnecessarily- to disfiguring surgery, radiotherapy and chemotherapy, although none of these treatments may not actually work.
Now that the equipment has arrived and our audit shows that it is being under-utilized, what should we do to ensure that its optimal use? Organize diagnostic camps in villages? Lecture in the community on benefits of screening programmes to avert breast cancer related morbidity and mortality? Seek support from voluntary agencies to educate and mobilise people? Include mammogram in annual health check up campaigns, regardless of participants’ age? If mammograms are unlikely to result in meaningful health benefit in resource limited settings, should a rural teaching hospital divert several hundred thousand rupees from other services to invest in equipment simply because of academic compulsions?
My answer is no. After all, a mammogram, even in a teaching hospital costs Rs.600, an amount rural women can ill afford to spend on preventive healthcare every year. This month, when our hospital decided to hike the annual health insurance premium from Rs. 25 to Rs. 35, even this small increment generated some heat and unease among the villagers. The same money could save hundreds of lives of patients with pesticide poisoning and venomous snake bites- common causes of preventable death in rural settings. The departments must grow, residents must be adequately trained during their MD program, healthcare seekers must have an access to new technology, and mandatory requirements need to be met. Nobody would deny that. But when technology is expensive and the risk reduction in mortality extremely low, how do we balance the trade off between pluses and minuses?
A recent BMJ editorial suggests a middle path: women should not be offered annual mammograms as a part of annual health check but should be told the downsides (needless biopsy, surgery, radiation and chemotherapy) and benefits (small reduction in death rates) and should be encouraged to “make a decision that is right for them”. Put simply, women must clearly know that mammograms can diagnose cancers when none exist, and can miss some cancers. No woman, in my setting, would ever agree for mammographic screening if we honestly share with her the current evidence on benefits and downsides of screening, more so because the potential benefits are very small and would accrue several years later.
I totally agree with you sir. The bmj editorial clearly says that with the current trend more than 50 % breast cancer is overdiagnosed. We also need to consider that in India, why only in sewagram , the population is struggling for basic medical facilites.They even dont get investigated , forget over-investigations. In our set up instead of generalising the benefits, we should pick up high risk population ,discuss with them and let them decide what they want to choose.
Thank You Dr. Kalantri for inviting me to your blogs. Good to hear about mamo being done in Sevagram. The real incidence of cancer in India is under reported but certainly it is lower than in developed countries. Screening diagnoses cancer early when it is treatable and curable. Survival data is difficult to establish because there are so many factors and co-morbid conditions influencing it besides cancer.
Mammogram diagnoses breast cancer 2 years before it is palpable. In India where people have to pay for everything, offering to high-risk population can be helpful but it should be offered to everyone above 40yrs of age. Can be done every 2-3 yrs then, if not every year. Its true mammogram alone is not enough. The center should offer biopsies and ultrasound facilities for further work up.
There should not be any doubt in minds of doctors against it because, its
screening only that has practically eradicated cervical cancer from developed countries.
My outlook towards patients and life has changed after exposure to western medicine. I have many 90 yrs old, getting chemotherapy for cancer and I am able to give them a good quality of life even at this age.
Are pap smears advocated too, it’s a bigger problem there ?
Renu Lamba
Medical oncologist/hematologist, USA