essay on cancer screening

• Program Finder
• Admissions Services
• Course Directory
• Academic Calendar
• Hybrid Campus
• Lecture Series
• Convocation
• Strategy and Development
• Implementation and Impact
• Integrity and Oversight
• In the School
• In the Field
• In Baltimore
• Resources for Practitioners
• Articles & News Releases
• In The News
• Statements & Announcements
• At a Glance
• Student Life
• Strategic Priorities
• Inclusion, Diversity, Anti-Racism, and Equity (IDARE)
• What is Public Health?

Bringing Informed Decision-Making to Cancer Screening

“Get screened” shouldn’t be the full message, says one cancer prevention expert.

Aliza Rosen

Screening for various cancers before a person experiences symptoms can help detect cancer in the early stages when treatment is often more effective. But there’s more to the message of “get screened” than most people realize, says Otis Brawley , MD, a Bloomberg Distinguished Professor with joint appointments in Epidemiology and the Sidney Kimmel Comprehensive Cancer Center, who emphasizes the importance of routine, high-quality screening with adequate follow-up.

For Cancer Prevention Awareness Month, Brawley talked with Public Health On Call host Stephanie Desmon about why it’s important for everyone to understand both the benefits and the risks of cancer screening in order to make informed decisions. This article is adapted from their conversation.

Cancer screening is more complex than just getting a test.

Many people think you just get the test, and if the test finds cancer, there is benefit. In fact, it’s far more complicated than that.

While family practice doctors and internal medicine doctors tend to be educated on it, it’s not something all doctors learn about in medical school. 

There are cancers—for example, in the prostate and breast—that a person will never be bothered by, because they will ultimately die from something totally unrelated.

Cervical cancer screening saves lives.

In the case of cervical cancer —detected early with a Pap smear or advanced HPV testing— screening clearly saves lives . Women should be screened starting in their 20s. Certain tests should only be done once women are in their 30s through their 60s.

Don’t just get a mammogram. Get routine, high-quality mammography.

Screening for breast cancer saves lives, and it’s recommended that most women start at age 45. However, the message so frequently is to get a mammogram, when the message should be to get into a program of routine, high-quality mammography.

For example, most mammogram vans do not offer the opportunity for previous mammograms to be looked at. High-quality mammography, in my opinion, means that a person’s mammograms from last year and the year before are compared to this year’s.

Colonoscopies aren’t the only way to screen for colorectal cancer.

With colorectal cancer screening , everybody thinks “colonoscopy, colonoscopy.” Colonoscopies save lives and they can be done every 10 years. There’s also stool blood testing, which can be done every year, and stool DNA tests, which can be done every three years. Starting at age 45, those things should be done with adequate follow-up .

Lung cancer screening saves lives, but it’s not without risks.

There are about 140,000 to 150,000 lung cancer deaths a year in the United States. If we had full-scale lung cancer screening , we know that we would prevent perhaps 10,000 of them, but we would actually cause 1,500 to 1,800 deaths because of the diagnostics .

In lung cancer screening, it’s common that a radiologist will see something on an image that could be lung cancer, but could also be an old fungal infection or a scar from a bacterial infection 60 years prior. The only way to figure out whether or not it’s lung cancer is a transthoracic needle biopsy, which involves a controlled stab of a needle through a person’s chest and into the lesion while the person is in a CT scanner. If you stab enough people, you’re going to potentially cause a collapsed lung, and it’s possible the person will have a heart attack.

It’s recommended that people with an extensive smoking history understand the potential risks and benefits, and then find a high-quality screening program. That means a hospital or clinic that has thoracic surgery, good radiology, and good pulmonary medicine.

Prostate cancer screening is controversial. Here’s why.

The approach to prostate cancer screening has changed dramatically over the last 20 years. Now, about half of all men with screen-detected prostate cancer are told that the next step should be observation. The majority of those men are never going to be treated because they don’t need to be cured.

Most professional organizations, including the U.S. Preventive Services Task Force and Medicare, recommend “fair balance,” meaning informed decision-making. There have been studies that show that prostate cancer screening doesn’t save lives, and at least one study that shows that it does save lives, but very few.

One study suggests that prostate cancer screening with a blood test and digital rectal exam will reduce risk of death by 20%. Here’s what that actually means:

If you screen 1,000 men in their 50s on a regular basis over 15 to 20 years, you will diagnose 100 of those 1,000 men with prostate cancer, and ultimately four will die. If you take 1,000 men of the same age, and you don’t screen them over that same period of time, you will diagnose about 60 with prostate cancer because of symptoms, and five will die. That five per 1,000 unscreened going to four per 1,000 screened is where the 20% reduction in risk of death comes from. But it’s at a cost of almost doubling the man’s risk of being diagnosed with prostate cancer.

After an abnormal screen, follow-up is essential.

One of the problems we find is people have an abnormal screen and then don't get the diagnostics or treatment. Women will get a mammogram, be told there’s an abnormality, and a repeat mammogram and additional testing may be needed. A larger portion of poorer women don’t return for that follow-up evaluation.

One study suggests that of the 45,000 or so women who die from breast cancer every year, approximately 10% die because they never got a mammogram. And somewhere around 20-25% die because they did not get adequate follow-up or treatment following an abnormal mammogram.

Not everyone has access to the same quality screening.

In the case of mammography in the U.S., the proportion of Black women and white women in their 50s and 60s who get screened is the same, about 60%. The problem is that Black women more often get screened in centers that don't have previous mammograms for comparison.

With lung cancer screening, we see middle- and upper-middle-class individuals going to high-quality centers and poorer people going to community hospitals that don't offer all the various specialties that ensure high-quality screening.

One famous study of colon cancer screening and treatment showed that poor people in California were going to overcrowded hospitals, and the quality of the screening and diagnosis was impacted. In the hospitals poor people went to, a pathologist had to deal with six patients a day, but in the hospitals where middle-class people with good insurance went, the pathologist only had to deal with two patients a day. So there was a difference in quality because the doctor spent more time analyzing the patients with better insurance.

Each person should make their own informed decisions around screening.

Cancer screening saves lives. But that doesn't mean the recommendation is for everyone to get it. It means that we should have a conversation and respect people’s concerns. Those who are concerned or hesitant to get screened, perhaps ought not to. Those who want to get screened ought to be able to get screened, and we should remove financial barriers for them to do so.

Aliza Rosen is a digital content strategist at the Johns Hopkins Bloomberg School of Public Health. 

• Otis Brawley on Cancer's Critical Socioeconomic—Not Just Racial—Disparities
• Cervical Cancer is Preventable
• The Promise and Perils of the Lung Cancer Screening Tool (Podcast)

Related Content

The Public Health Strategy Behind Baltimore’s Record-Low Infant Mortality Rate

How Dangerous is Dengue?

Faculty Profile: Kadija Ferryman

9 Things to Know About Sun Safety and Skin Cancer

Filters and Digital Health Program Reduced Participants' Arsenic Levels by Nearly Half in American Indian Households Relying on Well Water

• U.S. Department of Health & Human Services

• Virtual Tour
• Staff Directory
• En Español

You are here

Science, health, and public trust.

April 27, 2022

Putting Cancer Screening in Perspective

By Paul Pinsky, Ph.D., Chief, Early Detection Research Group, NCI Division of Cancer Prevention; Philip Castle, Ph.D., M.P.H., Director, NCI Division of Cancer Prevention; Maureen Johnson, Ph.D., Executive Secretary, President’s Cancer Panel; and Samantha Finstad, Ph.D., Senior Health Science Policy Advisor, President’s Cancer Panel

It’s common wisdom that “catching the cancer early” is always a good thing. It can be a key factor in being able to survive cancer. You often hear, “luckily, they caught it early,” or the converse, “unfortunately, they didn’t detect it until it had spread” when people talk about friends or relatives with a cancer diagnosis. But the reality of cancer screening is not that simple.

The overall goal of cancer screening is to reduce cancer morbidity (illness) and mortality (death). There is no question that appropriate screening reduces illnesses and deaths due to cancer. Cervical and colorectal cancer incidence has declined in the last few decades by about 55% and 45%, respectively. Death rates have declined even more. These have been due primarily to routine screening.

Some types of screenings can detect cancer early (e.g., mammography for breast cancer and low-dose CT for lung cancer). Others can detect cancer early as well as detect cancer precursors, which can prompt action to prevent the development of cancer (e.g., colonoscopy screening for colorectal cancer and Pap smears and/or HPV testing for cervical cancer). Preventing cancer, even a curable cancer, is a large benefit in itself because it can reduce the many burdens to patients associated with a cancer diagnosis. 

But when communicating information about cancer screenings to the public, it’s important to discuss the benefits and the risks. Cancer screening will not necessarily benefit every patient who gets it. A patient could still succumb to cancer despite it being detected early. Others may survive even if their cancer was missed early on and caught at a later stage. And for some patients, screening can actually cause harms.

Screening may lead to the overdiagnosis of indolent (symptomless) cancers. These are cancers detected through screening that would never have become symptomatic in the patient’s lifetime. There is evidence of overdiagnosis associated with various types of screening, most notably PSA screening for prostate cancer. Overdiagnosis of cancer can lead to treatment, or overtreatment, and have serious side effects. For example, impotence and urinary incontinence are associated with prostate cancer surgery.

Screening can also lead to false positives—when people get a positive screening test but no cancer is found. Since screening tests are usually given to healthy people with a low risk of harboring cancer, the tests need to have a high specificity, or the ability to avoid too many false-positive results. A false-positive result can cause anxiety, require additional clinical visits and diagnostic procedures like imaging and biopsies, and lead to high costs for both the medical system and patient. For example, for mammography screening, around 8−12% of women will receive a false positive result at any given screening visit, and up to 45% will receive at least one false positive result over a ten year period of regular screening.

Since cancer screening is intended for those who have no signs or symptoms of cancer, it is important that the benefits strongly outweigh the risks. Cancer screening guidelines can change as new research shows which populations would benefit most from screening with the least harm. For example, more people became eligible for lung cancer screening in 2021, when the U.S. Preventive Services Task Force updated their eligibility recommendations, lowering the minimum age and the amount a person has smoked over their lifetime (or smoking pack-years).

For new screening approaches, establishing the high sensitivity of a test—the ability to find someone who does have cancer—is an important first step in determining its clinical utility. But it is only a first step. Researchers must also demonstrate that the benefits outweigh the harms. Such evidence generally requires a randomized clinical trial in which subjects are randomized to a screening and control arm. The primary outcome is typically mortality from the cancer in question. 

There is much discussion lately about the new “multi-cancer early detection” (MCED) tests. Also called liquid biopsies, these are blood tests that can detect multiple different cancer types simultaneously. To date, there has been limited research on the clinical utility of such tests—in other words, if they actually reduce illness and death. As these tests develop, it’s crucial to keep in mind that a sensitive test does not necessarily indicate clinical utility, or that the benefits of MCED screening would outweigh the harms.

While the benefits of appropriate screening are undeniable, it is important to acknowledge that harms can also be associated with screening; more is not always better. When describing cancer screening, make sure to refer to the current guidelines and clarify that screening isn’t for everyone. It should be done only for the right people at the right time.

Connect with Us

• More Social Media from NIH

The Harms of Cancer Screening They Don't Warn You About

Hospitals and doctors fail to fully inform potential patients..

Posted October 3, 2022 | Reviewed by Gary Drevitch

• Cancer screening can lead to harm as well as provide benefit, but doctors and screening providers fail to warn about the risk..
• Advanced screening finds many earlier smaller cancers that are "overdiagnosed," and would never cause the patient any harm.
• The diagnosis "You have cancer" leads many to choose more aggressive and risky surgery than their particular case requires.
• Those surgeries cause harm, ranging from minor issues to death itself, and cost the health-care system billions of dollars.

October is Breast Cancer Awareness month. The world will turn pink. Recommendations for mammography will be everywhere. But few if any of those recommendations will include information about the harms that mammography can lead to. Yes, harms.

Decades of screening by ever-more perceptive advanced technologies have taught us that not all cancers kill. In fact, many tiny early cancers that screening can now detect never spread, or cause harm, or any symptoms at all. This is true for common types of breast, prostate, thyroid, skin, and lung cancer. They are confirmed as cancer under a microscope based on the size and shape and arrangement of their cells, but these cancers are “overdiagnosed," meaning that we’d never know we had them had screening not found them.

This overdiagnosis can sometimes lead to profound harm. Deeply frightened by the three awful words from our doctor — “You have cancer” — we understandably often pursue more aggressive and potentially harmful treatment than our clinical condition warrants. We have breasts and prostate glands and thyroid glands removed to rid ourselves of cancers that would never have caused any harm, by procedures that have side effects ranging from the minor to death itself. You'd think that doctors and hospitals and advocacy groups that encourage screening would also let us know about those risks, so we can be fully informed as we weigh the pros and cons of mammography.

Yet consider the new Breast Cancer Screening and Diagnosis information resource just published by the National Comprehensive Cancer Network , a group of 32 of the top cancer centers in the U.S. It offers clear and helpful information about breast cancer, and explains mammography and its benefits. But in its 51 pages, there is not a mention of the potential harm of mammography. The words "overdiagnosis” and "overtreatment" never appear. The problems are not even hinted at—even in the section titled “Risk assessment for screening." Nor are they alluded to in the section labeled “Questions to ask," which begins: “In shared decision making, you and your health care provider (HC) discuss the risk for developing breast cancer and agree to a screening schedule.” If you rely on this guide, the discussion of risk includes nothing about the potential harm mammograms can sometimes lead to; only the benefits.

One explanation for this failure to fully inform might be because the authors of the NCCN guidance either deny that overdiagnosis occurs, or don't think it’s that serious. They certainly know about it: Hundreds of research papers have firmly established that it’s a serious problem. So serious, in fact, that scientific panels in France and Switzerland have even suggested phasing out screening mammography altogether, since its life-saving benefits are real but modest (in the U.S., mammography saves between 1 and 2 women per 1,000 screened over 10 years) while the frequency of overdiagnosis and overtreatment leading to real harm is far greater. A recent study of Danish and Norwegian women also found that the harms of overdiagnosis may outweigh the benefits of mammography. The National Breast Cancer Coalition agrees: “Screening mammography of all women has demonstrated only a modest, if any, benefit in reducing breast cancer mortality and is associated with harms that may outweigh those benefits."

A less-benign interpretation would also note that the NCCN consists of institutions that profit from the screening and cancer care they provide. That could also be a part of why many cancer centers promote cancer screening. In fact, some hospitals provide screening free of charge — free screening that generates patients (customers) for those hospitals.

Imbalanced communication about screening that fails to note its risks is not only a problem with breast cancer. Many hospitals aren't informing men about the risks of prostate cancer screening any better than the NCCN does with mammography. A recent review of 607 U.S. cancer centers that recommend prostate cancer screening found that four in ten failed to mention anything about the potential harms of that screening. And one in four failed to suggest that men discuss the pros and cons of screening with their doctors, as recommended by the U.S. Preventive Services Task Force (USPSTF). Major cancer centers accredited by the National Cancer Institute were twice as likely as non-NCI accredited centers to fail to recommend shared decision-making . And eight in ten of all 607 centers also failed to inform men that the USPSTF recommends that testing stop at age 70.

A simpler explanation for all of this may be that society’s emotional relationship with the Emperor of All Maladies has yet to catch up to the progress we’ve made fighting the disease. A cancer diagnosis is no longer the death sentence many still believe it to be. As many as two-thirds of all cancers can now be treated as chronic diseases or cured altogether. Yet two-thirds of Americans, when asked, "What's the first word that comes to mind when you hear the word cancer?” answer "Death."

So we want every tool possible to give ourselves some sense of control against this dreaded threat. Which is why belief in screening is deeper than faith in many religions. Study after study finds that people choose cancer screening even when they are expressly told it’s more likely to harm them than help them. And study after study finds that doctors do the same thing the NCCN has done: Inform patients about the benefits of screening without fully informing them about its risks.

The problem of overdiagnosis of cancer is real, and its cumulative economic and human health costs are enormous. Research for my book due out next year, tentatively titled Rethinking Our Fear of Cancer: How excessive worry about a dread disease does great harm all by itself (in press, Johns Hopkins University Press) estimates that lumpectomies, mastectomies, or double mastectomies for overdiagnosed breast cancer conservatively cost the U.S. health-care system an estimated $2.5 billion. The overtreatment of prostate cancers that would never have caused any harm costs the health care system another $860 million annually.

Individual women considering a mammogram or men thinking about a PSA test don’t care about overall costs to the health care system. They want to know what’s advisable for them, which is what the NCCN booklet and cancer center screening recommendations are supposed to help with. Sadly, people relying on these communications for complete and balanced information to make choices about their health are not getting it. That failure to accurately and fully inform puts people at risk and contributes to significant harm.

David Ropeik is a retired Harvard Instructor, author, consultant, and public speaker on risk perception, risk communication, and risk management.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Teletherapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Therapy Center NEW
• Diagnosis Dictionary
• Types of Therapy

Understanding what emotional intelligence looks like and the steps needed to improve it could light a path to a more emotionally adept world.

• Coronavirus Disease 2019
• Affective Forecasting
• Neuroscience

Open Access is an initiative that aims to make scientific research freely available to all. To date our community has made over 100 million downloads. It’s based on principles of collaboration, unobstructed discovery, and, most importantly, scientific progression. As PhD students, we found it difficult to access the research we needed, so we decided to create a new Open Access publisher that levels the playing field for scientists across the world. How? By making research easy to access, and puts the academic needs of the researchers before the business interests of publishers.

We are a community of more than 103,000 authors and editors from 3,291 institutions spanning 160 countries, including Nobel Prize winners and some of the world’s most-cited researchers. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too.

Brief introduction to this section that descibes Open Access especially from an IntechOpen perspective

Want to get in touch? Contact our London head office or media team here

Our team is growing all the time, so we’re always on the lookout for smart people who want to help us reshape the world of scientific publishing.

Home > Books > Bioethics in Medicine and Society

Ethical Concerns Regarding Breast Cancer Screening

Submitted: 04 June 2020 Reviewed: 23 September 2020 Published: 13 October 2020

DOI: 10.5772/intechopen.94159

Cite this chapter

There are two ways to cite this chapter:

From the Edited Volume

Bioethics in Medicine and Society

Edited by Thomas F. Heston and Sujoy Ray

To purchase hard copies of this book, please contact the representative in India: CBS Publishers & Distributors Pvt. Ltd. www.cbspd.com | [email protected]

Chapter metrics overview

760 Chapter Downloads

Impact of this chapter

Total Chapter Downloads on intechopen.com

Total Chapter Views on intechopen.com

The incidence and mortality of breast cancer are rising in the whole world in the past few decades, adding up to a total of around two million new cases and 620,000 deaths in 2018. Unlike what occurs in developed countries, most of the cases diagnosed in the developing world are already in advanced stages and also in women younger than 50 years old. As most screening programs suggest annual mammograms starting at the age of 50, we can infer that a considerable portion of the new breast cancer cases is missed with this strategy. Here, we will propose the adoption of an alternative hierarchical patient flow, with the creation of a diagnostic fast track with referral to timely treatment, promoting better resources reallocation favoring the least advantaged strata of the population, which is not only ethically acceptable but also a way of promoting social justice.

• breast cancer
• public health

Author Information

Rodrigo goncalves *.

• Breast Surgery Sector, Discipline of Gynecology, Department of Obstetrics and Gynecology, Hospital das Clinicas of the University of Sao Paulo Medical School, Brazil

Maria Carolina Formigoni

José maria soares.

• Discipline of Gynecology, Department of Obstetrics and Gynecology, Hospital das Clinicas of the University of Sao Paulo Medical School, Brazil

Edmund Chada Baracat

José roberto filassi.

*Address all correspondence to: [email protected]

1. Introduction

According to data from the World Health Organization (WHO), the number of deaths due to cancer will increase up to 45% between 2008 and 2030 and 70% of those deaths will occur in developing countries [ 1 ]. To try and change this scenario, the WHO recommends the implementation of cancer control programs that must include cost-effective measures on healthy life style, vaccination programs and screening programs [ 2 ]. A screening program consists in a set of coordinated actions with the objective of reducing cancer mortality through early stage diagnosis in an asymptomatic population, with adequate referral to diagnostic and treatment facilities. These programs have four main components: the definition and recruitment of the target population, adequate offer of diagnostic tests with quality assurance, guaranteed offer of follow up exams and biopsies to confirm findings from the initial diagnostic tests, and referral to treatment facilities and timely navigation through the health system [ 3 ]. Although screening programs present the potential benefit of reducing mortality, they are not risk-free. The main risks of such a program are the false-positive and false-negative results, and also the occurrence of over diagnosis. All these can lead to clinical and psychological repercussions and, also, to the increase in the health care system expenditure. To address this issue, the Public Health Agency of Canada performed a study to estimate the harms of the local breast cancer-screening program in 7 years, according to age, and the main results can be seen in Table 1 [ 4 ].

Benefits and harms of mammographic breast cancer screening [ 4 ].

In this text, we will use Brazil as a model to discuss screening programs in the developing countries. In the Brazilian setting, breast cancer is the most frequent type of cancer, responsible for 16,724 deaths in 2017 and with an estimate of 66,280 new cases in 2020 [ 5 ]. This scenario, however, has some peculiarities when compared to developed countries in the North America or Europe; 41.1% of all cases in Brazil happen in women younger than 50 years old and the majority of the operable cases is diagnosed in locally advanced stages, being 53.3% of the cases in stage II and 23.2% in stage III [ 6 ]. These characteristics are not typical of a country with a well-established breast cancer-screening program. The strategy adopted in Brazil states that women over 50 should get a mammogram every two years between 50 and 69 years old [ 7 ]. However, due to the early age of diagnosis that we observe in this developing country, we can argue that more than 40% of the diagnosed women are not eligible to the screening program in the first place. Moreover, the late presentation at diagnosis raises the hypothesis that the current screening program is not effective or that the patients do not have proper access to it. Added to that, the mortality due to breast cancer in Brazil has been increasing in the last decades [ 8 ]. All these issues taken together generate an ethical dilemma to be explored, once the investment of public resources in an ineffective program impacts negatively the whole society. This way, more effective resources reallocation strategies should be implemented to address this dilemma.

In this chapter we will discuss the breast cancer screening programs in developing countries and the main evidence regarding the barriers in the access to the healthcare system. Beyond that, we will address the main ethical questions related to breast cancer screening from the Rawls’s distributive justice [ 9 ] perspective, from the utilitarianism concepts [ 10 , 11 ] and from the principles of autonomy and non-maleficence. Lastly, we will propose the support to an alternative approach to breast cancer in developing countries, maximizing the cost–benefit ratio in the use of public resources.

2. Recommendations to breast cancer screening around the world

The U.S. Preventive Services Task Force (USPSTF) is an independent volunteer panel of American experts that develops recommendations regarding the efficacy of preventive services to asymptomatic patients. These recommendations are based on both benefits and harms that programs might cause, without consideration to the cost of the intervention. Current data about mammographic screening are solid regarding the benefits of this strategy when used in women over 50 years old and the USPSTF recommends a mammogram every two years, in women between 50 and 74; however, this same agency does not consider that there is enough evidence to support mammographic screening from 40 to 49 years old in asymptomatic patients without increased risk to breast cancer [ 12 ]. This recommendation is due to the fact that screening in this age range results in a smaller number of prevented deaths when compared to more advanced ages; also leads to a larger number of unnecessary biopsies; and to the possibility of psychological problems, like anxiety, because of the large number of false-positive results. While mammographic screening of 10,000 asymptomatic women between 50 and 59 years old can prevent 8 breast cancer deaths, the same strategy adopted in asymptomatic women between 40 and 49 years old would prevent only 3 breast cancer deaths [ 13 , 14 ]. Another harm associated with mammographic screening of an asymptomatic population considered by the USPSTF when issuing their recommendation is the occurrence of over diagnosis. Although it is extremely complex to calculate the proportion of diagnosed cases that would never evolve to cancer, the best estimates from randomized clinical trials suggest the occurrence of over diagnosis in 20% of the cases due to mammographic screening [ 15 ].

Another agency that carefully evaluated the cost–benefit ratio of mammographic screening in asymptomatic women between 40 and 49 years old was the Ontario Health Technology Advisory Committee through a systematic review of the literature [ 16 ]. This work included an evaluation of the USPSTF report [ 17 ], the Canadian Preventive Services Task Force (CPSTF) report [ 18 ], a Cochrane systematic review [ 19 ], five health technology assessments and eight randomized clinical trials [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] with the objective to assess the reduction of the breast cancer mortality in this age range attributable to mammographic screening. This agency reached a similar conclusion as the USPSTF that the mammographic screening in an asymptomatic population between 40 and 49 years old is not effective in reducing breast cancer mortality and that the harms associated with this intervention, like exposure to radiation, high rate of false-negatives leading to delays in diagnosis and high rate of false-positives with associated psychological harmful effects should not be overlooked.

The Brazilian College of Radiology (BCR) and Brazilian Society of Mastology (BSM) however issued a different recommendation, based on different published articles of international literature and methodologically inferior to the ones evaluated and with a clear selection bias [ 25 , 28 , 29 ]. In these studies, it was demonstrated a breast cancer mortality reduction between 18% and 38% in the studied populations. The main point to justify the recommendation of mammographic screening for asymptomatic women between 40 and 49 years old is to emphasize that in this developing country there is a higher proportion of breast cancer patients in this age range when compared to developed countries [ 30 ]. Despite the fact that it is a recommendation for Brazil, it did not include a single Brazilian study in the analysis. This scenario is repeated throughout Latin America as it has been shown in a report by The Economist Intelligence unit. Cancer care registries are lacking in Latin America due to insufficient coverage of the population and also due to low quality [ 31 ]. Without local high-quality data, it is impossible to perform local health technology assessments and the decision-making process is jeopardized.

3. Ethical implications of mammographic screening

Carefully considering the recommendations of these three different countries with very diverse populations, we can conclude that although mammographic screening in women between 40 and 49 provide a modest benefit in reducing breast cancer mortality, the occurrence of adverse effects is more pronounced.

We can also note that the BCR and BSM adopt a paternalistic approach, reflecting the principle of beneficence. In the meantime, the USPSTF and the CPSTF advocate that the screening decision should be shared with the patient. This way, patients that are more risk averse could opt out of the screening program and patients that value more the potential benefits could opt in, following the principles of non-maleficence and autonomy. However, what we must ask is whether it is possible to convey important information regarding the risks associated with a screening program in a clear and, more important, neutral manner. In this sense, it is of utmost importance that the autonomy principle is respected and that patients are not manipulated to undergo tests or treatments which they do not agree with, due to the use of biased information.

Addressing this issue, Biddle introduced the concept of epistemic risk, defined as the risk of error that comes up at any moment in the process of knowledge production [ 32 ]. These errors can happen because of biases during the data collection step and also because of decisions made in scenarios of uncertainty. These decisions reflect the set of values of the involved researchers and have consequences to human health and to the definition of public policies. Rudner agrees with this argument and suggests that it’s impossible to prove any hypothesis with full certainty, as there is always a possibility of error. This way, researchers must judge what is the necessary amount of data to accept or reject a hypothesis and this judgment depends on the set of values of the researcher and on the importance of the consequences an error can lead to [ 33 ]. Pramesh et al. discuss such a conflict in depth when they justify the necessity of a randomized clinical trial to prove a hypothesis raised by a cross-sectional study, as they believe the data gathered in the latter is not sufficient to support the decision-making process [ 34 ].

The reasoning to support a mammographic screening program for asymptomatic women below the age of 50 is not free of the risk of epistemic risks. One kind of epistemic risk associated with to mammographic screening is the inductive risk, defined as the risk of incorrectly accept or reject a hypothesis based on the available evidence [ 35 ]. Breast surgeons must accept or reject that a patient has a disease, frequently a ductal carcinoma in situ (DCIS), that will evolve causing symptoms and death based on evidence that does not guarantee the veracity of this hypothesis. That happens mostly because of the lack of evidence to predict which cases of DCIS will evolve to become invasive carcinomas. Another epistemic risk, the one in the gathering of data of breast biopsies, occurs in the evaluation of the differential diagnosis between atypical hyperplasia and DCIS. While the first ones are treated with a small surgical procedure, the latter requires surgical excision followed by radiation therapy and, in some cases, endocrine therapy for 5 years. This way, an error committed by the pathologist might lead to an enormous impact in the treatment of the patients. As pathologists have different formations and different experience backgrounds, and as the biopsy evaluation is a subjective process, this is an epistemic risk that is hard to be assessed. In order to try and decrease the odds of such an error is the development of image analyses software. Mercan et al. evaluated 240 breast biopsies comparing the performance of three experienced pathologists and an automated image analysis method. In this study, the automated method performed better than the pathologists in differentiating atypical hyperplasia and DCIS, becoming a promising alternative for the near future [ 36 ]. As we saw in these two examples, the information conveyed to the patients eligible to screening are not obtained in the absence of the researchers personal judgment and values. Thus, more than just respecting the autonomy principle in the shared decision-making process, healthcare workers must convey not only the necessary information but also their values and personal beliefs used by them to define their diagnostic and therapeutic decisions. As long as there is ambiguity in the results of mammographic screening studies in asymptomatic women below the age of 50, the priority should be debating the advantages and disadvantages of this strategy, instead of discrediting their opponents [ 37 ].

4. Current situation of mammographic screening

In Brazil, as in many developing countries, there is no public policy to the implementation of an organized mammographic screening program. As mentioned previously, there is a recommendation from the Brazilian National Cancer Institute (INCA) for mammogram every two years for women between 50 and 69 years old [ 7 ] and the main medical societies recommend an annual mammogram for women starting at 40 years of age [ 30 ].

This difference in recommendations happens due to complex interactions between the country’s decision makers’ interests, beliefs, perspectives and personal values. In the present scenario, with this disparity of recommendations, patients present late stage diagnosis, worse than the ones observed in Norway before the implementation of the local mammographic screening program ( Table 2 ) [ 38 ].

Prevalence of breast cancer according to stage in the state of São Paulo between 2000 and 2017, and in Norway before the implementation of mammographic screening.

Adapted from Tiezzi et al. [ 38 ].

To evaluate the necessity to expand the INCA’s recommendation to other age ranges, Brito et al. analyzed all breast cancer cases, all DCIS cases and all breast cancer related deaths in the city of Aracaju between 1998 and 2014, dividing pages according to age groups [ 39 ]. The breast cancer incidence trends remained stable over the studied period across all age groups. Both incidence and cancer-specific mortality in that municipality were similar to the ones observed in countries with the same human development index. The authors concluded that, as these rates remained stable in all age groups, including the ones in which screening is recommended, the investment of public resources to screen women below the age of 50 or over the age of 69 is not justifiable.

A broader study by Rodrigues et al. evaluated retrospective data regarding mammograms between 2008 and 2016 in the public health system [ 40 ]. Around nineteen million mammograms were performed in this period with an increase in coverage of 14.5% annually between 2008 and 2012 followed by a stable period between 2012 and 2017. The population coverage of mammogram varied in the period from 14.4% to 24.2% of the target population. This number is far from the 70% coverage recommended by the WHO, necessary to effectively reduce breast cancer-specific mortality [ 41 ]. Rodrigues et al. also evaluated the number of mammogram machines available in the country, their geographical distribution and the total number of exams performed in 2016 [ 42 ]. In this study, it was demonstrated that Brazil has 4628 machines with a capacity of 14,279,654 exams per year. In 2016, however, only 4,073,079 exams were performed, 29% of the total capacity, displaying a clear under-use of the available infrastructure. The low coverage of the target population with the stable trend in the past few years associated with the under-use of the available infrastructure raises the hypothesis of the existence of barriers to access to the healthcare system.

The Barretos Cancer Hospital adopted an alternative to improve the coverage of the screening program with the use of mobile mammogram machines in trucks reaching 108 municipalities in the northeastern region of São Paulo, targeting women between 40 and 69 years old. Greenwald et al. evaluated the efficacy of this initiative from 2010 to 2015 [ 43 ] and, in this period, 122,634 women were evaluated with a coverage of 54.8% of the target population, referral of 12.25% of these women were referred for additional exams with a cancer detection rate of 3,63/1000 women. 92.51% of the referrals to treatment centers were successfully accepted. The results obtained by this program are very promising, showing the potential to be expanded to other regions and other countries.

5. Barriers to access the healthcare system

Brazil is a developing country with a population of 209.3 million inhabitants with enormous social and economical disparities between its 5 regions [ 44 ]. Moreover, there are also inequalities in the distribution of human resources and health infrastructure with a significant variation in the number of hospital beds and physicians dedicated to oncological patients leading to significant differences in health outcomes [ 8 ]. Another source of outcome variability is the duality of access to the healthcare system. Every Brazilian citizen has unrestricted access to the public health system (PHS) and the richer portion of the population also has access to private healthcare providers through out-of-pocket direct expending or through healthcare insurance companies. This duality of the system is perverse in a way that it perpetuates the idea that a small portion of the population has access to state-of-the-art diagnostic and treatment facilities while the majority of the population, around 71%, depends exclusively on the PHS with all its limitations. When comparing this two scenarios, we observe a striking difference in the initial stage of the breast cancer patients; the majority of the patients seen in the private setting is diagnosed with early stage tumors, whereas the majority of patients that depend on the PHS is diagnosed with locally advanced tumors [ 45 ], a clear indication that difficulties to access the healthcare system are the main obstacles to early detection. 37% of the breast cancer cases diagnosed in the PHS are stage III or IV while in the private sector this number falls to 16.2% [ 46 ]. These data are corroborated by national studies that showed intervals of 75 to 185 days between initial symptom presentation and initial biopsy [ 45 ] and a median interval of 113.4 days between indication and initiation of radiation therapy [ 47 ]. For comparison purposes, patients seen in the private setting can have diagnostic tests and start treatment in less than 30 days.

To identify the main barriers to access to the PHS, Vieira et al. conducted a systematic review of the literature identifying 30 publications on this topic [ 48 ]. In a general analysis, it has been identified an underuse of mammogram machines on the north and northeast regions of the country and a mammogram coverage of only 35% of the Brazilian women, most of them in the private setting. The main issues related with not having a mammogram performed are non-white ethnicity, low educational level, low familiar income and not having health insurance. Another interesting finding of this study is that normally the treatment of breast cancer is performed in big cities and patients end up traveling more than 100 miles from their residences to the hospitals [ 49 ]. Even before the start of treatment, patients have to face delays of more than 60 days in 36.9% of the cases, because of inefficient referral and navigation. The main issues related with delays in the initiation of treatment were non-white ethnicity, not having a partner, low educational level, early stage breast cancer and dependence of the PHS [ 50 ]. Exclusive dependence on the PHS and non-white ethnicity were also associated with higher breast cancer-specific mortality [ 51 ].

6. Recommendation and discussion of the ethical dilemma

Considering the inefficacy of the screening programs in developing countries and the lack of solid evidence supporting screening of asymptomatic women below the age of 50 years old, we recommend resources reallocation to improve access to the healthcare system and the implementation of a fast track between diagnostic and treatment facilities to symptomatic patients, based on the hierarchical flow proposed by Migowski et al. ( Figure 1 ) [ 52 ]. This algorithm proposes three different actions: educational activities in primary care facilities to raise awareness regarding breast cancer and also the potential benefits and harms of mammographic screening; to offer the option of screening mammogram to asymptomatic women aged 50 to 69 during their visit to the primary healthcare provider; and to promote priority access to symptomatic patients, without the need of prior scheduling, in which the ones with suspicious lesions will be referred to diagnostic facilities. This recommendation is supported by Rawls’ two principles of justice [ 9 ]. The first principle governs that all persons have equal rights and freedoms. The second principle governs that the adoption of policies that generate social or economical inequalities is only acceptable if it favors the least advantaged portion of society. The promotion of educational activities proposed by Migowski et al. [ 52 ] is supported by Rawls’ first principle since it standardizes the access to a basic right, education. The second part of the recommendation is justified by Rawls’ second principle of justice. The adoption of a fast track to symptomatic patients, removing the need of a prior appointment or referral, promotes the reallocation of public resources to remove barriers in the access to care, reducing delays in diagnosis and treatment and, therefore, reducing inequalities in favor of the least advantaged part of the population that relies solely in the public health system. Although the recommendation favors a part of the population, it does not violate individual rights, as asymptomatic patients will still have access to screening mammogram in their routine visits to their primary healthcare providers. Moreover, the proposed recommendation promotes equal access to breast cancer diagnosis and treatment as it removes the age boundaries, starting to provide care to women below the age of 50 years old, an age range responsible for a large amount of new cases in developing countries and that were not previously included in the past recommendation [ 6 ].

Hierarchical flow to promote early diagnosis and treatment of breast cancer. Adapted from Migowski et al. [ 52 ].

Let us consider for a moment a hypothetical scenario in which the healthcare system works perfectly without any access barriers. Even in this setting, mammographic screening as it is currently suggested would not be ideal in developing countries. The current evidence that recommends mammographic screening is not unanimous and large randomized clinical trials did not show a robust mortality reduction attributable to it [ 13 , 53 ]. Moreover, even if these studies showed a significant mortality reduction attributable to screening mammogram, their results would hardly be applicable to the developing countries’ realities. Those studies were conducted in countries with high human development index (HDI) and in the context of organized screening. Brazil and most developing countries have lower HDIs and promote opportunistic screening due to the weak organizational structure of the healthcare system. This way, the international studies that assessed the effectiveness of mammographic screening lack the necessary external validity to be applied in developing countries. A recent article published by Vale et al. suggested, that the opportunistic screening program employed in the state of São Paulo, Brazil, promoted an increase in early stage diagnosis without, however, presenting data regarding mortality reduction [ 54 ]. Without data showing mortality reduction attributable to the screening program it is impossible to conclude whether this model is effective or not. Adding up to that data we have some concerning facts associated with screening women between the age of 40 and 49; we observe that less than one death from breast cancer is avoided for every one thousand screening mammograms performed; two hundred and ninety-four false-positive results ( Table 1 ) generate additional diagnostic procedures leading to economical impact to the health system and also physical and psychological impacts to the patients. Based on everything that was exposed in this paragraph, we can conclude is not adequate from Bentham’s and Mill’s utilitarianism perspective [ 10 , 11 ].

In this context, with the shortage of resources to invest in an organized mammographic screening program and without solid data to justify its implementation, can we accept a sub-optimal program? On the one hand, the inexistence of a screening program can lead to the increase in the number of cases diagnosed in late stages, for which the treatment options might be inaccessible and, sometimes, ineffective. On the other hand, developing countries, such as Brazil, sometimes lack the necessary infrastructure to perform timely screening mammograms to the whole eligible population and the consequent breast biopsies of lesions identified through screening [ 55 ]. In order to consider a screening program adequate, it must be acceptable, accessible, and sustainable, it must promote equity and it must be economically efficient to the target population [ 56 ]. As it has been demonstrated in this chapter, the Brazilian mammographic screening program is not accessible, since the coverage does not reach 30% of the target population [ 42 ]. This program is not sustainable either since there is a huge delay between the identification of an abnormal mammogram and the necessary biopsy to confirm the diagnostic. Due to the incapacity to adequately follow-up and refer patients with abnormal findings, the risk of a false-positive result must be considered clinically and ethically relevant. Finally, it’s been demonstrated that mammographic screening in developing countries is not cost-effective when compared to the alternative of treating patients with palpable initial lesions [ 57 , 58 ]. Contemplating all these issues, Sedhom et al. argued that clinical examination of the breast with fast referral to avoid delays in diagnosis and treatment, although not a screening program, must be considered a more pragmatic and adequate choice than screening mammogram in developing countries [ 59 ].

7. Conclusion

When weighing the benefits and harms of a mammographic screening program in a developing country, in a context where breast cancer-specific mortality has been increasing in the past few decades, it is extremely hard to justify increasing the age range to women aged 40 to 49 years old from an utilitarian perspective, since the amount of resources to establish and make the system work adequately is prohibitive. An alternative strategy that promotes easy access and fast referral of symptomatic patients, relegating a secondary role to mammographic screening, favors a larger and more vulnerable part of the population that depends solely on the PHS. This reallocation of resources to favor the least advantaged members of society is not only ethically justifiable but also a way of promoting social justice.

Conflict of interest

Rodrigo Goncalves has received consultation fees from EMS Pharmaceuticals in 2019 and 2020 and from Novartis in 2019, not related to the topics of this chapter.

The remaining authors do not have any conflicts of interest to disclose.

• 1. WHO. Key statistics on cancer. 29/02/2020]; Available from: https://www.who.int/cancer/resources/keyfacts/en/
• 2. WHO. National Cancer Control Programmes. Available from: https://www.who.int/cancer/nccp/en/
• 3. INCA, Rastreamento organizado do câncer de mama 2011
• 4. 1000 person tool. 2020 [cited 2020 09/11/2020]; Available from: https://canadiantaskforce.ca/tools-resources/breast-cancer-update/1000-person-tool/
• 5. INCA. Estatísticas de câncer. 2020 29/02/2020]; Available from: https://www.inca.gov.br/numeros-de-cancer
• 6. Simon, S.D., et al., Characteristics and prognosis of stage I-III breast cancer subtypes in Brazil: The AMAZONA retrospective cohort study. Breast, 2019. 44: p. 113-119
• 7. INCA, Diretrizes para a detecção precoce do câncer de mama no Brasil. 2015
• 8. da Mota Almeida Peroni, F., et al., Realizing the right to health in Brazil’s Unified Health System through the lens of breast and cervical cancer. Int J Equity Health, 2019. 18(1): p. 39
• 9. Rawls, J., A theory of justice. Rev. ed. 1999, Cambridge, Mass.: Belknap Press of Harvard University Press. xxii, 538 p
• 10. Bentham, J., An Introduction to the Principles of Morals and Legislation
• 11. Mill, J.S., Utilitarianism
• 12. Siu, A.L. and U.S.P.S.T. Force, Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med, 2016. 164(4): p. 279-96
• 13. Nelson, H.D., et al., Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med, 2016. 164(4): p. 244-55
• 14. Nelson, H.D., et al., Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med, 2009. 151(10): p. 727-37, W237-42
• 15. Marmot, M.G., et al., The benefits and harms of breast cancer screening: an independent review. Br J Cancer, 2013. 108(11): p. 2205-40
• 16. Medical Advisory, S., Screening mammography for women aged 40 to 49 years at average risk for breast cancer: an evidence-based analysis. Ont Health Technol Assess Ser, 2007. 7(1): p. 1-32
• 17. Humphrey, L., et al., in Screening for Breast Cancer. 2002: Rockville (MD)
• 18. Ringash, J. and C. Canadian Task Force on Preventive Health, Preventive health care, 2001 update: screening mammography among women aged 40-49 years at average risk of breast cancer. CMAJ, 2001. 164(4): p. 469-76
• 19. Olsen, O. and P.C. Gotzsche, Screening for breast cancer with mammography. Cochrane Database Syst Rev, 2001(4): p. CD001877
• 20. Alexander, F.E., The Edinburgh Randomized Trial of Breast Cancer Screening. J Natl Cancer Inst Monogr, 1997(22): p. 31-5
• 21. Andersson, I. and L. Janzon, Reduced breast cancer mortality in women under age 50: updated results from the Malmo Mammographic Screening Program. J Natl Cancer Inst Monogr, 1997(22): p. 63-7
• 22. Bjurstam, N., et al., The Gothenburg breast screening trial: first results on mortality, incidence, and mode of detection for women ages 39-49 years at randomization. Cancer, 1997. 80(11): p. 2091-9
• 23. Frisell, J. and E. Lidbrink, The Stockholm Mammographic Screening Trial: Risks and benefits in age group 40-49 years. J Natl Cancer Inst Monogr, 1997(22): p. 49-51
• 24. Miller, A.B., et al., The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomized screening trial of mammography in women age 40 to 49 years. Ann Intern Med, 2002. 137(5 Part 1): p. 305-12
• 25. Moss, S.M., et al., Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years’ follow-up: a randomised controlled trial. Lancet, 2006. 368(9552): p. 2053-60
• 26. Shapiro, S., Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance Plan. J Natl Cancer Inst Monogr, 1997(22):p. 27-30
• 27. Tabar, L., et al., The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up. Radiol Clin North Am, 2000. 38(4): p. 625-51
• 28. Hellquist, B.N., et al., Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort. Cancer, 2011. 117(4): p. 714-22
• 29. Jonsson, H., et al., Service screening with mammography in Northern Sweden: effects on breast cancer mortality - an update. J Med Screen, 2007. 14(2): p. 87-93
• 30. Urban, L., et al., Breast cancer screening: updated recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations. Radiol Bras, 2017. 50(4): p. 244-249
• 31. Decision-making for cancer care: A review of current practice and opportunities for improvement in Latin America. 2019, The Economist Intelligence Unit
• 32. Biddle, J.B., Epistemic risks in cancer screening: Implications for ethics and policy. Stud Hist Philos Biol Biomed Sci, 2019: p. 101200
• 33. Rudner, R., The Scientist Qua Scientist Makes Value Judgments
• 34. Pramesh, C.S., et al., Ethics of “standard care” in randomised trials of screening for cervical cancer should not ignore scientific evidence and ground realities. Indian J Med Ethics, 2013. 10(4): p. 250-1
• 35. Douglas, H., Inductive risk and values in science
• 36. Mercan, E., et al., Assessment of Machine Learning of Breast Pathology Structures for Automated Differentiation of Breast Cancer and High-Risk Proliferative Lesions. JAMA Netw Open, 2019. 2(8): p. e198777
• 37. Ennis, R. and A. Jotkowitz, Good ethics begins with sound medicine: prostate cancer screening and chemoprevention. Am J Bioeth, 2011. 11(12): p. 26-7
• 38. Tiezzi, D.G., et al., Current Breast Cancer Screening Scenario in Brazil. Revista Brasileira de Ginecologia e Obstetrícia, 2019. 41: p. 633-635
• 39. Brito, E.A.C., et al., Assessing trends of breast cancer and carcinoma in situ to monitor screening policies in developing settings. Sci Rep, 2019. 9(1): p. 14144
• 40. Rodrigues, D.C.N., et al., Temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service between 2008 and 2017. BMC Public Health, 2019. 19(1): p. 959
• 41. WHO, Cancer control: knowledge into action. WHO guide for effective programmes: prevention. 2007, Geneva: WHO
• 42. Rodrigues, D.C.N., et al., Difficult Access and Poor Productivity: Mammography Screening in Brazil. Asian Pac J Cancer Prev, 2019. 20(6): p. 1857-1864
• 43. Greenwald, Z.R., et al., The performance of mobile screening units in a breast cancer screening program in Brazil. Cancer Causes Control, 2018. 29(2): p. 233-241
• 44. Bank, W., Brazil - systematic country diagnostic. 2016
• 45. Werutsky, G., P. Nunes, and C. Barrios, Locally advanced breast cancer in Brazil: current status and future perspectives. Ecancermedicalscience, 2019. 13: p. 895
• 46. Lee, B.L., et al., Breast cancer in Brazil: present status and future goals. Lancet Oncol, 2012. 13(3): p. e95-e102
• 47. TCU, Relatório de Auditoria Operacional: Política Nacional de Atenção Oncológica. , S.d.F.e.A.d.P.d. Governo, Editor. 2011
• 48. Vieira, R., A. Formenton, and S.R. Bertolini, Breast cancer screening in Brazil. Barriers related to the health system. Rev Assoc Med Bras (1992), 2017. 63(5): p. 466-474
• 49. Oliveira, E.X., et al., [Access to cancer care: mapping hospital admissions and high-complexity outpatient care flows. The case of breast cancer]. Cad Saude Publica, 2011. 27(2): p. 317-26
• 50. Medeiros, G.C., et al., [Determinants of the time between breast cancer diagnosis and initiation of treatment in Brazilian women]. Cad Saude Publica, 2015. 31(6): p. 1269-82
• 51. Guerra, M.R., et al., Breast cancer survival and health iniquities. Cad Saude Publica, 2015. 31(8): p. 1673-84
• 52. Migowski, A., et al., Guidelines for early detection of breast cancer in Brazil. III - Challenges for implementation. Cad Saude Publica, 2018. 34(6): p. e00046317
• 53. Miller, A.B., et al., Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ, 2014. 348: p. g366
• 54. Vale, D.B., et al., Downstaging in opportunistic breast cancer screening in Brazil: a temporal trend analysis. BMC Cancer, 2019. 19(1): p. 432
• 55. Vizcaino, I., et al., Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screening mammography. Radiology, 2001. 219(2): p. 475-83
• 56. Shah, S.C., et al., Cancer Control in Low- and Middle-Income Countries: Is It Time to Consider Screening? J Glob Oncol, 2019. 5: p. 1-8
• 57. Gelband, H., et al., Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities, 3rd edition. Lancet, 2016. 387(10033): p. 2133-2144
• 58. Groot, M.T., et al., Costs and health effects of breast cancer interventions in epidemiologically different regions of Africa, North America, and Asia. Breast J, 2006. 12 Suppl 1: p. S81-90
• 59. Sedhom, R. and B. Gyawali, When Is a Suboptimal Approach to Cancer Screening Better Than None? AMA J Ethics, 2020. 22(2): p. E93-101

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Continue reading from the same book

Edited by Thomas F. Heston

Published: 19 May 2021

By Omur Sayligil

619 downloads

By Paulo Santos, Pedro Teixeira, Helena Beça and Albe...

830 downloads

By Neerja Aggarwal, Pawan Kumar Kare and Sudip Kumar ...

2157 downloads

Essay: Raising awareness about prostate cancer

Other than skin cancer, prostate cancer is the most common cancer in men and is the second most common cause of cancer death in the United States.

The American Cancer Society estimates that in 2021 more than 248,000 American men will be diagnosed and more than 34,000 men will die of prostate cancer. Nearly 1 in 8 men will be afflicted by this disease in their lifetime and 1 in 41 men will die of prostate cancer.

Most commonly, prostate cancer manifests as a localized, silent disease, progressing slowly with minimal to no symptoms. Once the disease has spread out of the prostate to adjacent organs, lymph nodes or bones, symptoms become more prevalent. These include pain, urinary problems, neurologic symptoms, and more.

Data have shown that active screening can lead to early diagnosis. Studies with long-term follow-up have demonstrated an approximate 30 percent decrease in prostate cancer mortality when screening is implemented. In fact, the implementation of prostate cancer screening has been one of the main reasons for the decrease in prostate cancer-specific death by more than 50 percent from 1993 to 2017.

Screening for prostate cancer is simple and quick, performed with a digital rectal exam (DRE) assessing prostate size and contour and a blood test for prostate-specific antigen (PSA). PSA is a protein made by cells located in the prostate gland (both normal cells and cancer cells). The risk of being diagnosed with prostate cancer increases as the PSA blood level increases.

The National Comprehensive Cancer Network (NCCN) guidelines recommend that men over the age of 45 should discuss prostate cancer screening with their physicians. For men at increased risk (known family history, known genetic risk factors, or African ancestry) discussion about screening should start even earlier at age 40.

When prostate cancer is diagnosed at an early stage, and is still localized, the cure rate is incredibly high, with a nearly 100 percent five-year cancer-free survival rate. Once prostate cancer is diagnosed, various treatment options are available, ranging from “active surveillance” (frequent monitoring of the disease with no active treatment) to radiation or surgery and other therapeutic options.

Novel scientific discoveries, new treatment options and robust research published in the last decade have led to significant advances in the diagnosis and treatment of this common malignancy.

Despite the continuous increase in the incidence and prevalence of prostate cancer and a constant rising rate of cancer-specific death, not all men actively seek preventive care and undergo screening.

September is Prostate Cancer Awareness Month. During this time, various attempts are made across the country to raise awareness of this highly prevalent cancer and promote screening and early detection.

At Upstate Urology at the Mohawk Valley Health System (MVHS), we are organizing a free screening event at various dates and times throughout the month of September. These events are being scheduled so as to adhere to social distancing guidelines, with individual appointments being made.

It’s important that you don’t put off screenings during this time of COVID, and we encourage all men between the ages of 45-75 to use this opportunity to be screened for prostate cancer.

Visit mvhealthsystem.org/urology for more information.

As a urologist treating prostate cancer patients and as a son of a prostate cancer survivor, I hope our call is answered, and with your help, we will succeed in raising awareness and spreading the word.

Please join our important quest to fight this cancer by reaching out to more men and improving early detection rates.

Dr. Hanan Goldberg, MD, MSc, is assistant professor at SUNY Upstate Medical University and chief of Upstate Urology at the Mohawk Valley Health System (MVHS).

A cancer breakthrough and the heroes behind it get spotlight in new show

“The Cancer Detectives,” a new American Experience documentary on PBS , tracks the fascinating and surprisingly frustrating backstory of the Pap smear, a cervical cancer screening test that’s now routine but was once anything but.

The film takes viewers back to the days before Pap smears, a time when cervical cancer was rightfully feared by patients and doctors alike. A century ago, cervical cancer was a major killer of women. Early detection was impossible, and sexual stigma and shame kept women from discussing it.

So it’s not surprising that when an immigrant physician from Greece, George Papanicolaou , nicknamed “Dr. Pap,” discovered a way to detect changes in cervical cells, his breakthrough was largely disregarded by the scientific community.

It would take a massive public relations war against the unspeakable cancer to make the Pap smear a routine part of cervical cancer screening — a war waged in part by Black OB/GYN Helen Dickens, Japanese American illustrator Hashime Murayama and a group of women committed to cancer prevention.

The film documents the sometimes maddening hurdles they faced, from Murayama’s arrests for being an “enemy alien” during World War II to the racism and sexism that Dickens faced as she attempted to practice medicine and spread the news about cervical cancer screening.

Spoiler alert: They succeeded. Thanks in part to the Pap smear, cervical cancer incidence in the United States has fallen by more than 70 percent since the 1950s.

Luckily, knowing the end of the story doesn’t detract from the fascinating tale, which is rife with historical injustice. Social and scientific progress can be slow, but “The Cancer Detectives” recognizes the tireless efforts of a group of people whose work deserves to be remembered.

“American Experience: The Cancer Detectives” premieres on PBS stations on March 26 at 9 p.m. Eastern time and will stream on PBS.org.

• What to do about jaw pain, and when to worry April 8, 2024 What to do about jaw pain, and when to worry April 8, 2024
• Want a mood boost? Get out there and try something new. April 8, 2024 Want a mood boost? Get out there and try something new. April 8, 2024
• An Ozempic baby boom? Some GLP-1 users report unexpected pregnancies. April 5, 2024 An Ozempic baby boom? Some GLP-1 users report unexpected pregnancies. April 5, 2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation

Lily c. taylor.

1 The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom

2 School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom

Alison Hutchinson

Rebecca a. dennison, juliet a. usher-smith, associated data.

All relevant data are contained within the paper and/or Supporting Information files.

Introduction of risk stratification within population-based cancer screening programmes has the potential to optimise resource allocation by targeting screening towards members of the population who will benefit from it most. Endorsement from healthcare professionals is necessary to facilitate successful development and implementation of risk-stratified interventions. Therefore, this review aims to explore whether using risk stratification within population-based cancer screening programmes is acceptable to healthcare professionals and to identify any requirements for successful implementation.

We searched four electronic databases from January 2010 to October 2021 for quantitative, qualitative, or primary mixed methods studies reporting healthcare professional and/or other stakeholder opinions on acceptability of risk-stratified population-based cancer screening. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Data were analysed using the Joanna Briggs Institute convergent integrated approach to mixed methods analysis and mapped onto the Consolidated Framework for Implementation Research using a ‘best fit’ approach. PROSPERO record CRD42021286667.

A total of 12,039 papers were identified through the literature search and seven papers were included in the review, six in the context of breast cancer screening and one considering screening for ovarian cancer. Risk stratification was broadly considered acceptable, with the findings covering all five domains of the framework: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. Across these five domains, key areas that were identified as needing further consideration to support implementation were: a need for greater evidence, particularly for de-intensifying screening; resource limitations; need for staff training and clear communication; and the importance of public involvement.

Conclusions

Risk stratification of population-based cancer screening programmes is largely acceptable to healthcare professionals, but support and training will be required to successfully facilitate implementation. Future research should focus on strengthening the evidence base for risk stratification, particularly in relation to reducing screening frequency among low-risk cohorts and the acceptability of this approach across different cancer types.

Introduction

Cancer is a leading cause of global mortality with approximately 10 million cancer deaths and over 19 million new cancer diagnoses occurring in 2020 [ 1 ]. Moreover, these figures are expected to increase by almost 50% over the next two decades, amounting to a predicted 28.4 million cases in 2040 [ 1 ]. Prevention and early detection through population-based screening programmes is an effective way to reduce cancer incidence and/or mortality [ 2 , 3 ]. However, as well as these benefits, cancer screening programmes are associated with costs and harms. These harms include false positive or false negative screening tests, overdiagnosis and overtreatment (where a cancer that would never cause any symptoms is diagnosed and treated), physical harms from screening or subsequent tests, and negative psychological impacts [ 3 , 4 ]. Screening also incurs financial and resource costs within healthcare systems and increasing screening capacity in response to rising cancer incidence is not feasible in settings where resources are both finite and overstretched [ 3 , 5 ]. Most cancer screening programmes operate a fixed regime where eligibility is based on age and/or sex and screening intervals are determined by the screening results, rather than additional individual level risk factors [ 5 ]. For example, all women aged over 25 in England are invited for cervical screening and those with a positive HPV result are invited for further screening with a reduced interval irrespective of their age or other individual level risk factors for cervical cancer. There is increasing interest in risk stratification within cancer screening programmes in order to improve the balance of benefits and harms for patients and distribute limited healthcare resources in the most efficient way [ 5 – 7 ].

Risk stratification involves tailoring elements of the cancer screening programme, such as test modality, screening interval or eligibility criteria, based on personal risk determined using individual level characteristics. Such an approach ensures that screening is targeted to those with the highest cancer risk whilst minimising harm to people of lower risk [ 5 , 7 ]. For example, high risk individuals may be invited to attend screening from an earlier age or to attend more frequently and those of low risk may receive reduced intervention or even forgo screening entirely [ 6 , 7 ].

Implementing risk stratification into cancer screening programmes could maximise diagnostic yields while using the same quantity of resources by distributing them more efficiently [ 5 , 6 ]. This approach not only confers benefits to the patients undergoing screening but will also impact on healthcare professionals (HCPs) and wider stakeholders involved in screening service provision [ 5 ]. In particular, service providers and other stakeholders stand to benefit through optimising allocation of scarce resources, reduced financial burden, decreased waiting times, and potential improvements in patient compliance with screening recommendations [ 5 ]. Furthermore, there is an additional benefit of identifying suitable candidates for risk reducing interventions and enabling clinicians to use patients’ risk level in shared decision-making [ 5 ]. However, risk stratification also requires introducing complexity into screening programmes, such as increased burden relating to the engagement and risk-based management of patients, supplementary workforce training, and ethical challenges associated with endorsing reduced screening [ 8 ]. This has implications not only for those responsible for executing and monitoring the programmes, but also for those involved in delivery. HCPs within primary care and those directly involved in the programmes are also a first point of contact for individuals invited to take part in screening.

As well as being safe, affordable, and efficient, screening programmes must also be acceptable to all those involved from a clinical, social, and ethical perspective if they are to be successful [ 9 ]. Therefore, the views of HCPs on the acceptability of using risk stratification within population-based cancer screening programmes must be understood to facilitate successful development and implementation of risk-stratified interventions [ 7 , 8 , 10 , 11 ]. Previous reviews have identified a lack of evidence surrounding acceptability and expressed a need for greater understanding of HCPs’ perspectives on acceptability, including anticipated organisational barriers and facilitators [ 8 , 12 , 13 ]. Furthermore, risk stratification represents a complex, large-scale change for health systems and may be influenced by organisational constraints and challenges. As such there is a need to understand acceptability within the wider organisational and structural healthcare landscape and to engage stakeholders across all areas [ 6 , 12 ]. This review aims to explore whether risk stratification within population-based screening programmes is acceptable to HCPs and to identify any requirements for successful implementation.

We performed a systematic literature review in line with a previously established study protocol (PROSPERO 2021 CRD42021286667). The methods used for the systematic literature review detailed here were the same as those used for a parallel review focused on the acceptability of risk stratification within cancer screening programmes from the perspective of the general public as detailed in the aforementioned study protocol.

Search strategy

We performed an electronic literature search of MEDLINE, Embase, Web of Science and PsycINFO from the 1 st of January 2010 to the 31 st of November 2021 using a combination of title and abstract search terms and MeSH terms including ‘risk stratification’, ‘cancer’, ‘screening’, ‘acceptability’ and related synonyms (see S1 Table for the full search strategy). The date was restricted based on the results of preliminary searches and in order to capture contemporary views towards risk-stratified cancer screening due to the advances made in identifying and sequencing genetic variants and their use in cancer risk prediction modelling [ 14 , 15 ].

Study selection

We included English language studies that were published in peer reviewed journals that fulfilled the following eligibility criteria:

• Quantitative, qualitative, or primary mixed methods studies
• Presented in the context of population-based screening
• Specific to risk-stratified cancer screening, where risk stratification is defined as including two or more individual level risk factors beyond age and sex, including phenotypic or genetic factors, in combination to systematically determine elements of the screening programme according to individual risk
• Include healthcare professional, health service provider, and/or other stakeholder opinions on acceptability, where acceptability is defined according to the Theoretical Framework of Acceptability (TFA) as “A multi-faceted construct that reflects the extent to which people delivering or receiving a health intervention consider it to be appropriate , based on anticipated or experienced cognitive and emotional responses to the interventions” [ 16 ].

Studies conducted in the context of cancer surveillance/monitoring pathways, case finding, or investigating acceptability of non-risk-stratified screening were excluded. Studies conducted exclusively with participants who have high-risk cancer genes (e.g. BRCA1 , BRCA2 , PALB2 ) were excluded as these individuals are managed within surveillance programmes outside of general population-based screening.

With the support of an information specialist, one reviewer (LT) conducted the database searches, removed duplicates, and reviewed titles and abstracts for all citations. A second reviewer (RD, AH, KL) independently screened 10% of citations and any discrepancies were resolved in the presence of a third reviewer. At least two reviewers (LT, RD, AH, KL) reviewed all citations eligible for full text review. Studies that were considered ineligible by both reviewers were excluded and any areas of disagreement were resolved at consensus meetings including all researchers. The reference lists of two previous systematic reviews about risk-based breast cancer screening [ 17 , 18 ] and the reference lists of all eligible studies were reviewed via the same process to identify any papers that were not found by the literature search.

Data extraction and synthesis

A primary reviewer (LT) completed the preliminary phase of data extraction for all eligible studies using a standardised form including title, author and year, primary aim, setting, cancer type(s), sample size, demographic characteristics, study design, and method of analysis. A second stage of data extraction in which the results, themes (if applicable) and the authors’ conclusions from each included study was completed by the primary reviewer and 50% of papers underwent data extraction by a second independent reviewer (KL) to reduce bias.

Data extraction and synthesis followed the Joanna Briggs Institute convergent integrated approach to mixed methods systematic reviews [ 19 , 20 ]. This approach was taken as it is recommended where the research question is able to be answered by both quantitative and qualitative data [ 19 – 21 ]. All data presented in the results section of the eligible papers were extracted directly into NVivo 12 software (QSR International Pty Ltd; released 2018), including relevant tables and supplementary results. As in the convergent integrated approach, quantitative data from quantitative and primary mixed methods studies were first extracted from each study and then transformed into qualitative statements. Each statement was a textual description, including relevant numerical results, produced by narrative interpretation of the data. These were presented alongside contextual anchors to preserve the integrity of the findings [ 20 ]. The qualitative statements generated by transforming the data in this way were combined with the qualitative data and all were coded according to the Consolidated Framework for Implementation Research (CFIR), drawing on a ‘best fit’ approach [ 22 – 24 ].

The CFIR was chosen for its extensive coverage of domains having been developed from a number of other implementation frameworks, including the Diffusion of Innovations Theory [ 24 , 25 ]. It is comprised of five high level domains: Intervention characteristics, Outer setting, Inner setting, Characteristics of individuals, and Process. The intervention in this case is risk-stratified screening. The outer setting includes external policies, guidance, and pressures. The inner setting refers to organisational factors such as the culture and resources available in healthcare systems. The individuals in question are the HCPs and the process relates to the spectrum of implementation activities from planning through to execution.

The ‘best fit’ approach involves coding data against an a priori framework and then using thematic analysis methods to accommodate any data that does not fit within the initial framework to generate a final framework that is a better fit for the data in question. Benefits of this approach include its specificity to the review context and a reduced likelihood that data will be inappropriately ‘shoehorned’ into an existing model [ 23 ]. Furthermore, this approach has been adopted frequently for analysis in systematic reviews relating to HCPs, health organisations, and wider health policy [ 26 – 28 ]. We began by coding the data according to the original CFIR framework and then reviewing the contents of each construct. Construct names were amended to better suit the meaning of the data within them, framework constructs with a high degree of overlap were merged, and new construct definitions were generated for any codes that did not sit comfortably in the a priori framework.

Once all the data had been coded against the final best-fit framework, sub-themes were synthesised via thematic analysis within each framework construct, involving the aggregation of closely related codes. To synthesise the data, we summarised the content of each sub-theme, and sought to identify and interpret areas of similarity, ambiguity, and disagreement.

The iterative process of data synthesis was conducted via a series of meetings by the first author (LT) who has limited experience of qualitative methods and a second researcher (RD) who has extensive experience in qualitative research. Initial coding and analyses were performed independently, and researchers then came together for subsequent revisions and to refine the final framework and lower-level themes.

Quality assessment

Quality assessment was performed by two independent reviewers (LT& RD/ KL) for all eligible papers using the Mixed Methods Appraisal Tool (MMAT) [ 29 ]. The MMAT is designed for the assessment of five different study types (qualitative research, mixed methods research, quantitative descriptive studies, randomised controlled trials, and non-randomised studies) and consists of a series of screening questions that can be answered as ‘yes’, ‘no’, or ‘can’t tell’. No studies were excluded on the basis of quality.

The search generated 12,039 citations, after removal of duplicates. Of these, 11,977 were excluded at title and abstract review with an agreement of 96%. A further 106 citations were excluded after full text screening and the most common reasons for exclusion at this stage were that the papers were non-empirical research or were not specific to the acceptability of risk stratification ( Fig 1 ). An additional paper was identified through searching the reference lists of the eligible citations, resulting in a total of seven papers eligible for inclusion in the review [ 30 – 36 ].

Study characteristics

The characteristics and key findings of each study are summarised in Table 1 . The majority of studies were in relation to breast cancer screening (N = 6/7, 86%) [ 31 – 36 ], with a single study conducted in the context of ovarian cancer screening [ 30 ]. A wide variety of HCPs were involved across the eligible studies, including clinicians, researchers, and operational staff, and sample sizes ranged from 11 [ 33 ] to 829 [ 30 ] participants. Studies took place across five high-income countries: four included participants from the UK [ 30 , 32 , 34 , 36 ], two from Canada [ 33 , 35 ], and one each from Germany, Sweden, and the Netherlands, respectively [ 31 , 32 ]. The majority of studies used qualitative methods in the form of interviews, focus groups, or deliberative consultation (N = 5/7, 71%) [ 31 , 33 – 36 ]. One study utilised a quantitative cross-sectional survey design [ 30 ] and a single primary mixed methods study using digital concept mapping was also included [ 32 ].

BC–breast cancer

GP–general practitioner

HCP–healthcare provider/healthcare professional

HR–human resources

Mammography screening 2.0 –individualised mammography screening

MD–Doctor of Medicine

The results of the quality assessment are presented in Table 2 . The qualitative studies were found to be of high quality across all MMAT domains [ 31 , 33 – 36 ]. The single primary mixed methods study was also of relatively high quality, scoring ‘yes’ for all MMAT domains except for ‘Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?’ for which it scored ‘can’t tell’ as the risk of non-response bias was unclear [ 32 ]. Finally, the quantitative study by Hann et al., was of lower quality, scoring ‘can’t tell’ or ‘no’ in two domains as it was uncertain whether the sample was representative and there was evidence of non-response bias where self-efficacy and knowledge scores were significantly lower among those who did not complete the survey ( p = 0.042 and p <0.001 respectively) [ 30 ].

All papers scored ‘Yes’ for screening questions 1 & 2 (S1. Are there clear research questions? S2. Do the collected data allow to address the research questions?)

✓ Yes

Χ No

? Can’t tell

‘Best fit’ CFIR framework

The majority of themes included in the a priori framework were compatible with the data, however two constructs were amended to better represent their contents and several of the original CFIR constructs were not applicable to this analysis. The best fit framework we generated is presented in Fig 2 . As in the original CIFR model, findings were categorised using five key domains and each of these domains contained high-level themes and lower-level sub-themes.

Constructs are divided across 5 domains and those in grey represent themes that were not applicable to this analysis. Construct names in italics represent those that have been amended to better suit the data as part of the ‘best-fit’ approach.

Strength of the evidence

As shown in Table 3 , the majority of constructs were discussed in several of the included studies, aside from the Inner setting themes ‘Tension for change’ and ‘Relative priority’ which were only briefly contributed to by two studies [ 31 , 35 ]. Although these two studies were of high quality, the strength of the evidence is lacking for these particular themes. Conversely, other themes were explored across many of the included studies, most notably ‘Knowledge and beliefs about the intervention’ which was considered in detail across all seven papers, resulting in strong cumulative evidence for this construct. Three qualitative studies [ 33 – 35 ] considered 15 or more of the constructs, contributing greatly towards several of the themes. Furthermore, these studies were of high quality, generating robust evidence for these constructs.

Circle = ‘yes’ for all MMAT domains

Square = ‘no’/’can’t tell’ for one or more MMAT domains

Clear = study briefly contributes to the theme

Filled = study strongly contributes to the theme

Intervention characteristics

An overview of the synthesised findings and illustrative quotes relating to the Intervention characteristics domain is given in Table 4 .

BOADICEA–Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm

FG–focus group

PCP–primary care provider/practitioner

RPM–risk prediction model

TI–telephone interview

UK–United Kingdom

Quotes in italics represent those from HCPs. Quotes that are not in italics represent those of the author.

HCPs roles have been included where available in the original paper.

Intervention source

Although the source of the intervention was only considered by HCPs in three studies, those that did consider this construct emphasized the importance of involving both HCPs and the general public in all stages of development and implementation [ 34 , 35 ]. Some concern was also raised about the role of cost in promoting the development of risk-stratified screening programmes and how this might be perceived by stakeholders if it were presented as one of the key drivers [ 34 ].

Evidence strength and quality

Two of the included studies focused specifically on introducing low-risk screening pathways. As such, much of the discussion around evidence strength was in relation to reducing screening for individuals at low risk [ 34 , 36 ]. HCPs expressed doubt over the strength of the evidence for reducing breast screening of low-risk women as part of a risk-stratified pathway, particularly in relation to interval cancers and the chance of low-risk women being diagnosed with aggressive, non-hormone dependent breast cancer before they are invited for screening [ 34 ]. This was echoed by a general call for more research and modelling studies to ensure that the features of a risk-stratified programme are evidence-based [ 33 , 36 ].

HCPs also highlighted the value of accurately modelling risk in developing confidence in risk estimates and in appropriately identifying risk-based cohorts [ 34 , 36 ]. The variables included in risk models and the stability of risk estimates over time factored into HCPs’ consideration of the available evidence. Individuals expressed concerns that risk models may not be accurate or stable enough to allow screening to confidently be reduced for low-risk women. Although they believed the strength of the evidence was the most important factor in determining the features of a risk-stratified programme, inaccuracies in self-reported data and the unpredictable nature of the variables used in risk modelling also resulted in scepticism [ 36 ].

Additionally, there was some disparity between the priorities of different professional groups. For example, clinicians in the UK deemed concerns surrounding accuracy of risk stratification to be the most important factor in women’s decision-making process to attend screening, whereas non-clinical professionals in the UK rated this as the least important factor [ 32 ]. Genetic counsellors in particular had reservations about the applicability of risk prediction models for different patient subgroups and PCPs questioned whether the benefits conferred by risk stratification would differ according to cultural inequalities [ 35 ].

Relative advantage or disadvantage

Some HCPs were optimistic about the impact of risk stratification on reducing demands on staff and screening programme resources, as well as reducing heterogeneity in service provision [ 34 , 35 ]. Other possible advantages of a risk-stratified approach included reducing harms such as overdiagnosis and overtreatment for low-risk individuals, particularly in the context of breast screening programmes that have received such criticism in the past [ 36 ].

HCPs further acknowledged that, in some cases, the current provision of cancer screening services is inadequate, and that introduction of a risk-stratified approach would represent an opportunity for health promotion activities [ 30 , 31 ]. Genetic counsellors in particular noted that risk stratification would make risk assessment much more accessible, allowing patients to overcome lengthy waiting lists. This was thought to be particularly advantageous for those at moderate to high risk [ 33 ].

Conversely, some participants speculated that moving away from the current system to one in which screening may be reduced for some members of the population would take away the reassurance that many people gain from attending screening [ 36 ]. For established screening programmes that the public are already familiar with, changes to the screening interval might raise anxiety about cancers being missed in the interim and generate increased disapproval of the screening programme [ 34 ].

Despite these seemingly opposing opinions, some HCPs identified that the likely impact of introducing risk stratification on healthcare resources would be neutral. Although reduced screening of low-risk cohorts may have benefits for staff workload, it is probable that inclusion of higher risk cohorts would balance out this effect [ 34 ].

HCPs acknowledged the complex nature of risk-stratified cancer screening compared to a standard programme and identified several barriers that would need to be addressed in order for risk stratification to be implemented in an acceptable way. These were predominantly concerns around time and resource constraints, as well as compatibility with existing screening infrastructure, which are discussed in greater detail in the ‘Compatibility’ and ‘Available resources’ sections below. The complexities of transitioning to risk-stratified screening were a fundamental concern for HCPs and a lack of consensus around how to address this was both recognised and perpetuated by participants [ 32 , 34 ].

Design quality and communications

The communication of individual risk and the underlying motivations for risk stratification were of chief concern for many HCPs. Participants highlighted that communication styles should be tailored to individuals as much as the screening programme itself and emphasised that clarity will be essential in supporting a transition away from the current screening rhetoric [ 35 , 36 ]. A need for new and adaptable risk communication tools was expressed to facilitate communication of risk, and participants felt these should be compatible with electronic systems and embedded in patient medical records [ 33 , 35 ].

Rainey et al., asked HCPs to consider the importance of communication from the perspective of patients [ 32 ]. Dutch clinicians believed ‘Communicating risk’ to be the most important factor for women’s decision-making process to attend risk-stratified screening. Yet, other Dutch professionals ranked this as the least important factor for decision-making, suggesting discrepancies in how different stakeholders value and prioritise risk communication [ 32 ].

While some HCPs anticipated the impact of risk stratification on resources would be neutral, the potential for increased financial costs associated was remarked upon. This was particularly relevant in the context of publicly funded health services where cost has a considerable bearing on policy [ 34 , 35 ]. The importance of cost-effectiveness evidence was emphasized, and participants felt this was likely to be a crucial consideration for wider stakeholders [ 34 ].

The concept of cost was also discussed in terms of time and resources. Some providers felt that risk stratification may go some way to addressing resource constraints [ 31 ]. However, others conveyed concern that risk-stratified cancer screening might actually increase costs and worsen waiting times in an already resource constrained environment [ 35 ]. Despite the importance of cost considerations for HCPs themselves, when asked to consider the views of women deciding whether to engage in risk-stratified cancer screening, Swedish healthcare providers rated financial concerns as being the least important factor to consider [ 32 ].

Outer setting

An overview of the synthesised findings and illustrative quotes relating to the Outer setting domain is given in Table 5 .

HCP–healthcare professional

MRI–magnetic resonance imaging

NHSBSP–National Health Service Breast Screening Programme

Patient needs and resources

This was a diverse construct that also contained perceived barriers and facilitators for those receiving the intervention. This construct was examined in depth by participants across five of the included studies [ 32 – 36 ].

When considering the psychological impact of risk stratification and receiving personalised risk estimates, HCPs tended to focus on the potential for negative ramifications. Increased anxiety, reduced reassurance, and feelings of insecurity were suggested barriers observed across all five studies [ 32 – 36 ]. Genetic counsellors in one study speculated that patients may experience unnecessary stress without timely and trustworthy answers to their questions about risk [ 33 ]. This was linked to their wider concerns that women who did not have a primary care provider (PCP) would have reduced access to risk stratified screening and would be less informed as a result [ 33 ]. Some participants also acknowledged the potential for positive implications such as reassurance or a sense of empowerment in knowing one’s risk level and the ability to inform other family members about risk [ 32 , 33 , 35 ].

Two papers focused on low-risk individuals and considered some of the potential barriers and facilitators relating to this group specifically [ 34 , 36 ]. HCPs in these studies questioned the ability of low-risk individuals to understand the meaning of risk estimates and the implications for screening opportunities, as well as the potential for interval cancers and delayed diagnoses [ 34 , 36 ].

Finally, HCPs explored public information needs and the role of informed decision making across all risk groups. Informed choice was generally seen as a good thing, suggesting that individuals may want to be informed of the advantages and disadvantages of risk-stratified screening and that their questions should be appropriately addressed, and support offered where applicable [ 32 – 34 , 36 ]. PCPs in particular felt that risk stratification could reduce anxiety levels and would be useful in shared decision-making when discussing breast cancer screening with women [ 33 ]. It was also acknowledged that different population subgroups may require different levels of support in understanding this new approach to screening [ 33 ].

External policy and incentives

HCPs emphasised the need for a new, homogenous set of evidence-based guidelines for risk-stratified cancer screening [ 31 , 35 ]. Current guidelines were perceived as inadequate and unclear, but it was noted that guidance may need to be region-specific in practice [ 35 ].

Inner setting

An overview of the synthesised findings and illustrative quotes relating to the Inner setting domain in given in Table 6 .

HP–health professional

Discussion around culture focussed on the roles and values held by different groups of healthcare providers, especially whose role or responsibility it is to interpret and communicate risk. It was generally accepted that risk should be interpreted by HCPs and not by lay individuals, but the supposed role of individual types of professional varied due to organisational assumptions [ 31 , 35 ]. Some participants, notably general practitioners (GPs), felt that all roles relating to genetic risk should be undertaken by a geneticist, believing that interpretation of risk across all cohorts lies within their remit [ 35 ]. Conversely, geneticists themselves were content to counsel high risk individuals but felt that conversations about average risk patients lay outside of their domain and belonged within primary care [ 35 ].

Rainey et al. reported other discrepancies across professional groups especially in the UK context, suggesting that individuals’ norms, values, and assumptions vary within the inner setting and indicating that the priorities of groups like genetic counsellors may not align with the priorities of other professionals, such a GPs [ 32 ].

Compatibility

When considering compatibility of risk-stratified cancer screening, HCPs predominantly debated the degree of fit between risk stratification and existing screening pathways and considered this in the context of risk in other medical settings. HCPs advocated for integration with existing screening infrastructure to minimise confusion and disruption [ 34 – 36 ]. However, as described when considering the complexity of risk-stratification compared with existing programmes, the introduction of a risk-stratified pathway was not discussed favourably, and participants had doubts about feasibility when compared to a more simplistic programme [ 34 , 36 ]. Notably, one participant felt that a risk-stratified programme would in fact be less challenging than anticipated as patients are already to exposed other risk-based health principles, for example antenatal screening [ 34 ].

Available resources

Many HCPs considered the level of resources available for implementation and sustained use of risk-stratified cancer screening programmes. Concerns about the ability for current resources to meet the demands of risk-stratified screening were present, alongside ideas of equity and managing the capacity for patient conversations [ 30 , 33 , 35 , 36 ]. Participants were unsure how resources could be equitably and efficiently distributed, especially in relation to the availability and distribution of human resources in the field of genetics [ 33 , 35 ].

Managing patient conversations was a key consideration across all risk groups, especially for those of low risk in comparison with other cohorts [ 35 ]. Providers felt that a new risk-based system would raise patient queries, necessitating more time for consultations, and implied that the healthcare system has an obligation to provide those answers [ 35 ].

As well as organisational assumptions around HCPs’ perceived roles within a risk-stratified programme, the availability of resources also influenced thoughts on whose responsibility risk communication should be. Despite the belief that conversations around risk should take place, HCPs were unsure whose responsibility this should be, given the time constraints and considerable workload experienced by individuals working in the health system [ 36 ]. Hann et al., found that participants who reported being unwilling to discuss risk status attributed this to a lack of available resources, including time [ 30 ]. PCPs felt that a lack of time was one of the most important barriers to risk-stratified screening, voicing fears that interpreting and explaining risk results may be too time consuming to address in a typical appointment [ 33 ]. This issue was also acknowledged in discussions with genetic counsellors and was strongly re-iterated by staff within management and operational roles [ 33 , 34 ].

Characteristics of individuals

An overview of the synthesised findings and illustrative quotes relating to the Characteristics of individuals domain is given in Table 7 .

HCP–healthcare professional/provider

Mammography screening 2.0—individualised mammography screening

Knowledge and beliefs about the intervention

HCPs’ knowledge and beliefs about the intervention were discussed widely across all of the included studies and can broadly be categorised as either positive or negative beliefs about risk stratification of cancer screening programmes, overlapping with considerations around the relative advantage or disadvantage.

One paper in particular noted that PCPs were confused about the difference between participating in risk assessment and participating in the screening programme itself and this influenced their beliefs about the benefits and harms of a risk-stratified programme [ 33 ]. This misunderstanding continued throughout the study, and it was clear that PCPs would benefit from having terminology associated with risk stratification clearly defined [ 33 ]. One genetic counsellor highlighted the confusion between the processes of risk assessment and diagnosis and suggested PCPs may need these clarified as distinct concepts [ 33 ]. Geneticists felt that a better understanding of such concepts may help PCPs make more appropriate and efficient referrals to tertiary genetics services [ 33 ].

Self-efficacy

Despite some negative beliefs about the intervention, HCPs generally felt confident in their ability to implement risk-stratified cancer screening in one survey. Over 80% of participants were willing to discuss stratified interventions for patients at all risk levels and would feel confident in explaining what low, intermediate and high-risk scores mean [ 30 ]. However, GPs ranked significantly lower ( p <0.001) than other clinicians in terms of self-efficacy in managing consultations about cancer risk, whereas genetic specialists scored the highest overall [ 30 ]. A similar trend was reported for participants’ knowledge of ovarian cancer and genetics, where GPs scored significantly lower than other clinicians ( p <0.001), particularly in questions relating to genetics [ 30 ]. Notably, slightly fewer HCPs felt confident in explaining an intermediate risk score to patients, and willingness to discuss interventions with high-risk individuals was reduced in comparison with intermediate and low-risk groups [ 30 ].

Individual stage of change

Despite being in favour of risk-stratified screening in principle, many HCPs expressed a reluctance to deviate from traditional practices, especially for long established screening programmes such as mammography screening [ 31 , 34 , 35 ].

An overview of the synthesised findings and illustrative quotes relating to the Process domain is given in Table 8 .

BC- breast cancer

EMR–electronic medical records

IT–information technology

NHS–National Health Service

The concept of planning the implementation of risk-stratified screening was explored by five studies [ 31 , 33 – 36 ]. A key concept within this was planning which risk factors should be included to provide a risk model that is acceptable to both patients and professionals and how this information should be collected [ 34 – 36 ]. Additionally, HCPs advocated for pilot testing and feasibility assessment before risk-stratified screening is rolled out on a larger scale [ 33 , 34 ].

Engaging members of the public and increasing awareness of risk-stratified cancer screening was noted by participants in two studies [ 33 , 35 ]. HCPs recognised the value of exposing both healthcare staff and the general public to the concepts of risk assessment and risk stratification to foster acceptability [ 33 , 35 ].

External change agents

Participants were wary of the media’s ability to portray risk-stratified cancer screening negatively and the potential this has to confuse or even discourage the public from participating [ 34 , 36 ]. To avoid this, HCPs suggested engaging the media with risk stratification to influence perceptions of the intervention in a positive way whilst also making sure that reliable evidence is being shared by media sources to prevent miscommunication [ 34 , 36 ].

When reflecting on how to successfully execute risk-stratified screening, HCPs focused on the infrastructure required; this was especially important as current infrastructure was seen as outmoded and incapable of handling the necessary operations for risk stratification [ 33 – 35 ]. Participants called for improvements to electronic medical records systems and advised that these should be integrated with risk assessment and communication tools [ 33 , 35 ].

Reflecting and evaluating

Reflecting and evaluating the intervention was only considered briefly in two of the included studies [ 33 , 34 ]. In addition to pilot studies, HCPs observed a need for feedback and evaluation to take place at all stages of the implementation process, including ongoing monitoring after the introduction of risk-stratified programmes [ 33 , 34 ].

Principle findings

To our knowledge, this is the first systematic review of the acceptability of risk-stratified cancer screening across all cancer types from the perspective of HCPs. A total of seven studies were included in the review, the majority of which explored the acceptability of risk stratification in relation to breast cancer screening. Our synthesis indicates that many aspects of risk-stratified cancer screening are acceptable to HCPs and other stakeholders, who viewed it as a sensical method of achieving a better balance of harms, benefits, and costs. Additionally, we highlight a number of important facilitators and barriers that must be addressed for successful implementation, as well as considerations for associated policy. In particular, there is a need for greater evidence, particularly supporting the safety of de-escalated screening for low-risk groups, consideration of resource limitations, training and communication needs, and a need for public involvement throughout.

Comparison with other literature

The attitudes of HCPs reported in this review are broadly consistent with the attitudes of the general public towards risk stratification of population-based cancer screening. Overall, risk stratification was seen as acceptable in principle, which is congruent with numerous studies reporting that the public are largely optimistic about risk stratification [ 7 , 10 , 37 – 50 ]. We found that HCPs had some concerns about the evidence for reducing screening for those at low-risk and the psychological and physical implications of reduced or no screening. Similar concerns have also been expressed by the public, emphasising that there are more barriers to reducing screening for low-risk patients than increasing screening for those at high risk [ 7 , 39 , 40 , 42 , 44 – 46 , 48 , 51 – 53 ]. A further similarity between the views of HCPs and the public is the need for clear and accessible communication with patients, to enable informed choice and to avoid worsening existing inequalities [ 43 , 54 ].

Although not in the context of risk stratification per-se, changes to cervical cancer screening programmes in order to implement human papillomavirus (HPV) testing and change the intervals of screening based on HPV status have also reported similar barriers to acceptability among HCPs. In those studies, many HCPs reported positive attitudes towards increasing screening intervals for women with a normal HPV co-test whereas as others reported concerns over possible harms to patients, including increasing the risk of pre-cancers and cancer diagnoses due to longer screening intervals [ 55 , 56 ]. A key barrier to changing this programme is the well-established nature of cervical screening processes and guidelines and reluctance for change, which was similarly reported by HCPs in this review [ 57 ]. However, educational interventions have been successful in improving the likelihood of HCPs finding increased screening intervals acceptable in the context of HPV testing [ 58 ]. This suggests that addressing the training and educational needs of HCPs in relation to risk-stratified cancer screening could similarly improve overall acceptability of risk stratification within cancer screening.

Smit et al. have explored HCPs views towards polygenic risk testing in clinical practice outside of the context of risk-stratified cancer screening and reported similar concerns over potentially incorrect risk estimates and the evidence underlying risk scoring [ 59 ]. These findings are relevant to risk stratification as risk prediction models may incorporate genetic data in the future. Furthermore, this study reported a lack of knowledge and self-efficacy around ordering polygenic risk tests and incorporating risk scores into clinical practice [ 59 ]. As in this review, this was particularly significant among non-genetics specialists [ 59 ]. Similarly, Smit et al. report that comprehensive guidelines, education, and supportive resources are essential pre-requisites to using genetic risk scores in clinical practice [ 59 ].

Implications for policy, practice, and research

This review suggests that robust evidence will be required in order for HCPs to accept risk-stratified cancer screening, particularly in the case of low-risk cohorts [ 34 , 36 ]. For a risk model to be considered acceptable to HCPs there should be transparency regarding the included variables, and these should be practical to obtain in order to address doubts over the inclusion of potentially inaccurate data, self-reported variables, and validation of risk prediction models across different populations. Consequently, it will be important to demonstrate the strength of the evidence to clinical staff in particular if they are to recommend reduced screening with confidence.

HCPs also acknowledged that cost-effectiveness evidence is an essential consideration for policy makers, particularly in the context of publicly funded healthcare systems. However, the participants within the included studies felt policy makers should exercise caution when conveying the financial impetus for risk stratification to the general public to avoid undermining communication of the health benefits associated with risk-stratified screening.

Alongside a need for greater evidence, a further barrier to implementation expressed in the included studies is the complex nature of risk-stratified cancer screening. Specifically, concerns about time and resource constraints need to be addressed alongside the provision of evidence that risk stratification will not have a negative impact on an already resource-limited healthcare system. A risk-stratified cancer screening programme that uses more resources is unlikely to be acceptable to HCPs. Introduction of a new screening pathway could generate a need for increased patient communication and support, and health systems should have the capacity to meet those needs before implementation. PCPs in particular felt that this should not necessarily be the responsibility of frontline staff so as not to exacerbate current workforce constraints, thus an alternative system such as engaging dedicated personnel, or an external telephone helpline should be considered [ 33 , 36 ].

Many HCPs expressed positive beliefs about risk stratification, however habitual screening methods are entrenched in clinical practice, and it may take time and training for HCPs to adopt skilled and sustained use of risk-stratified screening. The roles of individuals within a risk-stratified screening programme should be clearly defined and developed in conjunction with HCPs themselves to ensure acceptability. Norms, assumptions, and cultural values appear to differ between professional groups, suggesting that professional background may impact perceptions of the intervention. For example, geneticists who are already familiar with risk assessment may adapt more readily and require less training and support that HCPs who are less experienced in this area, such as GPs. Similarly, educating HCPs about a risk-stratified programme and providing clear guidance is essential in ensuring that individuals are confident in facilitating implementation.

Some HCPs, predominantly those in primary care, may have lower self-efficacy and genetic knowledge, and be confused by the difference between participating in risk assessment, participating in screening, and being diagnosed with cancer. This underscores the need to clearly define these as distinct concepts as part of HCPs’ training and is particularly necessary as they stressed that the interpretation of individual risk should be left to clinicians and not to lay persons in case of misunderstanding or incorrect interpretation [ 31 , 33 ]. Although participants found discussion around risk and communication of risk estimates to be largely acceptable, clarity around handling patients at moderate risk will be needed to increase confidence in interactions with these patients. Likewise, PCPs will require additional support in order to appropriately recommend risk-stratified interventions to high-risk patients, and to support the communication and understanding of risk which until now has typically been managed by genetic specialists.

Linked with the need for training and support, in order to enable shared decision making and discussions around risk, clinicians will require risk communication tools that complement existing technological infrastructure and provide standardised information in formats that are accessible to all patients. Infrastructure, such as electronic medical records systems, must be compatible with and capable of executing risk-stratified screening if the intervention is to be perceived as acceptable by clinicians. Moreover, these processes should be well-integrated to enable simple, rapid, and routine use within clinical practice. Alongside this, revised screening guidelines should be clearly communicated to HCPs with uniform guidance that is congruent with policy advice at all levels and is evidence based.

HCPs also considered communication with the public and noted that the influence of the media on public perceptions of risk stratification has the potential to be either positive or negative. Therefore, it will be important to engage the media as external change agents to facilitate dissemination of accurate information and generate credibility around risk-stratified cancer screening. This is particularly relevant in reassuring low-risk members of the public who face a reduction in screening opportunities in comparison with the current system [ 36 ].

Many HCPs highlighted the importance of engaging patients in shared decision-making and in consulting the public throughout all stages of development and implementation. As there is potential for both positive and negative psychological impacts of risk stratification, informed choice and patient support should be prioritised to ensure that a risk-stratified approach is understood and accepted by the public. Ultimately, the findings of this review suggest that for HCPs to find risk-stratified cancer screening acceptable, it is essential to understand whether it is acceptable from the perspective of the general public.

Strengths and limitations

A key strength of this review is the use of an established framework, the CFIR [ 24 ]. Only minor revisions were required as part of the ‘best fit’ approach, indicating that it was a suitable framework for interpreting the data [ 23 ]. Despite this, there was a clear gap in the literature around a number of CFIR constructs. These tended to focus more on issues of implementation and systems-level change, rather than the fundamentals of acceptability, indicating a need for further research specific to the changes required across healthcare systems to implement risk stratification. The use of robust and clear definitions for key terminology such as ‘risk stratification’ and ‘acceptability’ ensured the findings of this review are specific and relevant. A further strength is the adoption of a mixed methods approach which enabled the inclusion of both quantitative and qualitative studies, providing a comprehensive review of the evidence. However, our search only yielded seven eligible papers, out of over 12,000 citations identified in the search, which highlights the challenges of conducting a systematic review in implementation research where the terminology used in reporting is often broad and heterogenous. Additionally, the quality of the included literature was found to be high, particularly across qualitative studies, increasing confidence in the overall review findings.

A limitation of this review is that the studies included are predominantly concerned with breast cancer screening. The results may, therefore, not be applicable across the spectrum of different cancer types or new cancer screening programmes and this should be addressed in future research. Similarly, all the included studies were conducted in high-income countries meaning that we are unable to comment on the views of HCPs in low-income countries that may have less well-established screening programmes and this warrants further exploration. Furthermore, it was challenging to separate the views of different groups of professionals in some cases as not all of the included studies distinguished between participants’ respective roles. We chose to exclude literature relating to familial cancer syndromes or high penetrance genes, meaning the findings of this review are not applicable to these populations. However, these groups are generally recognised as high risk and are not part of population-based cancer screening programmes. Finally, we did not include any grey or unpublished literature meaning the results of our review may be subject to publication bias. We did conduct a pilot search of the grey literature and did not identify any, we therefore believe the risk of missing data is low.

This review found that risk stratification of population-based cancer screening is acceptable to the majority of HCPs. Many barriers and facilitators to implementation were considered, highlighting the importance of public involvement, training, and communication, as well as a demand for more evidence around reducing screening for low-risk groups and managing resource limitations. These points must be addressed to facilitate successful implementation of risk-stratified cancer screening.

Supporting information

The full search string that was used to search MEDLINE and Embase databases, and was adapted to search Web of Science and PsycINFO.

Acknowledgments

We thank Veronica Phillips, Assistant Librarian, University of Cambridge Medical Library, for her help developing the search strategy.

Funding Statement

This study is funded by a National Institute for Health and Care Research Advanced Fellowship (NIHR300861). https://www.nihr.ac.uk/ JUS (Advanced Fellowship NIHR300861) is funded by the NIHR for this research project. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

125 Breast Cancer Essay Topic Ideas & Examples

🏆 best breast cancer topic ideas & essay examples, 💡 most interesting breast cancer topics to write about, 📌 simple & easy breast cancer essay titles, 👍 good essay topics on breast cancer.

• Breast Cancer: Concept Map and Case Study Each member of the interdisciplinary team involved in treating patients with cancer and heart disease should focus on educational priorities such as:
• Health Psychology: Going Through a Breast Cancer Diagnosis He is unaware that she has been diagnosed with depression and that she is going for breast screening Stress from work is also a contributing factor to her condition. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
• Breast Cancer and Its Population Burden The other objectives that are central to this paper are highlighted below: To determine which group is at a high risk of breast cancer To elucidate the impact of breast cancer on elderly women and […]
• Mindfulness Practice During Adjuvant Chemotherapy for Breast Cancer She discusses the significance of the study to the nursing field and how nurses can use the findings to help their patients cope with stress.
• Breast Cancer: The Effective Care Domain Information about how the patient is seen, how often the patient is seen, and whether she will return for mammograms can be collected and analyzed to verify the successful intervention to extend consistency with mammograms.
• Garden Pesticide and Breast Cancer Therefore, taking into account the basic formula, the 1000 person-years case, the number of culture-positive cases of 500, and culture-negative of 10000, the incidence rate will be 20 new cases.
• Breast Cancer as a Genetic Red Flag It is important to note that the genetic red flags in Figure 1 depicted above include heart disease, hypertension, and breast cancer.
• Breast Cancer Surveillance Consortium Analysis Simultaneously, the resource is beneficial because it aims to “improve the delivery and quality of breast cancer screening and related outcomes in the United States”.
• Drinking Green Tea: Breast Cancer Patients Therefore, drinking green tea regularly is just a necessity- it will contribute to good health and physical vigor throughout the day and prevent severe diseases.
• Breast Cancer Prevention: Ethical and Scientific Issues Such information can potentially impact the patient and decide in favor of sharing the information about the current condition and risks correlating with the family history.
• Breast Cancer: Epidemiology, Risks, and Prevention In that way, the authors discuss the topics of breast cancer and obesity and the existing methods of prevention while addressing the ethnic disparities persistent in the issue.
• Breast Cancer Development in Black Women With consideration of the mentioned variables and target population, the research question can be formulated: what is the effect of nutrition and lifestyle maintained on breast cancer development in black women?
• Breast Cancer in Miami Florida The situation with the diagnosis of breast cancer is directly related to the availability of medicine in the state and the general awareness of the non-population.
• Breast Cancer: Genetics and Malignancy In the presence of such conditions, the formation of atypical cells is possible in the mammary gland. In the described case, this aspect is the most significant since it includes various details of the patient’s […]
• Genes Cause Breast Cancer Evidence suggests the role of BRCA1 in DNA repair is more expansive than that of BRCA2 and involves many pathways. Therefore, it is suggested that BRCT ambit containing proteins are involved in DNA repair and […]
• Breast Cancer. Service Management The trial specifically looks at the effect on breast-cancer mortality of inviting women to screening from age 40 years compared with invitation from age 50 years as in the current NHS breast-screening programme.
• Fibrocystic Breast Condition or Breast Cancer? The presence of the fibrocystic breast condition means that the tissue of the breast is fibrous, and cysts are filled with the liquid or fluid. The main characteristic feature of this cancer is that it […]
• Coping With Stress in Breast Cancer Patients Therefore, it is important for research experts to ensure and guarantee adherence to methodologies and guidelines that define scientific inquiry. However, various discrepancies manifest with regard to the initiation and propagation of research studies.
• Breast Self-Examination and Breast Cancer Mortality Though it is harsh to dismiss self-exams entirely due to studies that indicate little in deaths of women who performed self-exams and those who did not, the self-exams should not be relied on exclusively as […]
• Breast Self-Exams Curbing Breast Cancer Mortality The results of the study were consistent with the findings of other studies of the same nature on the effectiveness of breast self-examination in detecting and curbing breast cancer.
• Taxol Effectiveness in Inhibiting Breast Cancer Cells The following were the objectives of this experiment: To determine the effectiveness of Taxol in inhibiting breast cancer cells and ovarian cancer cells using culture method.
• Control Breast Cancer: Nursing Phenomenon, Ontology and Epistemology of Health Management Then, the evidence received is presented in an expert way leading to implementation of the decision on the management of the disease.
• Breast Cancer: Effects of Breast Health Education The design of the research focused on research variables like skills, performance, self-efficacy, and knowledge as the researchers aimed at examining the effectiveness of these variables among young women who underwent training in breast cancer […]
• Community Nursing Role in Breast Cancer Prevention However, early detection still remains important in the prevention and treatment of breast cancer. The community has thus undertaken activities aimed at funding the awareness, treatment and research in order to reduce the number of […]
• Self-Examination and Knowledge of Breast Cancer Among Female Students Shin, Park & Mijung found that a quarter of the participants practiced breast self-examination and a half had knowledge regarding breast cancer.
• “Tracking Breast Cancer Cells on the Move” by Gomis The article serves the purpose of examining the role of NOG, a gene that is essential in bone development and its role in breast cancer.
• Breast Cancer Survivorship: Are African American Women Considered? The finding of the analysis is that the issue of cancer survivorship is exclusive, developing, and at the same time it depends on what individuals perceive to be cancer diagnosis as well as personal experiences […]
• Gaining Ground on Breast Cancer: Advances in Treatment The article by Esteva and Hortobagyi discusses breast cancer from the aspect of increased survival rates, the novel treatments that have necessitated this and the promise in even more enhanced management of breast cancer.
• Effects of Hypoxia, Surrounding Fibroblasts, and p16 Expression on Breast Cancer The study was conducted to determine whether migration and invasion of breast cancer cells were stimulated by hypoxia, as well as determining whether the expression of p16 ectopically had the potential to modulate the cell […]
• Breast Cancer: Preventing, Diagnosing, Addressing the Issue In contrast to the MRI, which presupposes that the image of the tissue should be retrieved with the help of magnetic fields, the mammography tool involves the use of x-rays.
• Dietary Fat Intake and Development of Breast Cancer This study aimed to determine the relationship between dietary fat intake and the development of breast cancer in women. The outcome of the study strongly suggests that there is a close relationship between a high […]
• The Detection and Diagnosis of Breast Cancer The severity of cancer depends on the movement of the cancerous cells in the body and the division and growth or cancerous cells.
• Breast Cancer: WMI Research and the Current Approaches Although the conclusions provided by the WHI in the study conducted to research the effects of estrogen and progesterone cessation on the chance of developing a breast cancer do not comply with the results of […]
• Breast Cancer Susceptibility Gene (BRCA2) The mechanisms underlying the genetic predisposition to a particular disease are manifold and this concept is the challenging one to the investigators since the advent of Molecular Biology and database resources.
• Prediction of Breast Cancer Prognosis It has been proposed that the fundamental pathways are alike and that the expression of gene sets, instead of that of individual genes, may give more information in predicting and understanding the basic biological processes.
• Breast Cancer Survivors: Effects of a Psychoeducational Intervention While the conceptual framework is justified in analysis of the quality of life, there is the likelihood of influence of the context with quality of life adopting different meanings to patients in different areas and […]
• Providers’ Role in Quality Assurance in Breast Cancer Screening In order to ensure the quality assurance of mammography, the providers involved in the procedure need to be aware of the roles they ought to play.
• Clinical Laboratory Science of Breast Cancer The word cancer is itself so much dreaded by people that the very occurrence of the disease takes half of the life away from the patient and the relatives.
• Induced and Spontaneous Abortion and Breast Cancer Incidence Among Young Women There is also no question as to whether those who had breast cancer was only as a result of abortion the cohort study does not define the total number of women in population.
• New Screening Guidelines for Breast Cancer On the whole, the Task Force reports that a 15% reduction in breast cancer mortality that can be ascribed to the use of mammograms seems decidedly low compared to the risks and harm which tend […]
• Breast Cancer in Afro- and Euro-Americans It is seen that in the age group of more than 50 years, EA was more at risk of contracting cancer, as compared to AA.
• Breast Cancer Assessment in London In light of these developments, it is therefore important that an evaluation of breast cancer amongst women in London be carried out, in order to explore strategies and policy formulations that could be implemented, with […]
• Breast Cancer: Crucial Issues The textbook also notes the significant racial differences in survival rates, mainly attributed to socioeconomic and cultural factors, including lack of available specialized care. Medical professionals and local communities highly appreciate the value of early […]
• Breast Cancer: At-Risk Population, Barriers, and Improvement Thus, the principal purpose of Part Two is to explain why older women face a higher risk of getting breast cancer, what barriers lead to this adverse state of affairs, and how to improve the […]
• Breast Cancer: Moral and Medical Aspects In addition to the question of the surgery, there is an ethical problem associated with the genetic characteristics of the disease.
• Breast Cancer and AIDS: Significant Issues in the United States in the Late 20th Century Thus, the given paper is going to explain why these activists challenged regulatory and scientific authorities and what they demanded. That is why the enthusiasts challenged their practices and made specific demands to improve the […]
• Breast Cancer Risk Factors: Genetic and Nutritional Influences However, the problems of genetics contribute to the identification of this disease, since the essence of the problem requires constant monitoring of the state of the mammary glands to detect cancer at an early stage.
• Breast Cancer Genetics & Chromosomal Analysis In this paper, the chromosomal analysis of breast cancer will be assessed, and the causes of the disorder will be detailed.
• Breast Cancer: The Case of Anne H. For this reason, even females with a high level of health literacy and awareness of breast cancer, such as Anne H, might still belong to the group risk and discover the issue at its late […]
• Breast Cancer Diagnosis Procedure in Saudi Arabia The fact is that, the health care program in this geographic area is associated with the encouragement of all the women in the area to be subjected to the examination for the breast cancer, as […]
• Breast Cancer and the Effects of Diet The information in noted clause is only a part of results of the researches spent in the field of the analysis of influence of a diet on a risk level of disease in cancer.
• Genetic Predisposition to Breast Cancer: Genetic Testing Their choice to have their first baby later in life and hormonal treatment for symptoms of menopause further increase the risk of breast cancer in women.
• Breast Cancer: Causes and Treatment According to Iversen et al this situation is comparable to the finding of abnormal cells on the surface of the cervix, curable by excision or vaporization of the tissue.
• Monoclonal Antibodies in Treating Breast Cancer The most important function of the lymph glands is that their tissue fluid carries the cancer cells that have been detached from the tumour to the closely located lymph gland.
• Breast Cancer: Women’s Health Initiative & Practices The new standard of care shows evidence that a low-fat diet, deemed insignificant by the WHI study, is beneficial to women for preventing or improving their risks of breast cancer.
• Hormone Receptor-Positive Breast Cancer Pathophysiology The contemporary understanding of the etiopathogenesis of breast cancer addresses the origin of invasive cancer through a substantive number of molecular alterations at the cellular level.
• Complex Fibroadenoma and Breast Cancer Risk Furthermore, KB decided that she did not need to remove the lump surgically she was advised to document changes after regular breast exams and return to the clinic in case of new concerns.
• Breast Cancer: Health Psychology Plan The goal of the plan is to identify the psychological issues and health priorities of the subject and propose a strategy for addressing them.
• Best Practices in Breast Cancer Care Based on this, the final stage of therapy should include comprehensive support for patients with breast cancer as one of the main health care practices within the framework of current treatment guidelines.
• Complementary and Alternative Medicine for Women With Breast Cancer The treatment of breast CA has developed over the past 20 years, and many treatment centers offer a variety of modalities and holistic treatment options in addition to medical management.
• Breast Cancer Screening in Young American Women It is proud to be at the forefront of widespread public health initiatives to improve the education and lives of young women.
• Screening for Breast Cancer The main goal of this paper is to describe the specific set of clinical circumstances under which the application of screening is the most beneficial for women aged 40 to 74 years.
• Annual Breast Cancer Awareness Campaign It may also need more time to be implemented as the development of the advertisement, and all visuals will take time.
• Breast Cancer Patients’ Life Quality and Wellbeing The article “Complementary Exercise and Quality of Life in Patients with Breast Cancer” examines the role of complementary exercises towards improving the lives of women with breast cancer.
• Breast Cancer Patients’ Functions and Suitable Jobs The key symptom of breast cancer is the occurrence of a protuberance in the breast. A screening mammography, scrutiny of the patient’s family history and a breast examination help in the diagnosis of breast cancer.
• Jordanian Breast Cancer Survival Rates in 1997-2002 This objective came from the realization that the best way to test the efficacy of breast cancer treatment and to uncover intervening factors influencing the efficacy of these treatments was to investigate the rates of […]
• Breast Cancer Awareness Among African Americans There are reasons that motivate women to seek mammography for example the belief that early detection will enable them treat the cancer in early stages, and their trust for the safety of mammogram. Social marketing […]
• Breast Cancer Screening Among Non-Adherent Women This is one of the aspects that can be identified. This is one of the short-comings that can be singled out, and this particular model may not be fully appropriate in this context.
• Breast Cancer: Treatment and Rehabilitation Options Depending on the site of occurrence, breast cancer can form ductal carcinomas and lobular carcinomas if they occur in the ducts and lobules of the breast, respectively. Breast cancer and treatment methods have significant effects […]
• Women Healthcare: Breast Cancer Reducing the levels of myoferlin alters the breast cancer cells’ mechanical properties, as it is evident from the fact that the shape and ability of breast cancer cells to spread is low with reduced production […]
• Breast Cancer Public Relations Campaign Audiences It is clear that the breast cancer campaign will target at women in their 30-40s as this is one of the most vulnerable categories of women as they often pay little attention to the […]
• Health Information Seeking and Breast Cancer Diagnosis Emotional support is also concerned with the kind of information given to patients and how the information is conveyed. It is equally significant to underscore the role of information in handling breast cancer patients immediately […]
• Current Standing of Breast Cancer and Its Effects on the Society It then places particular focus on the testing and treatment of breast cancer, the effects and conditions associated with it, from a financial point of view, and the possible improvements worth making in service or […]
• Breast Cancer: Disease Prevention The first indicator of breast cancer is the presence of a lump that feels like a swollen matter that is not tender like the rest of the breast tissues.
• Breast Cancer Definition and Treatment In the case where “the cells which appear like breast cancer are still confined to the ducts or lobules of the breast, it is called pre-invasive breast cancer”.”The most widespread pre-invasive type of breast cancer […]
• Breast Cancer Symptoms and Causes The mammogram is the first indication of breast cancer, even though other indications such as the presence of the lymph nodes in the armpits are also the early indications of breast cancer.
• Breast Cancer Incidence and Ethnicity This paper explores the different rates of breast cancer incidence as far as the different ethnic groups in the US are concerned as well as the most probable way of reducing the rates of incidence […]
• Treatment Options for Breast Cancer This type of breast cancer manifests itself in the tubes/ducts which form the channel for transporting milk from the breast to the nipple.”Lobular carcinoma: this type of cancer usually begins in the milk producing regions […]
• Risk Factors, Staging, and Treatment of Breast Cancer This is so because huge amounts of resources have been used in the research and the development of the breast cancer drugs that in effect help the body to combat the cancer by providing additional […]
• Case Management for Breast Cancer Patients In this respect, preventive measures should be taken in order to decrease the mortality rates all over the world in terms of cancer illness and breast cancer in particular.
• The Second Leading Cause of Death is the Breast Cancer
• The Benefits and Effects of Exercise on Post-Treatment Breast Cancer Patients
• Women’s Experiences Undergoing Reconstructive Surgery After Mastectomy Due To Breast Cancer
• Advanced Technology Of The Treatment Of Breast Cancer
• Using Genetic Testing For Breast Cancer
• The role of Perivascular Macrophages in Breast Cancer Metastasis
• The Psychological Aspect Of Coping With Breast Cancer
• An Analysis of an Alternative Prevention in Breast Cancer for Young Women in America
• The Complicated Biology of Breast Cancer
• The Impact Of Tamoxifen Adjuvant Therapy On Breast Cancer
• The Prevalence Of Breast Cancer Among Black Women
• The Embodiment Theory, Holistic Approach And Breast Cancer In The South African Context
• The Long-Term Evolution of Quality of Life for Breast Cancer Treated Patients
• The Signs and Early Prevention of Breast Cancer
• The Effect of Fast Food In Developing Breast Cancer among Saudi Populations
• The Effect Of Breastfeeding On Ovarian And Breast Cancer
• The Best Method Of Medicine For The Treatment Of Breast Cancer: Cam Or Drugs
• The Causes of Breast Cancer – Genetically or Environmentally Influenced
• The Symptoms, Causes and Treatment of Breast Cancer, a Malignant Disease
• The Risks, Characteristics and Symptoms of Breast Cancer, a Malignant Disease
• The Most Common Cancer In The UK: Breast Cancer
• Types Of Preventive Services For A Higher Risk Of Breast Cancer
• The Effect of Raloxifene on Risk of Breast Cancer in Postmenopausal Women
• The Impact of Culture and Location on Breast Cancer Around the World
• Understanding Breast Cancer, Its Triggers and Treatment Options
• The Risk, Development, Diagnosis, and Treatment of Breast Cancer in Women
• The Pathophysiology of Breast Cancer
• The Effects Of DNA Methylation On Breast Cancer
• The Treatment and Management Options for Breast Cancer Patients
• Alternative Forms Of Medicine For Breast Cancer Rates
• The Impact of Nutrition on Breast Cancer and Cervical Cancer
• The Economic Evaluation of Screening for Breast Cancer: A Tentative Methodology
• The Etymology of Breast Cancer, Types, Risk Factors, Early Detection Methods, and Demographics
• What Are The Symptoms And Treatments For Breast Cancer
• Treatments And Treatment Of Breast Cancer Therapy
• The Various Views and Approaches in the Treatment and Management of Breast Cancer
• The Growing Health Problem of Breast Cancer in the United States
• The Importance of Considering Breast Cancer Prevention Aside from Treatment
• The Different Ways That Can Reduce the Risk of Having Breast Cancer
• The Use of Radiation for Detection and Treatment of Breast Cancer
• The Condition Of Breast Cancer And Its Relevant Treatment
• The Relationship between a High-Dairy Diet and Breast Cancer in Women
• Treatment of Solid Tumors including Metastatic Breast Cancer
• Which Is More Effective In Reducing Arm Lymphoedema For Breast Cancer Patients
• The Use Of Telomerase In Diagnosis, Prognosis, And Treatment Of Cancer: With A Special Look At Breast Cancer
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, March 2). 125 Breast Cancer Essay Topic Ideas & Examples. https://ivypanda.com/essays/topic/breast-cancer-essay-topics/

"125 Breast Cancer Essay Topic Ideas & Examples." IvyPanda , 2 Mar. 2024, ivypanda.com/essays/topic/breast-cancer-essay-topics/.

IvyPanda . (2024) '125 Breast Cancer Essay Topic Ideas & Examples'. 2 March.

IvyPanda . 2024. "125 Breast Cancer Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/breast-cancer-essay-topics/.

1. IvyPanda . "125 Breast Cancer Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/breast-cancer-essay-topics/.

Bibliography

IvyPanda . "125 Breast Cancer Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/breast-cancer-essay-topics/.

• Cancer Essay Ideas
• Skin Cancer Questions
• Leukemia Topics
• Palliative Care Research Topics
• Pathogenesis Research Ideas
• Tuberculosis Questions
• DNA Essay Ideas
• Biochemistry Research Topics
• Gene Titles
• Human Papillomavirus Paper Topics
• Nursing Care Plan Paper Topics
• Hypertension Topics
• Stem Cell Essay Titles
• Osteoarthritis Ideas
• Diabetes Questions