Breast cancer screening: can the iBreastExam bridge the gap?
Authors: Julius Gbenga Olaogun, Olayide Sulaiman Agodirin
Journal: The Lancet Global Health (2022)

Breast cancer is the most prevalent cancer and leading cause of cancer-related deaths in women worldwide.1Sung H Ferlay J Siegel RL et al.Global cancer statistics 2020: Globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2021; 71: 209-249Crossref PubMed Scopus (13427) Google Scholar In high-income countries with robust health-care systems and population screening programmes, most breast cancer is detected early and treatment outcomes are remarkable. Presentation at an advanced stage is common in low-income and middle-income countries (LMICs), and treatment outcomes are poor due to late detection, insufficient diagnostic equipment, and inadequate access to health care.2Olaogun JG Omotayo JA Ige JT Omonisi AE Akute OO Aduayi OS Socio-demographic, pattern of presentation and management outcome of breast cancer in a semi-urban tertiary health institution.Pan Afr Med J. 2020; 36: 363Crossref PubMed Scopus (3) Google Scholar, 3Olayide A Samuel O Ganiyu R et al.How effective is the treatment of locally advanced and metastatic breast cancer in developing centres? A retrospective review.Ethiop J Health Sci. 2015; 25: 337-344Crossref PubMed Google Scholar, 4Aziz Z Iqbal J Akram M Effect of social class disparities on disease stage, quality of treatment and survival outcomes in breast cancer patients from developing countries.Breast J. 2008; 14: 372-375Crossref PubMed Scopus (26) Google Scholar Therefore, efforts geared at improving early diagnosis will be worthwhile. The recognised early breast cancer detection modalities include self-breast examination, clinical breast examination, and mammography. In high-income countries, mammography is the gold standard for breast cancer screening.5Fletcher SW Elmore JG Clinical practice. Mammographic screening for breast cancer.N Engl J Med. 2003; 348: 1672-1680Crossref PubMed Scopus (311) Google Scholar Mammography application in LMICs is limited by the age distribution, availability and affordability of resources, and shortage of experienced practitioners. The Lancet Global Health Article by Victoria Mango and colleagues6Mango VL Olasehinde O Omisore AD et al.The iBreastExam versus clinical breast examination for breast evaluation in high risk and symptomatic Nigerian women: a prospective study.Lancet Glob Health. 2022; 10: e555-e563Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar used the portable intelligent iBreastExam, a handheld screening device, to evaluate women aged 40 years or older who were symptomatic or at high risk with a family history of breast cancer. They compared the iBreastExam with clinical breast examination performed by experienced surgeons and used imaging (mammography or ultrasound) as a reference standard. To our knowledge, this type of study was the first in Nigeria and possibly in Africa. Aside from contributing data to the literature on applicability of the iBreastExam in sub-Saharan Africa, the research was timely and fits well within the context of current research and practice in LMICs, in which there are numerous unresolved challenges of breast cancer screening. The authors were thoughtful to include women at high risk because currently, the most effective strategy for LMICs is the downstaging of breast cancer. The study generated essential data that might be the basis for further research on breast cancer diagnosis, downstaging, and screening in LMICs. Mango and colleagues6Mango VL Olasehinde O Omisore AD et al.The iBreastExam versus clinical breast examination for breast evaluation in high risk and symptomatic Nigerian women: a prospective study.Lancet Glob Health. 2022; 10: e555-e563Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar showed that the iBreastExam performed well, showing superior sensitivity over clinical breast examination for any breast lesion (63%, 95% CI 57–69 vs 31%, 25–37; p<0·0001) and similar sensitivity to clinical breast examination for suspicious lesions (86%, 70–95 vs 83%, 67–94; p=0·65). The findings show that the iBreastExam has potential to bridge some deficiencies and gaps in the decision-making process, especially for community health-care providers. In the diagnostic detection algorithm, the iBreastExam will perhaps be well suited as a prescreening device as intended in the study. Performing with higher sensitivity, but lower specificity, than clinical breast examination places the iBreastExam at a lower position in this decision making algorithm. Furthermore, low specificity of the iBreastExam in this study implies that additional diagnostic investigation will be necessary, thereby putting more financial pressure on patients. To mitigate this occurrence, when the iBreastExam is fully available for use, clinical breast examination training should be considered to complement the iBreastExam in triaging patients for further investigations. High sensitivity and specificity would be most desirable, and maintaining a high sensitivity might be an acceptable trade-off for a device designed to be used by inexperienced community health-care providers. There are some limitations of this study, despite its successes. Breast cancer screening is recommended from age 40 or 50 years in most centers in high-income countries. Understandably, the current research included women aged 40 years or older; however, the best age to begin screening for breast cancer in Nigerian women is unknown. Breast cancer incidence seems to decline with age and nearly a third of all African women with breast cancer are younger than 40 years,7Agodirin O Aremu I Rahman G et al.Demographic pattern, tumor size and stage of breast cancer in africa: a meta-analysis.Asian Pac J Cancer Care. 2021; 6: 477-492Crossref Google Scholar thus, adopting the cutoff age of 40 years or older in most centres in LMICs might miss up to 30% of women with breast cancer in Africa. Although the comparison between dense and non-dense breasts might provide the probable performance of the iBreastExam in women younger than 40 years, knowing the impact of young age, breast density, and small lesions on performance of the iBreastExam would be helpful. More broadly, the acceptance of a diagnosis and intentional delay of treatment are substantial issues that need attention in Nigeria.8Egwuonwu OA Anyanwu SN Nwofor AM Efficacy of neoadjuvant chemotherapy in down staging locally advanced pre-menopausal breast cancer in Eastern Nigeria: is four courses adequate?.J Cancer Res Ther. 2013; 9: 638-643Crossref PubMed Scopus (6) Google Scholar, 9Ayoade BA Salami BA Agboola AJ et al.Beliefs and practices associated with late presentation in patients with breast cancer; an observational study of patient presenting in a tertiary care facility in Southwest Nigeria.J Afr Cancer. 2015; 7: 178-185Crossref Scopus (8) Google Scholar, 10Agodirin O Olatoke S Rahman G et al.Impact of primary care delay on progression of breast cancer in a Black African population: a multicentered survey.J Cancer Epidemiol. 2019; 20192407138Crossref PubMed Scopus (7) Google Scholar At the institutional level, the government's commitment to provide equipment and training personnel cannot be overemphasised before the iBreastExam device becomes widely applicable. In conclusion, the study shows that with minimal training, inexperienced health-care providers can use the iBreastExam successfully and achieve higher sensitivity than with clinical breast examination. The iBreastExam can overcome the issue of a shortage of specialists for early detection of breast cancer in Nigerian communities, thus showing the potential to reduce incidence of advanced stage breast cancer and might lead to improvement in survival. We declare no competing interests. The iBreastExam versus clinical breast examination for breast evaluation in high risk and symptomatic Nigerian women: a prospective studyThe iBreastExam by nurses showed a high sensitivity and NPV, but lower specificity than surgeon's clinical breast examination for identifying suspicious breast lesions. In locations with few experienced practitioners, the iBreastExam might provide a high sensitivity breast evaluation tool. Further research into improved specificity with device updates and cost feasibility in low-resource settings is warranted. Full-Text PDF Open Access