Status of breast cancer screening strategies and indicators in Iran: A scoping review
Zahra Omidi1, Maryam Koosha1, Najme Nazeri2, Nasim Khosravi3, Sheida Zolfaghari4, Shahpar Haghighat1
1 Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
2 Department of Lifestyle and Health Management Research, Medical Laser Research Center, ACECR, Tehran, Iran
3 Department of Physical Education and Sport Sciences, Faculty of Humanities, Tarbiat Modares University, Tehran, Iran
4 Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
|Date of Submission||27-Dec-2020|
|Date of Decision||08-Sep-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||17-Mar-2022|
Dr. Shahpar Haghighat
Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran
Source of Support: None, Conflict of Interest: None
Background: This scoping review aimed to investigate the status of breast cancer (BC) preventive behaviors and screening indicators among Iranian women in the past 15 years. BC, as the most common cancer in women, represents nearly a quarter (23%) of all cancers. Presenting the comprehensive view of preventive modalities of BC in the past 15 years in Iran may provide a useful perspective for future research to establish efficient services for timely diagnosis and control of the disease. Materials and Methods: The English and Persian articles about BC screening modalities and their indicators in Iran were included from 2005 to 2020. English electronic databases of Web of Science, PubMed, and Scopus, and Persian databases of Scientific Information Database (SID) and IranMedex were used. The critical information of articles was extracted and classified into different categories according to the studied outcomes. Results: A total of 246 articles were assessed which 136 of them were excluded, and 110 studies were processed for further evaluation. Performing breast self-examination, clinical breast examination, and mammography in Iranian women reported 0%–79.4%, 4.1%–41.1%, and 1.3%-45%, respectively. All of the educational interventions had increased participants' knowledge, attitude, and practice in performing the screening behaviors. The most essential screening indicators included participation rate (3.8% to 16.8%), detection rate (0.23–8.5/1000), abnormal call rate (28.77% to 33%), and recall rate (24.7%). Conclusion: This study demonstrated heterogeneity in population and design of research about BC early detection in Iran. The necessity of a cost-effective screening program, presenting a proper educational method for increasing women's awareness and estimating screening indices can be the priorities of future researches. Establishing extensive studies at the national level in a standard framework are advised
Keywords: Breast cancer, Iran, prevention, scoping review, screening
|How to cite this article:|
Omidi Z, Koosha M, Nazeri N, Khosravi N, Zolfaghari S, Haghighat S. Status of breast cancer screening strategies and indicators in Iran: A scoping review. J Res Med Sci 2022;27:21
|How to cite this URL:|
Omidi Z, Koosha M, Nazeri N, Khosravi N, Zolfaghari S, Haghighat S. Status of breast cancer screening strategies and indicators in Iran: A scoping review. J Res Med Sci [serial online] 2022 [cited 2022 Sep 24];27:21. Available from: https://www.jmsjournal.net/text.asp?2022/27/1/21/339778
| Introduction|| |
Breast cancer (BC) is the most common female cancer worldwide, representing nearly a quarter (23%) of all cancers in women. In Iran, in 2015, the number of BC patients was 12802, and the age-standardized incidence rate was 32.63/100,000. Hence, the age distribution of BC compared to its counterparts is low because of its relatively young population. Almost 51% of patients were under 50 years old. It is estimated that about 10,000 women are diagnosed and treated for BC each year.,
Approaches to reducing cancer's global burden include two major strategies: Screening and early detection and active preventive intervention. Screening, as one of the most critical early detection methods, has been performed in low- and middle-income countries in only 2.2% of women aged 40–49 years. The findings confirmed that screening methods were less common in Iranian women, and there is no systematic screening strategy for BC in Iran.
Screening methods are mammography, breast self-examination (BSE), and clinical breast examination (CBE). Although mammography screening was approved as an effective method, a study demonstrated that this method is not cost-effective in Iran. BSE can enhance women's awareness, empowerment, and responsibility to their health. The previous studies showed that almost 60% of females did not know how to perform BSE or did not have the necessary skills to do it.,, CBE is considered a low-cost method with a broader implementation ability that requires no equipment. Different factors such as demographic variables, awareness, literacy, social, and economic conditions can affect BC screening behaviors which should be considered in planning a cost-effective strategy to control BC in Iranian women.
Presenting the comprehensive view of preventive modalities of BC in the past 15 years in Iran may provide a helpful perspective for future research to establish efficient services for timely diagnosis and control of the disease. Hence, this scoping review aims to present an overall demonstration of observational and interventional screening status in Iran. Introducing screening indicators in related articles may provide useful data for policy-makers to implement a proper strategy to control the disease.
Scoping review question
“What are the results of articles related to BC screening strategies and indicators in Iran in the past 15 years?”
Scoping review sub-questions
“What are the status of BC prevention behavior and influencing factors on screening behaviors?”
“Which educational interventions are effective in improvement of screening behavior?”
“What are the statistical indicators of BC screening?”
All the published articles about BC prevention in Iran from January 2005 to January 2020 were included in the study. English online electronic databases of Web of Science, PubMed and Scopus, and Persian databases of SID and IranMedex were used.
| Methods|| |
This study is part of a big project to study different aspects of BC in Iran. All of the published articles about BC in Iran within the defined time horizon were included in the study. They covered various aspects of epidemiology, genetics, prevention, diagnosis, treatment, and supportive care in BC. The prevention subgroup was categorized into two themes, screening modalities and indicators, prevention behaviors, and their barriers. The studies in the field of screening strategies and indicators were assessed in this scoping review.
Details of data sources and methodology of the big project between 2005 and 2015 time horizon have been presented in another article. The same methodology was extended to articles published up to 2020. The current study consists of all articles published from January 2005 to 2020. English online electronic databases of Web of Science, PubMed, and Scopus, and Persian databases of SID and IranMedex were used. English search formula was “BC” OR “breast carcinoma” OR “breast tumor” OR “breast neoplasm” AND Iran. Persian search formula was a combination of Iran with the words of Breast tumor, BC, Breast carcinoma, and Breast neoplasm [Appendix 1].
Source of evidence screening and selection
Screening of primary search and dividing to subgroups was achieved by three experienced reviewers in the field of BC; two surgeons and one epidemiologist. Totally 7478 studies consisting of 4893 English and 2585 Persian abstracts were included in the main project, of which 949 abstracts were located in the prevention subgroup. In this step, 522 items (225 English and 297 Persian) were included by deleting unrelated studies and duplicated titles, abstracts, and full text of articles. The results of 246 articles in the field of screening strategies and indicators were considered eligible for this review. After assessing full texts, 136 articles were excluded, and 110 studies consisting of 81 English and 29 Persian were evaluated.
It should be noted that the results of the two articles have been presented in two tables jointly. Reasons of exclusion were irrelevancy (53 articles), just abstract presentation (7 articles), no relation to the Iran population (8 articles), letter to editor (3 articles), review article (2 articles), BC population study (4 articles), inaccessible full paper (1 article), qualitative study (3 articles), and duplication (55 articles). In this phase, the reason for duplications was to publish an article in either Persian and English or two or more journals [Chart 1].
Studies reviewed were classified into three categories according to their main themes, including observational (58 articles), interventional (37 articles), and statistical indicators (17 articles).
The research team obtained the full texts of the abstracts. If it was not available, a letter was sent to the author to take the necessary information. Two reviewers critically evaluated the selected articles by a checklist. In case of disagreement, they discussed and decided about their eligibility.
Because of the wide variation in the methodology and results of the included studies, an Excel sheet was designed for data extraction. The first part of the datasheet was “general information” such as the title, the place and time of the study, and publication year. The second part included “methodological information” consisting of study design, sample size, studied population, intervention modality, and measurement tools. The third part was composed of “outcome measurements”, such as performance of the screening method, effect of interventions, different screening indicators such as recall rate, participation rate, response rate, and detection rate. All of the articles were extracted by two reviewers, and the research team manager organized the two extracted forms into one sheet.
Since the main objective of this scoping review was to demonstrate the distribution of BC prevention researches in Iran, no article was excluded from the study due to low quality. To show the limitations of studies, we assigned the incomplete data with “NA,” which stands for “Not Assigned.”
Analysis and presentation of results
Rate of screening behavior performance, affecting factors, the impact of different educational interventions and statistical indicators such as detection rate, recall rate, and participation rate were extracted from the included studies. Articles that more than one-third of the presented data pertained to the years before 2005 were excluded from the study. If an article was published in either Persian and English or two or more journals, just their English version and the first publication were included. The details of data in each subject were presented in a separate table.
| Results|| |
The results of 246 articles in the field of screening strategies and indicators were considered eligible for this review. After assessing full texts, 136 articles were excluded, and 110 studies consisting of 81 English and 29 Persian were evaluated [Appendix 2].
Inclusion of sources of evidence
The included studies in this field were subcategorized in observational studies (58 articles), educational interventions (37 articles), and statistical indicators (17 articles). The essential data of those three objectives consisting of general information, methodological information, and outcome measurement indices were recorded in separated tables. More details have been presented in [Appendix 3].
The finding results are presented in three following subheadings:
Observational studies of BC screening
Among 58 articles in [Table 1], 56 items were cross-sectional, and 2 items were survey studies. Most of the studied populations were females referred to Healthcare centers (HCCs). Factors influencing screening behaviors consisted of health belief model (HBM) components, fear, proactive coping, state of mind and advocacy, educational level, positive family history of breast cancer, family support, awareness, physician recommendation, and age. Four articles had introduced “physicians and treatment staff” as the most important sources of information about screening behaviors.,,,
Achievement of BSE by the best estimate varied from no experience to 79.4%. As well as, regular BSE was 4.5% to 47.5%. Performing annual CBE was reported in 4.1%-41.1% of participants, and mammography had been performed in 1.3%-45% of females. The results of three studies showed 52.9%, 30.9%, and 60% of females did not know how to perform BSE or did not have the necessary skills to do it.,, The 5-year and lifetime risk perception of BC was subjectively assessed by the visual analog scale (VAS) from 0 to 100. The mean of 5-year BC risk perception was 0.89 ± 0.89, and its lifetime risk perception was 8.87 ± 3.84. Higher 5-year risk perception was demonstrated to have more predictive power for performing mammography while not predicting achieving BSE or CBE.
Effect of educational interventions on screening behavior
[Table 2] demonstrates 37 studies related to educational interventions and their impact on BC screening promotion. The design of studies was clinical trial (6 articles), randomized clinical trial (29 articles), and randomized field trial (2 articles). Females who referred to HCCs consisted majority of participants. The number of the sample ranged from 43 to 600 subjects. The educational methods mostly were in-person, except for two studies which were telephone counseling. Most educational models were HBM (13 studies), extended parallel process model (1 study), BASNEF (1 study), theory of planned behavior (TPB) (2 studies), systematic comprehensive health education and promotion (1 study), and HBM + TPB (1 study). The in-person education was achieved by methods like group discussion, role-playing, or peer education. Different instruments such as short messages, PowerPoint, media, lecture, mobile phone were applied. The result of the studies showed that educational interventions increased the knowledge, attitude, and practice of participants in performing the screening behaviors such as mammography, CBE, and BSE. It led to improved health belief, self-efficacy, the behavioral intention of screening, and perceived susceptibility/severity/benefits/barriers.
The statistical indicators of BC screening
This category includes the results of statistical studies in the field of BC prevention [Table 3]. Seventeen studies with different designs consisting of cross-sectional (13 articles), clinical trial (1 article), field trial (1 article), longitudinal (1 article), and cost-effectiveness (1 article) were included in this subgroup. The majority of participants were females referred to HCCs. Some studies had presented the psychometric assessment of the Persian version of BSE Behavior Predicting Scale, BC awareness measure, and Champion HBM Scale. The development of some tools in BC prevention strategies consisted of MSS (Mammography Social Support scale in Iran), BC screening chart, and ASSISTS instrument and model. In two studies, the response rate to BSE and CBE ranged from 81% to 100%., The participation rate in the screening program was reported from 3.8% to 16.8% in two studies., BC detection rate has been reported in some studies with different designs. In a cross-sectional study on females admitted to the mammography center in a hospital, BC was detected in 2.3% of 526 screened patients. BC detection rate of non-diagnostic mammography in 9395 subjects was 8.5 per 1000 mammography. In BC screening of 26606 females, the detection rate of 24 per100000 was reported in CBE and mammography evaluation; the false-positive detection rate of mammography was 7.5% in this screening program. Sehhati Shafaie conducted a project on 5,000 females referred to BC hospital for screening. They recorded 996 sonography and 636 mammography reports with 40 and 183 abnormal cases, respectively, and found one BC by performing 14 fine needle aspiration (FNA). The screening mammography, diagnostic sonography, biopsy, and abnormality rates were 27.4%, 26%, 1.4%, and 33% in a screening project, respectively. Results of a study indicated that the mean scores of females' BC screening belief and multidimensional health locus of control were 40.72 ± 10.41 and 67.78 ± 17.67, respectively.
| Discussion|| |
This paper reviewed the status of BC screening strategies and indicators in Iran. The studies were assessed and discussed in three themes of observational studies, interventional studies, and statistic indicators as follows:
Observational studies of BC screening
At this time, mammography is the gold standard of the BC early detection method. Hence, it is necessary to specify the status of mammography performance in Iran. In the current study, the range of performing of mammography between 2005 and 2020 was 1.3%–45%, while in a systematic review assessing Persian language articles of two databases between 2001 and 2010, 3%–26% of Iranian females had done mammography screening. Although a study showed that the rate of screening mammography in Iran was lower than in developed countries such as the USA and the UK, the results of a screening program in Saudi Arabia resulted in 27.7% of mammography achievement. One of the reasons for this difference may be the lack of a BC screening program in Iran; hence, the results reported were extracted from various limited studies with high heterogeneity regarding the study population, sample size, and design. On the other hand, some research has revealed that mammography is an expensive modality and not a cost-effective method for BC screening in Iran., Further, studies focusing on other screen methods are suggested.
BSE and CBE are considered as more available, low-cost, and low-technical requirement screening strategies. This study showed that the performance of BSE and CBE ranged between 0%–79.4% and 4.1%–41.1%, respectively, and 30.9%–60% of females did not have appropriate skills to do BSE. Similar to our results, a study on Arab females demonstrated that 69% of subjects did not know how to do BSE. According to the current review, the low self-efficacy of females in applying screening behaviors may affect BSE achievement. Self-efficacy is one of the most important predictors of screening behaviors,,,, and the performance of BSE in females with higher self-efficacy is 1.17 times more than others. Therefore, it can be concluded that by improving females' self-efficacy, their skills in screening behaviors will also improve. Hence, education about BC screening methods is worthy of being insisted on by the health system. It may be a more logical strategy for low- and middle-income countries in which breast awareness is more beneficial, too. In conclusion, since there is no national study to demonstrate accurate indicators, most of the current results have been reported from small and limited studies, which cause a wide range of affectivity. It seems that more accurate epidemiologic studies are necessary to indicate the frequency of BSE and CBE achievement in Iranian women.
Effect of educational interventions on screening behavior
The effect of various educational modalities on screening behaviors has been studied in different Iranian researches. The in-person method was used by most studies, except for two studies that used telephone counseling. Most of them showed that education effectively enhanced females' knowledge, attitude, practice of screening behaviors. Still, no study compared in-person with virtual education to reveal which method is more effective in Iran. Given the growth of using the Internet, novel technologies such s online social networks, smartphone applications, and virtual learning can be cost-effective. Some features of this technology, such as more availability, low_price, and offering a more attractive platform, make it a helpful modality for future research studies.
In this scoping review, most educational interventions resulted in satisfied effects.,,, It may show that the health system's educational modalities for BC prevention are more important than the training methods. Selecting a suitable educational method facilitates access to defined objectives, and it depends on many factors, such as socioeconomic status, health priorities, and cancer preventive policies. If early detection of BC is a priority of the health system of Iran, indeed, education programs should be organized as one of the essential correlated factors. On the other hand, promoting the population's awareness induces some diagnostic and treatment demands for BC detection. If we do not provide needed requirements, our health policy goal won't be reached. Related studies in Iran have focused on identifying the educational needs of the specified Iranian population with different races, cultures, incomes, etc.,,,,, Hence, they cannot be generalized to the total population of Iran. Thus, implementing national research with a more potent methodology and stratified demographic characteristics is suggested.
The statistical indicators of BC screening
The statistical indicators are one of the most important principles for health policymaking to evaluate the cost-effectiveness of an intervention. They include abnormal rate, detection rate, recall rate, participation rate, etc. The BC detection rate in three studies was reported with a different study population. In one of the studies achieved in Zanjan, a city of Iran, 526 women admitted to the mammography center were assessed. The detection rate had been reported by 2.3% of 526 screened patients. Another research was conducted at a tertiary referral university hospital, and 9395 digital mammographies were performed, and they detected 8.5 cancer patients in 1000 women who underwent nondiagnostic mammography. The third study was conducted in ten cities of Iran in which over 26,000 women aged 35 and higher with low socioeconomic status were evaluated. The results showed a detection rate of 24 per 100000 females. Although all three studies have reported a detection rate, differences in methodology make them non-integral. The detection rates of invasive BC based on accurate population screening are targeted at >0.5, ≥2.7, and ≥5 per 1000 screens in Canada, the United Kingdom, and Australia, respectively. Also, the detection rates for in situ BC in the United Kingdom and Australia are considered ≥0.4 and ≥1.2 per 1000 screens, respectively. The detection rate in Iran has been reported higher than in European countries and even higher than 2.7 in Asian counterpart countries. One of the reasons for this difference is how females were evaluated, which means the reported statistics indicators in Iran were not extracted from a national study and some of them are just the result of limited research in a specific population. The studied population, the recruited sample size, or study design can affect these indices. On the other hand, the limitation of detection rates estimation factors like workforce skill, sensitivity or specificity of equipment, and essential resources have not been appropriately assessed in Iranian studies. Hence, it seems that the evaluation of screening effectiveness in randomized controlled clinical trials at the national level is necessary to reach more accurate information.
Another statistic indicator is the abnormal call rate, which is vital to assessing mammography image quality and interoperation. It is defined as a percentage of abnormal mammography per number of screens. In Iran, it has been reported 28.77% and 33%., The abnormal call rate for the initial screen in Europe is considered <7, and in all of the countries like Canada, the United Kingdom, Australia, and New Zealand are considered <10. This indicator is related to the recall rate. Recall rate indicates if screening mammography resulted in a recommendation for further imaging or surgical/clinical visit because of an abnormality on the screening exam. The European Guidelines and the American College of Radiology considered recall rates <7% and <10%, respectively, as acceptable recall rates. A high abnormal rate induces a high recall rate and increases unnecessary tests and false positives results. According to our result, the recall rate in Iran was 24.7% in total, and for the first and subsequent mammography was 29% and 22%, respectively. Similar to the previously reported indices, the abnormal call rate and recall rate in Iran has not been extracted from a national screening study. As a result, to determine whether our country needs a BC screening program or not, these indicators must be estimated in the standard and targeted studies, and it is beneficial to be considered as a research priority in the health policy system of Iran.
The participation rate represents the percentage of people who participate in a screening program and can be affected by acceptability, accessibility, promotion of screening, and the capacity of the plan. This index showed 16.8%, 20% in urban areas, and 10% in rural areas of Iran., The participation rate in screening mammography in Canada, the United Kingdom, Australia, and New Zealand is estimated at ≥70%. The comparison between statistics shows a low participation rate among Iranian women, which can have consequences such as reducing the cost-effectiveness of screening programs. It may be due to the low level of awareness in Iranian females, which impacts their attitude toward the importance of BC prevention. Females' attitudes can be reformed by cooperating with mass media such as radio, television, or social networks with the health system.
On the other hand, most of the screening costs are paid by patients themselves and may affect their acceptability of some screening strategies and lowers this index compared to the other countries. Some studies have shown that mammography screening is not a cost-effective intervention in Iran., Hence, most insurances support the cost of diagnostic modalities, and the screening tests should be paid out of pocket. Proving more insurance coverage or accessibility facilities by the health system of Iran can improve the participation rate index.
In this review, we did not find any study for evaluating the BSE or CBE cost-effectiveness in the Iranian population. Considering the importance of those screening methods in limited resources countries, establishing a comparative analysis will provide helpful evidence for policy-makers for early detection of BC in Iran.
| Conclusion And Recommendations|| |
This scoping review demonstrated that we have many unknown facts about BC early detection in Iran. It is not clear which strategy is the best. Establishing the national level studies with a standard framework may present screening indices more accurately.
Implications of the findings for research
The necessity of a national screening program in a country with a low incidence of BC, presenting a proper educational method for increasing women's awareness, and estimating screening indices can be the priorities of future Iranian researches.
The researchers at the Breast Cancer Research Center appreciate the financial support of Roche Company for the development of this valuable breast cancer road map which facilitates future researches in Iran. This article does not contain any studies with human participants or animals performed by any of the authors.
Financial support and sponsorship
This study was a part of a comprehensive project to review the different aspects of breast cancer in Iran. A grant from Roche Company funded the leading research.
Conflicts of interest
There are no conflicts of interest.
| Appendix 1: Search strategy|| |
Details of data sources and methodology of the big project between 2005-2015 time horizon have been presented in another article (13). The same methodology was extended to articles published up to 2020. The current study consists of all articles published from January 2005 to 2020. English online electronic databases of Web of Science, PubMed, and Scopus, and Persian databases of SID and IranMedex were used. English search formula was “BC” OR “breast carcinoma” OR “breast tumor” OR “breast neoplasm” AND Iran. Persian search formula was a combination of Iran with the words of Breast tumor, BC, Breast carcinoma, and Breast neoplasm.
| Appendix 2|| |
After reviewing the title, 522 items (225 English and 297 Persian) were included by deleting unrelated studies and duplicated titles, abstracts, and full text of articles. The results of 246 articles in the field of screening strategies and indicators were considered eligible for this review. After assessing full texts, 136 articles were excluded, and 110 studies consisting of 81 English and 29 Persian were evaluated.
Reasons of exclusion were irrelevancy (53 articles), just abstract presentation (7 articles), no relation to Iran population (8 articles), letter to editor (3 articles), review article (2 articles), BC population study (4 articles), inaccessible full paper (1 article), qualitative study (3 articles), and duplication (55 articles).
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[Table 1], [Table 2], [Table 3]