February 20, 2013
Local volunteers increase early breast cancer detection in rural Sudan
WEST LAFAYETTE, Ind. — A team led by a Purdue University researcher engaged local volunteers to overcome the stigma and social barriers faced by women in sub-Saharan Africa that prevent early screening for breast cancer and lead to unnecessary deaths.
A study published in the current early online issue of the journal The Lancet Oncology found that the program increased breast cancer detection in women in rural Sudan, where lack of resources, social stigmatization and religious beliefs can keep women from seeking help.
In Africa, breast cancer is the most commonly diagnosed cancer in women and the second leading cause of death in women, said Sulma Mohammed, the Purdue professor who led the study.
"Patients in Africa often present with late-stage breast cancer that has spread to other organs and is very difficult to treat," said Mohammed, an associate professor of cancer biology in Purdue's College of Veterinary Medicine and member of Purdue's Center for Cancer Research. "There is a strong social stigma associated with the disease and a great lack of awareness of the importance of early detection. The same approaches that are successful in the United States don't work in these rural areas. We need an approach that could overcome the barriers preventing these women from seeking help because thousands of women are dying needlessly."
Mohammed, who is from Sudan, said the social barriers to screening programs and early detection are especially difficult to overcome.
"The stigma surrounding cancer is so great that people hide the disease from their family and friends and will not seek treatment until they are in severe pain," she said. "Women in rural areas where men are allowed more than one wife have a great fear of being disfigured by surgery and losing a husband and support for their children."
In addition, some African communities are Muslim and women cannot expose their breasts to a male doctor or nurse as part of a screening program.
"We used young female volunteers from the community so that the screenings came from a familiar and trusted person who shares the patient's social fabric and belief system," Mohammed said. "If you are approached by someone you know and trust, you tend to be more relaxed and more forthcoming with any symptoms you may have."
The research team first met with village leaders to discuss the effects of cancer on their community and to get approval of their screening program. The leaders then chose candidates for the training, Mohammed said.
Mohammed's team included physicians Dafalla Omer Abuidris and Anas O. Ahmed from the National Cancer Institute at the University of Gezira in Sudan, and physicians Ahmed Elsheikh, Majdeldien Ali, Hassan Musa, Elgaili Elgaili and Imadeldien Sulieman from the faculty of medicine at the University of Gezira.
Health-care workers provided a five-day intensive training course to female volunteers from selected villages in cancer risk factors, the importance of early detection and how to examine breasts for abnormalities. The volunteers then went door to door in their village to screen women 18 and older. The volunteers referred women with suspected breast cancer to the district hospital for diagnosis. The program also included a cancer awareness campaign for both men and women.
Between Jan. 1, 2010, and Oct. 15, 2012, in Keremet County 10,309 women were screened, which is roughly 70 percent of the female population. Breast abnormalities were found in 138 women, who were then referred to the district hospital. Seventeen of the women referred were diagnosed with various stages of breast cancer. After treatment 12 were reported to be disease-free and had good prognosis as of the most recent follow-up.
In contrast, in the socially and economically similar villages of Abugota County, where no screenings took place, four women reported to a health center and three were diagnosed with advanced breast cancer and had poor prognosis.
"Despite the small size of the screened population, 12 women were diagnosed with breast cancer and treated that otherwise may not have been seen until their cancer progressed into an advanced stage," Mohammed said. "We hope that one day such screening programs will be common throughout rural Africa."
In addition to the social barriers, sub-Saharan African countries like Sudan do not have the infrastructure, resources, equipment or trained personnel to follow successful initiatives used in the United States and other high-income countries.
Mammography-based screening, which is standard in many countries, is not a realistic screening model for sub-Saharan Africa, Mohammed said.
"For the time being, let's forget looking deeper through mammography and start by catching the stuff we can see and feel," she said. "Awareness campaigns and self-examination are cheap, easy to implement and could have a dramatic effect on the survival chances of these women."
Even if it were feasible, mammography-based screening methods may not have as great an impact in Africa. Mammography-based screening has not been shown to be beneficial to women younger than 40, and breast cancer in African women occurs most often in women 34-45 years old, she said.
The Sudan National Cancer Institute-funded study is ongoing, and the team plans to follow the women who took part in the study for at least five years. Mohammed said the group also is working to spread the program to another state in Sudan.
Writer: Elizabeth K. Gardner, 765-494-2081, firstname.lastname@example.org
Source: Sulma Mohammed, 765-494-9948, email@example.com
Breast-Cancer Screening with Trained Volunteers in a Rural Area of Sudan: A Pilot Study
Dafalla Omer Abuidris, Ahmed Elsheikh, Majdeldien Ali, Hassan Musa, Elgaili Elgaili, Anas O Ahmed, Imadeldien Sulieman, Sulma Ibrahim Mohammed
Background: Breast cancer has a low cure rate in low-income and middle-income countries because patients often present with late-stage disease that has metastasized to other organs. We assessed whether the implementation of a cancer awareness and breast examination programme that uses local, volunteer women could increase the early detection of breast cancer in a rural area of sub-Saharan Africa.
Methods: We did this pilot study in two counties in Gezira State, Sudan. We chose Keremet (56 villages) as the experimental county and Abugota (79 villages) as the control county. Female volunteers from villages in Keremet were trained in the detection of breast abnormalities. When trained, volunteers visited households in their village and screened women aged 18 years or older for breast abnormalities, referring women with suspected breast cancer for medical diagnosis and, if necessary, treatment at the district hospital. We also ran a cancer awareness programme for both men and women in study villages. Villages in the control population received no intervention. This study is ongoing.
Findings: Between Jan 1, 2010, and Oct 10, 2012, 10,309 (70%) of 14,788 women in Keremet were screened. 138 women were identified as having breast abnormalities and were referred to the district hospital for diagnosis and treatment. 20 of these women did not report to the hospital. Of the 118 women who did report, 101 were diagnosed with benign lesions, eight with carcinoma in situ, and nine had malignant disease. After treatment, 12 of the 17 women with either carcinoma in situ or malignant disease (four had early breast cancer and eight had ductal carcinoma in situ) were disease-free and had a good prognosis. In the control villages, only four women reported to the centre: one was found to have a benign lesion while three were diagnosed with advanced disease.
Interpretation: Our findings show that a screening programme using local volunteers can increase the detection of breast cancer in asymptomatic women in low-income rural communities. These findings can inform policy-makers' decisions in the design of cancer control programmes in Sudan and other similar areas in sub-Saharan Africa.
Funding: Sudan National Cancer Institute