Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Cochrane Breast Cancer has produced several reviews relevant to the detection of breast cancer. In April 2023, these were added to with a new review of training health workers in low- and middle-income countries to do breast examinations. Here is the lead author, Shahin Sayed from the Aga Khan University in Nairobi Kenya, to tell us about the importance of the review and its findings.

Shahin: Mortality rates from breast cancer are higher in low- and middle-income countries, partly because women in these countries often present with advanced breast cancer, due to the lack of programs to detect the disease early. Early detection of smaller tumours through clinical breast examinations could be a cost-effective approach to improve this but requires health workers to be adequately trained.
In low- and middle-income countries, advanced screening methods such as mammography are often unavailable or too expensive. Consequently, many women do not have the opportunity for early detection of breast cancer, which is crucial for effective treatment. Sociocultural barriers and lack of awareness about breast cancer symptoms can also contribute to delayed diagnoses. Training health workers in clinical breast examinations might bridge this gap by providing a feasible way to detect cancer early, especially in resource-limited settings.
Clinical breast examination training would empower local health workers, including nurses and community health workers, to perform examinations and educate women about breast health. This should lead to earlier referrals for treatment, which would improve survival rates by allowing treatment to start early and reduce the need for more extensive and expensive interventions.
Therefore, our review investigates whether training health workers in low- and middle-income countries in clinical breast examination improves early breast cancer detection, accuracy of diagnosis, mortality rates, and women’s knowledge and uptake of these examinations. We aimed to evaluate not just the immediate outcomes of training but also its broader impact on health systems and patient behaviour. The focus was on whether trained health workers could effectively use clinical breast examinations to identify early signs of breast cancer and whether this training could be sustainably integrated into existing healthcare practices.
We were willing to include a range of comparative effectiveness studies from community settings and have been able to analyse studies from diverse settings, such as India, the Philippines, and Rwanda.
In total, we included four studies involving nearly 950,000 women, among whom just under 600 breast cancer cases were detected. The trained health workers identified more early-stage cancers than untrained workers. However, the evidence quality was low. This means that further high-quality studies are needed to confirm the findings and to explore additional outcomes such as cost-effectiveness and longer follow-up.
In summary, training health workers in low- and middle-income countries to perform clinical breast examinations has the potential to improve the detection of early breast cancer. However, more robust studies are required to establish the effectiveness and broader impacts of this training. This includes understanding how the training affects long-term health outcomes, the cost-effectiveness of such programs, and how well health workers can maintain their skills over time. More data are needed to see if integrating the training into national health strategies would provide a sustainable way to enhance breast cancer detection and treatment in resource-limited settings, with the possibility of saving lives and improving health outcomes.

Mike: Thanks, Shahin. If you would like to learn more about this review and watch for updates if additional evidence becomes available, it’s online at CochraneLibrary.com. A simple search for ‘clinical breast examination for detection of breast cancer’ will provide a link to it.