1 EDITORIAL/EDİTÖRDEN The Journal of Breast Health 2011 Vol: 7 • No: 1 Meme Sağlığı Dergisi 2011 Cilt: 7 • Sayı: 1 A mong women, breast cancer is the most common cause of cancer-related death worldwide, and case fatality rates are highest in low-resource countries. Over 457,000 deaths result from breast cancer annually, accounting for >1.6% of female deaths from all causes (1). Projecting to 2010, the an- nual global burden of new breast cancer cases will be 1.5 million, and an ever-increasing majority will be from Low Middle Income Countries(LIMC). Globally, breast cancer is the most common can- cer among women, comprising 23% of the 1.1 million female can- cers that are newly diagnosed each year (1,2). Approximately 4.4 million women who were diagnosed with breast cancer in the last 5 year currently are alive, making breast cancer the single most prevalent cancer in the world. Despite the common misconcep- tion that breast cancer is predominantly a problem of wealthy countries, the majority of breast cancer deaths in fact occur each year in developing rather than developed countries. Breast cancer is an urgent public health problem in high-resource regions and is becoming an increasingly urgent problem in low- resource regions, in which incidence rates have been increasing by up to 5% per year. Although global breast cancer incidence rates have increased by approximately 0.5% annually since 1990, breast cancer rates in Turkey, Japan, Singapore, and Korea have doubled or tripled in the past 40 years (2). Despite the younger age structure of most developing countries, breast cancer already accounts for approximately 45% of the incident cases and 54% of the annual deaths (2). The breast cancer burden in LMICs predictably will continue to increase in coming years on the basis of 1) increasing life expec- tancy and 2) shifting reproductive and behavioral patterns associ- ated with heightened breast cancer risk(Westernizing Life). Even assuming conservatively that there will be no change in under- lying age-specific rates, there could be a nearly 50% increase in global incidence and mortality between 2002 and 2020 due to demographic changes alone (1,2). These increases will be dispro- portionately high in the developing world. Favorable breast cancer survival rates in developed countries have been attributed to early detection by screening and timely and effective treatment. But, poorer survival in LMICs is largely due to the late presentation of the disease( lack of awareness, low education, lack of screening programms), which, when coupled with limited resources for diagnosis and treatment, leads to par- ticularly poor outcomes(2). Breast cancer screening modalities include breast self-examina- tion (BSE), clinical breast examination (CBE), and screening mam- mography. Final results from trials of BSE in Russia and Shanghai have been published (3,4,5). The effect of BSE on all-cause mortality in St. Petersburg, Russia, a community without routine mammogra- phy screening, was evaluated in a trial that met criteria for fair quality. Despite a significant increase in the number of cases of breast cancer detected when BSE instruction was provided, there was no reduction in all-cause mortality (3). A good-quality randomized trial conducted in Shanghai, China, indicated breast cancer rates of 6.5 per 1000 for women instructed in BSE and 6.7 per 1000 for control participants after 11 years of follow-up (6). The number of women who died of breast cancer was the same in both groups. Published meta-analyses of randomized trials and nonrandomized studies of BSE also indicate no significant differences in breast cancer mortality between BSE and control groups (7,8,9). Few trials have evaluated the effectiveness or harms of CBE in decreasing breast cancer mortality. In countries with widely prac- ticed mammography screening, the use of CBE rests on its addi- tional contribution to mortality reduction. The Canadian National Breast Screening Study-2 trial (CNBSS-2 trial), which compares mammography with CBE versus CBE alone, showed no difference in mortality between these 2 approaches (10). Breast cancer is known to have an asymptomatic phase that can be detected with mammography. Mammography screen- ing is sensitive (77% to 95%), specific (94% to 97%), and ac- ceptable to most women (11). Screening mammography is the single modality that has been shown to improve breast can- cer mortality in prospective randomized trials, but its cost is prohibitive in many settings. When screening mammography is employed in LMICs, target populations and screening inter- vals need to be selected in a way that is judged to be optimal for the overall population and within the scope of available resources. Breast cancer carries poorer prognosis in young pa- tients and its frequency in women below 40 years of age is 20% BREAST CANCER SCREENING: CURRENT CONTROVERSIES Vahit Ozmen, MD, FACS Professor of Surgery Editor in-Chief The Journal of Breast Health President Turkish Breast Diseases Societies