Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Should low-income countries invest in breast cancer screening?


With the increase in incidence and mortality of breast cancer in low-income countries (LICs), the question of whether LICs should promote breast cancer screening for early detection has gained tremendous importance. Because LICs have limited financial resources, the value of screening must be carefully considered before integrating screening programs into national healthcare system. Mammography—the most commonly used screening tool in developed countries—reduces breast cancer-specific mortality among women of age group 50–69, but the evidence is not so clear for younger women. Further, it does not reduce the overall mortality. Because the women in LICs tend to get breast cancer at younger age and are faced with various competing causes of mortality, LICs need to seriously evaluate whether mammographic screening presents a good value for the investment. Instead, we suggest a special module of clinical breast examination that could provide similar benefits at a very low cost. Nevertheless, we believe that LICs would obtain a much greater value for their investment if they promote primary prevention by tobacco cessation, healthier food and healthier lifestyle campaigns instead.

This is a preview of subscription content, log in to check access.


  1. 1.

    Porter P (2008) “Westernizing” women’s risks? Breast cancer in lower-income countries. N Engl J Med 358:213–216

  2. 2.

    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87–108

  3. 3.

    Gyawali B (2016) Me, Too. J Global Oncol 2:99–104

  4. 4.

    Badwe R, Hawaldar R, Nair N et al (2015) Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. Lancet Oncol 16:1380–1388

  5. 5.

    Sankaranarayanan R, Swaminathan R, Brenner H et al (2010) Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol 11:165–173

  6. 6.

    Groot MT, Baltussen R, Uyl-de Groot CA, Anderson BO, Hortobagyi GN (2006) Costs and health effects of breast cancer interventions in epidemiologically different regions of Africa, North America, and Asia. Breast J 12(Suppl 1):S81–S90

  7. 7.

    Donnelly TT, Khater AH, Al-Bader SB et al (2014) Factors that influence awareness of breast cancer screening among Arab women in Qatar: results from a cross sectional survey. Asian Pac J Cancer Prev 15:10157–10164

  8. 8.

    El Bcheraoui C, Basulaiman M, Wilson S et al (2015) Breast cancer screening in Saudi Arabia: free but almost no takers. PLoS ONE 10:e0119051

  9. 9.

    El Saghir NS, Khalil MK, Eid T et al (2007) Trends in epidemiology and management of breast cancer in developing Arab countries: a literature and registry analysis. Int J Surg 5:225–233

  10. 10.

    Niens LM, Zelle SG, Gutierrez-Delgado C et al (2014) Cost-effectiveness of breast cancer control strategies in Central America: the cases of Costa Rica and Mexico. PLoS ONE 9:e95836

  11. 11.

    Lauby-Secretan B, Scoccianti C, Loomis D et al (2015) Breast-cancer screening–viewpoint of the IARC Working Group. N Engl J Med 372:2353–2358

  12. 12.

    Prasad V, Lenzer J, Newman DH (2016) Why cancer screening has never been shown to “save lives”-and what we can do about it. BMJ 352:h6080

  13. 13.

    Nyström L, Andersson I, Bjurstam N, Frisell J, Nordenskjöld B, Rutqvist LE (2002) Long-term effects of mammography screening: updated overview of the Swedish randomised trials. Lancet 359:909–919

  14. 14.

    Gelmon KA, Olivotto I (2002) The mammography screening debate: time to move on. Lancet 359:904–905

  15. 15.

    Gøtzsche PC (2004) On the benefits and harms of screening for breast cancer. Int J Epidemiol 33:56–64

  16. 16.

    Data WB. http://data.worldbank.org/country/nepal. Accessed 13 July 2015

  17. 17.

    Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L (2016) Effectiveness of breast cancer screening: systematic review and meta-analysis to update the 2009 U.S. preventive services task force recommendation. Ann Intern Med 164:244–255

  18. 18.

    Corbex M, Bouzbid S, Boffetta P (2014) Features of breast cancer in developing countries, examples from North-Africa. Eur J Cancer 50:1808–1818

  19. 19.

    Pathy NB, Yip CH, Taib NA et al (2011) Breast cancer in a multi-ethnic Asian setting: results from the Singapore-Malaysia hospital-based breast cancer registry. Breast 20(Suppl 2):S75–S80

  20. 20.

    Najjar H, Easson A (2010) Age at diagnosis of breast cancer in Arab nations. Int J Surg 8:448–452

  21. 21.

    Nelson HD, Pappas M, Cantor A, Griffin J, Daeges M, Humphrey L (2016) Harms of breast cancer screening: systematic review to update the 2009 U.S. preventive services task force recommendation harms of breast cancer screening. Ann Intern Med 164:256–267

  22. 22.

    Siu AL (2016) Screening for breast cancer: U.S. preventive services task force recommendation statement screening for breast cancer. Ann Intern Med 164:279–296

  23. 23.

    Shastri A, Shastri SS (2014) Cancer screening and prevention in low-resource settings. Nat Rev Cancer 14:822–829

  24. 24.

    Bhoo-Pathy N, Yip CH, Hartman M et al (2013) Breast cancer research in Asia: adopt or adapt Western knowledge? Eur J Cancer 49:703–709

  25. 25.

    Niksic M, Rachet B, Duffy SW, Quaresma M, Moller H, Forbes LJL (2016) Is cancer survival associated with cancer symptom awareness and barriers to seeking medical help in England[quest] an ecological study. Br J Cancer 115:876–886

  26. 26.

    WHO (2007) Cancer Control. Knowledge into Action. WHO Guide for Effective Programs. Early Detection. http://www.who.int/cancer/publications/cancer_control_detection/en/

  27. 27.

    Devi BC, Tang TS, Corbex M (2007) Reducing by half the percentage of late-stage presentation for breast and cervix cancer over 4 years: a pilot study of clinical downstaging in Sarawak, Malaysia. Ann Oncol 18:1172–1176

  28. 28.

    Kardinah D, Anderson BO, Duggan C, Ali IA, Thomas DB (2014) Short report: limited effectiveness of screening mammography in addition to clinical breast examination by trained nurse midwives in rural Jakarta, Indonesia. Int J Cancer 134:1250–1255

  29. 29.

    Okonkwo QL, Draisma G, der Kinderen A, Brown ML, de Koning HJ (2008) Breast cancer screening policies in developing countries: a cost-effectiveness analysis for India. J Natl Cancer Inst 100:1290–1300

  30. 30.

    Mittra I, Mishra GA, Singh S et al (2010) A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening. Int J Cancer 126:976–984

  31. 31.

    Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA (2014) Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 348:g366

  32. 32.

    Pisani P, Parkin DM, Ngelangel C et al (2006) Outcome of screening by clinical examination of the breast in a trial in the Philippines. Int J Cancer 118:149–154

  33. 33.

    Grosse Frie K, Ramadas K, Anju GA et al (2013) Determinants of participation in a breast cancer screening trial in trivandrum district, India. Asian Pac J Cancer Prev 14:7301–7307

  34. 34.

    Bobo JK, Lee NC, Thames SF (2000) Findings from 752 081 clinical breast examinations reported to a national screening program from 1995 through 1998. J Natl Cancer Inst 92:971–976

  35. 35.

    Miller ABMP, Harirchi IM, Lotfi MHMP et al (2015) Yazd breast cancer project profile; a community based trial for the evaluation of self-examination and physical examination of the breast cancer disease. Iran J Med Sci 40:531–536

  36. 36.

    Hassan LM, Mahmoud N, Miller AB et al (2015) Evaluation of effect of self-examination and physical examination on breast cancer. Breast 24:487–490

  37. 37.

    Murillo R, Diaz S, Perry F et al (2016) Increased breast cancer screening and downstaging in Colombian women: a randomized trial of opportunistic breast-screening. Int J Cancer 138:705–713

  38. 38.

    Mittra I, Baum M, Thornton H, Houghton J (2000) Is clinical breast examination an acceptable alternative to mammographic screening? BMJ 321:1071–1073

  39. 39.

    Harford JB (2011) Breast-cancer early detection in low-income and middle-income countries: do what you can versus one size fits all. Lancet Oncol 12:306–312

Download references


This paper was presented in part at the 10th European Breast Cancer Conference (EBCC), Amsterdam, The Netherlands. Dr. Gyawali received Fellowship Grant for Developing Countries from the EBCC to participate and present in the conference.

Authors’ contribution

BG conceptualized the study and wrote the first draft. All authors provided intellectual feedback, made revisions and approved the final manuscript.

Author information

Correspondence to Bishal Gyawali.

Ethics declarations

Conflict of interest

Unrelated to the paper, Yuichi Ando has received grants from Sanofi, Torii Pharmaceutical, Nippon Kayaku, Mitsubishi Tanabe Pharma and Mochida Pharmaceutical; grants and personal fees from Chugai Pharmaceutical, Takeda Pharmaceutical, Daiichi Sankyo, Kyowa Hakko Kirin, Eisai, Taiho Pharmaceutical, Yakult Honsya and Merck Serono; and personal fees from Ono Pharmaceutical, Eli Lilly Japan, Pfizer, Novartis Pharma, Janssen Pharmaceutical, Hisamitsu Pharmaceutical, Mochida Pharmaceutical, AstraZenaca, GlaxoSmithKline, ASKA Pharmaceutical, Terumo and Bayel Holdings. All other authors declare no competing interests.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gyawali, B., Shimokata, T., Honda, K. et al. Should low-income countries invest in breast cancer screening?. Cancer Causes Control 27, 1341–1345 (2016). https://doi.org/10.1007/s10552-016-0812-8

Download citation


  • Breast cancer
  • Screening
  • Mammography
  • Clinical breast examination
  • Cost-effectiveness