Skip to main content

A situational analysis of breast cancer early detection services in Trinidad and Tobago

Abstract

Purpose

A situational analysis of breast cancer (BC) early detection services was carried out to investigate whether Trinidad and Tobago (T&T) has the framework for successful organized national screening.

Methods

An online survey was designed to assess the availability, accessibility, quality control and assurance (QC&A), and monitoring and evaluation (M&E) mechanisms for public and private BC early detection. A focus group with local radiologists (n = 3) was held to identify unaddressed challenges and make recommendations for improvement.

Results

Major public hospitals offer free detection services with wait times of 1–6 months for an appointment. Private institutions offer mammograms for TTD$240 (USD$37) at minimum with same day service. Both sectors report a lack of trained staff. Using 1.2 mammograms per 10,000 women ≥40 years as sufficient, the public sector’s rate of 0.19 mammograms per 10,000 women ≥40 years for screening and diagnosis is inadequate. Program M&E mechanisms, QC&A guidelines for machinery use, delays in receipt of pathology reports, and unreliable drug access are further unaddressed challenges.

Conclusion

T&T must first strengthen its human and physical resources, implement M&E and QC&A measures, strengthen cancer care, and address other impediments to BC early detection before investing in nationally organized BC screening.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F (2015) Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 136(5):E359–E386. doi:10.1002/ijc.29210

    CAS  Article  PubMed  Google Scholar 

  2. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65(2):87–108. doi:10.3322/caac.21262

    Article  PubMed  Google Scholar 

  3. DeSantis CE, Bray F, Ferlay J, Lortet-Tieulent J, Anderson BO, Jemal A (2015) International variation in female breast cancer incidence and mortality rates. Cancer Epidemiol Biomark Prev 24(10):1495–1506. doi:10.1158/1055-9965.EPI-15-0535

    Article  Google Scholar 

  4. Institute NC SEER cancer statistics factsheets: female breast cancer. http://seer.cancer.gov/statfacts/html/breast.html. Accessed 9 Dec 2016

  5. Hashemi SH, Karimi S, Mahboobi H (2014) Lifestyle changes for prevention of breast cancer. Electron Physician 6(3):894–905. doi:10.14661/2014.894-905

    PubMed  PubMed Central  Google Scholar 

  6. Colditz G, Bohlke K (2014) Priorities for the primary prevention of breast cancer. CA 00:1–9. doi:10.3322/caac.21225

    Google Scholar 

  7. Ga Colditz, Bohlke K (2015) Preventing breast cancer now by acting on what we already know. npj. Breast Cancer 19:19–22. doi:10.1038/npjbcancer.2015.9

    Google Scholar 

  8. Hajian S, Vakilian K, Najabadi KM, Hosseini J, Mirzaei HR (2011) Effects of education based on the health belief model on screening behavior in high risk women for breast cancer, Tehran, Iran. Asian Pac J Cancer Prev 12(1):49–54

    PubMed  Google Scholar 

  9. Ceber E, Turk M, Ciceklioglu M (2010) The effects of an educational program on knowledge of breast cancer, early detection practices and health beliefs of nurses and midwives. J Clin Nurs 19(15–16):2363–2371. doi:10.1111/j.1365-2702.2009.03150.x

    Article  PubMed  Google Scholar 

  10. Schopper D, de Wolf C (2009) How effective are breast cancer screening programmes by mammography? Review of the current evidence. Eur J Cancer 45(11):1916–1923. doi:10.1016/j.ejca.2009.03.022

    Article  PubMed  Google Scholar 

  11. Burton R, Bell R (2013) The global challenge of reducing breast cancer mortality. Oncologist 18(11):1200–1202. doi:10.1634/theoncologist.2013-0315

    Article  PubMed  PubMed Central  Google Scholar 

  12. Jatoi I, Miller AB (2003) Why is breast-cancer mortality declining? Lancet Oncol 4(4):251–254

    Article  PubMed  Google Scholar 

  13. Luciani S, Cabanes A, Prieto-Lara E, Gawryszewski V (2013) Cervical and female breast cancers in the Americas: current situation and opportunities for action. Bull World Health Organ 91(9):640–649. doi:10.2471/BLT.12.116699

    Article  PubMed  PubMed Central  Google Scholar 

  14. Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Saldana K, Ferreyra M, Debiasi M, Liedke PE, Touya D, Werutsky G, Higgins M, Fan L, Vasconcelos C, Cazap E, Vallejos C, Mohar A, Knaul F, Arreola H, Batura R, Luciani S, Sullivan R, Finkelstein D, Simon S, Barrios C, Kightlinger R, Gelrud A, Bychkovsky V, Lopes G, Stefani S, Blaya M, Souza FH, Santos FS, Kaemmerer A, de Azambuja E, Zorilla AF, Murillo R, Jeronimo J, Tsu V, Carvalho A, Gil CF, Sternberg C, Duenas-Gonzalez A, Sgroi D, Cuello M, Fresco R, Reis RM, Masera G, Gabus R, Ribeiro R, Knust R, Ismael G, Rosenblatt E, Roth B, Villa L, Solares AL, Leon MX, Torres-Vigil I, Covarrubias-Gomez A, Hernandez A, Bertolino M, Schwartsmann G, Santillana S, Esteva F, Fein L, Mano M, Gomez H, Hurlbert M, Durstine A, Azenha G (2013) Planning cancer control in Latin America and the Caribbean. Lancet Oncol 14(5):391–436. doi:10.1016/S1470-2045(13)70048-2

    Article  PubMed  Google Scholar 

  15. WHO (2012) Trinidad and Tobago Cancer Profile 2014.2010–2012

  16. Wa Warner, Morrison RL, Lee TY, Williams TM, Ramnarine S, Roach V, Slovacek S, Maharaj R, Bascombe N, Bondy ML, Ellis MJ, Toriola AT, Roach A, AaM Llanos (2015) Associations among ancestry, geography and breast cancer incidence, mortality, and survival in Trinidad and Tobago. Cancer Med. doi:10.1002/cam4.503

    Google Scholar 

  17. Mungrue K, Ramdath J, Ali S, Cuffie WA, Dodough N, Gangar M, Mohammed L, Mungroo V, Ramsahai J, Shah M (2014) Challenges to the control of breast cancer in a small developing country. Breast Cancer 8:7–13. doi:10.4137/BCBCr.s12780

    PubMed  PubMed Central  Google Scholar 

  18. Naraynsingh V, Hariharan S, Dan D, Bhola S, Bhola S, Nagee K (2010) Trends in breast cancer mortality in Trinidad and Tobago-A 35-year study. Cancer Epidemiol. doi:10.1016/j.canep.2009.11.003

    PubMed  Google Scholar 

  19. Taioli E, Attong-Rogers A, Layne P, Roach V, Ragin C (2010) Breast cancer survival in women of African descent living in the US and in the Caribbean: effect of place of birth. Breast Cancer Res Treat 122:515–520. doi:10.1007/s10549-009-0702-9

    Article  PubMed  Google Scholar 

  20. Camacho-Rivera M, Ragin C, Roach V, Kalwar T, Taioli E (2015) Breast cancer clinical characteristics and outcomes in Trinidad and Tobago. J Immigr Minor Health 17(3):765–772. doi:10.1007/s10903-013-9930-5

    Article  PubMed  Google Scholar 

  21. Murillo R, Diaz S, Perry F, Poveda C, Pineros M, Sanchez O, Buitrago L, Gamboa O, Lozano T, Yu H, Wang CY, Duggan C, Thomas DB, Anderson BO (2016) Increased breast cancer screening and downstaging in Colombian women: a randomized trial of opportunistic breast-screening. Int J Cancer 138(3):705–713. doi:10.1002/ijc.29801

    CAS  Article  PubMed  Google Scholar 

  22. Lui CY, Lam HS, Chan LK, Tam KF, Chan CM, Leung TY, Mak KL (2007) Opportunistic breast cancer screening in Hong Kong; a revisit of the Kwong Wah Hospital experience. Hong Kong Med J 13(2):106–113

    CAS  PubMed  Google Scholar 

  23. Teh YC, Tan GH, Taib NA, Rahmat K, Westerhout CJ, Fadzli F, See MH, Jamaris S, Yip CH (2015) Opportunistic mammography screening provides effective detection rates in a limited resource healthcare system. BMC Cancer 15:405. doi:10.1186/s12885-015-1419-2

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hertl K, Primic-Zakelj M, Zgajnar J, Kocijancic I (2006) Performance of opportunistic breast cancer screening in Slovenia. Neoplasma 53(3):237–241

    CAS  PubMed  Google Scholar 

  25. de Gelder R, Bulliard JL, de Wolf C, Fracheboud J, Draisma G, Schopper D, de Koning HJ (2009) Cost-effectiveness of opportunistic versus organised mammography screening in Switzerland. Eur J Cancer 45(1):127–138. doi:10.1016/j.ejca.2008.09.015

    Article  PubMed  Google Scholar 

  26. Welch HG, Prorok PC, O’Malley AJ, Kramer BS (2016) Breast-cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med 375(15):1438–1447. doi:10.1056/NEJMoa1600249

    Article  PubMed  Google Scholar 

  27. Puliti D, Duffy SW, Miccinesi G, de Koning H, Lynge E, Zappa M, Paci E, Group EW (2012) Overdiagnosis in mammographic screening for breast cancer in Europe: a literature review. J Med Screen 19(Suppl 1):42–56. doi:10.1258/jms.2012.012082

    Article  PubMed  Google Scholar 

  28. Tosteson AN, Fryback DG, Hammond CS, Hanna LG, Grove MR, Brown M, Wang Q, Lindfors K, Pisano ED (2014) Consequences of false-positive screening mammograms. JAMA Intern Med 174(6):954–961. doi:10.1001/jamainternmed.2014.981

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hofvind S, Ponti A, Patnick J, Ascunce N, Njor S, Broeders M, Giordano L, Frigerio A, Tornberg S, Project E, Euroscreen Working G, Van Hal G, Martens P, Majek O, Danes J, von Euler-Chelpin M, Aasmaa A, Anttila A, Becker N, Pentek Z, Budai A, Madai S, Fitzpatrick P, Mooney T, Zappa M, Ventura L, Scharpantgen A, Hofvind S, Seroczynski P, Morais A, Rodrigues V, Bento MJ, Gomes de Carvalho J, Natal C, Prieto M, Sanchez-Contador Escudero C, Zubizarreta Alberti R, Fernandez Llanes SB, Ascunce N, Ederra Sanza M, Sarriugarte Irigoien G, Salas Trejo D, Ibanez Cabanell J, Wiege M, Ohlsson G, Tornberg S, Korzeniewska M, de Wolf C, Fracheboud J, Patnick J, Lancucki L, Ducarroz S, Suonio E (2012) False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes. J Med Screen 19(Suppl 1):57–66. doi:10.1258/jms.2012.012083

    Article  PubMed  Google Scholar 

  30. Yaffe MJ, Mainprize JG (2011) Risk of radiation-induced breast cancer from mammographic screening. Radiology 258(1):98–105. doi:10.1148/radiol.10100655

    Article  PubMed  Google Scholar 

  31. Miglioretti DL, Lange J, van den Broek JJ, Lee CI, van Ravesteyn NT, Ritley D, Kerlikowske K, Fenton JJ, Melnikow J, de Koning HJ, Hubbard RA (2016) Radiation-induced breast cancer incidence and mortality from digital mammography screening: a modeling study. Ann Intern Med 164(4):205–214. doi:10.7326/M15-1241

    Article  PubMed  PubMed Central  Google Scholar 

  32. Gotzsche PC, Nielsen M (2011) Screening for breast cancer with mammography. Cochrane Database Syst Rev 1:CD001877. doi:10.1002/14651858.CD001877.pub4

    Google Scholar 

  33. Biller-Andorno N, Juni P (2014) Abolishing mammography screening programs? A view from the Swiss Medical Board. N Engl J Med 370(21):1965–1967. doi:10.1056/NEJMp1401875

    Article  PubMed  Google Scholar 

  34. Chantal Cases MDP, Eric Drahi, Sylvie Fainzang (2016) Concertation citoyenne et scientifique. Rapport du comité d’orientation

  35. Organization WH (2014) Position paper on mammography screening. WHO, Geneva, p 78

    Google Scholar 

  36. Shyyan R, Masood S, Badwe RA, Errico KM, Liberman L, Ozmen V, Stalsberg H, Vargas H, Vass L, Global Summit D, Pathology P (2006) Breast cancer in limited-resource countries: diagnosis and pathology. Breast J 12(Suppl 1):S27–S37. doi:10.1111/j.1075-122X.2006.00201.x

    Article  PubMed  Google Scholar 

  37. Health Statistics and Information Systems W (Revision July 2015) Service availability and readiness assessment (SARA): an annual monitoring system for service delivery. Reference Manual

  38. Organisation WH (2007) Cancer control: knowledge into action. WHO Guide for Effective Programmes, Early Detection

    Google Scholar 

  39. Trinidad & Tobago yellow pages http://tntyp.com/. 2016

  40. Office CS Trinidad and Tobago 2011 Population and Housing Census Demographic Report

  41. Elkin EB, Ishill NM, Snow JG, Panageas KS, Bach PB, Liberman L, Wang F, Schrag D (2010) Geographic access and the use of screening mammography. Med Care 48(4):349–356. doi:10.1097/MLR.0b013e3181ca3ecb

    Article  PubMed  PubMed Central  Google Scholar 

  42. Autier P, Ouakrim DA (2008) Determinants of the number of mammography units in 31 countries with significant mammography screening. Br J Cancer 99(7):1185–1190. doi:10.1038/sj.bjc.6604657

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  43. Office USGA mammography: current nationwide capacity is adequate, but access problems may exist in certain locations. U.S. General Accounting Office, Washington, DC

  44. Ranger B, Littrup PJ, Duric N, Chandiwala-Mody P, Li C, Schmidt S, Lupinacci J (2012) Breast ultrasound tomography versus MRI for clinical display of anatomy and tumor rendering: preliminary results. AJR Am J Roentgenol 198(1):233–239. doi:10.2214/AJR.11.6910

    Article  PubMed  PubMed Central  Google Scholar 

  45. Malur S, Wurdinger S, Moritz A, Michels W, Schneider A (2001) Comparison of written reports of mammography, sonography and magnetic resonance mammography for preoperative evaluation of breast lesions, with special emphasis on magnetic resonance mammography. Breast Cancer Res 3(1):55–60

    CAS  Article  PubMed  Google Scholar 

  46. Luparia A, Mariscotti G, Durando M, Ciatto S, Bosco D, Campanino PP, Castellano I, Sapino A, Gandini G (2013) Accuracy of tumour size assessment in the preoperative staging of breast cancer: comparison of digital mammography, tomosynthesis, ultrasound and MRI. Radiol Med 118(7):1119–1136. doi:10.1007/s11547-013-0941-z

    Article  PubMed  Google Scholar 

  47. Shin HJ, Kim HH, Ahn JH, Kim SB, Jung KH, Gong G, Son BH, Ahn SH (2011) Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy. Br J Radiol 84(1003):612–620. doi:10.1259/bjr/74430952

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  48. Warner E, Messersmith H, Causer P, Eisen A, Shumak R, Plewes D (2008) Systematic review: using magnetic resonance imaging to screen women at high risk for breast cancer. Ann Intern Med 148(9):671–679

    Article  PubMed  Google Scholar 

  49. Lehman CD, Blume JD, Weatherall P, Thickman D, Hylton N, Warner E, Pisano E, Schnitt SJ, Gatsonis C, Schnall M, DeAngelis GA, Stomper P, Rosen EL, O’Loughlin M, Harms S, Bluemke DA, International Breast MRICWG (2005) Screening women at high risk for breast cancer with mammography and magnetic resonance imaging. Cancer 103(9):1898–1905. doi:10.1002/cncr.20971

    Article  PubMed  Google Scholar 

  50. Dowsett M, Cuzick J, Ingle J, Coates A, Forbes J, Bliss J, Buyse M, Baum M, Buzdar A, Colleoni M, Coombes C, Snowdon C, Gnant M, Jakesz R, Kaufmann M, Boccardo F, Godwin J, Davies C, Peto R (2010) Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen. J Clin Oncol 28(3):509–518. doi:10.1200/JCO.2009.23.1274

    CAS  Article  PubMed  Google Scholar 

  51. Early Breast Cancer Trialists’ Collaborative G, Clarke M, Coates AS, Darby SC, Davies C, Gelber RD, Godwin J, Goldhirsch A, Gray R, Peto R, Pritchard KI, Wood WC (2008) Adjuvant chemotherapy in oestrogen-receptor-poor breast cancer: patient-level meta-analysis of randomised trials. Lancet 371(9606):29–40. doi:10.1016/S0140-6736(08)60069-0

    Article  Google Scholar 

  52. Early Breast Cancer Trialists’ Collaborative G (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365(9472):1687–1717. doi:10.1016/S0140-6736(05)66544-0

    Article  Google Scholar 

  53. Early Breast Cancer Trialists’ Collaborative G, Coleman R, Powles T, Paterson A, Gnant M, Anderson S, Diel I, Gralow J, von Minckwitz G, Moebus V, Bergh J, Pritchard KI, Bliss J, Cameron D, Evans V, Pan H, Peto R, Bradley R, Gray R (2015) Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet 386(10001):1353–1361. doi:10.1016/S0140-6736(15)60908-4

    Article  Google Scholar 

  54. PAH Organisation (2016) Mammography services quality assurance: baseline standards for Latin America and the Caribbean. PAHO, Washington

    Google Scholar 

  55. Yip CH, Smith RA, Anderson BO, Miller AB, Thomas DB, Ang ES, Caffarella RS, Corbex M, Kreps GL, McTiernan A (2008) Guideline implementation for breast healthcare in low- and middle-income countries: early detection resource allocation. Cancer 113:2244–2256. doi:10.1002/cncr.23842

    Article  PubMed  Google Scholar 

  56. 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(7):1172–1176. doi:10.1093/annonc/mdm105

    CAS  Article  PubMed  Google Scholar 

  57. Corbex M, Burton R, Sancho-Garnier H (2012) Breast cancer early detection methods for low and middle income countries, a review of the evidence. Breast 21:428–434. doi:10.1016/j.breast.2012.01.002

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The project was supported by the Caribbean Cancer Research Initiative and Washington University School of Medicine Institute for Public Heath, Public Health Cubed (PH3) Grant, and Washington University School of Medicine (GSAS/CGFP Fund 94028C) (W.A.W.).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kimberly Badal.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Badal, K., Rampersad, F., Warner, W.A. et al. A situational analysis of breast cancer early detection services in Trinidad and Tobago. Cancer Causes Control 29, 33–42 (2018). https://doi.org/10.1007/s10552-017-0937-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10552-017-0937-4

Keywords

  • Breast cancer
  • Trinidad and Tobago
  • Screening
  • Early detection
  • Health service evaluation
  • Situational analysis
  • Primary prevention