Integration of breast cancer screening program in the primary health services, Iran, 1999

Objectives. The ministry of health and Jahad daneshgahi conducted a research on integration of breast cancer screening in to the health network as a pilot study in the 1996. The location of this pilot study was Shahrchord, Mobarakeh and Lanjan districts. The objective was to assess the compliance of health network to run this new program.

Screening tests were clinical examination and breast self-examination (BSE). Target group was 30 years and older women who were screened for 2 rounds of screening (one-year interval). Target group was examined by Behvarz/ health worker in health network and the suspicious cases of breast lump were referred to general physician. Likewise, the suspicions cases in clinical examination performed by general physician were referred to surgeon. Health workers recommended BSE and general physicians used Fine Needle Aspiration, too. Surgeons used biopsy for definite diagnosis. In 1999, after two rounds of screening (two years), an assessment program was conducted on this pilot study. It is important to note that effectiveness of screening program is assessed by the estimation of mortality rate reduction in about 5-10 years with comparing study (screening) and control (non- screening) groups.

Evaluation criteria are: feasibility and effectiveness. l. Indicators of Feasibility: • Acceptability Acceptability In this assessment is equal to response rate or coverage. The coverage for screening was 66% in the first round and 53% in the second. • Cost-effectiveness Data for this indicator was not available, therefore it was not measured. • Proportion of diagnosed cases Percentage of total malignant cases to total biopsies was 7%. - First round: Pick up rate was 28 m 100000 women. Percentage of malignant cases to total biopsies was 15%. - Second round: Pick-up rate was 10 to in 100000 women. Percentage of malignant cases to total biopsies was 2%. • Proportion of positive tests who followed, diagnosed and treated Information of treated cases who were diagnosed by surgeons was not available. First round: 92% of positive tests in Behvarz/ Health worker examination were client of general physician (8% Attrition Rate) and 25% of positive tests in general physician examination were client of surgeon (75% Attrition Rate). Percentage of malignant cases to positive tests in Behvarz/ health worker examination was% 0.1. Second Year: 77% of positive tests in Behvarz/ Health worker examination were client of general physician (23% Attrition Rate) and 45% of positive tests in general physician examination were client of surgeon (55% Attrition Rate). Percentage of malignant cases to positive tests of Behvarz/ Health worker examination was%0.1. 2. Indicators of Effectiveness: • Specific mortality reduction rate in diagnosed cases through screening This indicator was not estimated because there is not cancer registration system in our country. • Reduction of breast cancer staging by screening Stages in first round were 11 % (I), 33% (II), 33 (Ill) and 23% (JV). Data of stages in second round was not available. Comparing stages in screening group and control group was impossible because of missing cancer registration system. • Percentage of cases diagnosis by screening Estimation of this indicator was impossible because of missing cancer registration system.

As show the results, coverage rate of screening program was low and declining and covered age groups was not appropriate. Attrition rates were high and there was not any appropriate follow-up plan. Attrition cases may be malignant or false positive and they have used and expense in other services in the health system, and their follow-up data was missing, too. Data of effectiveness indicators were not available because there is not any cancer registration system. Implementation of a useful mass population screening program needs to assess effectiveness of screening because of high cost of program, false positive and false negative cases follow-up. Therefore, the first step for any control program of cancer in this country is implementation of cancer registration system.