Opportunity for breast cancer screening in limited resource countries: a literature review and implications for Iran.

Young age at occurrence and advanced tumour stage at diagnosis should urge health policy makers to focus on strategies that will help to reduce breast cancer burden in Iran. However, fundamental knowledge to select the optimal control strategy is limited. In this review paper we summarize considerations for launching a successful mass screening program in Iran using a thorough search of the literature focusing on screening activities for breast cancer in limited resource countries (LRCs). The Pubmed and Web of Knowledge databases were used for literature searches with the terms "breast neoplasm' and "screening' in combination with "limited resource countries', or "developing countries'. In addition, the bibliographies of selected references were also searched and utilized. More than 200 articles were found from 2005 to June 2011, of which 96 met the inclusion criteria. Papers were reviewed and categorized as follows: necessity and adoption of screening guidelines in LRCs (n=44); pilot implementation and barriers to screening program in LRCs (n=25); knowledge and attitudes on breast cancer and screening behaviour in LRCs (n=27). The results of the reviewed studies show that the rising trend of breast cancer incidence in LRCs has made it a health priority. Financial constraints to implement mammography screening in LRCs promote the use of alternative but less accurate screening modalities such as physical breast examination. Starting a breast cancer screening program in LRCs faces several challenges related to country's resources status, health service capacity and community awareness. Conservative attitudes toward women, fatalism and misconception on breast cancer risk factors and screening behaviour could seriously prohibit women's participation. In conclusion, given the lack of quantitative information and implementation research on breast cancer control in Iran, our ability to give a clear advice for breast cancer screening in Iran is limited. Iran should adopt a tailor-made strategy for mass screening with great emphasis on reducing the number of advanced stage tumours or "down-staging'. Combination of two approaches, clinical breast examination (CBE) and mammography would be promising given the increased competence of health care professional and public awareness. Equally important, a control plan should be started small and expanded gradually.