title: Performance of a subsidised mammographic screening programme in Malaysia, a middle-income Asian country.
abstract: The incidence of breast cancer in Asia is increasing because of urbanization and lifestyle changes. In the developing countries in Asia, women present at late stages, and mortality is high. Mammographic screening is the only evidence-based screening modality that reduces breast cancer mortality. To date, only opportunistic screening is offered in the majority of Asian countries because of the lack of justification and funding. Nevertheless, there have been few reports on the effectiveness of such programmes. In this study, we describe the cancer detection rate and challenges experienced in an opportunistic mammographic screening programme in Malaysia.
  
  
  
  From October 2011 to June 2015, 1,778 asymptomatic women, aged 40-74 years, underwent subsidised mammographic screening. All patients had a clinical breast examination before mammographic screening, and women with mammographic abnormalities were referred to a surgeon. The cancer detection rate and variables associated with a recommendation for adjunct ultrasonography were determined.
  
  
  
  The mean age for screening was 50.8 years and seven cancers (0.39%) were detected. The detection rate was 0.64% in women aged 50 years and above, and 0.12% in women below 50 years old. Adjunct ultrasonography was recommended in 30.7% of women, and was significantly associated with age, menopausal status, mammographic density and radiologist's experience. The main reasons cited for recommendation of an adjunct ultrasound was dense breasts and mammographic abnormalities.
  
  
  
  The cancer detection rate is similar to population-based screening mammography programmes in high-income Asian countries. Unlike population-based screening programmes in Caucasian populations where the adjunct ultrasonography rate is 2-4%, we report that 3 out of 10 women attending screening mammography were recommended for adjunct ultrasonography. This could be because Asian women attending screening are likely premenopausal and hence have denser breasts. Radiologists who reported more than 360 mammograms were more confident in reporting a mammogram as normal without adjunct ultrasonography compared to those who reported less than 180 mammograms.
  
  
  
  Our subsidised opportunistic mammographic screening programme is able to provide equivalent cancer detection rates but the high recall for adjunct ultrasonography would make screening less cost-effective.
authors.affiliation: Cancer Research Malaysia, Subang Jaya, Malaysia.
authors.forename: Marianne
authors.initials: M
authors.lastname: Lee
authors.affiliation: Cancer Research Malaysia, Subang Jaya, Malaysia.
authors.forename: Shivaani
authors.initials: S
authors.lastname: Mariapun
authors.affiliation: Cancer Research Malaysia, Subang Jaya, Malaysia.
authors.forename: Nadia
authors.initials: N
authors.lastname: Rajaram
authors.affiliation: Cancer Research Malaysia, Subang Jaya, Malaysia.|University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Soo-Hwang
authors.initials: SH
authors.lastname: Teo
authors.affiliation: University of Malaya, Kuala Lumpur, Malaysia. chenghar.yip@gmail.com.|Subang Jaya Medical Centre, No 1, Jalan SS12/1A, 47500, Subang Jaya, Malaysia. chenghar.yip@gmail.com.
authors.forename: Cheng-Har
authors.identifier: 0000-0002-6507-9675
authors.initials: CH
authors.lastname: Yip
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D007182:Income; D008296:Malaysia; D008327:Mammography / Q000191:economics / Q000706:statistics & numerical data*; D008403:Mass Screening / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged
keywords: Asia; Breast cancer; Opportunistic mammographic screening