**Abstract**

The incidence and mortality of breast cancer are rising in the whole world in the past few decades, adding up to a total of around two million new cases and 620,000 deaths in 2018. Unlike what occurs in developed countries, most of the cases diagnosed in the developing world are already in advanced stages and also in women younger than 50 years old. As most screening programs suggest annual mammograms starting at the age of 50, we can infer that a considerable portion of the new breast cancer cases is missed with this strategy. Here, we will propose the adoption of an alternative hierarchical patient flow, with the creation of a diagnostic fast track with referral to timely treatment, promoting better resources reallocation favoring the least advantaged strata of the population, which is not only ethically acceptable but also a way of promoting social justice.

**Keywords:** breast cancer, screening, mammogram, public health, ethics

#### **1. Introduction**

According to data from the World Health Organization (WHO), the number of deaths due to cancer will increase up to 45% between 2008 and 2030 and 70% of those deaths will occur in developing countries [1]. To try and change this scenario, the WHO recommends the implementation of cancer control programs that must include cost-effective measures on healthy life style, vaccination programs and screening programs [2]. A screening program consists in a set of coordinated actions with the objective of reducing cancer mortality through early stage diagnosis in an asymptomatic population, with adequate referral to diagnostic and treatment facilities. These programs have four main components: the definition and recruitment of the target population, adequate offer of diagnostic tests with quality assurance, guaranteed offer of follow up exams and biopsies to confirm findings from the initial diagnostic tests, and referral to treatment facilities and timely navigation through the health system [3]. Although screening programs present the potential benefit of reducing mortality, they are not risk-free. The main risks of such a program are the false-positive and false-negative results, and also the occurrence of over diagnosis. All these can lead to clinical and psychological repercussions and, also, to the increase in the health care system expenditure. To address this issue, the Public Health Agency of Canada performed a study to estimate the harms

of the local breast cancer-screening program in 7 years, according to age, and the main results can be seen in **Table 1** [4].

In this text, we will use Brazil as a model to discuss screening programs in the developing countries. In the Brazilian setting, breast cancer is the most frequent type of cancer, responsible for 16,724 deaths in 2017 and with an estimate of 66,280 new cases in 2020 [5]. This scenario, however, has some peculiarities when compared to developed countries in the North America or Europe; 41.1% of all cases in Brazil happen in women younger than 50 years old and the majority of the operable cases is diagnosed in locally advanced stages, being 53.3% of the cases in stage II and 23.2% in stage III [6]. These characteristics are not typical of a country with a well-established breast cancer-screening program. The strategy adopted in Brazil states that women over 50 should get a mammogram every two years between 50 and 69 years old [7]. However, due to the early age of diagnosis that we observe in this developing country, we can argue that more than 40% of the diagnosed women are not eligible to the screening program in the first place. Moreover, the late presentation at diagnosis raises the hypothesis that the current screening program is not effective or that the patients do not have proper access to it. Added to that, the mortality due to breast cancer in Brazil has been increasing in the last decades [8]. All these issues taken together generate an ethical dilemma to be explored, once the investment of public resources in an ineffective program impacts negatively the whole society. This way, more effective resources reallocation strategies should be implemented to address this dilemma.

In this chapter we will discuss the breast cancer screening programs in developing countries and the main evidence regarding the barriers in the access to the healthcare system. Beyond that, we will address the main ethical questions related to breast cancer screening from the Rawls's distributive justice [9] perspective, from the utilitarianism concepts [10, 11] and from the principles of autonomy and non-maleficence. Lastly, we will propose the support to an alternative approach to breast cancer in developing countries, maximizing the cost–benefit ratio in the use of public resources.


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*Ethical Concerns Regarding Breast Cancer Screening DOI: http://dx.doi.org/10.5772/intechopen.94159*

to mammographic screening [15].

**2. Recommendations to breast cancer screening around the world**

The U.S. Preventive Services Task Force (USPSTF) is an independent volunteer panel of American experts that develops recommendations regarding the efficacy of preventive services to asymptomatic patients. These recommendations are based on both benefits and harms that programs might cause, without consideration to the cost of the intervention. Current data about mammographic screening are solid regarding the benefits of this strategy when used in women over 50 years old and the USPSTF recommends a mammogram every two years, in women between 50 and 74; however, this same agency does not consider that there is enough evidence to support mammographic screening from 40 to 49 years old in asymptomatic patients without increased risk to breast cancer [12]. This recommendation is due to the fact that screening in this age range results in a smaller number of prevented deaths when compared to more advanced ages; also leads to a larger number of unnecessary biopsies; and to the possibility of psychological problems, like anxiety, because of the large number of false-positive results. While mammographic

screening of 10,000 asymptomatic women between 50 and 59 years old can prevent 8 breast cancer deaths, the same strategy adopted in asymptomatic women between 40 and 49 years old would prevent only 3 breast cancer deaths [13, 14]. Another harm associated with mammographic screening of an asymptomatic population considered by the USPSTF when issuing their recommendation is the occurrence of over diagnosis. Although it is extremely complex to calculate the proportion of diagnosed cases that would never evolve to cancer, the best estimates from randomized clinical trials suggest the occurrence of over diagnosis in 20% of the cases due

Another agency that carefully evaluated the cost–benefit ratio of mammographic screening in asymptomatic women between 40 and 49 years old was the Ontario Health Technology Advisory Committee through a systematic review of the literature [16]. This work included an evaluation of the USPSTF report [17], the Canadian Preventive Services Task Force (CPSTF) report [18], a Cochrane systematic review [19], five health technology assessments and eight randomized clinical trials [20–27] with the objective to assess the reduction of the breast cancer mortality in this age range attributable to mammographic screening. This agency reached a similar conclusion as the USPSTF that the mammographic screening in an asymptomatic population between 40 and 49 years old is not effective in reducing breast cancer mortality and that the harms associated with this intervention, like exposure to radiation, high rate of false-negatives leading to delays in diagnosis and high rate of false-positives with

The Brazilian College of Radiology (BCR) and Brazilian Society of Mastology (BSM) however issued a different recommendation, based on different published articles of international literature and methodologically inferior to the ones evaluated and with a clear selection bias [25, 28, 29]. In these studies, it was demonstrated a breast cancer mortality reduction between 18% and 38% in the studied populations. The main point to justify the recommendation of mammographic screening for asymptomatic women between 40 and 49 years old is to emphasize that in this developing country there is a higher proportion of breast cancer patients in this age range when compared to developed countries [30]. Despite the fact that it is a recommendation for Brazil, it did not include a single Brazilian study in the analysis. This scenario is repeated throughout Latin America as it has been shown in a report by The Economist Intelligence unit. Cancer care registries are lacking in Latin America due to insufficient coverage of the population and also due to low quality [31]. Without local high-quality data, it is impossible to perform local health

associated psychological harmful effects should not be overlooked.

technology assessments and the decision-making process is jeopardized.

#### **Table 1.**

*Benefits and harms of mammographic breast cancer screening [4].*

*Bioethics in Medicine and Society*

main results can be seen in **Table 1** [4].

cost–benefit ratio in the use of public resources.

**old**

mammogram

*Benefits and harms of mammographic breast cancer screening [4].*

**50 to 59 years old**

Mammogram every two years

Overdiagnosis 3 3 No reliable data No reliable data

**60 to 69 years old**

Mammogram every two years

993 988 979 968

7 12 21 32

43 37 35 30

294 294 256 219

<1 1 1 2

1724 1333 1087 645

**70 to 74 years old**

Mammogram every two years

**Age Range 40–49 years** 

Screening strategy Annual

Women that will not have cancer

Women that will have cancer

Unnecessary biopsies

False-positive results

Deaths prevented by screening

Number needed to screen to prevent one cancer-related

death

**Table 1.**

of the local breast cancer-screening program in 7 years, according to age, and the

In this text, we will use Brazil as a model to discuss screening programs in the developing countries. In the Brazilian setting, breast cancer is the most frequent type of cancer, responsible for 16,724 deaths in 2017 and with an estimate of 66,280 new cases in 2020 [5]. This scenario, however, has some peculiarities when compared to developed countries in the North America or Europe; 41.1% of all cases in Brazil happen in women younger than 50 years old and the majority of the operable cases is diagnosed in locally advanced stages, being 53.3% of the cases in stage II and 23.2% in stage III [6]. These characteristics are not typical of a country with a well-established breast cancer-screening program. The strategy adopted in Brazil states that women over 50 should get a mammogram every two years between 50 and 69 years old [7]. However, due to the early age of diagnosis that we observe in this developing country, we can argue that more than 40% of the diagnosed women are not eligible to the screening program in the first place. Moreover, the late presentation at diagnosis raises the hypothesis that the current screening program is not effective or that the patients do not have proper access to it. Added to that, the mortality due to breast cancer in Brazil has been increasing in the last decades [8]. All these issues taken together generate an ethical dilemma to be explored, once the investment of public resources in an ineffective program impacts negatively the whole society. This way, more effective resources reallocation strategies should be implemented to address this dilemma. In this chapter we will discuss the breast cancer screening programs in developing countries and the main evidence regarding the barriers in the access to the healthcare system. Beyond that, we will address the main ethical questions related to breast cancer screening from the Rawls's distributive justice [9] perspective, from the utilitarianism concepts [10, 11] and from the principles of autonomy and non-maleficence. Lastly, we will propose the support to an alternative approach to breast cancer in developing countries, maximizing the

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