**6. Recommendation and discussion of the ethical dilemma**

Considering the inefficacy of the screening programs in developing countries and the lack of solid evidence supporting screening of asymptomatic women below the age of 50 years old, we recommend resources reallocation to improve access to the healthcare system and the implementation of a fast track between diagnostic and treatment facilities to symptomatic patients, based on the hierarchical flow proposed by Migowski et al. (**Figure 1**) [52]. This algorithm proposes three different actions: educational activities in primary care facilities to raise awareness regarding breast cancer and also the potential benefits and harms of mammographic screening; to offer the option of screening mammogram to asymptomatic women aged 50 to 69 during their visit to the primary healthcare provider; and to promote priority access to symptomatic patients, without the need of prior scheduling, in which the ones with suspicious lesions will be referred to diagnostic facilities. This recommendation is supported by Rawls' two principles of justice [9]. The first principle governs that all persons have equal rights and freedoms. The second principle governs that the adoption of policies that generate social or economical inequalities is only acceptable if it favors the least advantaged portion of society. The promotion of educational activities proposed by Migowski et al. [52] is supported by Rawls' first principle since it standardizes the access to a basic right, education. The second part of the recommendation is justified by Rawls' second principle of justice. The adoption of a fast track to symptomatic patients, removing the need of a prior appointment or referral, promotes the reallocation of public resources to remove barriers in the access to care, reducing delays in diagnosis and treatment and, therefore, reducing inequalities in favor of the least advantaged part of the population that relies solely in the public health system. Although the recommendation favors a part of the population, it does not violate individual rights, as asymptomatic patients will still have access to screening mammogram in their routine visits to their primary healthcare providers. Moreover, the proposed recommendation promotes equal access to breast cancer diagnosis and treatment as it removes the age boundaries, starting to provide care to women below the age of 50 years old, an age range responsible for a large amount of new cases in developing countries and that were not previously included in the past recommendation [6].

Let us consider for a moment a hypothetical scenario in which the healthcare system works perfectly without any access barriers. Even in this setting, mammographic screening as it is currently suggested would not be ideal in developing countries. The current evidence that recommends mammographic screening is not

**Figure 1.**

*Hierarchical flow to promote early diagnosis and treatment of breast cancer. Adapted from Migowski et al. [52].*

unanimous and large randomized clinical trials did not show a robust mortality reduction attributable to it [13, 53]. Moreover, even if these studies showed a significant mortality reduction attributable to screening mammogram, their results would hardly be applicable to the developing countries' realities. Those studies were conducted in countries with high human development index (HDI) and in the context of organized screening. Brazil and most developing countries have lower HDIs and promote opportunistic screening due to the weak organizational structure of the healthcare system. This way, the international studies that assessed the effectiveness of mammographic screening lack the necessary external validity to be applied in developing countries. A recent article published by Vale et al. suggested, that the opportunistic screening program employed in the state of São Paulo, Brazil, promoted an increase in early stage diagnosis without, however, presenting data regarding mortality reduction [54]. Without data showing mortality reduction attributable to the screening program it is impossible to conclude whether this model is effective or not. Adding up to that data we have some concerning facts associated with screening women between the age of 40 and 49; we observe that less than one death from breast cancer is avoided for every one thousand screening mammograms performed; two hundred and ninety-four false-positive results (**Table 1**) generate additional diagnostic procedures leading to economical impact to the health system and also physical and psychological impacts to the patients. Based on everything that was exposed in this paragraph, we can conclude is not adequate from Bentham's and Mill's utilitarianism perspective [10, 11].

In this context, with the shortage of resources to invest in an organized mammographic screening program and without solid data to justify its implementation, can we accept a sub-optimal program? On the one hand, the inexistence of a screening program can lead to the increase in the number of cases diagnosed in late stages, for which the treatment options might be inaccessible and, sometimes, ineffective. On the other hand, developing countries, such as Brazil, sometimes lack the necessary infrastructure to perform timely screening mammograms to the whole eligible

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

screening mammogram in developing countries [59].

**7. Conclusion**

**Conflict of interest**

population and the consequent breast biopsies of lesions identified through screening [55]. In order to consider a screening program adequate, it must be acceptable, accessible, and sustainable, it must promote equity and it must be economically efficient to the target population [56]. As it has been demonstrated in this chapter, the Brazilian mammographic screening program is not accessible, since the coverage does not reach 30% of the target population [42]. This program is not sustainable either since there is a huge delay between the identification of an abnormal mammogram and the necessary biopsy to confirm the diagnostic. Due to the incapacity to adequately follow-up and refer patients with abnormal findings, the risk of a false-positive result must be considered clinically and ethically relevant. Finally, it's been demonstrated that mammographic screening in developing countries is not cost-effective when compared to the alternative of treating patients with palpable initial lesions [57, 58]. Contemplating all these issues, Sedhom et al. argued that clinical examination of the breast with fast referral to avoid delays in diagnosis and treatment, although not a screening program, must be considered a more pragmatic and adequate choice than

When weighing the benefits and harms of a mammographic screening program in a developing country, in a context where breast cancer-specific mortality has been increasing in the past few decades, it is extremely hard to justify increasing the age range to women aged 40 to 49 years old from an utilitarian perspective, since the amount of resources to establish and make the system work adequately is prohibitive. An alternative strategy that promotes easy access and fast referral of symptomatic patients, relegating a secondary role to mammographic screening, favors a larger and more vulnerable part of the population that depends solely on the PHS. This reallocation of resources to favor the least advantaged members of society is not only ethically justifiable but also a way of promoting social justice.

Rodrigo Goncalves has received consultation fees from EMS Pharmaceuticals in 2019 and 2020 and from Novartis in 2019, not related to the topics of this chapter. The remaining authors do not have any conflicts of interest to disclose.

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

population and the consequent breast biopsies of lesions identified through screening [55]. In order to consider a screening program adequate, it must be acceptable, accessible, and sustainable, it must promote equity and it must be economically efficient to the target population [56]. As it has been demonstrated in this chapter, the Brazilian mammographic screening program is not accessible, since the coverage does not reach 30% of the target population [42]. This program is not sustainable either since there is a huge delay between the identification of an abnormal mammogram and the necessary biopsy to confirm the diagnostic. Due to the incapacity to adequately follow-up and refer patients with abnormal findings, the risk of a false-positive result must be considered clinically and ethically relevant. Finally, it's been demonstrated that mammographic screening in developing countries is not cost-effective when compared to the alternative of treating patients with palpable initial lesions [57, 58]. Contemplating all these issues, Sedhom et al. argued that clinical examination of the breast with fast referral to avoid delays in diagnosis and treatment, although not a screening program, must be considered a more pragmatic and adequate choice than screening mammogram in developing countries [59].
