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  Table of Contents  
Year : 2018  |  Volume : 55  |  Issue : 1  |  Page : 84-87

Assessment of breast cancer early detection program in Iraq-Sulaimania: Measuring the cancer detection rate

1 Department of Nursing, Darbandikhan Technical Institute, Sulaimani Polytechnic University, Sulaimani, Iraq
2 Maternal and Neonatal Nursing, College of Nursing, University of Sulaimani, Sulaimani, Iraq

Date of Web Publication23-Aug-2018

Correspondence Address:
Mr. Jamal K Shakor
Department of Nursing, Darbandikhan Technical Institute, Sulaimani Polytechnic University, Sulaimani
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_633_17

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 » Abstract 

Background: Low- and middle-income countries require to specify early detection programs and intervention models for breast cancer. The aim of this study was to assess the performance efficacy of an Iraqi early detection model in terms of cancer detection rate (CDR) and the method of participation in this program. Materials and Methods: Data from June 2007 to August 2016 was collected from the Breast Disease Treatment Center in the Sulaimani province in Iraq. A total of 40,491 women had registered at the center during that period for breast cancer screening, and cancer was detected in 793 women. Results: The CDR of the Iraqi program was 8.2 per 1000 screened women, and that of the mammograms was 42.02 per 1000 mammograms. Women mostly participated in the program by the self-referral method (77.54%). Conclusion: The performance of the Iraqi early detection model was effective with a high CDR, and most women participated by self-referral. This program could, therefore, be effective in low- and middle-income countries.

Keywords: Breast cancer, cancer detection rate, north Iraq, screening model

How to cite this article:
Shakor JK, Mohammed AK. Assessment of breast cancer early detection program in Iraq-Sulaimania: Measuring the cancer detection rate. Indian J Cancer 2018;55:84-7

How to cite this URL:
Shakor JK, Mohammed AK. Assessment of breast cancer early detection program in Iraq-Sulaimania: Measuring the cancer detection rate. Indian J Cancer [serial online] 2018 [cited 2022 Jul 1];55:84-7. Available from:

 » Introduction Top

Breast cancer is predicted to be a significant health burden in Iraq in terms of mortality, morbidity, and early detection. In the past decade, 23,792 new cases were registered and the incidence rate increased by 1.14% each year, from 26.64/100,000 in 2000 to 31.50 per 100,000 in 2009.[1] Like other developing countries, breast cancer in Iraq is diagnosed at the average early age of 49 years,[1],[2],[3] and mostly in the later stages of the disease. Two different studies have shown that most cases of breast cancer (26% and 34.1%) were diagnosed at stage 3 or 4, with only a few women (14.1% and 11.7%) diagnosed at stage 1.[3],[4] Early detection program is an essential intervention for breast cancer but is challenging to implement in most low- and middle-income countries (LMICs).[5] Therefore, the Iraqi Ministry of Health launched a national program for early detection and down staging of breast cancer in 2000.[6]

In high-income countries (HICs), opportunistic and organized screening programs have been used for breast cancer for two decades.[7],[8],[9] In LMICs, such as Iraq, however, distinct screening models face various challenges due to the high incidence of breast cancer at an early age.[6],[10] Unlike the HICs, the Iraqi model screens not only healthy women but also symptomatic women for early diagnosis.[11] The program relies on a restricted referral system of symptomatic women to the screening center.[6] As well as, Iraqi and other LMICs programs have distinct target populations, methods, and screening techniques.[10]

In developed countries, the self-referring method and cancer detection rate (CDR) are used as the main indicators for assessing the efficacy of a screening program.[12],[13] Different screening models have distinct CDRs. For instance, a Malaysian study found that the CDR of the opportunistic screening model was 0.52% and that of organized screening model was 1.25%.[14] The self-referral rate is an indicator of awareness, and a high rate has an effect on breast cancer stages.[7]

The aim of this study was to assess the effectiveness of the performance of an early detection program in Sulaimani (Iraq) in terms of CDR, and the awareness of women regarding the screening program by analyzing their socio-demographic characteristics.

 » Materials and Methods Top

Study population and data collection

The Sulaimani Directorate of Health covers the Sulaimani province, a large area in northern Iraq. It has a population of nearly 2 million, with 365,993 women aged over 20 years in 2008.[3] The Breast Disease Treatment Center (BDTC) was launched in 2007 in Sulaimani as the only early detection center for healthy and symptomatic women. Data for this study were collected from the archived electronic records of BDTC from June 2007 to August 2016, which contained data, such as name, age, and file code address of the eligible women. No files were made for girls younger than 14 years with clear sonography. In addition, data of the first and second visits, such as reason for visit, number of mammographies, sonographies, final needle aspiration (FNA), and core biopsies, which had been done at the center were manually recorded. During the screening period, there were in total 100,769 first and second visits, 40,491 women were registered as eligible for screening, and 793 of them were diagnosed with cancer.

Iraqi early detection model for screening and early diagnosis

The BDTC screening model is a combined program of mammography screening and early diagnosis for the symptomatic group. In this model, the target populations include healthy women (aged ≥ 40 years) and high-risk women (aged 35–40 years with family history of Breast cancer (BC) or nullipara) who are eligible for annual mammography screening, and symptomatic women presenting with lump, mass, skin dimpling, and nipple discharge. Screening tools in this model are breast self-examination, clinical breast examination (CBE), sonography, and mammography. Cases with positive sonography are referred to mammography and confirmed through core biopsy and FNA.

Data management

All data of the screened population were compiled and analyzed using Microsoft Excel. The screening detection rate per visitor, and per screening tools, per year were calculated as indicators of screening efficacy. The second indicator was the percentage of self-referred or systemic referred participants. The demographic characteristics of the participants are listed in table. Since the BDTC is a mixed screening program for both normal and symptomatic women, the participants were also stratified in terms of the screening reason or other reasons for early diagnosis (e.g., symptoms).

Approval concern

This study was approved by the University of Sulaimani and Sulaimani Directorate of Health.

 » Results Top

A total of 100,769 visits occurred to the BDTC between June 2007 and August 2016, of which 40,491 were the first visits of eligible women, and the remaining were for the second screening round or for women who were not eligible for the screening [Table 1]. From 2013 to August 2016, 53,121 women were screened either in the first round or second and/or more screening rounds. From 2008 to August 2016, 35,454 ultrasounds were performed while 18,083 mammograms were taken from 2009 to August 2016. From 2013 to August 2016, 967 core biopsies were done. A total of 793 women were diagnosed with breast cancer. The overall CDR was 8.2 per 1000 screened women, and the highest CDR (9.26) was observed in 2015. Similarly, overall CDR of mammogram was 42.02 per 1000 mammograms, and the highest detection rate of 66.40 per 1000 mammograms was observed in 2012. The overall CDR of core biopsies was 45.08%.
Table 1: Breast cancer screening detection rate of different techniques

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[Table 2] shows the women' method of participating in the program. From June 2013 to August 2016, 25,590 women (77.54%) were self-referred (direct method), and 5747 (22.45%) were referred by the health staff.
Table 2: Percentage of the participation methods from 2013 to 2016

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[Table 3] shows the reasons for which the women visited the center. The most common reason was breast pain 19,216 (60.67%), followed by feeling a lump 6254 (19.74%) and the presence of breast discharge 1260 (3.97%). A less number of women 3020 (9.53%) visited the center only for routine screening.
Table 3: The reasons for women to visit the center in 2013-2015

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Mean age of the participants and mean age at diagnosis of the different years are shown in [Table 4]. The overall mean age of screened women at the time of participation was 38.46 ± 10.29 years, and overall mean age of diagnosed women was 49.07 ± 11.41 years. Over the years of screening from 2007 to 2016, the mean age at diagnosis decreased from 49.1 ± 7.3 to 46.72 ± 13.88 years, while the mean age of the participants increased from 37.34 ± 10.21 to 41.93 ± 9.48 years. Most of the women were married 30,198 (87.3%) and lived in the center of the city 29,188 (73.6%). Only 10,466 (26.4%) participants lived in the suburban areas, although their proportion increased gradually during the screening period.
Table 4: Socio-demographic characteristic of screening participant per years

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 » Discussion Top

This study was based on the data taken from an early detection center in Iraq from June 2007 to August 2016. Out of the total 100,769 visiting women, 40,491 were eligible for screening, and cancer was diagnosed in 793 women. Most participants were married (87.3%) and lived in urban areas (Sulaimani; 73.6%), although the percentage of suburban participants increased gradually from 2007 to 2016. In addition, most women participated in the screening program due to the presence of certain symptoms, and only 9.53% participated in routine screening.

The performance of early detection program in the Iraqi model was overall effective, with a high CDR of 8.2 per 1000 screened women [Table 5]. This rate is higher compared with the 2.1 per 1000 seen in women aged 35–39 years presenting with positive CBE in Ireland. This is mainly due to the low incidence of BC in this age group in Ireland, although they presented the symptoms.[15] In the current study, CDR of screened mammogram was 42.02 per 1000 mammograms, which was higher compared with the rate in symptomatic women aged less 35 years in Ireland (39 per 1000 mammograms). In the Iraqi screening model, breast cancer was confirmed by core biopsy, which had the confirmation rate of 45.08%, while that in Ireland was 35%.[16]
Table 5: Breast cancer detection rate in different screening models through countries

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Although women in the UK and Netherlands have similar age at the time of screening, that is, 50 years, the CDR is higher in the UK. The likely reason is the screening interval, which is 3 years in the UK and 2 years in the Netherlands. However, in the Iraqi model, mammography was done more frequently, and the CDR remained high at 42.02 per 1000 mammograms. This may be due to the fact that CBE and sonography were performed before mammography, and the latter was mostly done for diagnosis instead of screening.

In the Czech Republic and Malaysia, the CDR was higher in the older women compared with younger women,[9],[14] who are most likely to visit the screening center only when they experience symptoms. Symptomatic young women require to be diagnosed in a clinical setting instead of screening program, and CDR among the clinically diagnosed women is high in Malaysia at 260 per 1000 mammograms.[14] Similarly, in the Iraqi model, the participants were younger with mean age of 38.46 ± 10.29 years, and thus presented with the symptoms and showed high CDR.

In most screening models worldwide, women aged more than 40 are eligible to participate in screening,[12],[14],[17],[18] while in developed countries, women aged 50 years or more are eligible for screening due to the higher mean age of diagnosed women.[19],[20] In the Iraqi program, the mean age of new participants increased from 37.34 ± 10.21 years in 2007 to 41.93 ± 9.48 years in 2016, and the mean age at diagnosis decreased from 49.1 ± 7.3 to 46.72 ± 13.88 years during the same period. The decreased age at diagnosis combined with increased age at screening may indicate shorter diagnosis period (from appearance of symptoms to the diagnosis of BC) since the women participated in the program soon after the symptoms appeared, and cancer had been detected earlier.

Although most women (90%) participated for the purpose of diagnosis, the high rate of self-referral (77.54%) indicates the efficacy of the Iraqi program. Most women were aware of the program, which had been introduced well during the study period. High rate of self- referral in symptomatic women in HICs has an impact on the breast cancer staging.[7]

The limitations of this study were that we could not determine the distinct CDRs in the healthy, high risk, and symptomatic groups, and CDR was not calculated in each screening round. The screening interval in early diagnosis could not be defined as in screening program. The effect of this program could be measured by determining the stages of the cancer, which were detected.

 » Conclusion Top

The performance of the Iraqi early detection model was effective, with a high CDR of 8.2 per 1000 screened women. Overall CDR of screening with mammography was 42.02 per 1000 mammograms. Women mostly participated by self-referral (77.54%). This program could be effective in the LMICs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Al- Hashimi MM, Wang XJ. Breast cancer in Iraq, Incidence, Trend 2000-2009. Asian Pac J Cancer Prev 2014;15:281-6.  Back to cited text no. 1
Molah Karim SA, Ghalib HH, Mohammed SA, Fattah FH. The incidence, age at diagnosis of breast cancer in the Iraqi Kurdish population and comparison to some other countries of Middle-East and West. Int J Surg 2015;13:71-5.  Back to cited text no. 2
Majid RA, Mohammed HA, Saeed HM, Safar BM, Rashid RM, Hughson MD. Breast cancer in kurdish women of northern Iraq: Incidence, clinical stage, and case control analysis of parity and family risk. BMC Womens Health 2009;9:1-6.  Back to cited text no. 3
Majid RA, Mohammed HA, Hassan HA, Al abulmahdi WA, Rashid RM, Hughson MD. A population-based study of Kurdish breast cancer in northern Iraq: Hormone receptor and HER2 status. A comparison with Arabic women and United States SEER data. BMC Womens Health 2012;12:1-10.  Back to cited text no. 4
Saldaña UK. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol 2014;5:465-12.  Back to cited text no. 5
Al-Alwan NA, Mualla FH. Promoting Clinical Breast Examination as A screening Tool for Breast Cancer in Iraq. Natl J Nurs Specialties 2014;27:75-3.  Back to cited text no. 6
David Moiel JT. Early detection of breast cancer using a self-referral mammography process: The Kaiser Permanente Northwest 20-Year history. Permanente J 2014;18:43-5.  Back to cited text no. 7
Schoor GV, Moss SM, Otten JD, Donders R, Paap E, den Heeten GJ, et al. Increasingly strong reduction in breast cancer mortality due to screening. Br J Cancer 2011;104:910-4.  Back to cited text no. 8
Majek O, Danes J, Skovajsova M, Bartonkova H, Buresova L, Klimes D, et al. Breast cancer screening in the Czech Republic: Time trends in performance indicators during the first seven years of the organised programme. BMC Public Health 2011;11:1-13.  Back to cited text no. 9
Yip CH, Smith RA, Anderson BO, Miller AB, Thomas DB, Suan Ang E, et al. Guideline implementation for breast health care in Low- and Middle-Income Countries. Am Cancer Soc 2008;113:2244-12.  Back to cited text no. 10
World Health Organization. Available from:[Last accessed on 2018 Jul 18].  Back to cited text no. 11
Lee EH, Kim KW, Kim YJ, Shin DR, Park YM, Lim HS, et al. Performance of screening mammography: A report of the alliance for breast cancer screening in korea. Korean J Radiol 2016;17:489-7.  Back to cited text no. 12
Bulliard JL, Ducros C, Jemelin C, Arzel B, Fioretta G, Levi F. Effectiveness of organised versus opportunistic mammography screening. Ann Oncol 2009;20:1199-3.  Back to cited text no. 13
Teh YC, Tan GH, Taib NA, Rahmat K, Westerhout CJ, Fadzli F, et al. Opportunistic mammography screening provides effective detection rates in a limited resource health care system. BMC Cancer 2015;15:2-6  Back to cited text no. 14
Buckley A, Healy N, Quinn A, O'Keeffe SA. The value of routine screening mammography in women aged 35-39 years in a symptomatic breast unit. Clin Radiol 2017;72:512-5.  Back to cited text no. 15
O'Cearbhaill RM, Hembrecht S, Devane LA, Rothwell J, Evoy D, Geraghty J, et al. Breast screening in symptomatic women over 35 years of age: Improvements in service efficiency. Ir J Med Sci [Epub ahead of print].  Back to cited text no. 16
Mittmann N, Stout NK, Lee P, Tosteson AN, Trentham-Dietz A, Alagoz O. Total cost-effectiveness of mammography screening strategies. Health Rep 2015;26:16-9.  Back to cited text no. 17
Van Ravesteyn NT, Migliorreti DL, Stout NK, Lee SJ, Schechter CB, Buist DS, et al. What level of risk tips the balance of benefits and harms to favor screening mammography starting at age 40? Natl Instt Health 2012;156:609-8.  Back to cited text no. 18
Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M. The benefits and harms of breast cancer screening: An independent review A report jointly commissioned by Cancer Research UK and the Department of Health (England) October 2012. Br J Cancer 2013;108:2205-35  Back to cited text no. 19
Nederend J, Duijm LE, Voogd AC, Groenewoud JH, Jansen FH, Louwman MW. Trends in incidence and detection of advanced breast cancer at biennial screening mammography in The Netherlands: A population based study. Breast Cancer Res 2012;14:1-12.  Back to cited text no. 20


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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