The 2009 Lebanese National Mammography Campaign: Results and Assessment Using a Survey Design

Breast cancer is the leading cancer among women globally. It comprises about 18% of all female diagnosed cancers [1]. In the developing world, breast cancer’s incidence rate is increasing at 3-4% [2]. In addition, 45% of the annual registered deaths are attributed to breast cancer [3]. In the Arab world, breast cancer constitutes between 13-35% of all female diagnosed cancers [4]. In Lebanon, a small Arab country with a total population of about four million, breast cancer is also the leading cancer among women [5].

According to the Lebanese National Cancer Registry (NCR), breast cancer constituted more than one-third of all female cancers [6,7]. In 2007, the crude breast cancer incidence rate was estimated at 82.9 per 100,000- female population, and the overall age-standardized rate (ASR) (using the total world population as a reference) was 91.8 per 100,000 female populations [8].

The mean age of breast cancer diagnosis in Lebanon is observed to be younger when compared to the west, where it ranges between 49.8 years and 50.8 years [9,10]. Studies also show younger age at presentation to be an independent worse prognostic factor for survival. Women with younger age at initial diagnosis are observed to have larger tumor sizes, more positive lymph nodes involvement, more negative hormone receptors, and higher tumor grades [7,9,10].

The ASRs rates observed in Lebanon tend to be lower than those observed in North America, West Europe, and Israeli Jews. However, they are higher than those observed in other Arab and several Asian countries like Iran, Malaysia, and Japan. More specifically, Lebanon is noted to have some of the highest age-specific incidence rates worldwide, particularly for the age groups: 35 to 39 years (where it is estimated at 67.7 per 100,000), 40 to 44 years (where it is estimated at 163.7 per 100,000), and 45 to 49 years (where it is estimated at 209.3 per 100,000) [7].

Improvements in breast cancer screening and early detection can be better achieved with a comprehensive understanding of the underlying risk factors deterring such behaviors. The biomedical risk factors for breast cancer reported in Lebanon are similar to those found elsewhere in the Middle East and the developed world. These include: reproductive risk factors (like early menarche, nulli-parity, late age at first birth, shorting duration of breastfeeding, and late menopause), use of oral contraceptive pill use, use of hormonal therapy, family history of breast cancer, minor breast lacerations, smoking, as well as obesity among post menopausal women [11-16]. However, other risk factors need to be further explored within the Lebanese context, in order to better address the burden of breast cancer in the country and influence pre-screening behaviors. Some of these factors include the impact of social, economic, cultural as well as religious elements.

For instance, in the United States health attitudes and beliefs towards breast cancer, knowledge, access to care, socio-economic status, educational level, health insurance, family history, having a regular physician, and having a recommendation from a physician have all been linked with increased Breast Self Exam (BSE), Clinical Breast Exam (CBE), and mammography use [17-20].

Screening often leads to earlier stage of diagnosis (counter-critiques with lead-time and length time bias), better prognosis, increased survival rates and better quality of life post disease management [21- 24]. While there are multiple screening methods, mammography remains the most effective mean to screen [21,22].

Recognizing the high incidence of breast cancer in Lebanon, the Ministry of Public Health (MOPH) and the Lebanese Breast Cancer National Task Force recommends breast self-examination (BSE) every month starting at the age of 20, and a clinical breast examination (CBE) every three years between the ages of 20 and 40. Starting at 40 years of age, annual mammography and CBE are recommended [25]. Furthermore, the MOPH has been offering reduced cost mammography screening annually, since 2002, in order to promote early breast cancer screening and detection among women.

Similar national screening programs are well noted to promote awareness as well as early and regular screening behavior. In the United States and as of 1990, national breast cancer screening with mammography (for women 40 years and older) has substantially increased, where utilization has increased from 30% in 1987 to that of 70% in 2000. In Australia, the Breast Screen program has achieved a 52% participation rate [26]. In Finland, the national screening program has achieved an 81% participation rate [27].

Beyond participation, these programs also have substantial impacts in reducing breast cancer morbidity and mortality and costs associated with treatment. In the United States, regular mammography screening for women 50 to 74 years old has reduced mortality from breast cancer by about 23% [28]. In Norway, its national led mammographyscreening program (since 1995) has resulted in a 24% reduction in breast cancer mortality due to screening [29]. In Sweden, mortality due to breast cancer among screened women (between the ages 40 to 69 years) has decreased to 63%, also as a result of the positive impacts of the nationally led mammography campaigns in the country [30]. Besides, it is estimated that regular mammography screening cuts down on treatment costs of fatal breast cancer by one third [31-33].

The availability of these annual national-based subsidized mammography campaigns in Lebanon represents a novelty for the Middle East region, where lessons can be learned and built upon for Lebanon as well as other countries in the region that lack national comprehensive awareness and screening programs [4].

The evaluation of the cost effectiveness, reach, coverage, and utilization of these campaigns is equally crucial in order to provide more optimal, cost effective and good quality screening programs. Such evaluation allows to better address gaps- that if properly resolvedcan improve utilization rates.

This paper describes the results of the three-month nationalbased mammography campaign conducted by the Lebanese MOPH between October-December 2009. It specifically addresses the impact of socioeconomic characteristics, lifestyle, reproductive history, and family history on participation in this campaign, as well as factors influencing first-time versus repeated participation. This paper also addresses the outreach adequacy of this campaign for the year 2009 in terms of its coverage, cost, method of advertisement, and rate of participation across the different Lebanese regions.

Setting, sample & design

The 2009 national mammography campaign was organized by the MOPH over a three-month period between October-December 2009. The campaign was advertised using different media channels: television messages, billboards, radio messages, text messages, etc. The MOPH subsidized the cost of mammography screening throughout Lebanon, where it was offered for free in the participating public radiology centers and at reduced price (of 27 US$=40,000L.L) in the private centers. The campaign targeted women 40 years and older and younger with high risk defined as having a family history of breast cancer.

A total of 83 (out of 110 invited to participate) hospitals, medical centers, and Non-Governmental Organizations (NGOs), both public and private, participated in this campaign. The total number of women participating in this campaign in 2009 was 10,953 women. Hence, the study represents a national based sample of convenience of data collected over three months in 2009 throughout the country.

The participating centers were distributed throughout the different Lebanese governorates. Most of these centers were located in Mount Lebanon (24, 31.2%), followed by 22 (27.4%) in Beirut, 6 (7.1%) in Bekaa, 16 (18.9%) in the North, and 13 (15.4%) in the South.

Data collection

Data were collected by the radiology technicians at these centers using a closed-ended structured questionnaire. All technicians (from the different participating centers) were trained on data collection prior to the campaign.

The Lebanese Breast Cancer National Task Force provided ethical approval for the data collection process, questionnaire as well as the overall campaign protocol. An oral consent was provided by the women before data collection. Women were ensured that the information collected was kept confidential, they had the right to refuse to fill out the questionnaire even after consent, and that refusal to take participate will not affect the services provided.

The questionnaire was divided into six main parts: sociodemographic characteristics, smoking behavior, reproductive health record, family history, information about the campaign, medical diagnosis and recommendations. The socio-demographic questions included: age, place of birth, marital status, and educational status) as well as questions on smoking habits. The reproductive health questions included: age of menarche, age of mensis, breast feeding, OCP and HRT use. The family history questions included breast cancer cases in the immediate or extended family. The medical diagnosis included results of the mammogram and other recommended tests. A section concerned with the campaign itself was also included and inquired about first time participation, methods women heard about the campaign, and perceived test cost. Prior to administering the questionnaire, consent from the women was obtained.

Data management and analysis

The data were entered on Microsoft Office Excel, by two dataentry personnel, and were later transferred to the Statistical Package for Social Sciences (SPSS) software-version 16 for management and analysis.

Analysis was primarily descriptive using mean, SD and ranges for continuous variables and frequency and percentage distribution for categorical variables. Bi-variate analysis included: CHI-square test of association, set at 5% type I error as well as independent sample T-test and ANOVA, also set at 5% type I error. Multi-variate backward logistic regression analysis was conducted using backward logistic regression. Best-fit model was chosen (p- values of 0.05 or lower were retained to decide upon the best fit model).

Descriptive analysis

Socio-economic characteristics: The mean age of women participating in this campaign was 49 years (+10) and the range varied between 16- 87 years. The mean height was 162 cm (+8); and mean weight was 69 Kg (SD 16). The mean Body Mass Index (BMI) was 27 Kg/m² (+6) and the range varied between 1-33.4 Kg/m². 8896 (84.1%) were married, 974 (9.2%) were single, 494 (4.7%) widowed, 209 (2%) divorced, and 11 (0.1%) engaged. Most of the women had intermediate educational level (2604 (26.5%)), followed by 2220 (22.6%) secondary, 1697 (17.2%) elementary, 1340 (13.6%) university higher studies, 942 (9.6%) university, 578 (5.9%) were illiterate, and 459 (4.7%) had a technical diploma TS/BT. 4263 (40.7%) were current smokers, 1114 (10.6%) ex-smokers, and 5093 (48.6%) never smokers. 24.1% of the women obtained their mammography from a public center, while 75.9% obtained it from a private center.

Reproductive history: The mean age of first menses was 13 years (+1.5), mean age at first marriage was 21.85 years (+5.6) and range (12- 73 years); mean age at first pregnancy was 23 years (+5.2) and range (12-49 years). The mean number of pregnancies was 4.2 (+2) range (0- 39). 6970 (82.9%) of the women indicated to have ever breast-fed, 5697 (52%) never used OCPs, 3495 (31.9%) were ex-users of OCP, and 487 (5%) were current users of OCPs. Also the majority, 7040 (79.7%), were non-HRT users, 1373 (15.5%) were ex-users of HRT, and 417 (4.7%) were current users of HRT.

Family history: Of the women having at least one family member diagnosed with breast cancer, 691 (8.9%) indicated that member to be an aunt on the mother’s side, 686 (8.8%) to be a sister, 596 (7.3%) to be a mother, 586 (7.5%) to be an aunt on the father’s side, 122 (1.6%) to be a grandmother on the mother’s side, 73 (0.9%) to be a grandmother on the father’s side, 69 (0.9%) to be a father, and 40 (0.5%) to be a daughter.

Diagnosis: Of the women attending to the 2009 mammography campaign, 1.3% were diagnosed with an ACR= 4, i.e. had suspicious findings, 0.6% were diagnosed with an ACR=5, i.e. had highly suspicious findings, and 0.3% were already diagnosed with breast cancer, i.e. had an ACR 6.

Information about the campaign: When women were asked how they heard about the campaign, 39.3% of the women said from television messages, followed by 23.6% who said from a friend, 22.2% from a physician, 16.8% from a poster, 10.4% as a result of routine checkup required, 3.2% from a brochure, and 0.5% from a text message. As for participation, 68.2% participated in this campaign for the first time and 97.8% of the women indicated they would repeat participation in the following year. Furthermore, 88.8% of the women considered the price of the mammography acceptable (Table 1).

Table 1: Descriptive Analysis: Sociodemographic, History, and Campaign-related characteristics.

Bivariate analysis

As mentioned earlier, 68.2% of the women indicated to participate in this campaign for the first time, compared to 31.8% who participated in the campaign before. Bi-variate analysis aimed to compare those participated in the 2009 campaign for the first time compared to those who have participated previously. Comparative analysis was done by socio-demographic, reproductive history, family history and campaign related variables.

There was no significant difference in BMI and age at first marriage between the women who participated in the campaign for the first time with those who participated previously. Age was significantly different, mean age of women who participated for the first time was 48.9 years (±9.9) compared to 51.04 years (±8.7) for those who participated previously (p-value <0.05). There was no significant difference for age at first menstruation, having a mean of 12.99 years (±2.25) for the former and 12.94 years (±2) for the latter, as well as for age at first pregnancy having a mean of 22.78 years (±5.9) for the former, and 22.68 years (±5) for the latter. Women who participated for the first time tended to have a higher mean of total number of pregnancies: 4.24 pregnancies (±2.5) compared to 4.1 pregnancies (±2.2) (p-value <0.05) for women who participated previously.

Among the women who participated in the campaign for the first time: 71.3% were current smokers compared to 66.0% were past or never smokers (p=0.000); 70.3% were single compared to 67.8% were married (p=0.183); 76.0% were illiterate compared to 67.0% have graduate education (p=0.000); 68.9% have ever breast fed compared to 67% who never breastfed (p=0.157); 70.3% were ever users of OCPs compared to 67.8% were never users (0.000); 70.7% were ever users of HRT compared to 65.7%; 68.3% had none of their family members affected compared to 57.8% having two or more family member affected (p=0.009); and 70.7% considered price as not acceptable compared to 67.5% who considered the price acceptable (p=0.035) (Table 2).

Table 2: Bivariate Analysis: Description of participation by Sociodemographic characteristics, Reproductive history and Campaign related factors.

Multivariate analysis

Backward multivariate logistic regression was conducted. The model included “First time participation” as the main dependant variable. Age and total number of pregnancies were included as continuous covariates. The categorical covariates included: smoking status, educational level, OCP use, HRT use and Family history. The covariates were selected based on the results of the bi-variate analysis.

The best-fit chosen model included only six covariates: age, educational status, smoking status, OCP use, HRT use, and family history.

On average, looking at the independent effect of each of these covariates, women who were not participating for the first time were less likely to be ever users of OCP (OR 0.870, 95%CI.762-.993). They were more likely to have a family history of breast cancer (OR 1.188, 95%CI 0.475-0.968). They were more likely to have higher educational levels (OR for intermediate level of education or was 2.391 with a 95%CI of 1.691-3.380; OR for secondary level education was 2.768 with a 95%CI of 1.948-3.933, and the OR for a university level education was 3.166 with a 95%CI of 2.151-4.661). They were more likely to be ever users of HRT (OR 1.246, 95%CI 1.059-1.466). They were more likely to be never smokers (OR 1.285, 95%CI 1.129-1.463) (Table 3).

Table 3: Multivariate Logistic Regression Analysis: Factors Affecting Women’s Participation in the Campaign.

The results of the current campaign showed that the average age of the participating women is around 49 (±9.67) years old. The majority of the women were currently married. The women mainly resided in Beirut or Mount Lebanon (from more urbanized areas in the country) and obtained their mammography in private centers. Family history of breast cancer among these women (followed similar familial clustering indicated in the literature) of mainly having: an aunt on the mother’s side with breast cancer (8.9%), and a sister (8.8%).

The majority of the women participated in this campaign actually did so for the first time (68.2%). The effectiveness of this campaign was highlighted by the fact that 97% the women indicated their willingness to repeat the exam next year and 88.8% considered the price to be acceptable.

When comparing women who previously participated in this national campaign to those participating for the first time, these women were independently and significantly more likely to be older, of higher educational levels, non-smokers, and have a family history of breast cancer.

The findings reported in this campaign, are similar to those reported elsewhere. Researchers in Saudi Arabia, Qatar, Egypt, Jordan, Iraq, and the West Bank found that marital status and a positive family history of breast cancer were predictors for screening [12,33-37]. Studies in the UAE, Saudi Arabia, Palestinian Authority, Israel, and Jordan as well as in the US also found that women with higher educational levels were more likely to undertake screening [33,35,36,38-40]. Additionally, those who live in urban areas, are employed, and receive a professional or family recommendation are more likely to undergo screening [35,40,41].

National mammography campaigns aim to increase breast cancer awareness and simultaneously to enhance screening and early detection by encouraging mammography utilization. Adib et al. [41] looked at mammography utilization during the previously held national campaigns (between 2002 and 2005) and estimated that the utilization rate of these campaigns is increasing in the country [42]. In that same study, Adib et al. [41] indicated that only 2.2% of the women indicated to have had a mammogram in the past. The study argued that these participation rates (observed between 2002-2005) were less than those reported in the west [43], but similar to those reported in developing nations.

In the 2009 Lebanese National Mammography Campaign, 31.8% of the women reported having a previous mammogram (though not necessarily through the previously held nationally mammography campaigns). This rate is rather more comparable to rates noted in westernized countries. For example, in Turkey, 25% of women indicated that they have had more than one mammogram [20], and 40% indicated so in the USA [44].

Lebanon’s national mammography campaigns are one of a few in the Middle East region, where breast cancer rates seem to demand such campaigns. The current 2009 campaign, over a three months period, was able to attract 10,953 women, minding that only 80/110 centers reported back. Hence, it could be expected that the numbers for the 2009 campaign are actually even higher. At the same time, it is worth noting that this number is more than triple the number of participants attracted during the prior-one-month national campaign conducted in 2008. This increased number in participation can possibly reflect improvements in breast cancer screening at the country level, and it can also have important implications to encourage women to seek regular screening during the subsequent yearly campaigns.

The women in this campaign indicated that television messages, a friend, and the physician were their main exposure routes about this campaign. Additionally, the majority of the women considered the subsidized mammography cost acceptable. Having said this, it is plausible to believe that the women who participated in this campaign were those who could actually afford the subsidized price being offered, had more access, and were better aware because of their educational background.

There remains a need to critically assess the coverage and outreach of the Lebanese national mammography campaigns in order to further promote regular participation across the different segments of women population, improve the effectiveness of these campaigns in the subsequent years, and enhance social justice at the national level. It is as essential that these campaigns truly reach all segments of society and women across different socioeconomic strata.

Focusing on the fact that the majority of the women obtained their mammograms at a private center (minding that mammography screening was subsidized for free at public centers) demands equal critique. It is possible that the participating women do not have trust in the quality of mammography offered at the public centers, or the public centers do not have enough capacity to accommodate all participating women. It could also mean that these centers are not as accessible to the women as the private centers. Additionally, a substantial number of women reside in more rural (disadvantaged) areas that the campaign still does not reach. For these women, reaching to the nearest center to obtain screening can be very tedious and transportation costs may not be easily affordable. These critiques are commonly shared with Adib et al. [41], who also demonstrated that the utilization rates of these national campaigns could be hampered by obstacles such as: availability, affordability, and access to health centers [42].

Concerned authorities (MoPH collaboratively together with the civil society/NGOs, etc) need to implement more effective strategies to increase participation in these national mammography campaigns. Such strategies should focus on subsidizing these campaigns and simultaneously improving the quality of rendered services in the public sector, in order to enhance women’s trust to use the mammography services offered by the public sector,. They should also focus on addressing additional barriers associated with transportation and access that can further hinder women participation.

Furthermore, taking into account the cultural-sensitivity of each area will ensure catering to a larger segment of the population. Examples on such could include using simplified media messages (whether through television, radio or brochures) to entice women to participate. Since Lebanon is a small country, addressing these challenges is feasible and will improve the regular utilization of these national mammography campaigns.

One limitation associated with this study is that only an overview of the total number of women, who participated, as opposed to actual national mammography utilization rates, can be provided. This is due to the absence of a national Lebanese census, which hinders calculating actual rates of utilization from these campaigns because of the lack of an accurate denominator. Another limitation is associated with information bias, since the data were based on self-report. However, this was partially controlled for as all the questions were close ended. Selection bias is also possible. As already noted, women who participated in this campaign were more likely to have better access and educational background. Important strengths associated with this assessment include the large and diverse sample size from the different regions in Lebanon. The study power is very adequate and offers an acceptable degree generalizability of the campaign findings.

Life expectancy in Lebanon is on the rise, thus, more women will be reaching the ages of 40–60 years soon. Studies have shown that regular screening for breast cancer in these age groups can decrease over all mortality due to breast cancer by 20–35% [45,46]. In the 2009 campaign, education and perceived susceptibility influenced utilization of screening. As such, other factors beyond education and perceived susceptibility should be further explored in order to improve the effectiveness and the outreach of this national endeavor. To fully understand these factors, social justice and equity should become a national priority. Hence, the following recommendations for the future are suggested:

1. Campaigns should stress upon the importance of having regular and annual mammography, for women 40 years of age or older, irrespective of the previous year’s results

2. Increasing the promotion/marketing for these campaigns not only during but also before the actual start of the campaign. A specific emphasis on television messages need to be maintained (as this was the main route of exposure of the women about the campaign)

3. Enhancing the promotion of national equity and social justice by- for example- intensifying efforts to increase outreach -specifically among the needy population and those residing in remote areas- by providing alternative means such as mobile clinics, etc.

4. Improving the quality of mammography in the underprivileged areas of Lebanon and in the public centers -where quality of services rendered is speculated to be discrepantly less favorable

5. Improving the capacity of public centers to accommodate more women

6. Decreasing the time needed for the women to obtain the test results back

Hoffmann-La Roche Ltd. (Lebanon) for funding this national campaign on yearly basis, within the context of the Ministry of Health rules and regulations. To all participating Public and Private Hospitals and radiology centers. To all Radiology specialists (technicians and doctors) for making this campaign possible every year. To all participating women, without whom this work will not be possible. Last but not least, to Ms. Maya Abou Saad for data entry and management. The Lebanese Breast Cancer National Task Force provided ethical approval for the study and over all campaign protocol. Participating women provided informed oral consent prior to data collection.