Breast Cancer Diagnosis by Mammography in Kazakhstan-Staging Results of Breast Cancer with Double Reading

Breast cancer is of great improtance throughout Asia (Ferlay et al., 2013) including Central Asia, the incidence rate for example being recently found to be increasing in Kazakhstan (Bilyalova et al., 2011; Igissinov et al., 2011; 2012). Reported risk factors include unfavorable living conditions, chronic stress, unilateral breastfeeding, breastfeeding less than 3 months and over 2 years, abortions, and hereditary predisposition (Toleutay et al., 2013). In addition, a direct strong correlation between the degree of contamination with high pollution emissions in the atmosphere from stationary sources and the incidence of breast cancer has been described (Bilyalova et al., 2012). The situation in Central Asia may be complicated by higher rates in Russians than Turkic inhabitants. (Igisinov et al., 2005). It has been stressed that clinical and public health interventions should be aimed at both women and healthcare providers to use mammography as a tool for early detection of breast cancer in Kazakhstan (Chukmaitov et al., 2008). However, while mammography screening is cost-effective in most Western countries, this may not be the case in Asian countrie sfor reasons of incidence rate or racial characteristics, such as dense breast tissue (Yoo et al., 2013). On possible way to improve accuracy is by double reading of mammograms, even as an adjunct to real-time single reading plus immediate assessment (Caumo et al., 2011). In Iran, despite no


Introduction
Breast cancer is of great improtance throughout Asia (Ferlay et al., 2013) including Central Asia, the incidence rate for example being recently found to be increasing in Kazakhstan (Bilyalova et al., 2011;Igissinov et al., 2011;2012).Reported risk factors include unfavorable living conditions, chronic stress, unilateral breastfeeding, breastfeeding less than 3 months and over 2 years, abortions, and hereditary predisposition (Toleutay et al., 2013).In addition, a direct strong correlation between the degree of contamination with high pollution emissions in the atmosphere from stationary sources and the incidence of breast cancer has been described (Bilyalova et al., 2012).The situation in Central Asia may be complicated by higher rates in Russians than Turkic inhabitants.(Igisinov et al., 2005).
It has been stressed that clinical and public health interventions should be aimed at both women and healthcare providers to use mammography as a tool for early detection of breast cancer in Kazakhstan (Chukmaitov et al., 2008).However, while mammography screening is cost-effective in most Western countries, this may not be the case in Asian countrie sfor reasons of incidence rate or racial characteristics, such as dense breast tissue (Yoo et al., 2013).On possible way to improve accuracy is by double reading of mammograms, even as an adjunct to real-time single reading plus immediate assessment (Caumo et al., 2011).In Iran, despite no

Breast Cancer Diagnosis by Mammography in Kazakhstan -Staging Results of Breast Cancer with Double Reading
Eldar Beysebayev*, Kazbek Tulebayev, Tylek Meymanalyev significant improvement in the cancer detection rate by double reading, a lower recall rate was thought to be a more helpful consequence (Moradi et al., 2013).
Since very litimited information is available in the international literature regarding mammography screening in Kazakhstan, the present descritive study was performed to provide baseline data for more analytical analyses kin the future.

Materials and Methods
This study was conducted at the Kazakh Research Institute of Oncology and Radiology in close cooperation with the staff of oncology clinics and medical departments of universitiesinvolved in breast cancer screening acroos the country.Fundamentals and principles of mammographic screening for the Republic of Kazakhstan were developed on the bases of European guidelines: 1) Type of screening-populational; 2)screening methodmammography of both breasts in 2 projections; 3) the interval -once in every 2 years; 4) the target group -women aged50, 52,54,56,58,60years.Mammograms are made at primary health centers (PHC) in the various Oblasts, with women of the indicated age groups, together with the completed documentation and "primary readings" sent to the city or Regional Oncology Center, where doctors radiologists perform a 'second reading'.Interpretation of the results of mammography performed by classifying BI-RADS.The emphasis in organizational and methodological aspects is on obligatory performance of 'double readings' of mammograms by two independent radiologists.

Results
Data for mammograhy and second readings in different areas of Kazakhstan for 2012 and the first nine months of 2013 are shown in Table 1.A total 459,816 women aged 50, 52, 54, 56, 58 and 60 years were screened in 2012 and  379,903 in the first 9 months of 2013.Clear variation was noted across the country, with higher rates achieved so far for 2012.Similarly, data for stages of breast cancers are shown in Table 2.No clear relationships between percentage second reading and total or early stage cancers could be discerned.While significant age-related differences in the detection of breast cancer were not observed, women aged 50 were more likely to undergo screening than their older  doi.org/10.7314/APJCP.2015.16.1.31 Organizational and Methodical Aspects of Breast Cancer Diagnosis by Mammography in Kazakhstan counterparts in both rural and urban settings (see Figure 1).In addition, numbers of individuals screened were higher for cities than villages (see Figure 2) while percentages of screenees who were positive for cancer was far greater in the urban group.These data also confirmed a lack of variation in prevalence across age groups.

Discussion
The priority of this researchwas to report 'double readings' of screening mammograms in the Kakazhstan context.While the relative proportions of stage I and II as compared to stage III-IV were relatively high it is difficult to compare the data with other series in other countries given the lack of any control groups of non-screened individuals, although one study in Khanty-Mansiysky Autonomous Region-Yugra demonstrated similar results (Zakharova, 2013).The accuracy of staging may be affect by the primary method of obtaining material because fine needle aspiration biopsy, in some cases provides poor information (Cherenkov et al., 2013).Also the actual benefits of double reading (cf Caumo et al., 2011;Moradi et al., 2013) could not be ascertained with the comparison groups included here.Clearly in the future, there should be attention paid to differences between screened and non-screened regarding staging of lesions and mortality or survival.Given the preponderance of numbers undergoing mammography in urban and compared to rural groups, despite similar perecntage compliance, and the much higher actual rates for cancer positives, any future work should take these parameters into account and also if possible the ethnic groups of people involved.Incidence rates are known to be generally higher in cities than villages, for example in China (Wu et al., 2014).The focus here was on those aged 50-60 as reported also for China (Shi et al., 2013), a little later than the 40-459 group of screened women in Turkey found to be positive (Kayhan et al., 2014)..
It is well known that ethnicity can affect breast cancer knowledge and compliance with screening recommendations in Kazakhstan (Chukmaitov et al., 2008) and rates of breast cnacer for example in Kyrgystan between Russian and Turkic peoples (Igisinov et al., 2005).Whether there might be any correlate between rates of cancer positives and screenees by geographical location in Kazakhstan should also be assessed, taking into consideration the findings of Bilyalova et al. (2012).
The question of effects of screening on incidence rates, as recently reported for Australia (Beckmann et al., 2014) should also be a focus for future attention.The major problem of psossible over-diagnosis could not be addressed in the present study but certainly needs attention in the future.The role that additional modalities like ultrasonography could play, especially in detecting breast cancer in young women with high-density and relatively small breasts (Wang et al., 2014).
In conclusion, our data fprovide an initial survey of mammography screening and breast cancer identification in Kazakhstan, a Central Asian country with great geographical and ethnic variation.Hopefully future work will provide a clearer picture of the efficacy of screening, with possible attention to high risk groups and different target ages.

Figure 1 .
Figure 1.Percentage Compliance with Mammography in Different Age Groups for City and Village

Figure 2 .
Figure 2. Percentages of Individuals Undergoing Mammography in Different Age Groups for a) Rural and b) Urban Populations who were Positive for Breast Cancer