Mobile mammography vans: Bridging breast cancer screening access gap in remote areas

By: Dr Fiaz Maqbool Fazili

 Breast cancer represents a critical public health challenge in low- and middle-income countries (LMICs) like India and the Kashmir region, where late-stage diagnosis and limited resources contribute to disproportionately high mortality rates. In these settings, innovative strategies such as mobile mammography vans offer promise for extending screening access to remote villages. This essay examines the comparative effectiveness of mammography versus clinical breast examination (CBE), the value of early mammographic detection of non-palpable lesions, and implementation insights from regional experts like Dr Fiaz Fazili, contextualised within the unique challenges of LMICs.

Breast cancer screening modalities: mammography vs. clinical examination

A. Mammography: precision and early detection – Mammography remains the gold standard for detecting breast cancer before lesions become clinically palpable. Studies confirm it identifies microcalcifications and tumours “1–3 years before physical manifestation”, enabling intervention when treatment is most effective. In LMICs, where 60–70% of cases present at advanced stages, this lead time is transformative. For example, mammography’s sensitivity ranges from “77–95%” in detecting early-stage tumours (stage 0–I), compared to CBE’s “40–69%”. Its ability to detect ductal carcinoma in situ (DCIS)—a precursor to invasive cancer—further underscores its preventive value.

B. Clinical breast examination: a pragmatic alternative – Where mammography infrastructure is scarce, CBE offers a viable alternative. A 20-year Mumbai trial demonstrated “30% mortality reduction” in women over 50 through biennial CBE screening, achieved via trained community health workers. CBE requires minimal technology, reduces costs by “80–90%” compared to mammography, and is less affected by dense breast tissue common in younger LMIC populations. However, its effectiveness hinges on provider training and standardised protocols—variables inconsistently available in rural India and Kashmir.

“Mammography” – sensitivity 77–95%, specificity 85–94%, cost per screen (USD) $25–50, mortality reduction.
“CBE” – sensitivity 40–69%, specificity 86–94%, cost per screen $2–5, mortality reduction 25–30%.
“Self-exam” – sensitivity 12–41%, specificity low, cost per screen minimal, mortality reduction no evidence.

The power of early detection: lead time and survival gains – Mammography’s capacity to identify “non-palpable lesions” translates into quantifiable survival benefits:
– Stage shift: screen-detected cancers in LMICs are “3× more likely” to be node-negative and sub-2cm, enabling breast-conserving surgery instead of mastectomy.
– Survival impact: early detection raises 5-year survival rates to “>90%” (vs. “<40%” for stage III–IV). In Ethiopia, Markov models estimate mammography could gain “2,500+ life-years” per 100,000 women screened.
– Economic efficiency: treatment costs for early-stage cancer are “60–80% lower” than late-stage care—a critical factor where health budgets are strained.

Mobile mammography vans: bridging the access gap – In Kashmir’s remote villages and India’s tribal regions, fixed mammography facilities are often inaccessible. Mobile vans equipped with “portable digital units” and telemedicine capabilities address this through:
– Geographic reach: units travel to villages, offering screening integrated with health camps (e.g., Aliya Begum Centre reported “20% higher uptake” via van-based camps).
– Cost challenges: while van deployment doubles accessibility, operational costs remain high. Ethiopia’s analysis showed mammography costing “$3,224–$4,739 per life-year gained”—exceeding the WHO cost-effectiveness threshold (3× GDP per capita = $2,808).
– Hybrid models: pairing vans with “community health worker-led CBE” optimises resources. High-suspicion CBE cases receive on-site mammography, reducing unnecessary tests by “30–50%”.

Insights from Kashmir: author’s advocacy – Author, a surgical oncologist in Kashmir and GCC member, highlights systemic gaps exacerbating diagnostic delays:
– Misdiagnosis epidemic: in a recent interaction with Omar Abdullah, the author cited cases like a “20-year-old man” whose metastatic cancer was initially treated as back pain—emblematic of cognitive biases and fragmented care.
– Infrastructure gaps: he notes Kashmir’s “<10 mammography units” for 7 million people, with rural patients facing “4-week waits”. Mobile vans alone are insufficient without “pathology linkages” and specialist follow-up.
– Awareness-participation divide: despite campaigns, “<30% of Kashmiri women” attend screenings due to stigma, travel costs, or distrust. Dr Fazili advocates “mosque- and school-based education” to normalise screenings.

Implementation strategies for LMICs
A. Phased screening integration
– Step 1: population awareness via community health workers (CHWs), emphasising symptomatic presentation.
– Step 2: CBE-led screening by CHWs for women “>40 years”, with mobile mammography for “high-risk groups” (e.g., family history, BRCA mutations).
– Step 3: centralised telemedicine hubs for mammography interpretation, reducing radiologist shortages.

Financial sustainability
– Public-private partnerships: Bank Alfalah and Roche’s “$220,000 partnership” funds free screenings and treatment in many countries, demonstrating scalable models.
– Cross-subsidisation: urban screening centres subsidise rural van operations (e.g., India’s National Cancer Grid proposal).

Workforce innovation
– Training “non-specialists” in CBE and basic mammography interpretation.
– Task-shifting: our neighbouring country’s Lady Health Workers programme increased screening coverage by “45%” in 3 years.

Toward contextualised and equitable screening – Mammography’s ability to detect non-palpable lesions offers unparalleled opportunities for early intervention in LMICs. However, its cost and infrastructure demands necessitate pragmatic integration with CBE and mobile platforms. As my Kashmir experience illustrates, success requires “tailored approaches”: mobile vans for remote access, CHWs for community engagement, and policy reforms ensuring diagnostic-therapeutic continuity. Investments must prioritise “cost-reduction” (e.g., AI-assisted imaging) and “financial protection” to prevent catastrophic expenditures.

Patients don’t die from untreatable cancers, but from unseen ones. By anchoring programmes in equity and innovation, India and Kashmir can transform breast cancer from a death sentence to a manageable condition.

(Dr Fiaz Maqbool Fazili, Senior Consultant Surgeon (Onco-Surgery; Breast), Clinical Auditor and Consultant; Hospital & Healthcare Policy Planning; Patient Safety & Quality Care (QPS) Improvement)