BRINGING BREAST CANCER DIAGNOSIS TO THE DEVELOPING WORLD - With a Cell Phone?

By Andrew Degnan

Published on March 2009

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The cell phone may be the unlikely hero in providing women across the globe with much-needed breast cancer screening and diagnosis.

Each year, about half a million women die of breast cancer throughout the world and, with gains in the treatment of infectious disease, the number of women with breast cancer in the developing world is only expected to increase in proportion to a greater average life expectancy¹. Researchers at UC-Berkeley and Hebrew University of Jerusalem propose a new means of aiding the diagnosis of breast cancer by coupling the cell phone with electrical impendence tomography (EIT), a novel imaging method already shown to detect abnormalities in breast tissue^{2, 3}.

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The team, led by Boris Rubinsky, tested this innovative, cell phone-based imaging system in a proof-of-concept trial reported in PLoS ONE. In this system, an array of electrodes placed on the patient measures the conductivity of the breast tissue. Researchers have already shown tumors of the breast can be delineated based on their differing conductivity from normal tissue³.This EIT device is connected to a cell phone that relays the raw outputthereby consolidating the more technical aspects of the system in a manageable, central location. There, or anywhere in the world, an imaging specialist can interpret the resulting image and relay the results back to the local practitioner and patient.

The researchers in this study show that commonplace cell phone capabilities such as multimedia messaging (MMS), text-messaging, and even fax-like transmission can relay the readouts from the EIT imaging device quickly and easily. At the central data center, a computer translates this data into meaningful readouts that can help surgeons localize a mass and clinicians properly manage the patient’s cancer. There is no need for a computer at the patient site and little training would be required for users of this technology.

This technology may just be the solution to the problem of bringing radiology to the most remote parts of the globe. The disparity between radiology services in resource-poor countries, especially rural areas, and the developed world has only widened with the advent of more advanced technology. In 1980, The WHO estimated that over half the population of resource-poor countries could not access even basic radiological services⁵. In spite of the work of the World Health Imaging System for Radiography (WHIS-RAD), many still have no means of receiving an X-ray let alone more advanced imaging studies such as CT and MRI^{2, 6}.

The lack of basic X-ray mammography in rural and impoverished communities throughout the world has meant women present with advanced-stage breast cancer that is more difficult to treat and deadlier⁴. Rubinsky and colleagues hope to mitigate this problem with the development of an imaging system that is simple and cost-effective.

Because EIT utilizes electrical differences in tissue and does not use harmful radiation, it averts the ancillary risks of conventional mammography⁷. In addition, it is much cheaper and requires less training and maintenance.(7) All of these attributes make it an ideal candidate for use in regions of the world that cannot afford comprehensive radiological services or are too remote to receive bulkier equipment.

Admittedly, EIT will never surpass other imaging modalities in terms of accuracy, nor can readers expect to see EIT replace CT or MRI in industrialized nations. It is hoped, however, that EIT will be found across the global community and serve as a more affordable, safer alternative to these other imaging modalities.

This system could be used in conjunction with other forms of telemedicine communication to link clinicians and radiologists in the developed world with their colleagues in resource-poor countries to improve care and encourage the education of local physicians⁸.

It is clear that better breast cancer diagnosis must also coincide with the introduction of more therapeutic options. Dr. Benjamin Anderson of the Breast Health Global Initiative writes:

Breast conserving therapy – a technique which avoids total removal of the breast] is not a luxury to be reserved for the wealthy…a woman undergoing mastectomy for cancer in some countries may face rejection from her husband and divorce…women may choose death over loss of their breast⁹.

One remedy to this problem involves coupling the EIT system with an interventional therapy called irreversible electroporation – a technique that disrupts the cell membrane to ablate tissue in a minimally-invasive manner¹⁰. Thus, the same cell phone that we rely on for calling friends and family may bring both diagnosis and treatment to the remotest village in Africa or the most impoverished city in Latin America.

The authors are hopeful:

We believe that this concept has the potential for decreasing the complexity of operating the imaging system at the patient site and make state of the art diagnostic imaging as well as interventional imaging available to people and places that do not have adequate medical imaging now².

If this novel EIT system is to remedy the lack of access to mammography in the developing world, it must be deployed in a multidisciplinary program which involves the training of local technicians on use and repair of the devices. Use of the EIT system should be accompanied by implementation of formal breast cancer screening campaigns, and the advancements in the availability and quality of therapeutic options. In light of the dearth of oncologists (roughly one per million persons in Sub-Saharan Africa), radiologists and surgeons in these resource-poor countries would rely heavily on the charitable support of other nations – an obstacle that persistently thwarts efforts to improve care in the developing world¹¹. Moreover, for this screening approach to work and for these populations to participate, women in these regions must be educated on breast cancer, including the teaching of breast self-examination¹².

The limitations of a cell phone-based, EIT breast cancer screening intervention, largely relate to the inextricable link between low GDP and lack of access to advanced medical and surgical care. This approach offers an alternative to a traditional, high cost mammography-based program.

Rubinsky has already received interest in this cell-phone-based imaging system from organizations and hospitals across the globe including Ecuador, Rwanda, and India.

They hope to extend their findings from this proof-of-concept trial of simulated breast cancer detection into a full-scale clinical evaluation. Also, the group is continuing their work with cell-phone technology to detect internal bleeding within the abdomen and head in order to ameliorate the large mortality associated with undetected hemorrhage. The ramifications of cell-phone based EIT imaging are large and far-reaching.

It is hoped that with the introduction of this novel, cost-effective system of breast cancer detection that more women in impoverished countries will receive earlier diagnosis and benefit from more minimally invasive treatment – all thanks to creative research and the common cell phone.

Andrew J. Degnan is currently a 2nd-year medical student at the George Washington University School of Medicine in Washington, DC. His professional interests lie in diagnostic imaging and the use of technology in medicine. He hopes to contribute to the advancement of international access to imaging modalities through his intended career in radiology. He can be reached for comment and questions at adegnan@gwmail.gwu.edu.

References:

1. World Health Organization. Original Global Burden of Disease (GBD) 2002 Estimates. Available from: http://www.who.int/healthinfo/global_burden_disease/en/index.html

2. Granot Y, Ivorra A, Rubinsky B. A New Concept for Medical Imaging Centered on Cellular Phone Technology. PLoS ONE. 2008 April; 3(4):e2075. Available from: http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0002075

3. Cherepenin VA, Karpov AY, Korjenevsky AV, Kornienko VN, Kultiasov YS, Ochapkin MB, Trochanova OV, Miester JD. Three-Dimensional EIT Imaging of Breast Tissues: System Design and Clinical Testing. IEEE Transactions on Medical Imaging. 2002 Jun; 21(6):662-667.

4. Miller AB. Early Detection of Breast Cancer in the Emerging World. Zentralbl Gynakol. 2006; 128:191-195.

5. Gomez-Crespo G. Rural Radiology: training. Proc. R. Soc. Lond. 1980; 209:131-138.

6. Mindel S. Role of Imager in Developing World. Lancet. 1997 Aug 9;349:426-429.

7. Brown BH. Electrical Impedance Tomography (EIT): A Review. J Med. Eng. & Tech. 2003 May/Jun; 27(3):97-108.

8. Patterson V, Swinfen P, Swinfen R, Azzo E, Taha H, Wootton R. Supporting Hospital Doctors in the Middle East by Email Telemedicine: Something the Industrialized World Can Do to Help. J of Medical Internet Research. 2007;9(4):e30.

9. Anderson BO, Khalil EA. Breast Conservation Without Mammography? Oncology Practice in the Real World of Limited Resource Countries. The Breast Journal. 2006; 15:575-579.

10. Rubinsky B. Irreversible Electroporation in Medicine. Technology in Cancer Research and Treatment. 2007 Aug; 6(4):255-259.

11. Igene H. Global Health Inequalities and Breast Cancer: An Impending Public Health Problem for Developing Countries. The Breast Journal. 2008; 14(5):428-434.

12. Okobia MN, Bunker CH, Okonofua FE, Osime U. Knowledge, attitude and practice of Nigerian women towards breast cancer: a cross-sectional study. World J Surg Oncol. 2006 Feb 21; 4:11.