Discussion

The changes in demographics and in the incidence rate of BC in the last decades surely represent serious and important challenges for health care system in Slovenia. Despite the content and context of these changes in Slovenia, the number of midwifery graduates, the contents of midwifery students' curriculum, the numbers of maternity wards and maternity hospitals have remained more or less constant and without sensible changes in recent years.

All the data about changes in demographic indicators with potential impact on the increase of BC incidence rates in Slovenia may not have been shown in this report. However, the changes in number of live births, number of live births per 1,000 population, total fertility rate, age of mother at first birth and age of mother at birth in total, and mean age of death in women in the period from 1961 to 2006, certainly suggest that there are now many more women exposed to the risk of BC than four or five decades ago (Armstrong & Nguyen, 1999; Bryant, 2004; Curado et al (Eds.), 2009; Henderson et al, 1996; International Agency for Research in Cancer, 2008; Soerjomataram et al 2008). The changes in demographic indicators and the increase in the incidence rate of BC in Slovenia in the last decades should at the very least stimulate a debate about changes in priorities in activities of midwives and related experts and specialists today and in the future. One of the future priorities for midwives could be early detection and prevention of BC that would include informing women about BHA and about risk factors of BC on an individual basis. In Slovenia and some other countries midwives already occupy a central position in education of young women about sexual and reproductive health, family planning and contraception (Ministry of Health & Government of Republic of Slovenia, 2011a). It should not be difficult to imagine the midwives establishing a trustful and confidential professional relationship with women in late teens or early twenties, informing them about BHA, BSE, CBE, BC, age adjusted BC risk factors and their reduction or elimination, performing CBE according to guidelines and later in their lives informing them about BC mammography screening programs.

About two thirds of all cancer cases are diagnosed in economically developed countries and about one third in LMIC countries (Forouzanfar et al, 2011; International Agency for Research in Cancer, 2008; Mellstedt, 2006). In the year 2010 the majority of women with BC in economically and industrially developed countries were aged 50 years or more. However, in developing countries there were twice as many women with BC aged 15-49 years than in developed countries, with the incidence rate of BC overall rising rapidly (Forouzanfar et al, 2011; International Agency for Research in Cancer, 2008; Mittra, 2011; Yeole & Kurkure, 2003). In view of these developments, it is agreed that mammography is not an appropriate BC screening test for LMIC countries. It is expensive, technologically complex and requires highly skilled experts and quality control (Berlin & Hall, 2010; Frank et al, 2000; Harford, 2011; Mittra, 2011; Nelson et al, 2009; U.S. Preventive Services Task Force, 2009). Conversely, CBE is relatively easy and inexpensive to perform (Mittra, 2011; Nelson et al, 2009). However, its effectiveness in reducing BC mortality is still regarded as controversial (Nelson et al, 2009), although the results of Canadian National Breast Screening Study-2 strongly suggest such an effect (Miller et al, 2000; Mittra, 2011). Two major randomized trials in Mumbai and Cairo comparing CBE and no screening are now addressing this dilemma. In Mumbai CBE and education are performed by female health workers who underwent five months of additional training, while in Cairo examinations are performed by female physicians who received two months of special training (Boulos et al, 2005; Mittra et al, 2010). In both studies there have been difficulties in assuring follow-up, a problem in many cases due to low levels of health awareness and motivation in screened communities (Miller, 2008; Mittra et al, 2010; Mittra, 2011). It is intriguing to speculate that this problem may otherwise not be encountered in Slovenia or other developed countries. These two studies may confirm the effectiveness of CBE and its use in LMIC countries may obviate the perceived need for establishing complex mammography screening programs, especially since a large proportion of women diagnosed with BC in these countries are aged 15-49 years.

The results of Mumbai and Cairo studies may strengthen the arguments for use of CBE by midwives in Slovenia and elsewhere. Altogether, the activities of midwives working with women on an individual basis, whether alone or as a part of a multidisciplinary team in a referral practice, including informing and teaching women about BHA, giving other information and performing CBE, could be described as lifetime breast health monitoring, a development of practice described already more than thirty years ago (Breslow & Somers, 1977).

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