Breast cancer in Morocco: screening, mammography and treatment pathway

01Breast cancer in Morocco, the leading oncological issue for women#

Breast cancer is by far the leading cancer in women in Morocco as in most countries worldwide, and it represents a major public health issue due to its high incidence, potential severity, and especially the possibility of near-systematic cure when diagnosed at an early stage. This double characteristic — high frequency and stage-conditional curability — justifies all efforts of awareness, screening and structured management.

According to data from the Cancer Registry of the Greater Casablanca Region (RCRC) and the National Oncology Institute (INO), which constitute reference sources for Moroccan oncological epidemiology, approximately 11,500 new cases of breast cancer are diagnosed each year in Morocco, representing about 38% of all female cancers. This proportion is comparable to that observed in Europe and North America, but with worrying epidemiological particularities specific to Morocco.

The average age at diagnosis is 48 years in Morocco, about 10 years younger than in Europe (58-60 years in France). This earliness is partly explained by the younger Moroccan demographic pyramid, but also by specific biological and environmental factors under investigation. This particularity makes Moroccan breast cancer often more biologically aggressive, with a higher proportion of triple-negative tumours (without hormone receptors or HER2, more difficult to treat) and inflammatory forms.

The 5-year survival rate is approximately 55% in Morocco, compared to 85-90% in Europe and the United States. This dramatic prognostic differential is not explained by lower quality of care itself — modern Moroccan therapeutic protocols are aligned with international standards — but by diagnostic delay: approximately 60% of breast cancers are diagnosed in Morocco at a locally advanced or metastatic stage (extended stages II, III, IV), compared to 30-40% in Europe. However, at equivalent stage, the prognosis is globally comparable. The fight against breast cancer in Morocco therefore mainly involves the fight against diagnostic delay: awareness, organised screening, facilitated access to care.

The essential message for all women: a breast cancer detected early (stages 0, I) is cured in more than 95% of cases by relatively light treatments (conservative surgery, radiotherapy, sometimes hormonotherapy). Conversely, a cancer diagnosed at metastatic stage IV has a guarded prognosis with 5-year survival below 30%. This prognosis difference according to stage is the most powerful medical argument in favour of regular screening — every month gained on diagnosis can literally save a life.

02Risk factors to know#

Several factors increase the risk of breast cancer during life. Identifying these factors allows both stratifying individual surveillance and acting on modifiable factors. However, it should be kept in mind that 70% of breast cancers occur in women without identifiable risk factors — which justifies generalised screening in all women after a certain age.

Non-modifiable factors

Age is the leading risk factor: 80% of breast cancers occur after age 50, and risk continues to increase with age until 70-75 years. Female sex is obviously the main factor — male breast cancers exist but represent less than 1% of cases. First-degree family history (mother, sister, daughter) with breast cancer multiplies risk by 2 to 5 according to the number of relatives and the age of their diagnosis. Breast cancer in several first-degree relatives, or in a young relative (before 40), should raise suspicion of a genetic predisposition.

BRCA1 and BRCA2 gene mutations (Breast Cancer 1 and 2) are the most known genetic predispositions. They confer a lifetime breast cancer risk of 60 to 80% in carrier women, and also increase the risk of ovarian cancer, more rarely pancreatic cancer. An oncogenetics consultation with BRCA genetic testing is indicated in case of suspicious family history (multiple relatives, early cancers, male breast cancers, ovarian cancer in the family). In case of positive mutation, several prevention strategies are proposed: close surveillance by breast MRI from age 30, chemoprevention with tamoxifen, even bilateral prophylactic mastectomy in some cases. Other rarer mutations (TP53, PALB2, CHEK2) are also associated with increased risk.

Reproductive history influences risk. Early menstruation before age 12, late menopause after 55, nulliparity (absence of pregnancy carried to term), first pregnancy after age 30, and absence of breastfeeding are associated with moderately increased risk due to longer cumulative exposure to endogenous oestrogens. Conversely, early and numerous pregnancies, prolonged breastfeeding, are relatively protective. Personal history of contralateral breast cancer, in situ carcinoma, at-risk lesions (atypical hyperplasia, lobular in situ carcinoma) increase subsequent risk. High mammographic density (dense breasts) is an independent risk factor and also complicates screening.

Modifiable factors

Several lifestyle-related factors are modifiable and can reduce risk. Overweight and obesity after menopause increase risk by approximately 50% through increased peripheral oestrogen production by adipose tissue. Maintaining a healthy weight (BMI between 18.5 and 25) is protective. Alcohol consumption is dose-dependent: each 10-gram tranche of alcohol per day (one standard glass) increases risk by about 30%. Women at familial risk should particularly limit or even avoid alcohol. Sedentary lifestyle is associated with a modest increase in risk, and regular physical activity (at least 150 minutes per week) reduces it by about 20%.

Smoking, long considered neutral towards breast cancer, is now recognised as a risk factor, particularly for women who started smoking before the first pregnancy. Hormone replacement therapy (HRT) prescribed during menopause modestly increases risk (multiplication by 1.2-1.3) particularly after 5 years of use, justifying regular reassessment of indication, use of the minimum effective dose, and transdermal route. Exposure to thoracic ionising radiation (radiotherapy for mediastinal cancer in young women for example) significantly increases subsequent risk.

03Monthly self-examination, a simple and fundamental gesture#

Monthly breast self-examination is recommended by WHO for all women from age 20. This simple practice, taking less than 5 minutes, allows familiarising with one's body and quickly detecting any suspicious modification. It does not replace screening mammography but usefully complements it, particularly between examinations.

The ideal time for self-examination is 8 to 10 days after the start of menstruation, when the breasts are least tense and nodular (hormonal modifications make breasts sometimes painful and lumpy in the second part of the cycle, making the examination less reliable). For postmenopausal women, choose a fixed date of the month (1st or 15th for example) which will be easier to remember. Regularity is more important than technical perfection — a summary but regular examination is better than a perfect but sporadic examination.

The three-step method

Step 1: visual inspection in front of a mirror, in good light. Three successive positions to observe carefully. Arms along the body, observe the symmetry of the two breasts, the general shape, the position of the nipples, the appearance of the skin. New asymmetry (which did not exist before) should prompt consultation. Arms raised above the head, observe again and look for skin retractions appearing when raising the arms, dimples appearing in certain places. Hands placed on the hips exerting pressure, which contracts the pectoral muscles and accentuates skin abnormalities. Look for at each position: new asymmetry, skin retraction (forming a hollow), localised redness or oedema, modification of the nipple (retraction, deviation, spontaneous discharge), orange peel (thick, lumpy skin reminiscent of orange peel, worrying sign).

Step 2: palpation lying on the back. Lie down, place a small pillow or folded towel under the right shoulder to examine the right breast, and place your right arm behind your head. With the 3 joined fingers (index, middle, ring) of the left hand, palpate the right breast performing circular movements first gently then more firmly to reach deep layers. Proceed systematically in spiral from the nipple outward, or in quadrants, covering the whole breast. Do not forget the armpit where the lymph nodes are located which can be enlarged in case of cancer (gently palpate, the arm falling along the body). Repeat the same examination for the left breast.

Step 3: examination of the nipple. Gently grasp the nipple between thumb and index and exert gentle pressure. Verify the absence of spontaneous discharge during pressure. A clear milky discharge can be physiological (often benign galactorrhoea), but a bloody, brownish, or purulent discharge is abnormal and justifies a quick consultation.

04Warning signs#

Several clinical signs should lead to a medical consultation within 2 to 3 weeks maximum, without dramatising but without delaying. These signs do not necessarily mean cancer (80% of palpable nodules are benign — cysts, fibroadenomas, fibrocystic mastopathies), but only a doctor can confirm it after examination and investigations.

The most common sign is the palpable lump in the breast or armpit, generally painless at first. Any new lump, larger than 1 cm, of firm consistency, poorly defined, fixed to deep planes or to the skin, must be taken seriously and lead to rapid investigations. A modification of the general shape of the breast (deformity, new asymmetry) persisting beyond a cycle is suspicious.

Skin and nipple abnormalities are also important. Skin retraction (skin forming a hollow) or an "orange peel" appearance (thickened, lumpy, sometimes reddish skin reminiscent of orange peel) are very evocative signs and should lead to urgent consultation. Recent nipple retraction (different from a known congenital retraction), a deviated or ulcerated nipple, persistent desquamation of the nipple (suspicious of mammary Paget's disease) are also worrying. Bloody or clear spontaneous discharge from a nipple requires consultation. Extensive and warm redness of part of the breast, persisting several weeks, may reflect inflammatory cancer — a rare but aggressive form requiring urgent treatment.

Other signs deserve attention: a persistent localised pain in a specific area of the breast (diffuse cyclic pain related to menstruation is generally benign, but fixed and persistent localised pain should be explored), a palpable lymph node in the armpit (axillary) or above the clavicle (supraclavicular), particularly if hard and fixed.

The life-saving attitude is to never wait "for it to go away". Even if the majority of abnormalities will ultimately be benign, better to consult for nothing than to miss an early diagnosis. A medical examination will allow either reassurance (probable benign cyst or fibroadenoma) or rapid organisation of necessary explorations (mammography, ultrasound, biopsy if needed).

05Screening mammography#

Mammography is the reference examination for breast cancer screening. It allows detecting cancers at a very early stage, sometimes several years before a lump becomes palpable, by visualising suspicious microcalcifications (typical early sign of in situ ductal carcinoma), suspicious opacities, subtle architectural distortions, density asymmetries between the two breasts.

Current recommendations

International recommendations globally converge towards mammographic screening every 2 years between 50 and 74 years in average-risk women. In Morocco, the National Cancer Prevention and Control Plan (PNPCC) 2020-2029 has adjusted these recommendations to Moroccan epidemiological specificity (earlier cancers) and proposes screening from age 45 for all women, with mammography every 2 years until age 75.

For high-risk women (confirmed BRCA mutations, multiple or early family history, personal history of thoracic irradiation, history of in situ carcinoma), earlier and more intensive screening is indicated: starting from 30 to 40 years depending on contexts, alternating annual mammography and breast MRI, sometimes additional ultrasounds. An oncogenetics consultation allows individualising these strategies.

The Moroccan national programme

The PNPCC, carried by the Ministry of Health in partnership with the Lalla Salma Foundation for Cancer Prevention and Treatment, organises a free screening for breast and cervical cancers in women aged 45 to 75. This programme is accessible in several structures.

Dedicated Screening Health Centres (CSD) are present in major Moroccan cities. Provincial and regional hospitals have mammography equipment. CHUs (Ibn Rochd in Casablanca, Ibn Sina in Rabat, Hassan II in Fes, Mohammed VI in Marrakech) are reference centres for complex cases. Lalla Salma Foundation mammobiles travel through rural regions to bring screening to populations far from urban centres. Beyond free screening, national campaigns like Pink October each year widely sensitise the population and facilitate access to screening.

The BI-RADS classification and conduct to follow

Mammography results are classified according to the BI-RADS (Breast Imaging Reporting And Data System) which standardises reading and recommendations.

A BI-RADS 1 or 2 mammography is reassuring and allows surveillance every 2 years. A BI-RADS 3 (probably benign) requires close control at 6 months to verify image stability, without requiring immediate biopsy. A BI-RADS 4 or 5 (suspicious or very suspicious) justifies a biopsy without delay to confirm or rule out the cancer diagnosis. This strategy avoids both unnecessary worry and diagnostic delay.

06Steps of confirmed diagnosis#

When a breast lesion is suspicious (BI-RADS 4 or 5), a structured diagnostic approach unfolds over a few weeks to precisely characterise the disease and plan optimal treatment.

The diagnostic step begins with biopsy of the lesion, generally performed by microbiopsy under ultrasound guidance (8 to 12 fine-needle samples under local anaesthesia, outpatient) or macrobiopsy under stereotactic guidance for microcalcifications not visible on ultrasound. Samples are analysed at the pathology laboratory which confirms or rules out the cancer diagnosis, specifies the histological type (most frequent infiltrating ductal carcinoma, lobular carcinoma, rarer forms), assesses the SBR grade (Scarff-Bloom-Richardson, from low grade I to high grade III reflecting aggressiveness), searches for hormone receptors (ER and PR, which guide towards hormonotherapy in case of positivity), assesses HER2 amplification (which indicates targeted therapy with trastuzumab if positive), measures the Ki-67 proliferation index.

The extension workup aims to assess possible diffusion of cancer to stage the disease. It generally includes a chest-abdomen-pelvis CT scan with injection (search for visceral metastases: lungs, liver, mediastinal nodes), a bone scintigraphy (search for bone metastases), sometimes a PET-scan for complex cases, a breast MRI if breasts are dense or to better characterise local extension. This extension workup allows establishing the TNM stage: T characterises the primary tumour (T1 < 2 cm, T2 between 2 and 5 cm, T3 > 5 cm, T4 invasion of skin or thoracic wall), N characterises lymph node involvement (N0 absent, N1-3 according to number and location of affected nodes), M characterises distant metastases (M0 absent, M1 present).

The Multidisciplinary Team Meeting (MDT) brings together several specialists (medical oncologist, radiotherapist, breast surgeon, radiologist, pathologist, sometimes geneticist, psycho-oncologist) to discuss each case and collegially decide on the optimal therapeutic strategy, individualised according to the patient and tumour profile. This multidisciplinary approach is now standard in Morocco in reference centres and considerably improves the quality of therapeutic decisions.

07Treatments available in Morocco#

The therapeutic arsenal for breast cancer has considerably progressed in recent decades, with today's precision medicine allowing personalised treatments according to molecular characteristics of each tumour. Morocco now has all modern therapeutics in its reference centres.

Surgery

Surgery remains the key step of curative treatment. Several options according to stage and location. Lumpectomy or conservative surgery removes the tumour with a margin of healthy tissue, preserving the breast. It is associated with axillary lymph node dissection (removal of some armpit nodes) or with the sentinel lymph node technique (analysis of the first node draining the tumour) according to stage. This conservative surgery is possible for early small tumours, and must be complemented by radiotherapy. Total mastectomy removes the entire mammary gland, indicated for extensive, multifocal, or recurrent tumours after lumpectomy. Breast reconstruction is now systematically offered to mastectomised patients, either immediate (in the same operative time) or delayed (a few months after the end of treatments). Several techniques exist: expansion prosthesis, musculocutaneous flap (DIEP, latissimus dorsi), reconstruction by lipostructure. The main breast oncological surgery centres in Morocco are the INO in Rabat, CHU Ibn Rochd in Casablanca, CHU Hassan II in Fes, CHU Mohammed VI in Marrakech, as well as several specialised private clinics.

Radiotherapy

Radiotherapy is administered after conservative surgery (systematically) or after mastectomy according to risk factors (lymph node involvement, tumour size). It consists of 25 to 33 daily sessions (Monday to Friday) over 5 to 7 weeks, sometimes with an additional "boost" targeted on the tumour bed. Modern techniques (3D conformal radiotherapy, IMRT, VMAT, radiotherapy in held breath for left breasts) allow precisely targeting the area to be treated while sparing as much as possible the heart, lungs and contralateral breast. Radiotherapy is available at INO Rabat, in CHUs and in several equipped private clinics (Casablanca, Rabat, Fes, Marrakech, Agadir).

Chemotherapy

Chemotherapy is indicated according to tumour profile (size, grade, lymph node involvement, receptors, HER2). It can be neoadjuvant (before surgery to reduce the tumour and allow conservative surgery, or to assess response to treatments) or adjuvant (after surgery to reduce recurrence risk). Classical protocols comprise 6 to 8 cycles spaced 21 days apart, associating several molecules (anthracyclines, taxanes, cyclophosphamide). Common protocols include FEC, FAC, AC-T, TC, EC-T according to cases. Side effects are significant (fatigue, alopecia, nausea, decreased immune defences) but largely improved by modern supportive care.

Hormonotherapy

Hormonotherapy is indicated for cancers expressing hormone receptors (ER+ and/or PR+, i.e. 70-80% of cases). In non-menopausal women, tamoxifen is the reference treatment at 20 mg per day for 5 to 10 years. In menopausal women, aromatase inhibitors (anastrozole, letrozole, exemestane) have demonstrated superiority to tamoxifen and are prescribed for 5 to 10 years. The prolonged duration of treatment significantly reduces late recurrences, hormone-sensitive breast cancer being able to recur years after initial treatment.

Targeted therapies

For HER2-positive cancers (15-20% of cases), trastuzumab (Herceptin) is administered for 1 year in addition to chemotherapy, with considerable benefit on survival. Several other HER2-targeted therapies are available: pertuzumab, T-DM1 (Kadcyla), trastuzumab-deruxtecan (Enhertu) for metastatic forms. For metastatic hormone-sensitive cancers, CDK4/6 inhibitors (palbociclib, ribociclib, abemaciclib) have revolutionised treatment with major benefit in association with hormonotherapy. These molecules are available in Morocco since 2018-2020. For the rare metastatic triple-negative breast cancers with BRCA mutation, PARP inhibitors (olaparib) are an option. Immunotherapy by checkpoint inhibitors (atezolizumab, pembrolizumab) is starting to have indications in triple-negative cancers.

Financial coverage

Breast cancer is recognised as ALD (Long-Term Disease), allowing 100% coverage by CNOPS, CNSS or AMO Tadamon of all care (surgery, radiotherapy, chemotherapy, hormonotherapy, surveillance, follow-up examinations). Costly targeted therapies (trastuzumab, CDK4/6 inhibitors) are also covered in ALD. For uninsured or very precarious patients, the Lalla Salma Foundation for Cancer Prevention and Treatment offers entirely free management in its contracted centres. INO centres ensure free care after social evaluation for the uninsured. The Moroccan system thus guarantees almost universal access to care for patients with breast cancer, which was not the case a few decades ago.

08Daily prevention#

Beyond screening, several primary prevention measures can reduce individual risk.

Regular physical activity of at least 150 minutes per week of moderate intensity reduces risk by approximately 20-25% according to meta-analyses. Walking, swimming, yoga are accessible to all. Maintaining a healthy weight (BMI between 18.5 and 25) is particularly important after menopause when excess weight strongly increases risk. Limitation of alcohol consumption to less than one glass per day, ideally with alcohol-free days, is one of the most impactful measures for women — alcohol is associated with about 4% of breast cancers in developed countries. Complete smoking cessation brings global health benefit including cardiovascular, and modest but real benefit on breast cancer. Prolonged breastfeeding (cumulative total of 12 months or more across all children) is protective and reduces risk by about 4% for each year of breastfeeding.

In terms of individual surveillance, monthly self-examination from age 20, annual gynaecological consultation with breast clinical examination, mammography every 2 years from age 45 within the framework of the national programme, are the pillars of early detection. For women at high familial risk, an oncogenetics consultation can lead to a BRCA test and an adapted surveillance or prevention strategy.

The essential message to remember: breast cancer is one of the most curable cancers when detected early. Making self-examination a reflex, consulting at the slightest doubt, participating in organised screening, are the best weapons to transform a potential cancer into a simple parenthesis of a few months in a life that continues normally.