Implementing the BCRADS System in Low-Resource Breast Cancer Settings

In low- and middle-income countries (LMICs), 40% to 60% of patients with breast cancer present with late-stage disease. To address these disparities, Soumen Das, MS, FACS, MRCS, FRCS, and his colleagues developed the Breast Clinical Reporting and Data System (BCRADS), a clinical counterpart to the Breast Imaging Reporting and Data System (BIRADS). This evidence-aligned triage system integrates patient history and clinical breast examination (CBE) to standardize frontline decision-making.

During the London Global Cancer Week, Das and his team received the Vanessa Moss Award for the BCRADS2 implementation study and their contributions to cancer care disparities in lower-middle income countries (LMIC). The study found a sensitivity of 93.2%, a specificity of 88.7%, and an area under the curve of 0.94.

In this interview with CancerNetwork®, Das, founder and director of the Institute of Breast Disease, Kolkata; and head of the Department of Surgical Oncology at Netaji Subhas Chandra Bose Cancer Hospital, discussed the clinical utility of BCRADS and its potential to reduce treatment initiation times globally.

CancerNetwork: Congratulations on your recently received Vanessa Moss award. Can you begin by discussing the significance of the award and how it will help you to advance your research, specifically with the BCRADS-2 study?

Das: The Vanessa Moss Award is given to research focused on cancer care disparities during London Global Cancer Week. Our team presented data on the BCRADS-2 study—the Breast Clinical Reporting and Data System. We are familiar with BIRADS for imaging; we have developed a clinical version. This study was selected for the award from approximately 65 to 80 clinical trials and presentations. For those of us working in LMICs like India, this recognition provides a significant platform to showcase our efforts.

Are you able to provide a brief overview of the BCRADS-2 study and the rationale behind it?

To understand the rationale, we must look at the natural history of breast cancer. While mammography can detect cancer before it is palpable, a lump generally needs to reach 1 to 2 cm to be felt by a patient or clinician. In LMICs, the median tumor size at presentation is 3.5 cm, and 70% of patients present with stage III or IV [disease], meaning the tumor is large or has already metastasized.

At this stage, mass installation of mammography is not a cost-effective model for these regions. Our focus must be on high-quality clinical breast examination to bring the size at detection down to 2 cm, which is easily palpable. The BCRADS-2 study aims to standardize clinical examinations. Our previous work showed significant heterogeneity in how different clinicians and practitioners interpreted breast lumps. BCRADS-2 seeks to eliminate that inconsistency through standardized reporting.

Are you able to touch upon the BCRADS-2 scoring system and the scoring flow?

When a patient consults a primary care physician, we use a fixed formula that combines patient history and clinical findings. Historical factors include age, family history, genetic predisposition, and prior chest wall radiation exposure, especially for childhood Hodgkin lymphoma. Clinical examination findings include breast asymmetry, skin or nipple changes, lump characteristics, and axillary involvement.

The clinician notes the presence or absence of these parameters to generate a score. A score of 7 or higher indicates a high likelihood of malignancy and serves as an alarm for the clinician. Based on this objective evaluation, we suggest the next course of action. Patients with benign or probably benign scores are followed up, while those with high scores are referred for biopsy. Very high scores trigger a fast-track referral system to expedite the diagnostic process.

How does the BCRADS-2 study address late-stage breast cancer presentation in low-resource settings, and where does it differ from imaging-based systems like BIRADS?

Most cancers in LMICs are palpable at presentation. The World Health Organization Global Breast Cancer Initiative (WHO GBCI) goal is to diagnose more than 60% of patients in stage I or II, where the chance of cure is significantly higher. Our research identified 2 types of delays: primary delay, which is the window between the patient feeling a lump and seeking care; and secondary delay, which occurs between the initial medical consultation and the final diagnosis.

Both delays contribute equally to late-stage presentation. BCRADS-2 provides objective criteria for the clinician seeing the patient for the first time, significantly reducing secondary delay. Unlike BIRADS, which requires radiological equipment, BCRADS relies on history and physical examination, making it accessible in areas where imaging is limited or unavailable.

Looking at the results of the study, there is a reported sensitivity of 93.2% and a specificity of 88.7%. How clinically reliable is the BCRADS score of 7 or more as a triage threshold?

This system is highly applicable for palpable lumps in areas where radiological access is an issue. It can be practiced anywhere without specialized gadgets. A doctor in a remote or rural area can use the BCRADS score to determine a definite path: referral, follow-up, or biopsy. While the high sensitivity may result in some false positives, the primary goal is to ensure no malignancy is missed. In the next phase of the program, we plan to integrate AI to further refine sensitivity and specificity.

What is the significance of demonstrating comparable diagnostic accuracy between clinicians and trained non-physician health workers?

Our study included physicians, breast care nurses, and [community] practitioners. We found no significant difference in their ability to identify lumps correctly using this system. This is vital for task-shifting in LMICs where there is a shortage of trained breast care physicians. We can utilize nurses and [community] practitioners as the primary level of triaging and screening, allowing us to decentralize oncology care and detect cancer earlier through objective clinical examination.

In what ways could BCRADS integration into primary care shorten diagnostic delays and improve treatment outcomes?

For patients with palpable breast lesions, secondary delay is a major hurdle. If BCRADS is implemented nationwide at the grassroots level—utilized by nurses, medical officers, and gynecologists—we can significantly reduce the time between the first consultation and diagnosis.

How will AI impact the future of the BCRADS-2 study?

The study initially used a paper format for scoring. We have since developed a digital application scheduled for launch in the coming months. We are currently training AI models to improve the precision of the system. By integrating AI into the app, we aim to reduce human error and further optimize the sensitivity and specificity of the tool.

How does BCRADS align with the WHO Global Breast Cancer Initiative (GBCI) goals?

The GBCI focuses on 3 pillars: early diagnosis, initiation of treatment, and completion of treatment. Their performance indices suggest that 60% of patients should be diagnosed in stage I or II, and treatment should begin within 60 days of diagnostic initiation. By reducing secondary delay, BCRADS supports the first pillar of early diagnosis. Furthermore, because the system provides a "call to action"—such as an immediate biopsy recommendation—it helps reduce the time to treatment initiation. Early diagnosis only saves lives if it is followed by early treatment.

Is there anything else you would like to highlight regarding the scope of this system?

While BCRADS was developed for LMICs, it is equally applicable to low-resource settings within high-income countries (HICs). We see pockets in developed nations where patients still present with stage III or IV disease and fungating masses due to various disparities. This is a global problem, and by implementing BCRADS and improving its precision through multi-centric studies and AI integration, we can address cancer care disparities across both HICs and LMICs.

Reference

Das S, Paul R, Mandal TK, et al. Community-integrated early breast cancer detection in LMICs using BC-RADS: the breast clinical reporting and data system (BCRADS-2 Implementation Study). Accessed January 23, 2026.