In a bare room in a remote government-run primary health center in Vapi, a city in the south-west Indian state of Gujarat, Meenakshi Gupta holds a diagram of a woman’s breast with five Braille-marked orientation tapes pasted on it. Speaking to the woman sitting on the bed, she says: “I’ll paste these skin-friendly tapes on your breast and use my fingertips to check it for any abnormalities.”
Gupta asks the woman to remove her upper garments, uses a hand sanitizer, and begins the routine examination. Dividing the chest into four zones with the tapes, she spends 30 to 40 minutes palpating every centimeter of the breast with varying pressure, before documenting her findings on her computer. Along with the patient’s medical history, Gupta will later send her findings to a physician for a diagnosis of any abnormalities and advice on further assessment.
Gupta is a Delhi-based medical tactile examiner (MTE), a new and emerging profession for blind and visually impaired women in India and Europe. She is a humanities graduate, blind since birth, trained for nine months in tactile breast examinations, a specialized form of clinical breast examination. Gupta’s blindness is not incidental to her role, but something that greatly aids her work.
Studies have proven that in the absence of visual information, the brains of blind people can develop heightened sensitivity in hearing, touch and other senses and cognitive functions. Frank Hoffmann, a Germany-based gynecologist who developed the idea of MTE has found that during their extensive examinations, MTEs can catch lumps as small as 6-8 millimeters. According to his unpublished research, that is less than the 10-20-milimeter lumps that many physicians without a visual impairment can find during examinations.
In India, 18 MTEs have been trained since 2017. Some of them are currently working at hospitals in Delhi and Bengaluru and a few are employed by the National Association of the Blind India Centre for Blind Women and Disability Studies (NABCBW), a non-profit in Delhi that also provides training.
In 2010 Hoffmann’s idea was developed into Discovering Hands, a social enterprise based in Mülheim, in Germany, which trains blind and visually impaired women as MTEs. The first peer-reviewed study investigating the feasibility of the approach showed that MTEs’ findings were similar to those of physicians.
Outside Germany, the country with the greatest number of MTEs is India. Here, breast cancer is the leading cause of death from cancer among women in most states. Sixty percent of cases are diagnosed at stage III or IV of the disease, reducing survival rates considerably. One study reported the five-year overall survival rate in Indian women to be 95 percent for stage I patients, 92 percent for stage II, 70 percent for stage III and only 21 percent for stage IV patients.
In 2017, Discovering Hands expanded to India through the NABCBW, whose staff received training from Germany to train MTEs. It’s hoped that this new avenue of cancer detection could have several advantages over existing approaches.
The standard test for breast cancer screening is mammography, which involves taking an X-ray of the breast. While this is commonplace in the West, its cost and complexity of use means it is harder to implement in low- and middle-income countries. And since mammography is less effective below the age of 50, alternatives are needed for younger women. One option is ultrasound – however, due to the high costs of employing radiologists and the ultrasound machines themselves, “they are not an affordable option for every medical facility”, says Mandeep Malhotra, a surgical oncologist practicing in Delhi and Gurugram.
A recent 20-year-long Indian study concluded that a clinical breast examination carried out every two years by primary health workers could help catch breast cancer at its early stages. This could reduce mortality by the disease by nearly 30 percent, in women over 50, the study concluded.
Clinical breast examination screening programs exist in India, but participation rates are “extremely inadequate”, according to a recent National Family Health Survey .Less than 1 percent of women had undergone breast cancer screening between 2019 and 2021 across India.
That is why training a para-health force of non-medical blind women to conduct specialized examinations could help in a big way, says Kanchan Kaur, senior director of breast surgery at Medanta super-speciality hospital, Gurugram. “It would mean finding smaller lumps in early and more curable stages of the disease by reaching out to a population that resists seeing a doctor because they feel healthy,” she says.
Examinations by MTEs are not meant to replace doctors or mammograms, but rather to take place work alongside medically trained teams as a first step for accurate routine breast cancer screening examinations, available even in areas with limited access to electricity.
Malhotra conducted a study on 1,338 women examined by the MTEs before the pandemic, comparing MTEs’ findings with radiological results of the same women. Malhotra found that the MTEs had a high sensitivity for detecting malignant cancers, at 78 percent (sensitivity is the measure of “true positives”). The number of malignant cancers that the MTEs missed (“false negatives”) was very low, at 1 percent.
. An Austrian study which compared physicians and MTEs found that the latter had a higher specificity and sensitivity. They were especially effective compared with physicians when examining patients with denser breast tissue, which typically makes detecting lumps harder.
Perhaps most importantly, MTEs help reduce the discomfort that women experience from undressing for a breast examination by a clinician who has no visual impairment.
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