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General Surgery

Early Detection/Screening

Early detection of breast cancer may provide better treatment options along with higher survival rate. Usually lower survival rates are seen in those cases where cancer has already spread outside the breast before being diagnosed. It is seen that about 9 out of 10 women can survive for the next 5 years if cancer is diagnosed before it has spread outside the breast. Conversely, only about 2 out of 10 women will survive if the cancer has spread to other parts of the body before being diagnosed.

Detection of breast cancer while it is still small and confined to the breast may help to provide the best and most effective treatment. The advantages of early detection of breast cancer include increased survival, better treatment options and improved quality of life. Age is considered as the major risk factor in the development of breast cancer as about 70% of cases of breast cancer are found in women aged 50 years and more. However, in younger women, tumors are comparatively larger and even more aggressive. Hence it is important that women of all ages should be aware about the benefits of early detection and treatment of breast cancer.

Early Detection Methods

The early detection or screening methods used for diagnosis of breast cancer include:

  • Breast awareness–Involves self-evaluation of breasts and reporting any abnormal changes to your doctor
  • Clinical breast examination– Involves physical examination of breasts by a medical or affiliated health professional
  • Screening mammography–Involve use of imaging techniques for detection of breast cancer
  • Screening MRI– MRI scan is used in the surveillance of the women’s breast for any sign and symptoms of breast cancer. At present, Medicare does not cover screening MRI under their paid benefits for women at high risks.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) serves uninsured women who are at high risks of breast cancer by providing free or low cost screening interventions. For more information visit the department’s website: www.cdc.gov/cancer

Evidence

Breast Awareness

More than half of breast cancer cases are diagnosed after self-examination of changes felt in the normal breast by a woman, despite recommended mammographic screening programs. This highlights the importance of self-examination of the breasts related to visible changes and abnormal feel that need to be reported. In the past, public health campaigns have encouraged specific techniques that women should use for self-examination of the breasts.

Pregnant or breastfeeding women can also prefer to examine their breasts on a regular basis. Women who do not prefer to do self-breast examination should be still aware of the normal look and feel of their breasts and report any changes to their doctor immediately.

In a UK study, involving about 63,000 women aged 45–64 years has revealed no significant difference in the number of deaths from breast cancer after 16 years of follow-up between women educated to use a regular approach of breast self-examination compared with those who did not receive any instructions. Hence, we concluded that breast self-examination is useful in detection early changes of breast cancer, but there is no evidence to promote the use of any one self-examination technique over another.

Clinical Breast Examination

Clinical trials based on mass screening, employing clinical breast examination lacks high-grade evidence regarding any reduction in number of deaths from breast cancer. As such no randomized controlled trial has compared the data between screening and non-screening populations, although one such study is currently ongoing in India. Furthermore 15 clinical studies have compared the combined effects of mammography and clinical breast examination as well as the effects of mammography alone as a mass screening tool that revealed no significant difference in the number of deaths from breast cancer in the two groups after over 15 years of follow-up. Therefore there is no evidence for any additional benefit of clinical breast examination for women already undertaking a regular mammography screening. Despite this it seems that clinical breast examination may be beneficial for those women those who do not undergo regular clinical breast examination as well as mammography screening.

Mammography

Mammography is considered as a best technique for mass screening, as it reduces the death rate due to early detection of breast cancer. There is evidence of the maximum benefit of mammography in women aged 50–69 years. In all women, there is a probability that mammography may either generate pseudo negative or pseudo positive results. The possibility of pseudo negative or pseudo positive results is higher in younger women because their breast tissue is denser, making it more difficult to detect changes. Generally, breasts become less dense as women get older, particularly after menopause, this is why mammograms become more effective as women get closer to 50 years of age.
Balancing the benefit

All of the above methods do not possess a hundred percent accuracy for detecting breast cancer. The techniques may sometime fail to spot those changes related to breast cancer or even may lead to additional examinations as a result of a pseudo positive test. In addition, women may encounter issues such as the anxiety of waiting for test results, discomfort and inconvenience. Therefore based on the individual patient related factors such as age, family history, and personal preferences, each specific technique is considered.

Recommendations

Women at population risk (means high risk in the given population) of developing breast cancer include the following recommendations:

Breast Awareness

Breast awareness is recommended for women of all ages, irrespective of whether they have undergone mammographic or other screenings. Breast awareness includes self-assessment of the normal look and feel of the breasts and reporting any changes to the doctor. Normally no specific method is recommended for breast self-examination, but one should try to observe unusual changes that include:

  • Lumps in the breast especially if it is in one breast
  • Nipple discharge
  • Variation in size or shape of the breast or nipple
  • Redness over the breast skin
  • Unusual continuous pain, especially if it is one breast

Clinical Breast Examination

Usually clinical breast examination is not rigidly recommended as a screening method for women of all ages. Based on the individual needs and preferences of the patient as well as by consulting your doctor, a particular screening method may be recommended.

Mammographic Screening

Mammographic screening is usually not recommended for women younger than 40 years, whereas in women above 40 years, the nature of the method depends upon the individual’s condition and related risk factors.