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Breast cancer screening
1. Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist)
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow
Screening of Breast Cancer
2. 1.62 Lakh new cases per year (Incidence): 50% deaths
Commonest cancer among women (28%) and even in both sexes
combined (14%)
4 lakh prevalent cases (62%)
Breast Cancer scenario: India
4. Health Insurance plan study (1963-1997)
Randomization between three annual mammograms plus
CBE versus no screening
30% reduction in 10-year breast cancer mortality and 25%
reduction at 18 years follow up
History of mammographic
screening
6. Relative risk of breast cancer death reduced by 10-25% in
age group 40-75 years
Risk benefit more favorable for 60-69 years versus 50-59
years
Flaws and limitations:
Most before modern era of adjuvant therapy
Less advanced mammographic techniques
Trial design flaws: randomization, contamination
Evidence: Screening breast cancer
7. o Clinical breast examination
o Breast self examination
Screening modalities
8. Full length digital
mammography (FFDM)
Less false positive
Reduces the number of
women needing additional
imaging and biopsies
Newer screening technologies
9. Digital breast tomosynthesis
Increased sensitivities, lesser recall rates
Newer screening technologies
10. Molecular breast imaging
USFDA approved
Uses intravenous Tc 99m-Sestamibi and gamma camera to image the
breast
Better for screening dense breast
Cellular metabolism as opposed to structure is visible
Newer screening technologies
11. Abbreviated fast MRI (AB-MRI)
Takes 3-5 mins
Feasible, less costly and more
accessible
Newer screening technologies
14. Screening with annual mammography and MRI starting at age 30 years
Are known or likely carriers of BRCA mutation
Have other high risk genetic syndromes like Cowden, Li-Fraumeni syndrome
etc
Have been treated with radiation to the chest for Hodgkins disease
Have 20-25% or greater lifetime risk of breast cancer risk by estimation
models
High risk screening
15. Additional Recommendations: USPSTF
For teaching of BSE, there is moderate certainty that harms
outweigh benefits.
For CBE as a supplement to mammography, evidence is
lacking, and balance of benefits and harms cannot be
determined.
ACS does not recommend clinical breast examination for
breast cancer screening among average-risk women at any age
(qualified recommendation).
16. No study has documented decreased mortality with BSE
Chinese study on 2.66 lakh women showed no difference in
mortality, albeit increased incidence of benign breast diseases and
breast biopsies
Russian study on 1.24 lakh women showed no difference in
mortality. BSE group had higher proportion of early stage tumors
and also significant increase in proportion of breast cancer
patients surviving 15 years after diagnosis
Breast self examination
17. In women younger than 50 years: USG with CBE
Resources available with Mammography: prioritize women 50-65
years
Awareness and education starting at 30 years and CBE screening
(40-60 years) once in every 3 years
Access to FNAC and Biopsy should be made available
Combine education and CBE with cervical cancer at 30 years of age
18.
19. Best offered as an organized program
Informed discussion with women: Benefits, limitations and harms
False negative and false positives
Additional imaging and need for biopsy
Biologically indolent lesions
Availability of treatment resources
Screening implementation
20. Breast Screening
Risks of breast cancer screening tests:
False-negative test results
False-positive test results
Anxiety from additional testing may result from false
positive results.
Mammograms expose the breast to radiation.
There may be pain or discomfort during a mammogram.
Over diagnosis-a panel of experts concluded that over
diagnosis 11% to 19% does exist if breast cancers
diagnosed by screening
21. Incidence of DCIS has increased five folds
Heterogenous condition
Uniformly subjected to treatment
Increased rates of mastectomies/double
mastectomies
DCIS Trouble
22. Screening mammography decreases breast cancer mortality
Digital breast tomosynthesis and novel technologies
enhance the detection rates and decrease recall rates
Guidelines need to be adapted as per regional
variations/resources
Counselling and discussion with women desirous of
screening is a must before prescription of tests
Take home messages