2. Breast cancer (BC) screening – checking a woman’s breast
for cancer before there are signs and symptoms of the
disease.
A high level screening program requires high quality
screening, high coverage, high rate of participation and
effective diagnosis and treatment.
There is no such organised or opportunistic screening
program for breast cancer in India.
3. Why breast cancer screening?
• Increasing incidence of BC in younger age group
• Rising number of cases of BC in India
• Late presentation- directly decreasing the long term survival
• Lack of awareness and screening - Breast awareness is the single
most important factor responsible for better survival in the west
• Aggressive cancers in the young
4. What the Guidelines say
• The United States Preventive Task Force (USPTF) no
requirement of routine screening mammography in
women aged 40-49years, biennial screening before the age
of 50years should be an individual one, recommends
biennial screening mammography between ages of 50 and
70years.
• The American Cancer Society recommends women with
average risk should undergo regular screening
mammography at the age of 45yrs. Women of 45-54yrs
should be screened annually , > 55yr should transition to
biennial screening.
• WHO recommends mammography every 1-2years for
women aged 50 -69years
5. Present scenario in India
• The age standardized incidence rate for breast
cancer in India is 22.9/100000, 1/3 that of
western countries. 3 times higher in Urban areas.
• There is no organized, systematic, government
funded screening program. The screening is
usually “opportunistic screening”
• In India breast cancer peaks before the age of
50years. Thus there is a need to screen at 40-
49yrs.
6. Risk factors
A recent systematic review and meta analysis – revealed that extremely
dense breasts and first degree relatives with breast cancer were associated
with 2 fold increase in risk in women aged 40-49yrs. -
-Nelson HD et al, Risk factors for breast cancer for women aged 40 to 49years. A systematic
review and meta-analysis . Ann Intern Med 2012, 156: 635-48
Modifiable risk factors Non modifiable risk factors
Age at first childbirth Age
Breastfeeding practices
Obesity
Physical activity
Menopausal hormone therapy
Alcohol intake
Benign breast disease
BRCA 1 and 2 mutation carrier
Family history
Early menarche/ delayed
menopause
Increased breast density
Chest irradiation
7. Breast cancer detection
• Breast self examination (BSE)
• Clinical breast examination (CBE)
• Mammography
• Breast MRI for some high risk women
BSE being familiar with how the breast look and feel –can
help you notice symptoms such as lumps, pain or changes
in the size.
BSE can be an important way to find a BC early when it
is more likely to be treated successfully.
8. Self –examination and clinical examination
of breast
• BSE(monthly) and CBE(anually) are inexpensive and non invasive
procedures for regular examination of breast. Evidence supporting
the effectiveness of these 2 screening methods is controversial and
inferred
• A 2008 study of 400000 women in Russia an China reported that
BSE does not reduce BC mortality but increased unnecessary biopsy
and removal of suspicious tissue. Based on this the ACS no longer
recommends BSE as a screening tool.
• BSE has found to be more reasonable and feasible approach in
early detection and reduction of breast cancer mortality in India
and other developing countries.
9. BSE- shower, mirror and lying down- size, shape, symmetry,
dimpling, inverted nipple, puckering, asymmetric ridge at the
bottom, palpate lumps, nipple discharge.
10. Mammography
• Mammography is a special type of low dose ionizing
radiation imaging to create a detailed images of the
breast, reveals the lesion before it is palpable in an
asymptomatic woman
• Mammography is currently the best available
population based method to detect breast cancer in
early stage.
• The sensitivity is 67.8% and specificity is 75% when
combined with CBE the sensitivity 77.4% and modest
reduction in specificity 72%
11.
12. What are the harms of mammography
Every screening test has benefits and risks . The benefit is finding cancer early,
when it’s easier to treat.
False positive results – benign microcalcification, tissue summation
shadow
• Unnecessary follow-up tests and biopsies
• Anxiety and psychological distress
Over diagnosis
• Cancer that would never have progressed to clinical importance in
absence of screening
• Harms of treatment without any benefit
• Once cancer is diagnosed, no way to determine whether it is a case of
over diagnosis
False negative rate is 8-10% - dense parenchyma obscuring lesion, poor
positioning or technique incorrect interpretation.
• Pain during the procedure and radiation exposure, the amount of
radiation is small, but repeated X-rays my carry risk
13. Ultrasonography
• A widely available , useful adjunct to mammography
• Generally used to assist clinical examination of suspicious lesions
detected on mammography or physical examination
• As a screening device – poor specificity of 34%
• In Sep 2012, the FDA approved the first USG system, the somo-v
Automated Breast Ultrasound System (ABUS) in screening of
specifically with dense breast tissue. High frequency sound waves
with a 3-D volumetric image of entire breast.
• Currently USG recommended for highly anxious patients who
request for it and for women who have a h/o mammographically
occult carcinoma
14. MRI
• A combination of T1 weighted , T2 weighted and
3D contrast - enhanced MRI found to be highly
sensitive (99% when combined with
mammography and CBE)
• In high risk young women, BRCA1 or BRCA2
mutations
• Limited use as a general screening tool, 10 fold
higher cost and poor specificity (26%). More false
positive.
15. What is the current evidence for screening
women in the 40s?
• USPTF- 8% reduced risk of BC mortality
• ACS- 15% reduced risk of BC mortality
• Initiating screening at the age of 40 averts about 1 BC death
per 1000 women screened
most averted deaths among women aged 45-49
• Harms include false positive results and overdiagnosis. ( the
sensitivity and specificity of mammography are lower
among women aged 40-49yrs verses older women)
16. When should average risk pts stop
screening
• BC incidence increases with age.
• Continue biennial screening until the
remaining life expectancy is about 10 yrs
biennial screening estimated to reduce
breast cancer deaths for women in their 70s
Benefit of screening is low among women
>75y
17. BRCA1 and BRCA2 mutations
• BRCA1 and BRCA2 are human genes in Chromosome 17 and 13
which produce tumor suppressor proteins
• BRCA gene test the harmful inherited BRCA1 and BRCA2 mutations.
Genetic counseling is important part of the test.
• The test advised only when there is personal or family history of BC
at young age, bilateral BC, or both BC and Ovarian Ca, Male relative
with BC, relative with known BRCA mutations, Ashkenazi Jewish
descents
• If the family member with BC has no gene mutations, no benefit of
gene testing
• Cost Rs 20000 for each gene testing
18. BRCA mutation test results
• Positive for harmful BRCA mutation- high risk for
developing breast and ovarian Ca. 72% of BRCA1 and 69%
of BRCA2 by 80years (Caucasians) still 20% may not develop
. Increase screening surveillance, use of OCPs,
chemoprevention (tomoxifen, roloxifene),undergo
preventive surgery.
• Negative for harmful BRCA known mutations. General
population risk is 12%
• Ambiguous – test is positive for genetic mutation variant of
uncertain significance, has not been associated with Ca.
19. Take home message
• Breast cancer is a non existent entity, till a near and dear one suffers. Lack of
awareness and lack of screening, results in people presenting only when
symptomatic ie, stage 2B and beyond. In the West, 75% present at stage 1 and 2 ,
resulting in good survival
• Aggressive cancers in young are most, but not all are HER2+ve,ER/PR –ve or
HER2/ER/PR –ve have worst prognosis.
• One necessity is “BREAST AWARENESS” we cannot prevent this cancer , all we
have to do is to detect cancer early.
• Studies from India showed high acceptance of health care workers as educators.
• This demands a shift of our screening program from mammography to BSE and
from tertiary care facilities to primary health care facilities like trained non medical
personnel’s (ASHA) and even at the door step of the beneficiaries. Trained
community health workers would be like a nuclear chain reaction leading to
generation of home to home trained personals.
• BSE will not uproot the disease but could be a promising way to reduce the burden
of the disease to a significant extent.
