BSE and Mammography

Dr Sujata MittalSr. Consultant – Gynec. Oncology

PARAS HOSPITALS, GURGAON

Foundational Science – Breast Anatomy

UOQ contains a greater volume of tissue than any other quadrant

Incidence of Breast Cancer in India (ICMR)Number(#), Relative Proportion(%) & Rank(R) of leading sites of cancer

• Identify those who are going to develop/early breast cancer

• Low false positive rate• Low false negative rate• Inexpensive, reproducible• RCT should reveal reduction

in mortality• Available to masses

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Cancer Control Screening

• Average Risk

• High Risk

• BSE• CBE• Mammography• MRI• Tomography• USG• Thermal detection Monitors• Proteomics

Modalities Available Controversies • No SINGLE TEST (Combination)

(Opinion Vary)

• BSE ? BREAST AWARENESS

• MAMMOGRAPHY ? AGE

Breast Cancer Screening

Breast self-exam (BSE) first introduced

American Cancer society (ACS) initiated campaign Cancer’s Danger Signals “Look for a lump or Thickening in the Breast”

First studies evaluating BSE presented. Women confused about proper technique and relied on clinical breast exam

Russian study found BSE did not decrease Breast Cancer mortality

China study found no decrease of Breast Cancer deaths after giving women BSE instructions

Malaysia & other countries where Mammography is scarce, declared women should conduct monthly BSE

US Preventive Service Task Force (USPSTF) recommended against teaching BSE. ACS recommended against BSE.

Several new studies directly refute the China & Russia studies:

DUKEFound 46.6% of the cancers diagnosed were first found during the BSE & limitation of Mammography

HARVARD71% of cancers detected were first detected by BSE in women under 40

MAYO CLINICFound that women under 50 were more likely to find cancer by BSE than detected by Mammography

Still mixed messages

Susan G. Komen no longer recommends monthly BSE, but encourages women to become familiar with the way their breast normally look and feel(but, isn’t t hat a breast self-exam?)

USPSTF ACS ACOG

Recommends against clinicians teaching women

how to perform Breast self-examination

Recommends against clinicians teaching women how to perform Breast self

examination

Consider Breast self examination instruction for

high-risk patients. Breast self-awareness should be

encouraged and can include Breast self-examination

Recommendations for Breast Cancer Screening

• Breast Awareness empowers women to fight BC/disease not in terms of statistics used for mortality but on the qualitative effects of reductions in morbidity

• BSE in Conjunction with Mammography provide with added layer of protection

Controversy continues

Benefits & Harms of BSE

WOMEN SHOULD REMAIN INVOLVED IN THEIR

BREAST (HEALTH)

EMPOWERING WOMEN

AS EVERY WOMAN MATTERS / COUNTS

Message

• Screening Mammography

• Diagnostic Mammography

Mammography

Digital Mammogram vs. Traditional X-Ray Mammogram

Digital Mammogram Traditional X-Ray Mammogram

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Digital Mammogram MRI

Digital Mammogram vs. MRI

USPTSF• Biennial screening mammography beginning at age 50.(B Recommend)

• Evidence is insufficient for assessing the additional benefits of screening mammography in women past age 74

• Annual screening mammography beginning at age 45 with an option to begin at age 40. Transition to biennial screening at age 55 with option to continue annual screening

• Continue biennial screening mammography for as long as a woman is in good health and a life expectancy of has at least 10 years

• Annual Screening Mammography beginning at age 40

• Women aged 75 years and older should consult with their physicians to decide whether or not to continue screening mammography

Controversies in Mammography

ACS

ACOG

• Mammography Screening Increased detection of precancerous lesions / In-situ

• 25% of newly diagnosed BC cases in screening is DCIS.(FEA, ADH)

• Biological Significance and practical M/M Big challenge and still unclear

• Trials/Individual studies No reduction to 30-45% modest decrease in BC when screened every 1-2 years

Controversies in Mammography

• Despite Rising incidence of cancer breast • Decrease in Absolute Number of deaths

• Not attributed to mammography screening

• Risk stratified screening is gaining momentum

Mammography debate / controversy

• The most well known and extensively used breast cancer risk assessment model • Well validated, modified and improved after original development • Some limitations • Provides estimated 5-year and lifetime breast cancer risk based on:

– Current age (>35 and <85) – Age at menarche – Age at 1st live birth – Number of 1st degree relatives with breast cancer (0,1, >1) – Number of previous breast biopsies (1, >1) – History of atypical hyperplasia on prior breast biopsy – Race

ACOG, 2011; NCCN, 2013; NCI, 2013; Amir, 2010

Gail Model (NCI-GAIL MODEL)

• Breast cancer risk and BRCA mutation probability model

• Developed using data derived from the International Breast Intervention Study and other epidemiologic data

• Only model to incorporate extensive family history, reproductive/hormonal factors, genetic factors, AJ ancestry, and benign breast disease in one comprehensive model

• Some limitations

TYRER-CUZICK (IBIS) MODEL

IBIS MODEL

• Provides estimated 10-year and lifetime breast cancer risk and probability of a BRCA1 or BRCA2 mutation based on:

• Current age • Age at menarche/age at menopause • Age at 1st birth • Use of HRT • BMI • Abnormal breast biopsy findings • History of ovarian cancer • Family history of ovarian cancer, breast cancer (including • affected 1st degree male relatives) • AJ ancestry • Also accounts for half-siblings, and affected cousins/nieces, • Genetic test results of patient and family members • Cuzick, 2013

05/01/2321

• Should be used and start at the age of 40 years

• Majority of BC is preventable

• Chemoprevention is real possibility

Risk based stratification Screening for Breast Cancer

THANK YOU