Recently in the media, there has been much controversy about the importance of breast cancer screening. Latest research has shown that routine breast cancer screening can lead to more harm than good for patients. The newest recommendations by the United States Preventive Health Task Force show that screening must be individualized depending on the patients modifiable and nonmodifiable risk factors.
The main question you must be asking me is
“Dr Susarla, should I get screened for breast cancer? When should I start?”
Prevalence of breast cancer
Breast cancer is the most common form of noncutaneous cancers. It affects about 1 in 8 women by 90 years of age. In 2010, there were 200,000 documented cases of breast cancers and 54,000 cases of in situ disease.
There are many modifiable and nonmodifiable risk factors for breast cancer. You should use these risk factors to assess whether or not use are at higher risk of breast cancer.
Nonmodifiable risk factors include:
- Family history- about 75% of patients have NO family history of breast CA
- BRCA1 and BRCA2 mutations are present in only about 1 out of 10 women
- Female sex
- Race- Blacks have the highest mortality and Hispanics and American Indians have the lowest.
- First menstrual period younger than 12 years
- Menopause older than 55 years
- Dense breasts determined by radiographic images
- History of breast biopsies
- History of invasive breast cance
- Ductal carcinoma in situ or lobular carcinoma in situ
- History of ionizing radiation
- Diethylstilbestrol exposure, which was prescribed by 1938 and 1971 in pregnant women
- First childbirth after 35 years. Women who have children after 35 years have 3 times the risk of breast cancer
- Sedentary lifestyle
- Hormone replacement therapy
- Alcohol consumption
- Formula feeding. Breast feeding is protective against breast cancer.
Breast cancer mortality rates
Cancer is the second cause of mortality after heart disease on women. The top three cancers in the US are breast, lung, and colon cancer. Breast cancer is the most common form of non skin cancers in women. About 1 of 8 patients will die who are diagnosed with breast cancer.
Emphasis on breast cancer prevention, screening, and treatment
Although lung cancer has a higher incidence of mortality, a greater emphasis is placed on breast cancer prevention. Breast cancer has a high emotional significance for women because of sexuality issues and body image issues. Also, there is much social and political attention focused on breast cancer.
Effectiveness of screening tests
There are several characteristics for a good reliable screening test. A good screening test must have the following:
- High sensitivity to identify the true positives
- Easy to administer
- Widely available
- Reasonably priced
- Safe for patients
- No to no minimal discomfort
- Demonstrates improved health outcomes
There are also several questions you should ask before undergoing any types of screening:
- Can the disease be managed in a preclinical state leading to improved outcomes?
- Are there identifiable and modifiable associated with that individual and that disease?
- Does the disease constitute a significant health problem?
- Are there readily available and acceptable treatments for the disease?
Current USPSTF guidelines
Currently, there is no recommended routine screening in patients 40 to 49 years. Between the ages of 50 to 74, patients can get mammograms every 2 years depending on the individual situation. There is no recommendation to get mammograms after age 75 years. There is insufficient evidence to recomnmend clinical breast exam after age 40 years. There is also insufficient evidence to recommend technologies for screening (digital mammography, breast magnetic resonance imaging (MRI) study). Screening should be very individualized, especially when there are risk factors present. Your primary care physician should go through all of your modifiable and nonmodifiable risk factors. Then, a mammogram will be ordered if needed.
Risk of mammography screening
If every woman over the age of 50 years received mammography screening annually for 10 years, approximately 2500 woman would have to be screened to make the diagnosis of breast cancer in 1 woman. One-third to one-half of those 2,500 women with have a false-positive mammogram that will result in a biopsy or surgery on lesions that will not progress to mortality causing breast cancer. This resutls in psychological burden on the patient. This also results in additional tests, treatments, physician visits, and cost. Patients are also exposed to more radiation.
Self breast examinations and clinical breast examinations
Data has shown no improvement in breast cancer diagnosis with self breast exams or clinical breast exams. The USPSTF recommends against routine teaching, not performance of self breast exams. Most breast cancers around found incidentally in the shower or changing clothes. Also, the USPSTF recommends found insufficient evidence to perform clinical breast exams, digital mammography and breast MRI.
- Approximately one-third of patients who qualify for breast cancer screening do not receive screening due to lack of access, education, or awareness.
- Screening in patients should be individualized, depending on risk factors present, age, and patient history (e.g. finding breast mass during shower).
- Please speak to your primary care physician to discuss what options are best for you!