Breast Cancer Screening

120 Views Updated: 14 Dec 2018
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What is screening ?

Screening is looking for cancer before a person has any symptoms. This can help find cancer at an early stage. When abnormal tissue or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread. Scientists are trying to better understand which people are more likely to get certain types of cancer. This information helps doctor recommend who should be screened for cancer, which screening tests should be used and how often the tests should be done. If a screening test result is abnormal, you may need to have more tests done to find out if you have cancer. Women with a higher than average risk of developing breast cancer may be offered screening and genetic testing for the condition.

NHS Breast Screening Programme recommends that women between 50-70 years of age of should be screened once every three years. Screening is especially recommended for women with risk factors, a significant one being family history. Having a 1st-degree relative (mother, sister and daughter) with breast cancer doubles or triples the risk of developing the cancer. About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes, BRCA1 or BRCA2. If relatives of such a woman also carry the gene, they have a 50 to 85 % lifetime risk of developing breast cancer. Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and an improvement in survival rates.

Approximately 20 % of the cancers detected in a given year will be missed at screening, but wil become clinically evident in the period before the next screen (interval cancer).

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.
The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules and bulbs are linked by thin tubes called ducts.

Each breast also contains blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels lead to organs called lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter substances in lymph and help fight infection and disease. Clustures of lymph nodes are found near the breast in the axilla(under the arm) above the collarebone, and in the chest.

Breast cancer is the leading cause of death from cancer in women.
In India breast cancer is second only to cervical cancer and now we have the largest number of breast cancer patient worldwide. A recent study of breast cancer risk in India revealed that 1 in 28 women develop breast cancer during her lifetime. This is higher in urban areas being 1 in 22 in a lifetime compared to rural areas where this risk is relatively much lower being 1 in 60 women developing breast cancer in their lifetime. In India the average age of the high risk group in India is 43-46 years unlike in the west where a women aged 53-57 ears are more prone to breast cancer. Breast cancer occurs more often in white women than in black women. However, black women are more likely than white women to die from the disease.

Breast cancer occurs in men also, but the number of cases is small. History can affect the risk of breast cancer.

The risk factors influencing breast cancer are modifiable and non modifiable some of the risks are:

Having certain gene mutations (changes), such as in the BRCA1 or BRCA2 genes.

Menstruating at an early ageOlder age at first birth or never having given birthA family history (first degree relative, such as a mother, daughter or sister) with breast cancer.

Treatment with radiation therapy to the breast / chest.Breast tissue that is dense on a mammogram.

Taking hormones such as estrogen and progesterone for symptoms of menopause.

Obesity

Not getting enough exercise.

Drinking alcoholic beverages

Being white.

No breast feeding

Multiple abortion


Mammogram
Best Diagnostic lab in Delhi mammography is a standard procedure done as part of the triple test for diagnosing breast cancer. If the lesion is clinically suspicious and is not a cyst by ultrasonography or aspiration, then a biopsy is indicated despite the mammographic results. Its main use is for screening the rest of the breast and the contralateral breast for unsuspected cancer.The lump may have a classic appearance of a benign calcifying fibroadenoma, mixed radiographic density hamartoma, or fat lesion such as fat necrosis or a lipoma. The appearance of these lesions can be used to avoid a biopsy, so that in these cases, the diagnostic mammogram is very helpful.The lump may have a classic appearance of breast cancer and biopsy is clearly indicated. In this case, the mammographic findings could prevent a delay in diagnosis by making it clear that a biopsy is needed. This test may find tumors that are too small to feel. A mammogram may also find ductal carcinoma in situ (DCIS). In DCIS, there are abnormal cells in the lining of a breast duct, which may become invasive cancer in some women.

The following may affect whether a mammogram is able to detect (find ) breast cancer:

The size of the tumor.

How dense the breast tissue is.

The skill of the radiologist.

Women aged 40 to 74 years who have screening mammograms have a lower chance of dying from breast cancer than women who do not have screening mammograms.


Clinical breast exam (CBE)
A clinical breast exam is an exam of the breast by a path lab Delhi or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual. It is not known if having clinical breast exams decreases the chance of dying from breast cancer.

Breast self-exams may be done by women or men to check their breasts for lumps or other changes. It is important to know how your breasts usually look and feel. If you feel any lumps or notice and other changes, talk to your doctor.

Three ways of taking tissue samples for histopathological testing are:

Fine needle aspiration: A thin needle is inserted into the breast tissue around the areola (darkened area around the nipple) to take out a sample of cells and fluid.

Nipple aspiration: The use of gentle suction to collect fluid through the nipple. This is done with a device similar to the breast pumps used by women who are breast-feeding.

Ductal lavage: A hair- size catheter (tube) is inserted into the nipple and a small amount of salt water is released into the duct. The water picks up breast cells and is removed.

Confirmation of malignancy with cytology or histology is the minimum requirement for “indeterminate” or “high-risk” solid lesions.Fine-needle aspiration / Tru cut / core biopsy / surgical excision/ Incision biopsy / percutaneous breast biopsy for non-palpable disease are the various methods used to obtain tissue for pathological confirmation.

If a woman is being treated with neoadjuvant therapy it is essential to perform a biopsy to obtain the ER/PR status of the tissue.

Pathology

The various abnormalities of the breast include nipple discharge, inflammations, benign disorders, phyllodes / sarcomas  and carcinoma Most breast cancers are epithelial tumors that develop from cells lining ducts or lobules; less common are nonepithelial cancers of the supporting stroma (eg, angiosarcoma, primary stromal sarcomas, phyllodes tumor). Cancers are divided into carcinoma in situ and invasive cancer. Paget’s disease of the nipple is a form of ductal carcinoma in situ that extends into the overlying skin of the nipple and areola, manifesting with an inflammatory skin lesion and may become invasive. The pathological variations of breast cancer influence the prognosis.  In situ cancers (DCIS/LCIS) are slow growing, indolent tumors. Autopsy studies have indicated that the incidence of DCIS in asymptomatic women ranges from .02% to 18.2% indicating that some DCIS do not become evident during a women’s lifetime. Invasive carcinoma is primarily adenocarcinoma. About 80% is the infiltrating ductal type; most of the remainder is infiltrating lobular. The pathological variants with a favorable prognosis are tubular, cribriform, mucinous and adenoid cystic variants, while intermediate prognosis is seen with medullary, secretory and invasive lobular cancers. The most unfavorable pathology is high grade metaplastic, micropalliary, signet ring cell morphology, inflammatory cancer.

Staging

The TNM staging is traditionally used to stage breast cancer (link) Patients are clinically grouped into one of the following categories

Operable Breast CancerLarge Operable Breast CancerLocally Advanced Breast CancerMetastatic Breast Cancer
Treatment

Evidence based Guidelines

Breast cancer can be treated using a multimodality approach of surgery, chemotherapy, radiotherapy and targeted therapy. The treatment options vary as per the stage of the tumor. There are multiple ongoing clinical trials in breast cancer; TMH is involved in many of the same.
Information For Patients

Breast cancer is one of the commonest cancers in women in India. It is also one of the curable cancers if detected early. Any woman would dread getting cancer of the breast. Cancer subjects the family to unimaginable emotional stress. If you or someone you know has been diagnosed to have breast cancer it is important that you understand the disease, since ignorance breeds myths. We then have to fight not just the ‘CANCER’ but also the ‘MYTHS’.

The risks and benefits of screening for breast cancer may be different in different age groups.
Women, who have had radiation treatment to the chest, especially at a young age, are advised to have routine breast cancer screening. Yearly MRI screening may begin 8 years after treatment or by age 25 years, whichever is later. The benefits and risks of mammograms and MRIs for these women have not been studied.

There is no information on the benefits or risks of breast cancer screening in men.

No matter how old you are, if you have risk factors for breast cancer you should ask for medical advice about when to begin having breast cancer screening tests and how often to have them.

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