Screening: The Importance of Early Detection
Tumor size greatly affects mortality. The smaller the tumor, the more likely it is to be confined to the breast and therefore more responsive to treatment. In a study of 83,686 cases of women with primary breast cancer with tumor sizes ranging from 0.3 cm to 5 cm, and no lymph node involvement, the smallest tumors were associated with a mortality of 10% while the larger tumors were associated with a mortality of 25%. In women with tumor sizes ranging from 0.3 cm to 5 cm and positive lymph nodes, those with the smallest tumors had a 20% mortality and those with the larger tumors had a 40% mortality. Studies show improved mortality when breast cancer is detected as a small lesion, especially if it’s less than 2 cm.
In November 2009, the US Preventive Services Task Force (USPSTF) issued new guidelines for screening mammograms for women with no signs or symptoms of breast cancer. They recommend screening every two years in women ages 50 to 74. In women 75 years or older insufficient evidence exists to recommend routine screening. USPSTF recommends against routine screening of women aged 40 to 49 years because the risks of mammograms outweigh the benefits. These recommendations do not apply to women 40 years or older who are at increased risk or breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation. USPTSF recommends against routine clinical breast examination (CBE) unless the physician is committed to performing a more structured, standardized examination.
Various organizations are not in agreement with the USPSTF recommendations to not screen women ages 40 to 49. This contention has been further strengthened by a 2010 breast cancer screening study of 600,000 Swedish women that found annual mammography screening of women in their 40s reduces breast cancer death rate in these women by nearly 30%.
The American Cancer Society (ACS) in 2003 recommended annual mammography and clinical breast examination beginning at age 40. In 2003, The American College of Obstetrics and Gynecology (ACOG) recommended mammography every 1 to 2 years for women 40 to 49 and annually after the age of 50. ACOG recommends CBE and breast self-examination (BSE) for all women.
Breast tissue in younger women less than 40 tends to be both firmer and denser, making it more opaque to X-rays so that tumors are less likely to be detected. High risk women, especially those with BRCA1 or BRCA2 gene mutations or with a family history of breast cancer are advised against undergoing mammograms before the age of 20. Research presented in 2009 showed that women who underwent five or more annual mammograms starting at age 20, had a 2.5 times higher risk of breast cancer than those women not exposed to the mammography radiation.
It’s also important to emphasize that mammography can sometimes fail to detect tumors which can be felt on physical exam by the patient or the physician especially in women with dense breasts. Other imaging techniques include magnetic resonance imaging (MRI), ultrasound, and thermography. However, mammography remains the standard procedure for detecting breast cancer.
Physicians perform the clinical breast examination (CBE) as part of the routine physical and ACOG and ACS recommend yearly examinations for women age 40 and older. Periodic breast exams every three years are advised in women ages 20 to 40 especially if they have firm/dense breasts or a strong family history of breast cancer. While not an official recommendation, ACS suggests that women begin practicing breast self-examination (BSE) beginning at age 20 and they should have their exam technique reviewed by their physician or provider. Women practicing BSE should perform their exams after their menstrual period when breasts are less congested.
A study of breast cancer patients sorted by the frequency of BSE found those who practiced monthly BSE presented with a lump averaging 2.1 cm, infrequent BSE averaged 2.5 cm and no BSE averaged 3.6 cm. The group who did monthly BSE also had fewer axillary nodes affected by cancer.
Between 80 and 95% of all breast cancers are discovered by the patient, then confirmed by the physician and mammography. It’s been reasoned that if blind people can be taught to read Braille with their fingers, an individual has the capacity to be trained to detect small breast lumps. Because mortality is decreased with early detection, it’s incumbent on both physicians and women to improve their skills in performing breast examinations.
There are a number of methods for practicing breast examination and studies have shown considerable variation in effectiveness at detecting lesions. Two scientists from the University of Florida, Dr. Henry S. Pennypacker and Dr. Mark Kane Goldstein initiated a research program to improve the accuracy of the clinical breast examination. They developed life-like silicone breast models imbedded with varying sizes of simulated tumors. They found that with training and practice, human fingers can reliably detect a 0.3 cm imbedded lump approximately 80% of the time. They incorporated varying levels of pressure and a more systematic process to ensure a more comprehensive exam.
This methodology has been incorporated into a teaching method called MammaCare that is being incorporated in various women’s centers around the country. I became certified as a MammaCare clinical breast examiner to improve care to my patients and to teach them this technique so that they can do more accurate breast self-examinations.
COMING TOMORROW: WHERE DO WE GO FROM HERE?- CLICK HERE
RECAP CONSIDERING BREAST CANCER -REDUCING YOUR RISK BLOG SERIES
The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD – All Rights Reserved
Excerpt from “Outliving Your Ovaries” © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.