Guidelines for early detection

'Screening' is a systematic evaluation of a 'normal' individual to see if there is any underlying cancer. A 'normal' individual implies one who does not have any symptoms or signs of cancer. One must understand that, before a lump becomes sizeable, it may not be felt. By the time a lump in the breast becomes 'palpable' or can be felt, it usually will have reached a size of a few cm or more, and that will be a mimimum stage 2 cancer, if not more. As the size of a 'tumour' increases, its potential to spread elsewhere also increases, and also affects the patient's survival. So our aim is to catch the cancer before it is even felt as a lump, when it is very small; in other words, to detect it while it is in stage 1. A patient has the best chance of long survival if the cancer is detected in the first stage. There are various screening guidelines worldwide. The most commonly accepted and followed are the NCCN Guidelines . The following discussion elaborates on the NCCN Guidelines.


How do I select my doctor for 'Screening'?

Selection of a proper doctor trained in breast diseases is very important. I will give two examples for that:

  • A 38 years old lady (with a history of breast cancer in her sister) presented to me with a 4 cm lump in her right breast which turned out to be a cancer and had a few enlarged axillary nodes. She had noticed the lump only a few months back. However, on evaluating all past records, I found one mammogram done 2 years back (was advised by her gynecologist), just for screening; she did not have any lump or other symptom then. In that mammogram, there was a small area of stippled microcalcification, which was very suspicious (Stippled microcalcifications are pathognomonic for cancer) . The radiologist had also mentioned it in the report. But since there was no palpable lump, her gynecologist told her, not to worry. She didn't do anything for that for the next 2 years, and finally, was detected with cancer in the same site, in a minimum of clinical stage 2B. Finally after surgery, 5 (out of 27) nodes were positive for cancer and this placed her in stage 3A. So please understand here, the gynecologist advised the mammogram, but did not not know how to interpret or act, and the lady, who would have otherwise been detected with cancer of stage 1 and would have had more than 90% chance of 10 years survival, now ended up with stage 3A and will have about 60% chance of 5 year survival. So two years of wait have definitely decreased her life by 5 years.

  • A 32 years old lady presented to me with a history of heaviness in breast before the periods as well as pain in the breast for a few days before the periods. On clinical examination, breasts were normal, except for slightly engorged. Again here, her family doctor had advised her mammography (I wouldn't have advised her mammography, if at all needed, I would have gone for an ultrasound of the breast first). On the ultrasound which was done with the mammogram, there were multiple cysts of varying sizes in both the breasts, from few millimetres to 8 to 9 millimetres. She was overtly worried about cancer, and had already taken opinion from one surgeon and one gynecologist. One had advised surgery (!!) and the other had given some non specific medications. All I did was to reassure her, that this was nothing to worry about (She was visibly more worried about the cancer than the symptoms of pain and heaviness she had). I assured her that this was not cancer, this did not require surgery, this occurs in many women of her age - some have more symptoms while some have less symptoms, and that over a period of time, it will all settle. I gave her some symptomatic medications and some vitamin supplements and believe me, after three months, she was almost settled of symptoms and was very happy. Not that my medications worked or something, but it was the re assurance that worked.

So please ensure that the doctor you select is trained in breast diseases.

Guidelines defined by age

Normal risk woman, 20 to 40 years of age:

For a woman who does not have an increased risk for breast cancer and who is between 20 to 40 years of age, the screening (early detection) guidelines are as follows:

  • Clinical Breast Examination: This must be done every 1 to 3 years. Every year may sound impractical, but a visit to a doctor just once every three years should not be a problem.

  • Breast Awareness: Read below

Normal risk woman, more than 40 years of age:

For a woman who does not have an increased risk for breast cancer and who is more than 40 years of age, the early screening protocol is as follows:

  • Annual Clinical Breast Examination A yearly examination by a qualified and trained medical personnel is a must.

  • Annual Mammography From 40 to 50 years of age, yearly mammography is recommended. After 50 years of age, mammography may be done every 2 years.

  • Breast Awareness

Women with increased risk of breast cancer:

For a woman who has an increased risk for breast cancer, the screening (early detection) guidelines are as follows:

  • Annual clinical Breast Examination

  • Breast Awareness

  • Annual Mammogram: For women, who have received radiation therapy to the chest, a mammogram should be done annualy after 25 years of age. For those with a family history of breast or ovarian cancer, annual mammogram should start by 35 years of age. For women belonging to proven breast and ovarian cancer families (genetically) or those who have multiple first or second degree relatives with breast or ovarian cancers (and some other related cancers, explained below), an annual mammogram must start much early, by around 25 years of age.

  • MRI of the breast: In the above high risk categories, an annual MRI of the breast is also recommended as an adjunct to mammogram.

IMPORTANT!!! PLEASE READ

The main purpose of explaining these guidelines is to make the reader aware of what must be done. PLEASE DO NOT TAKE ANY DECISIONS BY YOUR OWN SELF REGARDING SCREENING MODALITY OR MAMMOGRAM OR MRI. Decision of risk and decision of screening modalities is an intricate issue and you must always consult a doctor first and with the doctor's guidance, calculate your risk of breast cancer, and plan the screening protocol. It is important to understand that a correct interpretation of screening is very important, else it can lead to unnecessary intervention and anxiety, or may result in a cancer being missed.

Which women are at an increased risk of developing breast cancer?

To explain in simple terms, following women have a higher than average risk of developing breast cancer:

  • Positive Family History: One or more family member (blood relation) has a history of breast or ovarian cancer

  • Genetic Predisposition: One or more family member (blood relation) is known to harbour a 'genetic' abnormality causing breast cancer. This significantly increases the risk of developing a breast cancer

  • Previous Radiation Therpay to chest wall: If a woman has received radiation therpay to chest wall for any cause, she stands an increased risk of developing breast cancer

  • High risk factors: Risk of developing breast cancer can be calculated by various means, the commonest is based on the GAIL model, for women above 35 years of age. After this calculation, if the 5 year risk of developing a breast cancer is greater than 1.7%, the women is considered to be at an 'increased' risk of developing breast cancer and must follow the 'increased risk' guidelines. If the 5 year risk is less than 1.7%, the woman is considered to be at a 'normal' risk for breast cancer and may follow the 'normal risk' guidelines.

What is Clinical Breast Examination (CBE)?

Clinical Breast Examination (CBE) implies a visit to a doctor, where the doctor makes a detailed evaluation of the patient's history and performs a body checkup including breast examination with an aim to detect any suspicious abnormality. A doctor, who is in touch with the subject and who has an experience in breast disorders may be able to pick up an early cancer even before it may manifest, as also may be able to appropriately rule out any cancer in a woman who may be having some breast symptom.

What is Breast Awareness?

Breast Awareness implies familiarity with one's own breast. A self examination can be done monthly during bath, best time being just at the end of menses. This helps to keep in notice any irregularity, any lumps, the skin, the nipple etc. Also, breast awareness also includes a knowledge of breast cancer. A woman should be aware of what possible changes could occur in a breast when a cancers develops in the breast.