Breast cancer screening

Amidst several guidelines, this is important to adapt them to Indian scenario and have wider applicability of indigenous guidelines

1. Dr Ajeet Kumar Gandhi MD (AIIMS), DNB (Gold Medalist) UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow Screening of Breast Cancer

2. 1.62 Lakh new cases per year (Incidence): 50% deaths Commonest cancer among women (28%) and even in both sexes combined (14%) 4 lakh prevalent cases (62%) Breast Cancer scenario: India

3. Why screening in breast cancer

4. Health Insurance plan study (1963-1997) Randomization between three annual mammograms plus CBE versus no screening 30% reduction in 10-year breast cancer mortality and 25% reduction at 18 years follow up History of mammographic screening

5. Evidence: Screening breast cancer

6. Relative risk of breast cancer death reduced by 10-25% in age group 40-75 years Risk benefit more favorable for 60-69 years versus 50-59 years Flaws and limitations: Most before modern era of adjuvant therapy Less advanced mammographic techniques Trial design flaws: randomization, contamination Evidence: Screening breast cancer

7. Clinical breast examination Breast self examination Screening modalities

8. Full length digital mammography (FFDM) Less false positive Reduces the number of women needing additional imaging and biopsies Newer screening technologies

9. Digital breast tomosynthesis Increased sensitivities, lesser recall rates Newer screening technologies

10. Molecular breast imaging USFDA approved Uses intravenous Tc 99m-Sestamibi and gamma camera to image the breast Better for screening dense breast Cellular metabolism as opposed to structure is visible Newer screening technologies

11. Abbreviated fast MRI (AB-MRI) Takes 3-5 mins Feasible, less costly and more accessible Newer screening technologies

12. Contrast enhanced mammography (CEDM) Positron Emission Mammography (PEM) PET/MR Imaging Thermography Microwave imaging Emerging screening technologies

13. Society Recommendations

14. Screening with annual mammography and MRI starting at age 30 years Are known or likely carriers of BRCA mutation Have other high risk genetic syndromes like Cowden, Li-Fraumeni syndrome etc Have been treated with radiation to the chest for Hodgkins disease Have 20-25% or greater lifetime risk of breast cancer risk by estimation models High risk screening

15. Additional Recommendations: USPSTF For teaching of BSE, there is moderate certainty that harms outweigh benefits . For CBE as a supplement to mammography, evidence is lacking, and balance of benefits and harms cannot be determined. ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

16. No study has documented decreased mortality with BSE Chinese study on 2.66 lakh women showed no difference in mortality, albeit increased incidence of benign breast diseases and breast biopsies Russian study on 1.24 lakh women showed no difference in mortality. BSE group had higher proportion of early stage tumors and also significant increase in proportion of breast cancer patients surviving 15 years after diagnosis Breast self examination

17. In women younger than 50 years: USG with CBE Resources available with Mammography: prioritize women 50-65 years Awareness and education starting at 30 years and CBE screening (40-60 years) once in every 3 years Access to FNAC and Biopsy should be made available Combine education and CBE with cervical cancer at 30 years of age

18. Best offered as an organized program Informed discussion with women: Benefits, limitations and harms False negative and false positives Additional imaging and need for biopsy Biologically indolent lesions Availability of treatment resources Screening implementation

19. Breast Screening Risks of breast cancer screening tests: False-negative test results False-positive test results Anxiety from additional testing may result from false positive results. Mammograms expose the breast to radiation. There may be pain or discomfort during a mammogram. Over diagnosis-a panel of experts concluded that over diagnosis 11% to 19% does exist if breast cancers diagnosed by screening

20. Incidence of DCIS has increased five folds Heterogenous condition Uniformly subjected to treatment Increased rates of mastectomies/double mastectomies DCIS Trouble

21. Screening mammography decreases breast cancer mortality Digital breast tomosynthesis and novel technologies enhance the detection rates and decrease recall rates Guidelines need to be adapted as per regional variations/resources Counselling and discussion with women desirous of screening is a must before prescription of tests Take home messages