Breast Cancer Screening

By JP Saleeby, MD

Breast cancer is the second most common cancer women face second only to lung cancer, however it is the most feared cancer or disease for most women. It occurs in about 12% of women who will live to the age of 90. Several well established factors increase the risk of breast cancer and they include family history, nulliparity (not having had children), early menarche (starting menstrual cycles early), advanced age and a personal history of breast cancer. Other risks include exposure to environmental toxins such as tobacco smoke that increase the chance for cancer growth. October is Breast Cancer Awareness Month. The American Cancer Society has many activities this month to bring this to the public attention.

Early education on self-breast exam and early screening is extremely important in achieving good outcomes. Self-exam and physician examination will detect cancer at a rate between 70 – 80%. Adding screening mammography (mammograms) will increase detection to 96 – 98%. It has been shown that early detection through clinical exam and mammography can reduce breast carcinoma mortality by 20 to 30%. Today’s gold standard for screening (mammograms) will still miss between 10 and 15% of neoplasm.

Therefore, if a clinically noted mass is followed by a negative mammogram the work up should then include a breast ultrasound and/or a fine needle aspiration cytology and close interval examinations. The modality of Magnetic Resonance Imagining (MRI) is a method of examining the breasts that is far more sensitive in picking up smaller tumor than Mammogram. MRI is widely used in Europe but has not taken on in the US yet. It is more expensive as a screening tool in the USA, but since it is so widely used in Europe it is actually less expensive there. Even with open biopsies of suspicious masses the diagnosis of a malignancy is one in about five biopsies performed. This may seem costly but the morbidity and mortality of missing a malignancy is even more so.

Screening should start with a baseline mammogram at age 35, or younger if there is a strong family history. Annual examinations should be performed once a woman reached 40 years of age, and self examination should be encouraged monthly starting at the age of twenty. Disease prevention & early screenings is the mainstay of a preventive medical practice despite the somewhat conservative recommendations made by medical specialty societies and the managed care industry. Oftentimes the risk-benefit ratio for cancer screening has the dollar as it’s bottom line, but if you are the unfortunate patient to have a cancer that was not detected early, then all the statistics in the world will not matter to you. My philosophy is to pay a little more in time and money upfront to assure a disease free state.

An important thing for women to remember is a positive family history alone increased lifetime risk of cancer to about 25%, that is double the incidence of no such history. Recently the interest has focused on cancers associated with germ line (inherited) genetic mutations. While approximately 5 – 10% of all breast cancer sufferers have a mutation in BRCA1 gene (located on chromosome 17) and BRCA2 gene (located on chromosome 13), this type of screening should only be done when a first degree relative with know cancer and a positive mutation is detected or whether a women falls into a certain ethnic group. Women who have inherited a BRCA1 or BRCA2 mutation have a relatively high lifetime risk of breast cancer (about 50-85%). Risk for cancer in the opposite breast of a woman with a BRCA1 mutation is about 25%. In such cases genetic screening may be advocated. Once a tumor is detected important prognostic determiners as stage of the disease, histology and nuclear grade, estrogen and progesterone receptor status and HER2/neu gene amplification tests are advisable.

For more information on Breast Cancer the following websites are helpful: http://cancerweb.ncl.ac.uk/cancernet/ and www3.cancer.org/cancerinfo. Also a call to the American Cancer Society at (800) ACS-2345 can be of help. To conclude, it is extremely important for women to maintain annual physical exams and aggressive cancer screening regiments. There are means to help prevent cancer in those women who seem predisposed. Screening is one thing, but taking measures to help prevent cancer growth is yet another. There are things women do on a daily basis that can increase their chances for breast cancer (and other cancers) that they are not aware. The programs advocated at my center are based on lifestyle modification, prevention, early detection, natural hormone replacement and nutritional medicine. Women should take a proactive approach to the breast cancer issue, for it may save their lives. This topic is one that is close to my heart, as my ex-wife is a breast cancer survivor.

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