Breast cancer screening

Dr Smita Barya (Goyal)

M.B.B.S., M.S.,F.M.A.S.,CIMP
Professor Obs & Gynae.
PMCH Udaipur
 Table of content

• Screening and screening test

• Importance and need of screening for breast cancer
• Risk factors for carcinoma breast
• Screening methods and tools
• Screening reccomendations
• Breast cancer screening in special situations
 Screening

“Checking for disease when there are no

symptoms.”
sceerning test sometimes termed as “medical
surveillance”, is medical test or procedure performed on
members of a defined asymptomatic population or
population subgroup to assess the likelihood of their
members having a particular disease.
 Statistics of breast cancer in india
• Breast cancer has ranked no1 cancer among indian females.

• As per Globacan data 2020, in india BC accounted for 13.5% of all cancers
and 10.6% of all cancers death.

• One in 28 women is likely to develop breast cancer during her life time.

• BC accounts about 1 in 3 of all new female cancers each year.

• Current trends says , higher proportion of disease is in younger age group of

indian women.

• Mizoram is “cancer capital of india”.

 Importance of breast cancer screening

• Rising incidence of ca breast across the globe.

• Rising incidence of ca breast in india.

• Rising incidence in younger age group.

Stage wise 5 year survival rate
 Benefit of breast cancer screening
• Screening of breast cancer can detect it in very early and asymptomatic
stage.

• Early detection of breast cancer is possible by breast cancer screening

only.

• Less aggressive treatment required in early stage, which can give

positive outcomes and can increase life expectancy of an individual
suffering from breast cancer.

• Decrease morbidity and mortality and disease burden of deadly and

comman clinical condition is possible , by early detection and treatment.
Screening of carcinoma breast
 Risk factors of carcinoma breast

Nonmodifiable risk factors

• Female gender ( 100 times more comman than in male)

• h/o benign breast disease with proliferative lesion with

atypia (RR 4-6) e.g. atypical lobular hyperplasia, atypical
ductal hyperplasia

• Family history of breast cancer, ovarian cancer, hereditary

syndrome- cowden syndrome, Li-Fraumeni syndrome, Peutz-
jeghers syndrome, lynch syndrome
• BRCA1 BRCA 2 Mutation-40 to 80% increased risk
• Early menarche and late menopause
• Dense breast on mammogram
Genetic screening for carcinoma breast
BRCA1 and BRCA2 gene mutation is most important gene
changes associated with hereditary breast cancer.

Other inherited gene mutations associated with breast cancer,

are-
• PALB2
• CHEK2
• ATM
• CDH1
• PTEN
• P53
BRCA1 & BRCA2 gene mutation
BRCA1 and BRCA2 gene mutations are
inheretid genes with very high risk of
developing breast cancer and other
cancers.

HBOC (hereditary breast and ovarian

cancer syndrome) is associated in women
and men with one of these gene changes.

Because of this strong association ,even

prophylactic mastectomy and
hysterectomy is advised at the age of 35
to 40 in these patient.
• Family history of breast/ovarian cancer is associated with
higher chances of breast cancer. This association is higher if-
- first degree related were affacted with cancer
- more number of family members got affected
- family h/o cancer in younger age
But
Most women with family h/o breast cancer do not have an
inherited gene change , they may be sporadic too.
 Breast Screening methods
• Breast self examination(BSE)
• Clinical breast examinatin(CBE)
• 2D mammogram
• Sonomammogram
• MRI
• 3 D mammogram (breast tomosynthesis)
• Thermography
 Breast self examination
• It is a screening method used in an attempt to detect early breast cancer.

• Recommended by various guidelines as screening of BC.

• It involves the women herself looking at and feeling each breast for
possible lump, distortion or swelling.

• According ACS and other guidelines it should be started from late teens
or early 20s.

• To be done on 5th to 7 th day of cycle in menstruating female and once

in a month by postmenopausal lady.
Method of BSE
 BSE interpretation
• Lumpy or nodular feel of the breast and increased
pain and tenderness may be physiological findings,
specially before menstruation, may needs reassurance
only.

• Any abnormality like skin changes, lump, changes in

nipple, difference in symmetry, discharge from
nipple, dimpling, reddness or skin rash should be
discussed urgently with a specialist.
Positive findings on BSE
 Advantage and disadvantage of BSE
• Advantage –it is a safe way to become familiar with the
normal look and feel of one’s breast. It can detect early
changes in the breast.

• Disadvantage- any kind of abnormality found during

BSE ,even benign pathology of breast can create great anxiety.

• It Can miss small lump and early malignant changes.

 Clinical examination of breast (CBE)

• CBE is physical examination of breast done by health care provider .

• It involve meticulous systemic examination of both breast, axilla
and supraclavicular space.
• CBE detects most breast cancers with senstivity 54% and specificity
94%.
• It Provide information during workup and management.
• ACOG recommends CBE in every 1to 3 year for 25 to 39 year age
group and yearly after 40 years of age.
• It can be considered as screening modality where cost
of screening mammography is considered too high.
 Screening mammogram
• Specialized medical imaging that uses a low-dose of X-ray to
examine the breast for early detection of cancer and other
breast disease. It is used as both diagnostic and screening tool.
It is called screening mammogram when done in a
asymptomatic women .

• Mammography is widely used and most commanly

recommended method of screening for carcinoma breast.
 Mammogram
• Types of mammography
1. Conventional mammogram
2. Digital mammography
3. 3D mammography /tomosynthesis

• Two X-rays are taken for each breast , where breast is

compressed and X-ray is taken in 2 views ,i.e. craniocaudal
and mediolateral view.
 Patient’s prepartion for mammography
• Preffered time is postmenstrual phase of menstrual cycle, to
reduce discomfort and for better imaging.

• Do not use deodorant, talcom powder or lotion under arm or

on breast on the day of testing. These can appear as calcium
spot on mammogram.

• Keep previous mammogram with you for comparision.

• Tell the technologist if u have any breast symptoms.

 Conventional Mammogram vs
digital mammogram

• Both are X-ray of breast

• Conventional mammograms are read and stored on film,

however digital mammograms are read and stored in a
computer so data can be enhanced, magnified, or manipulated
for further evaluation.
 Suspicious lesion on mammography

• Cancer look like micro-calcification , evident high density

mass with irregular indistinct or spiculated margin ,
architectural distortion asymmetric density.
• Apart from BSE and clinical breast examination screening
mammogram can detect nonpalpable changes of breast
malignancy, such as clustered microcalcifiacation and areas of
abnormal density.
 Disadvantage of mammography
• Painful procedure.

• Radiation hazards, especially high fibroglandular tissue is more

senstive for radiation.

• Although senstivity of mammography is around 75 % but it is having

less senstivity in detection of abnormalities in dense breast (senstivity
reduced to 50%). Senstivity is inversly proportional to density of breast.
 3D mammogram /Tomosynthesis

• Advanced form of mammography, more like but not exactly

same as CT scan.

• It uses x-rays to take a series of pictures of inside of the breast

from many different angles to generate thin cross-section. A
computer is used to make3-D pictures of breast from these x-
rays images.
3 D Mammogram/Tomosynthesis
 Pros of Tomosynthesis
• Can detect small breast cancer which can be missed on conventional
mammogram
.
• Greater accuracy in pinpointing the size, shape and location of breast
abnormalities, faclitate directed biopsy.

• Fewer unnecesssary biopsies or additional tests are required.

• Detect multiple breast tumors.

• Clear image of abnormalities.

• Higher senstivity even in dense breast.

2D vs 3D mammogram

Although 3D mammography is
superior than 2D
mammography, ACS screening
recommendations believes that
women should be able to
choose between 2D or 3D
mammogram pertaining to its
high cost and rare availability.
High cost of 3D mammogram
is also not covered by
insurance.
 USG breast/ Sonomammography

• Ultrasound is very senstive diagnostic modality for differential

diagnosis of breast lump but not solely recommended for
screening. The role of screening ultrasound remains
controversial.
• Ultrasound is considered complementry tool to mammography
for diagnosis of breast cancer. Concomittent use of usg along
with mammography increase the screening test results
significantly.
 MRI screening
• This method is highly senstive and low specificity to cancer
detection.
• Dynamic contrast enhanced MRI( DCEMRI),which uses
inectable gadolinium as contrast, has been recognized as the
most powerful method for detecting breast cancer.
• Routine use of screening MRI is not recommended for the
general population because of high cost and high false
positive cases.
• Studies says MRI is more senstive than mammography ,
( senstivity ranges from 71% to 100%), recommended in
women at high risk for familial breast cancer.
 Mammary Thermography

• Medical infrared thermography.

• It is a noninvasive and painless test done to check the early
breast changes , that could indicate breast cancer.
• It uses special infrared camera to measure the temperature of
the skin on breast surface.
• Used now a days for mass screening of breast cancer.

• Not come under reccomendation of screening of breast cancer.

MACHINE AND IMAGES
 Concept and technique of mammary
thermography
• With thermography equipment ,image of the targeted organ is taken
by infrared camera.

• With set temperature and set humidity and avoidance of sunlight in

the room, and specific setting in equipments these pictures are
taken.

• Dark colour indicate cooler area.

• Temperature difference between different tissue can be seen as

colour difference. More than .5 degree temperature difference of a
lesion from the surrounding tissue is considered abnormal.
• Thermography devices has only been cleared by FDA as an “
adjunctive” tool, referring to use alongside a primary
screening test like mammography . It is used for risk
assesment only .It should not be used alone as screening test
because of high false positive and false negetive test report as
screening test for breast cancer.

• Not recommended by ACOG,ACS ,NCI ,USPSTF

 Breast cancer screening recommendations

Guidelines
• WHO
• NCCN
• ACOG
• National cancer institute
• Association of breast surgeon
• American cancer society
• US preventive task force
 ACS screening recommendation for women
at high risk
Annual breast MRI and mammogram, typically starting 30 years of age.
• High risk women are-
1. Known BRCA1 BRCA2 gene mutation.
2.First degree relative with BRCA1 BRCA2 mutation, and have not
had genetic testing themselves.
3. Personal h/o radiation therapy to chest wall ,age between 10 to 30
years.
4. Have 20 to 25% higher chance of developing BC according to risk
assessment tool.
5. Have Li-Fraumeni syndrome, Cowden syndrome, bannayan –Riley
Ruvalcaba syndrome or first degree relative with one of these
syndrome .
• ACS recommends against MRI screening for women whose life
time risk of breast cancer is <15%.
• No recommendation against MRI in higher lifetime risk based on
certain factors ,such as
1. personal h/o breast cancer, ductal or lobular carcinoma in
situ, atypical ductal or lobular hyperplasia.
2. having extremely or heterogenously dense breast as seen
on mammogram.
 Screening in special cases
• Before initiation of hormone replacement therapy for
premature menopause or menopausal hormonal
therapy ,screening for breast cancer should be done…as
estrogen hormone can potentiate malignant lesions in breast.

• Screening mammogram and risk assessment for BC is integral

part of work up before commencement of HRT.
• Screening in long term hormonal contraceptive users
should be considered as estrogen and progesterone
hormones affects breast cancer risk.
 What next after positive screening
test

• Confimation of malignancy by tissue sampling and

oncologist consultation
• Tissue sampling by FNAC or tissue biopsy
• Tissue biobsy is ideal, it can be--
Core needle biopsy
Excisional biopsy or open biopsy

It is better to get imaging guided biopsy

 Risk assessment tools
• Gail model

• BCRAT-breast cancer risk assessment tool/ Gail2/

modified Gail

• Tyrer-Cuzik model or IBIS

 Cancer prevention
• Not all cancers can be prevented.
• Work for modifiable risk factors, like
avoid weight gain,
avoidance of smoking and alcohol
Promote first child birth before the age of 30 years and

motivation of mothers for breast feeding.

• Family history of breast cancer should be carefully taken and
genetic councelling and screening as per guidelines to be done
for early detection and management of breast cancer in
familial cases.
• Screening for breast cancer as per guidelines can prevent
morbidity and mortality associated with it.
 Take home messege
• Breast cancer screening and breast cancer awareness
can lead to significant reduction in breast cancer
related morbidity and mortality.
Go for
• Monthly breast self examination beginning at age 18
to 20 year.
• Annual clinical examination of breast after 40 and 1
to 3 yearly 20 to 39 year of age
• Consider reguler Yearly to 2 yearly mammogram
after 40 years of age.
• In case of family history of breast cancer go for
genetic councelling and screening.
Lets put our hands together for prevention of
breast cancer