Updated Breast Cancer Screening Guidelines

American Cancer Society has recently revised the breast cancer screening guidelines and they were featured in the a recent article in JAMA.

The most significant change has been the age of starting mammographic screening, which has been increased from 40 to 45 years. This change has been made after taking into account the lower incidence rate of breast cancer in this age group. Another factor which led to the delay in initiating screening was the higher number of false positive mammograms observed within this age group.

Recommendations:

  • Women with an average risk for breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation).
  • Women aged 45 to 54 years should be screened annually (qualified recommendation).
  • Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation).
  • Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation).
  • Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation).
  • The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation)

These guidelines are quite different from those of the US Preventive Services Task Force (USPSTF) and this is a cause of concern & confusion among patients. The following table highlights the differences between the two guidelines:

Mammography Screening Parameter ACS USPSTF
Starting age (y) 45 50
Screening frequency Annually to age 54 y, then biennially Biennially, beginning at age 50 y
Stopping age (y) For as long as a woman is in good health and has a life expectancy of at least 10 y 75
Total lifetime mammograms if screening continued to age 74 y (n) 20 13
Lifetime risk of dying of breast cancer (%) 1.8-1.9 2.0
Lifetime risk of dying of breast cancer with no screening is 2.7%.

Do these guidelines affect Indian patients?

Well, firstly India has no screening guidelines and only opportunistic screening is practiced by a very small segment of the population. Secondly, there are some studies which say that Indian breast cancer occurs at an earlier age and therefore screening should be initiated early.

These questions be answered if proper trials on this topic are carried out in the country. For the time being, we should lay more stress on creating awareness regarding breast cancer.

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Interesting Mammograms #1

Mammography is a vital tool used for screening & diagnosing breast lumps (benign & malignant). In this new thread, I will be sharing some interesting mammograms every week, which I see in my practice.

Case #1

Calcified Fibroadenoma in a 32 year old lady.

H/o lump in the left breast for the last 12 years. Not increasing in size & Painless.

X-ray mammography revealed an area of dense calficification (macrocalcification) at 9-10 o’ clock position.

Calcified Fibroadenoma

 

 

Case # 2: 

X-ray mammogram highlighting the difference between benign & malignant lymph nodes in the axilla.

History: 45 year old lady with an enlarging right breast lump x 4 months

On examination: 4×4 cm hard breast lump in the upper outer quadrant of the right breast with palpable axillary LN.

Mammogram showing the primary lesion (cancerous growth) in the right breast and malignant axillary LN on the right side (rounded LN with loss of fatty hilum).

Benign LN can be seen in the left axilla (with preserved fatty hilum).

Primary & nodes

 

The second mammography picture highlights the difference between malignant (right) & benign (left) lymph nodes in the axilla

Nodes

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Midline breast cancer without a lump in the breast: an extremely rare case

Sometimes breast cancer tends to surprise us and present in an unusual manner. In India, due to lack to awareness and a stigma attached with breast cancer, females from the rural set-up tend to present with locally advanced breast cancers. I happened to encounter one such case couple of years back and managing this case turned out to be quite challenging. We managed to publish this case in the Breast Disease Journal and it generated quite a discussion in all the forums where it was discussed. [Breast cancer presenting in the midline without a lesion in the breast: a therapeutic dilemma. Khandelwal R, Poovamma CU, Shilpy C, et al. Breast Dis. 2013 Jan 1;34(2):57-9.]

A 48- year- old post-menopausal lady presented to the Breast Clinic with complaints of a rapidly enlarging chest swelling for the last 8 months. The lesion had ulcerated one month back and she complained of a foul smelling discharge from the growth. There were no complaints of any lumps in the breast or axillae.

On examination, a 14 x 10 cms ulcero-proliferative lesion was seen over the midline of the chest extending 4 cms on either side of the midline. The lump had restricted mobility over the underlying chest wall. In addition, the patient had multiple, enlarged lymph nodes in both the axillae. No enlarged lymph nodes were felt in the supraclavicular fossa. No organomegaly was palpable in the abdomen.

Lesion over anterior chest wall

Lesion over anterior chest wall

A provisional diagnosis of soft tissue sarcoma of the chest wall was made but the presence of bilateral, hard axillary lymph nodes raised a suspicion of a breast carcinoma. Patient was then subjected to a CECT of the chest, which revealed a fungating soft tissue mass over the chest with bilateral axillary lymphadenopathy. MRI of the breasts failed to pick up any lesions in the breast. CT abdomen was unremarkable. A PET-CT done to look for distant metastasis, revealed a mildly hyper-metabolic anterior chest wall mass [SUV max 4.8] with bilateral axillary lymphadenopathy [SUV max 5.1]. There was no evidence of involvement of supraclavicular or internal mammary lymph nodes. No distal metastasis was observed on PET.

Following the imaging tests, an incisional biopsy of the lesion was performed, which to our surprise revealed an invasive ductal carcinoma (grade II) with DCIS. Immunohistochemistry revealed the tumor to be ER and PR positive but HER2 negative.

The case was extensively discussed in the tumor board and a decision was taken to treat the patient with neo-adjuvant chemotherapy. Patient received weekly Paclitaxel for six weeks, which was associated with a good response and the tumor regressed in size. A PET scan done following NACT revealed a residual lesion in the midline with bilateral axillary lymph nodes. PET scan did not reveal any lesions in the breast.

Following a good response to NACT, the patient was taken up for a wide local excision of the tumor with bilateral axillary dissection. As none of the breasts had any lesions, they were not addressed during the surgical procedure.  Patient had an uneventful post-operative period and three weeks later she was started on adjuvant chemotherapy, which was followed by radiotherapy to the chest wall.

Post Surgery

Post Surgery

Following completion of radiotherapy, the patient was started on Letrozole and was kept under regular follow-up. The patient remained symptom free for 1 year after surgery, after which she was lost to follow-up.

This was an extremely rare presentation of breast cancer and managing this patient was a therapeutic dilemma.

39 fibroadenomas removed using just two incisions!!

Yesterday, we performed a marathon fibroadenoma surgery, where we removed 39 fibroadenomas from both the breasts (19 from the right breast and 20 from the left) just by making one incision in each breast. We used a crescent incision in both the breasts and comfortably removed fibroadenomas measuring as big as 5-6 cms through that incision. The entire procedure lasted 2 hours and the patient was discharged the same day.

Although the smaller fibroadenomas could have been left behind (because they are not malignant) but the patient was very apprehensive about them and wanted all of them removed. The importance of the single incision (periareolar crescent) is that it makes the end cosmetic result quite good. I am sharing some intra-operative pictures in this post. Will update the post-operative and follow-up pictures soon.

Marking of the crescent incision.

Marking of the crescent incision.

 Fibroadenomas marked along with the incision. Smaller lesions were not marked.


Fibroadenomas marked along with the incision. Smaller lesions were not marked.

 

6x7 cm fibroadenoma removed through the incision

6×7 cm fibroadenoma removed through the incision

 

5x5 cm lesion removed through the left breast

5×5 cm lesion removed through the left breast

 

Starting the closure. Will share the post-op and follow up pictures soon

Starting the closure. Will share the post-op and follow up pictures soon

Patient & Provider Delays in the Management of Breast Cancer in India

A study, which I conducted during my undergraduate years titled “Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study” was published in the Journal of Royal Society of Medicine. This study was conducted in a government hospital at New Delhi, where majority of the patients were from the rural background. Patient delays are a well known fact and more so in breast cancer due to the apprehension shared by many Indian ladies regarding the examination of their breasts. It was not surprising to see that there was an average delay of around 70-75 days was observed in these patients, after the onset of symptoms till the time of the first consultation.

Adding to these patient delays,  63% of these patients first contact after the onset of the symptoms was with an unregistered medical practitioner (quack), which led to further delay in the diagnosis of breast cancer. Another shocking fact was that an average of three consultations were required before the diagnosis of breast cancer was made.

These points clearly highlight why the incidence of locally advanced breast cancer in India is so high!! This along with the aggressive biology of our tumors (high incidence of triple negative tumors), spells doom for most of the patients.

What are the steps which can be taken to avoid these delays in diagnosis?

  1. Spreading awareness about breast cancer: With communicable diseases gradually being controlled in our country, cancer is the next big epidemic which India is going to face. Proper steps need to be taken now to ensure India is ready to face this next big challenge. Awareness about Breast cancer should be increased among Indian women and I feel that Obstetricians and Pediatricians have a huge role to play in this. They should educate ladies regarding breast cancer during their pregnancy and follow-up visits.
  2. Improving the literacy level: In our study, we observed that literate patients were more likely to consult a qualified doctor and the time lag between the onset of symptoms and the first consultation was less in them as compared to illiterate ladies.
  3. Educating Primary Care Doctors: Although patient delays were largely responsible for the late presentation but there were instances, where breast cancer were not detected by primary care doctors. Special sessions should be conducted for these doctors to make them more aware about the signs and symptoms of various cancers.
  4. Hunting down quacks: Quacks lead to unnecessary delays not only in the management of Breast cancer but also other illnesses and our government should take appropriate measures to end this menace.

I know it is easier said than done but with these measures we can certainly cut down the delays in the management of Breast Cancer in India.

No delay

 

“Debunk the Myths” – Theme for World Cancer Day 2014

This year’s theme for the World Cancer Day –  “Debunk the Myths” is very apt for our country. Four myths have been highlighted by in this year’s agenda:myths

Source: www.worldcancerday.org

Myth 1:  We don’t need to talk about cancer
Truth: Whilst cancer can be a difficult topic to address, particularly in some cultures and settings, dealing with the disease openly can improve outcomes at an individual, community and policy level.

Myth 2: There are no signs or symptoms of cancer
Truth: For many cancers, there are warning signs and symptoms and the benefits of early detection are indisputable.

Myth 3: There is nothing I can do about cancer
Truth: There is a lot that can be done at an individual, community and policy level and with the right strategies; a third of the most common cancers can be prevented.

Myth 4: I don’t have the right to cancer care
Truth: All people have the right to access proven and effective cancer treatments and services on equal terms, and without suffering hardship as a consequence.

Everyone should come together and spread these messages across the community, so that maximum people can benefit from them. Another point which needs attention in our country is the Social Stigma, which some cancer survivors have to face. It needs to be highlighted that cancer is not contagious and that a cancer patient/survivor has the right to live a normal life.

AIIMS study reveals a link between OCP’s and Breast Cancer

The use of oral contraceptive pills (OCP’s) especially emergency contraceptive pills (morning after pills) is increasing rapidly among young women and this might be one of the factors responsible for the rise in the incidence of Breast Cancer in our country. Many studies conducted on this issue have failed to indicate a clear link between OCP’s and breast cancer. However, a recent study conducted by AIIMS, which was published in Indian Journal of Cancer has revealed a higher chance of breast cancer among regular users of OCP’s.

According to the study, breast cancer risk was found to be 9.5 times more in women with a history of consuming such pills regularly. The study included 640 women, out of which 320 were breast cancer patients. 11.9% breast cancer patients in the study had a history of using long term OCP’s as compared to 1.2% healthy individuals.

It is a well known fact that breast cancer is a hormone dependent cancer (mainly dependent of on estrogen) and the regular use of OCP’s leads to a disturbance in the normal hormonal status. Morning after pills (emergency contraceptive pills), which contain a higher dose of estrogen lead to a sudden surge in the levels of these hormones and are thought to be more harmful. The problem is that these pills are being consumed on a daily basis by many youngsters. The users of morning after pills were not included in this study.

Women should realize the importance of this study and more awareness needs to be created among young women regarding excessive use of emergency contraceptives. At the same point, more studies (prospective trials) are required on this issue to firmly establish a link between OCP’s and breast cancer.

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Source: http://timesofindia.indiatimes.com/city/delhi/The-pill-can-kill-AIIMS-study/articleshow/28251469.cms