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Guidelines for Breast Cancer Screening

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What are the Recommendations for Breast Cancer Screening?

Breast cancer is the second most common cause of death among women. It’s also one of the most preventable cancers. According to the American Cancer Society, approximately 182,000 new cases of breast cancer will be diagnosed this year. In 2016, there were 1.7 million new cases of breast cancer in the United States. In 2022 in the U.S., there are estimated 1,918,030 new cancer cases and 609,360 cancer deaths.

The most important things you can do to stay healthy is to get regular checkups, especially if you have a family history of breast cancer. There are many different types of breast cancer screening tests—and each type has its pros and cons. Some are more effective at detecting the disease, while others are more effective at preventing it. Knowing which type of test you should have done and when is an important part of taking care of your health, but it’s also something that’s not always easy to determine.

Why you Should do Breast Cancer Screening?

Breast cancer screening is a very important aspect of your overall health. It’s one of the most effective methods of detecting breast cancer early. In fact, regular screening has been proven to reduce the mortality rate from breast cancer by up to 50%.

Breast cancer screening tests can detect small changes to your breast tissue over time. If you have a screening test that shows a problem, your healthcare team can explore the area to see if the changes are related to cancer or something else. Treatments for breast cancer are generally more successful when it is detected and treated early.

The survival rate for people whose breast cancer was detected in an early stage is 99 percent, according to the American Cancer Society. The 5-year relative survival rate is lower when breast cancer is found at a later stage. The statistics from 2010 to 2016 show a general trend, so keep that in mind.

Breast Cancer Screening Guidelines

Different health organizations recommend different approaches to breast cancer screening. Here’s a summary of the guidelines published by several respected organizations.

American Cancer Society 

The American Cancer Society recommends that all women between the ages of 40 and 74 have a mammogram every two years. Women who have had a baby within the last three years should wait until after their child is one year old before having a mammogram. Women who have a history of breast cancer, dense breasts, or a strong family history of breast cancer should have a baseline mammogram as soon as possible.

The American Cancer Society also recommends that women over the age of 75 should not have a mammogram.

U.S. Preventive Services Task Force (USPSTF)

The USPSTF is a government-sponsored organization that develops guidelines for health care providers on whether or not certain medical tests or procedures are effective and safe. It is an independent panel of 15 medical experts who provide recommendations about preventive care.

According to USPSTF, If a mammogram doesn’t show any signs of cancer, there isn’t enough evidence to recommend additional screenings for denser breast tissue.

But the American Cancer Society says that more frequent mammograms are still recommended for women over 50 years old. “It is important to keep in mind that the current recommendations are based on data from studies done decades ago, said Dr. Elizabeth Ward, director of the Cancer and the World Trade Center Health Program at the National Cancer Institute. “The best way to reduce your risk for breast cancer is to have regular mammograms starting at age 40 and then every two years”.

American College of Obstetrics and Gynecology (ACOG)

Sharing decision-making between doctors and patients, along with counseling on the benefits and risks of various screening exams is emphasized by physician members of ACOG. If you don’t have any risk factors other than dense breast tissue, ACOG doesn’t recommend alternative or additional testing other than mammography.

People who are at higher risk of Breast Cancer

  • Gene Mutation: A BRCA gene mutation can increase your risk of developing breast cancer. If you’re worried that you might have a BRCA gene mutation, it’s important that you get tested. You can find out more about how to do this on the CDC’s website.
  • Denser Breast Tissues: You may have denser breast tissue if you’re overweight or obese. It’s important to work on losing weight if you want to reduce your risk of developing breast cancer.
  • Radiation Therapy: Exposure to radiation increases your risk of developing breast cancer. Compared to women who weren’t exposed to radiation, women who were exposed to radiation before the age of 20 were 3 times more likely to develop breast cancer. Radiation therapy is also used to treat some types of cancer.
  • Hormone Therapy: Hormone therapy is used to treat breast cancer that has spread to other parts of the body. It’s important to talk to your doctor about whether hormone therapy is right for you.
  • Blood Relations: A close relative of yours who has been diagnosed with breast cancer, as certain rare disorders, including Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome can increase your risk of developing breast cancer.
  • Age: As you get older, your risk of developing breast cancer increases. According to the American Cancer Society, “About 1 in 8 women will develop breast cancer in her lifetime.”
  • Diet and Lifestyle: Some foods and drinks can increase your risk of developing breast cancer. Avoiding these foods and drinks may help you lower your risk.

Discuss your risk factors with your doctor. You can use the CDC’s assessment tools to calculate your breast cancer risk.

What are the different types of Breast Cancer Screening?

Women are very well aware of the importance of breast cancer screening. They know that regular screening can help detect the disease early, and that it is a lifesaving treatment. There are many different types of breast cancer screening tests available. Knowing which one is right for you can make a big difference in whether or not you get diagnosed with breast cancer.

Changes in your breast tissue, including early signs of possible cancer, can be detected by healthcare professionals with a variety of different tests as:

Mammogram

Mammography is the study of breast using x-rays. A mammogram is an x-ray of the breast, which shows the fatty, fibrous, and glandular tissues. Screening mammograms are routinely administered (in annual health checkups) to detect breast cancer in women who have no apparent symptoms.

Doctors use a mammogram to look for early signs of breast cancer.

Women may hate mammograms for obvious reasons, but mammograms increase a woman’s chances of detecting breast cancer at an early stage.

Early detection of breast cancer is more likely curable. The American Cancer Society recommends an annual screening mammogram for every woman 40 years or older.

The risk of radiation from a mammogram is minimal,1 compared to its benefit of saving lives. It is important to realize that our body is exposed to natural radiation every day. Radiation from a mammography is almost equivalent to seven weeks of radiation from natural sources which is minimal compared with radiation from a CT chest scan which is equivalent to two years of natural radiation, and a PET-CT scan radiation which is equivalent to 8 years of radiation from natural sources. Hence, radiation from mammogram (equivalent to 7 weeks of natural radiation) is minimal.

Radiologists may perform additional studies such as an ultrasound of the breast,3 computed tomography (CT) scan,4 positron emission tomography (PET5) scan, or an magnetic resonance imaging (MRI) 6 to further evaluate a tumor, as these devices produce images with higher levels of resolution.

Sonogram

Ultrasonography plays an important role in the evaluation of breast cancer. Sonogram formed from ultrasound imaging is safe, and there is no risk of radiation since it does not use x-ray technology. Ultrasound could be the “first” diagnostic imaging method for young women with dense breast tissues, because mammograms of dense breast tissues are harder to interpret.

A sonogram may be done to look at the size, location, and structure of breast tissues, distinguish fluid-filled cysts from solid tumors, guide the doctor during a needle aspiration or biopsy, assess the stage (how deeply a tumor has penetrated the wall of an organ), and detect abnormal blood flows through vessels (Doppler ultrasound), because blood flow is different in tumors than in normal tissues.

Breast Biopsies

Radiology tests are good at finding abnormal sites (abnormality in appearance, size, and location of the suspicious area) within the body; however, it is difficult to establish malignancy, just based on how it looks. A biopsy of the abnormal tissues is the only diagnostic procedure that can definitely determine if the suspicious area is cancerous or not.

A breast biopsy is a procedure to remove tissue or sometimes fluid from the abnormal areas observed in sonograms/mammograms. The removed tissue/cells are examined under a microscope to diagnose breast cancer. A breast biopsy, if done under the guidance of a medical device (e.g., ultrasound) to detect the abnormal site, is called a guided biopsy.

Breast biopsy can be classified under five types:

  1. Fine needle aspiration (FNA)
  2. Core needle biopsy (CNB)
  3. Surgical biopsy (SB)
  4. Sentinel lymph node biopsy (SLNB)

Hormone Receptor Tests (ER, PR)

Hormone receptor testing is generally recommended for those diagnosed with invasive breast cancer. Hormone receptor tests will determine whether the breast cancer is receptive to hormones or not.

Hormone receptors are specialized proteins located on the cell surface. Many breast cancer tumors are likely to contain a large number of hormone receptors for estrogen and progesterone hormones.

The hormone receptors get attached (bound) to the hormones and signal the cells to start growing and multiplying. If cancer cells start getting such signals, the hormone receptors will promote the growth of more and more cancer cells. Hence, it is necessary for oncologists to block the hormone receptors from getting attached to the hormones (estrogen and progesterone) to prevent cancer growth.

Hormone therapy would respond well to breast cancers, which are positive for estrogen and/or progesterone. Knowing whether the cancer cells have hormone receptors is therefore valuable to decide the treatment plan.

Stages of Breast Cancer

Cancer staging is the process to determine how much cancer is in the body, where it is located, and how much it has spread. The most common and useful staging system for most types of cancers is the  TNM13 system suggested by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC).

Cancer staging helps the team of oncologists to design an appropriate line of treatment, based on the severity of cancer and its spread.

Stages of Breast Cancer with Indications are explain below:

Stage 0:

Abnormal cells are still contained in the duct where they initially appeared.

Stage I:

The tumor is less than 2 cm in diameter and small clusters of cancer cells may be found in the lymph nodes.

Stage II:

The tumor is smaller than 2 cm in diameter and has spread to the lymph nodes in the armpit

OR

The tumor is between 2 and 5 cm in diameter but has not spread to the lymph nodes in the armpit

Note: Stage II breast cancer is further classified as Stage II A and II B

Stage III:

The tumor maybe of any size, but

  • has spread either to the chest wall and/or the skin of the breast
  • has spread to at least 10 lymph nodes in the armpit, or the lymph nodes in the armpit are attached to each other or to other structures
  • has spread to lymph nodes near the sternum (breastbone)
  • has spread to lymph nodes below or above the clavicle (collarbone)

Note: Stage III breast cancer is further classified as Stage III A. III B, and III C

Stage IV:

Cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. Such distant tumor deposits are called metastases.

What should you expect during a mammogram screening exam?

When you’re expecting to undergo a mammogram, it can be quite scary! There are many things that can go wrong during the process, including pain, fear of the results, and the stress of waiting for the results. In addition to these negative emotions, there are also positive emotions that come with the results.

There are tips to help you prepare for the mammogram:

  • Breast usually less tender after your menstrual period. It would be better, if you plan to schedule your mammogram after one week of menstrual period.
  • It is highly recommended to schedule appointment for X-ray of breast. It is also important to note that, X-ray of breast may look distorted or find problems due to compromise results, if you use deodorant, any kind of lotion or ointment around your breast. So, avoid to use such items when you schedule appointment for X-ray.
  • While mammogram, you would be given a gown to wear, so you should wear two piece outfit because you have to remove your top.
  • X-Ray Testing lab will send final report to your doctor. So, make sure, bring your personal documents with doctor’s number that recommend you for mammogram.

It is quite possible that the procedure of screening exam of breast can be different but in general scenario, you will be provided a gown that can be easily open in the front. Technician will place your breast in the middle of X-ray machine plates to capture images. Make sure, you should not use any deodorant or lotion use on your breast.

Technician will take images of your breast from all angles that can be uncomfortable or little bit painful. The whole mammogram process normally completes in 20-25 minutes. Testing facility provider will send your reports to your doctor. After few days, doctor will discuss about your reports. If you do not receive any call from your doctor within a week to discuss your X-Ray reports, you should ask him about your reports.

What will happen if Mammogram results are not satisfactory?

Mammography is done by the radiologist who will detect and diagnose any abnormalities in your breast tissue. After doing mammography, the radiologist will look at the image to see the condition of your breasts. If the image shows a suspicious spot, he/she will refer you to the surgeon to check the problem.

After reviewing the image, the surgeon will remove any abnormal tissue in your breast. During the surgery, your physician will perform a biopsy which can check the tissue for cancer. The tissue will be sent to the laboratory for further testing. In order to diagnose whether there is cancer in the breast tissue, pathologists will examine the tissue under microscope to see any changes in cells.

After performing the biopsy, your physician will evaluate your health and will determine whether you should have a further test to confirm the diagnosis of cancer. Your physician may recommend a second round of mammogram in the future.

It is important to note that after you undergo mammography, it can increase your risk of developing cancer in other areas of your body such as lung.

Risks associated with Breast Cancer Screening

Breast cancer screening is a very personal decision, and it can be a difficult one to make. While mammograms and MRIs have proven effective at detecting breast cancers, they also carry a few risks. The most common side effects of breast cancer screenings are anxiety and a false positive, which means that the test was inaccurate and led to a false alarm. While the benefits of breast cancer screenings outweigh the risks, it is still important to weigh the risks and benefits carefully.

There are a number of risks associated with breast cancer screening. These risks are associated with the specific type of test you’re getting (such as mammography or a clinical breast exam), the amount of radiation exposure, and the type of treatment you may be required to undergo.

Radiation-Related Cancer Risks

Radiation exposure can lead to cancer in several ways. When X-rays travel through the body, they pass through the cell walls, and this causes ionization, which can damage the DNA in the cells. If this happens, it can cause a mutation in the genes, and it can also cause a chemical change in the cells. This is known as oxidative stress, and it can cause mutations that lead to cancer. After gene mutation, cancer specialists can further recommend genetic testing for breast cancer.

In a study that analyzed breast cancer incidence in 100,000 people between the ages of 50 and 74, it was found that mammography could have played a role in the development of breast cancer.

Another way that radiation can increase your risk of cancer is by damaging healthy tissues that surround the area being irradiated. This is called secondary injury, and it can also cause mutations. If you are getting a mammogram, this will not happen, but it can still happen during a CT scan.

Other Health Risks of breast cancer screening

Some other risks of breast cancer screening are:

  • False positives: The main problem with breast cancer screenings is false positives. These are tests that give you a positive result when you have no cancer. This means that you need to have a biopsy to determine if you actually have breast cancer. False positive result can also be a cause of anxiety.
  • Over-diagnosis of breast tumors: The second problem with breast cancer screenings is that they can cause over-diagnosis of breast tumors. Over-diagnosis means that you’ve been given a diagnosis of breast cancer when you don’t actually have it. This can lead to unnecessary treatment and surgeries.
  • Unnecessary biopsies of breast tissue: The third problem with breast cancer screenings is that they can lead to unnecessary biopsies of breast tissue. Biopsies are procedures in which doctors remove tissue from your breast. You may be asked to undergo a biopsy even if you have a negative screening test result.
    Conclusion

The fact that there are many different types of breast cancers means that there isn’t a single perfect screening method. Therefore, it’s important for women to speak to their doctor about which screening method will work best for them. Your doctor may recommend that you undergo a mammogram, a clinical breast exam, or both. Your doctor may suggest that you have another mammogram after you turn 40 years old. In some cases, you may need a more sophisticated screening test such as a digital mammogram.

Your doctor will take a medical history, perform a physical examination, and order the appropriate tests that are needed to determine whether or not you have breast cancer. A blood test, a bone scan, an MRI, or other imaging studies may be ordered. Based on these results, your doctor may then give you a recommendation regarding whether or not you should get a mammogram, what age you should start having regular mammograms, and when your next mammogram should be done.

 

Resources:

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  • Breast cancer screening. (2016).
    uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
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    Ngan TT, et al. (2020). Effectiveness of clinical breast examination as a ‘stand-alone’ screening modality: An overview of systematic reviews.
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  • What is a mammogram?
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