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Breast Cancer
Screening
Introduction
• Breast cancer is a fatal disease at advanced
stages; however, it can be controlled through
prevention and early detection.
• Breast cancer strikes women at all ages; indeed,
its incidence seems to drastically increase at the
age of forty.
Global Perspective
• Globally, breast cancer is the most frequently diagnosed
cancer in women, it is also the leading cause of cancer
death among women worldwide (ACS, 2011;
International Agency for Research on Cancer (IARC),
2008).
• About half of the new cases were expected to occur in
developing countries . Rates were high in North
America, Australia and Northern and Western Europe.
However, low rates were observed in large parts of
Africa and Asia (ACS, 2011).
• Breast cancer is the second leading cause of cancer death in
women, exceeded only by lung cancer.
• The chance that breast cancer will be responsible for a
woman's death is about 1 in 36 (about 3%).
• Death rates from breast cancer have been declining since
about 1989, with larger decreases in women younger than
50.
• These decreases are believed to be the result of earlier
detection through screening and increased awareness, as
well as improved treatment.
Breast Cancer In USA
• Breast cancer is the most common cancer among American
women, except for skin cancers.
• About 1 in 8 (12%) women in the US will develop invasive
breast cancer during their lifetime.
• About 40,000 women die from breast cancer
• After increasing for more than 2 decades, female breast
cancer incidence rates began decreasing in 2000, then
dropped by about 7% from 2002 to 2003.
Breast Cancer In Jordan
In Jordan, cancer is the second leading cause of
death, preceded only by cardiovascular diseases.
It is reported that the first cause of death in
Jordan is cardiovascular diseases representing
(35.9%) of all deaths in Jordan, followed by
Neoplasms which constitute (14.6%) (Ministry of
Health, 2012).
In the year 2009 the number of deaths due
to neoplasm was 2164 (14.6%), in males 1237
(14.4%) and in females 927 (14.9%) with male to
female ratio of 1.3:1; among females, breast
cancer has the highest mortality rate when
compared to other types of cancer (MOH, 2012).
In 2009 breast cancer was ranked the first
of all cancer types accounting for 19.6 % of all
new cancer cases (MOH, 2012). Furthermore, it
was ranked the first among cancer affecting
women accounting for 36.8 %, of the diagnosed
women, less than one third (3% and 26%) were
diagnosed at a stage of zero and one respectively
(MOH, 2012).
Can breast cancer be
prevented?
• Lowering your risk by changing those risk factors that can be
changed:
• Body weight, physical activity, and diet have all been linked to breast
cancer, so these might be areas where you can take action.
• Both increased body weight and weight gain as an adult are linked
with a higher risk of breast cancer after menopause. Alcohol also
increases risk of breast cancer. Even low levels of alcohol intake have
been linked with an increase in risk.
• Many studies have shown that moderate to vigorous physical
activity is linked with lower breast cancer risk.
• A diet that is rich in vegetables, fruit, poultry, fish, and low-fat dairy
products has also been linked with a lower risk of breast cancer in
some studies. But it is not clear if specific vegetables, fruits, or other
foods can lower risk.
• Most studies have not found that lowering fat intake has much of an
effect on breast cancer risk.
At this time, the best advice about diet and
activity to possibly reduce the risk of breast
cancer is to:
Get regular, intentional physical activity.
Reduce your lifetime weight gain by limiting your calories and
getting regular physical activity.
Avoid or limit your alcohol intake.
Women who choose to breastfeed for at least several months may
also get an added benefit of reducing their breast cancer risk.
Not using hormone therapy after menopause can help you avoid
raising your risk.
It’s not clear at this time if environmental chemicals that have
estrogen-like properties (like those found in some plastic bottles or
certain cosmetics and personal care products) increase breast
cancer risk. If there is an increased risk, it is likely to be very small.
Still, women who are concerned may choose to avoid products that
contain these substances when possible.
For women who are or may be at
increased risk
• If you are a woman at increased risk for breast cancer (for
example, because you have a strong family history of breast
cancer, a known genetic mutation of a BRCA gene, or you have
had DCIS, LCIS, or biopsies that have shown pre-cancerous
changes), there may be some things you can do to reduce
your chances of developing breast cancer.
• Before deciding which, if any, of these may be right for you,
talk with your doctor to understand your risk and how much
any of these approaches might lower this risk.
• Genetic testing for BRCA gene mutations
• Breast cancer chemoprevention
• Preventive surgery for women with very high breast cancer
risk
• For the few women who have a very high risk for breast
cancer, surgery to remove the breasts or ovaries may be an
option.
Preventive (prophylactic) mastectomy
Prophylactic oophorectomy (ovary removal)
Can breast cancer be found
early?
Breast Cancer Screening
Guidelines
Recent breast cancer screening recommendations are
emphasizing mammography (every one to two years) as the most
effective modality for early detection of the disease among women at
average risk (ACS, 2013; Jordan Breast Cancer Program (JBCP), 2011; US
Preventive Services Task Force (USPSTF), 2009).
American Cancer Society Guidelines
Women age 40 and older should have a screening
mammogram every year and should continue to do
so for as long as they are in good health.
• Current evidence supporting mammograms is even
stronger than in the past. In particular, recent evidence
has confirmed that mammograms offer substantial
benefit for women in their 40s. Women can feel
confident about the benefits associated with regular
mammograms for finding cancer early.
• However, mammograms also have limitations. A
mammogram will miss some cancers, and it sometimes
leads to follow up of findings that are not cancer,
including biopsies.
• Women should be told about the benefits, limitations,
and potential harms linked with regular screening.
• Mammograms can miss some cancers. But despite their
limitations, they remain a very effective and valuable tool for
decreasing suffering and death from breast cancer.
• Mammograms for older women should be based on the
individual, her health, and other serious illnesses, such as
congestive heart failure, end-stage renal disease, chronic
obstructive pulmonary disease, and moderate-to-severe
dementia.
• Age alone should not be the reason to stop having regular
mammograms. As long as a woman is in good health and
would be a candidate for treatment, she should continue to be
screened with a mammogram.
Clinical Breast Exam
• Women in their 20s and 30s should have a clinical breast exam
(CBE) as part of a periodic (regular) health exam by a health
professional, at least every 3 years.
• After age 40, women should have a breast exam by a health
professional every year.
• CBE is a complement to mammograms and an opportunity for
women and their doctor or nurse to discuss changes in their breasts,
early detection testing, and factors in the woman's history that
might make her more likely to have breast cancer.
• There may be some benefit in having the CBE shortly before the
mammogram.
• The exam should include instruction for the purpose of getting more
familiar with your own breasts.
• Women should also be given information about the benefits and
• limitations of CBE and breast self-exam (BSE).
• Breast cancer risk is very low for women in their 20s and gradually
increases with age.
• Women should be told to promptly report any new breast symptoms
to a health professional.
Breast Self-Exam
• Breast self-exam (BSE) is an option for women starting in their
20s.
• Women should be told about the benefits and limitations of
BSE.
• Women should report any breast changes to their health
professional right away.
• Research has shown that BSE plays a small role in finding
breast cancer compared with finding a breast lump by chance
or simply being aware of what is normal for each woman.
• Women who choose to do BSE should have their BSE
technique reviewed during their physical exam by a health
professional.
Women at high risk for breast cancer based on
certain factors should get an MRI and a
mammogram every year.
• This includes women who:
Have a lifetime risk of breast cancer of about 20% to 25% or
greater, according to risk assessment tools that are based
mainly on family history
Have a known BRCA1 or BRCA2 gene mutation
Have a first-degree relative (parent, brother, sister, or child)
with a BRCA1 or BRCA2 gene mutation, but have not had
genetic testing themselves
Had radiation therapy to the chest when they were between
the ages of 10 and 30 years
Have Li-Fraumeni syndrome, Cowden syndrome, or BannayanRiley-Ruvalcaba syndrome, or have first-degree relatives with
one of these syndromes
• The American Cancer Society recommends against MRI
screening for women whose lifetime risk of breast cancer is
less than 15%.
• There is not enough evidence to make a recommendation for
or against yearly MRI screening for women who have a
moderately increased risk of breast cancer (a lifetime risk of
15% to 20% according to risk assessment tools that are based
mainly on family history) or who may be at increased risk of
breast cancer based on certain factors, such as:
Having a personal history of breast cancer, ductal carcinoma
in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal
hyperplasia (ADH), or atypical lobular hyperplasia (ALH).
Having dense breasts (“extremely” or “heterogeneously”
dense) as seen on a mammogram
• If MRI is used, it should be in addition to, not instead of, a
screening mammogram.
• This is because while an MRI is a more sensitive test (it's more
likely to detect cancer than a mammogram), it may still miss
some cancers that a mammogram would detect.
• For most women at high risk, screening with MRI and
mammograms should begin at age 30 years and continue for
as long as a woman is in good health.
• But because the evidence is limited about the best age at
which to start screening, this decision should be based on
shared decision making between patients and their health
care providers, taking into account personal circumstances
and preferences.
• Several risk assessment tools, with names like the Gail model,
the Claus model, and the Tyrer-Cuzick model, are available to
help health professionals estimate a woman's breast cancer
risk.
National Guidelines
National efforts to promote universal screening for
Jordanian women are led by the JBCP; recommendations for
early detection of breast cancer in Jordan are consistent with the
international ones (ACS, 2013; USPSTF, 2009).
The JBCP recommends mammography every one to two
years for women at an average risk between 40 and 52 year-old,
and every two years for those who are 52-year old and above.
Clinical Breast Exam (CBE) is recommended for women at an
average risk between the ages 20-40 every 1-3 years, whereas
women at an average risk at the age of 40 and above should have
it yearly. Moreover, BSE is recommended to be performed every
month starting at the age of twenty (JBCP, 2012).
References
• http://www.cancer.org/acs/groups/cid/documents/webconte
nt/003090-pdf.pdf