Welcome back to the Surgery with Soul newsletter! We hope that this little monthly note from us to you are benefiting patients and health care practitioners alike. I also hope that we provide not only valuable information but a spark of inspiration! If you find this newsletter useful, please feel free to share it with patients, family or friends.
This month we take a brief look at a topic wrought with controversy and confusion – breast cancer screening. Breast cancer is one of the most published topics – in both academic and popular literature. Patients and clinicians are bombarded with exponentially increasing information around the disease and in the era where conspiracy theories abound, much suspicion exists about existing protocols. The use of mammography and other screening modalities are often central to this debate. While I will make sure that we look in depth at the evidence for (or the lack thereof ) of alternative emerging imaging modalities, our focus today will be on summarizing and making sense of existing guidelines. Although the academic debate surrounding screening has not progressed much until recently, public awareness of this issue has shifted dramatically. The vast press coverage of the Canadian National Breast Cancer Screening Study (CNBCSS) in 2014 suddenly brought the potential harms of screening into the public spotlight. The 25-year analysis of the CNBCSS showed (at both 10 and 15 years) that annual screening failed to reduce breast cancer mortality. It also provided the first-ever estimates of over diagnosis in a population-based annual screening program bringing which brought up the question – how often is too often and has in fact lead to many international policy changes moving away from blind annual screening.
Our approach to this hard nut to crack:
- Some general thoughts to keep in mind while you interpret the guidelines
- Risk assessment strategies
- A brief summery of the different modalities available and when they are applicable
- Bringing mindfulness to this conversation
- Awesome links to other resources you can explore
- Some general thoughts about the South African context to keep in mind when you interpret the guidelines
- South Africa does not currently have a national radiological screening policy for breast cancer. This means that screening is often done on the basis of medical aid or clinician recommendations. These are in turn based on international policies – the US policy being the most commonly cited. What to make of the fact that we don’t have a screening policy? That is a loaded question and will be answered differently by different experts. Also keep in mind that there is a difference between a guideline and policy (a policy can be enforced). The truth is that there really is arguments to made both ways. My opinion: having a national policy may help to standardize care and improve access to the health care system. This, however, should be based on our unique population and resources available and should not be used as an excuse to get in the way of individualized care and risk profiling. The focus should rather be on risk stratification with individualized screening strategies.
- We did, however, make huge strides over the last few years and a National Breast Cancer Policy has recently been approved – largely thanks to the united voices of cancer advocates and clinicians (do yourself a favour and take a look at the work of the Cancer Alliance). What does this policy say about screening? While it does not include a radiological screening policy, it does provide some screening guidelines that can be summarized:
- Women over 40 years attending a Primary Health Clinic/GP must have a clinical breast examination (Provider/physician Initiated Screening Clinical Breast Exams or “PISCBE”) biannually.
- All women attending Primary Health Clinics/GP’s should be given opportunistic breast education, taught breast self-examination or referred appropriately for this to be done
- Awareness messages should be disseminated for communities and health care workers that any woman who notices a change in her breast(s) should seek medical attention.
- All eligible women should have their risk of breast cancer determined and be managed according to protocol.
- Women at high risk of developing breast cancer should be considered for annual breast MRI in addition to mammography and clinical breast examination
- These are general guidelines and may leave a lot of room for interpretation. Although it may seem vague at first, it is in fact in line with where the future of cancer medicine lies: individualized management.
- The most commonly quoted guidelines are from the USA (medical aids often base their benefits on these):
|Country and organization
||Start screening at age, y
||Terminate screening at age, y
||Frequency of assessment
|United States Preventive Services Task Force (USPSTF) (7)
||Every 2 y (for women at average risk of breast cancer)
||Screening for women age 40–49 y is a grade C recommendation (“offer or provide this service for selected patients depending on individual circumstances”)
|American Cancer Society (ACS) (4)
||As appropriate based on life expectancy
||Annually then biennially at age 55 y and older
||Suggest continued screening as long as good health and life expectancy exceeding 10 y
|American College of Obstetricians and Gynecologists (ACOG) (3)
||As appropriate based on life expectancy
||Suggest discussing cessation of screening with physician starting at age 75 y
|American College of Radiology (ACR)/Society of Breast Imaging (SBI) (2)
||As appropriate based on life expectancy
||Suggest continued screening as long as life expectancy exceeds 5–7 y
2. Risk Assessment strategies and tools
- These tools have really helped us come a long way towards more individualized patient care
- On the forefront of providing the evidence for risk based rather than general screening guidelines is the ongoing WISDOM study (Women Informed to Screen Depending On Measures of risk). This is a multi center trial currently recruiting 100 000 patients for the study.
- What we want is better and more appropriate screening , not more screening
- The two most commonly used are the IBIS and BOADICEA online risk calculators – I also use these in my practice
- In essence it is algorithms based on known risk factors that calculates a patient’s current and lifetime risk for developing breast cancer
- Risk stratifying patients can greatly aid in planning their own personalized screening and also aid in deciding which modality to use ( e.g your very high risk patients should strongly consider MRI)
- Here is a link to another great article published on risk-based screening published in 2016.
- However – patients with low risk can still develop breast cancer! Never ignore any changes or new breast symptoms!
3. A brief summary of the different screening modalities and when they are applicable
3.1 Clinical breast examination (CBE)
- Refers to a breast examination performed by a
trained healthcare worker.
- CBE is relatively simple and inexpensive, but its efficacy in reducing mortality from breast cancer has not been directly tested in a randomised controlled trial.
- CBE has reported sensitivity of 40 to 69 per cent and specificity of 88 to
99 per cent in the literature.
- The usefulness of a proper clinical exam by an experienced clinician should not be underestimated.
3.2 Breast self-examination (BSE)
- Refers to an examination done by the patient self
- Systematic BSE has been recommended for over 70 years, despite lack of
compelling evidence of its efficacy in reducing deaths from breast cancer.
- It should be done at the same time and in the same manner every month – preferably a few days after the last day of menses
- My personal opinion: in patients that are AWARE of their own bodies and that notice changes, this is an excellent habit.
3.3 Digital screening mammography
- The screening modality of choice in woman over 40 with low to intermediate risk
- Note – diagnostic (not screening) mammography can also be used in younger woman depending on their breast density. It may also be used in addition to MRI in the screening of high risk young women.
- MLO and CC views should be obtained
- The addition of tomography greatly improves imaging quality
A brief and easy-read opinion piece I can recommend: Recent Controversies in Mammography Screening for Breast Cancer
3.4 Breast ultrasound
- Not a screening tool per se but often used as an important addition to mammography especially in dense breasts or to further evaluate an abnormality found
- Can be used as an alternative where mammography is not possible but does have limitations
Based on evidence from nonrandomized trials and observational studies, several expert groups recommend annual breast MRI screening along with mammography in patients with the following risk factors:
- BRCA mutation
- First-degree relative of BRCA carrier but untested
- Lifetime risk approximately 20-25% or greater, as defined by risk models
- Having received radiation to chest when aged 10-30 years
- Li-Fraumeni syndrome and first-degree relatives
- Cowden and Bannayan-Riley-Ruvalcaba syndrome
Bringing mindfulness to the conversation:
We all can do with a little added awareness. Many of us tend to live inside our heads, completely unaware of our own bodies. When it comes to early disease recognition, much can be said for our own innate awareness and intuition – if we cultivate it and pay close attention to it.
Make time to do a simple breath awareness exercise to get back in your body:
- Pick 10 minutes of quiet time and make sure you won’t be disturbed
- Sit comfortably – on a chair, on the grass or on the floor
- Close your eyes
- Deeply inhale and exhale
- Focus on your breath and feel your body rise and fall with each breath
- Try to quiet your thoughts and focus only on breathing in and out
- Do this for a few minutes and then draw your attention to your body sitting
- Feel the surface your sitting on, try to become aware of the palms of your hands and the soles of your feet. Breath into this space
- Slowly open your eyes
And that is a wrap on a quick look at breast cancer screening! I hope that you find the information practical and useful – please feel free to share this and comment below.