For primary care

1. EARLY DETECTION AND ITS
IMPLICATIONS ON TREATMENT
DR. JUSTINE NGWANDA
G.S RESIDENT

2.  Breast cancer (BC) is a cancerous growth arising
in the lining cells of the ducts or lobules in the
glandular tissue of the breast.
 BC is a multifactorial disease, and various
factors such as ageing, premature puberty, late
menopause, first pregnancy after the age of 30,
infertility, no breastfeeding, genetic factors,
chest radiography, birth control pills,
socioeconomic status, smoking and alcohol
consumption, inadequate physical activity,
unhealthy diet, over- weight and obesity, dense
breast tissue, and a history of other cancers
(especially ovarian and endometrial cancers)
play a role in the progress of it.

3. Increased risk of breast cancer with family history
is known
 20% and 25% of women diagnosed with breast
cancer have a positive family history
 The actual risk that family history conveys
depends on
 The number of relatives affected
 Their age at diagnosis
 Having a first degree relative with premenopausal
breast cancer greater risk >>>>>> a first-degree
relative with postmenopausal cancer

4.  One first-degree relatives with CA Breast
(mother or sister), the risk is 1.7 to 2.5
 Two or more first degree relatives (RR= 4-6
times)
 Second-degree relative with CA Breast (aunt,
grandmother), the risk is 1.5

5.  Women at higher risk of developing breast
cancer
 Those with a personal history of breast cancer
 Therapeutic radiation to the breast area
 Women with a family history of a first degree
relative with breast cancer at a young age
 Women with a biopsy diagnosis of cis or atypical
ductal hyperplasia.

6. “Detecting breast cancer
early improves survival,
lowers morbidity and
reduces the cost of care”

7.  Early detection Programs
Timely diagnosis for all women found to have abnormal findings and prompt stage-
appropriate treatment for all women proven by tissue diagnosis to have breast cancer
 Breast health awareness education
Breast health awareness includes public health and professional medical education on
the risk factors and symptoms of breast cancer and the importance of seeking medical
evaluation for breast concerns
 Clinical breast examination
CBE can be performed by trained non-physician providers in low resource settings
 Interventions across the continuum of care
according to resource level
Mammographic screening has been shown to reduce breast cancer mortality in high-
resource settings but CBE alone may be an acceptable screening method when
mammographic screening is unavailable, unaffordable or unrealistic.

8.  Mrs. X is a 46-year-old woman who presents to
hospital for enquiry about breast cancer.
 She informs that her 51-year-old friend was
diagnosed with breast cancer one month ago and
that she is worried about getting breast cancer.
 On further inquiry, she gives history that she
delivered her only child when she was 32 years
of age and has no family history for breast
cancer.
 She does not perform breast self-examinations
and has never had a mammogram. Mrs. X asks
advice on breast cancer screening.

9.  The efforts to improve early diagnosis of
breast cancer in a setting without
population-based screening depends on
women being aware of breast cancer signs
and symptoms, risks, and ultimately seeking
care for breast concerns.
 Most women would seek care if they noticed
a change in their breasts, but the low levels
of cancer knowledge, symptoms, and
common risk factors highlight the need for
targeted community education and
awareness campaigns.

10.  In Tanzania, national screening programs are not
properly established; clinicians and women still rely
on breast examination for early detection of Breast
cancer.
 Although the gold standard for early detection
programs in high-resource settings is mammographic
screening, clinical breast exam (CBE) in low-resource
settings has been used and is a necessary tool in any
breast health program for frontline evaluation of
patients with breast symptoms.
 Breast self-examination is vital in detecting
abnormalities in the breast.
 Breast self-examination provides opportunities for
females to be conversant with their breast, thereby
reporting any changes.

11.  Early diagnosis of symptomatic women relies on
breast cancer awareness by patients, their
community and frontline health professionals.
 Health systems require trained frontline
personnel competent in CBE and breast health
counseling to coordinate care through a referral
network for timely breast cancer diagnosis and
treatment.
 Early detection screening programs can be
opportunistic (i.e., initiated during routine
patient visit) or organized (i.e., initiated by
invitation sent to a targeted at risk patient
population.

12.  Self breast examination
 Clinical breast examination
 Clinical breast exam (CBE) performed by a
trained healthcare provider involves a
physical examination of the breasts and
underarm.
 CBE is a basic element of breast health care
and should be offered to any woman with a
breast finding that she identifies as abnormal
for her.

13. A clinical
breast exam is
performed by
a healthcare
professional to
detect any
abnormalities
and warning
signs
Breast self
exam is
something every
woman should
do once a month
at home

14.  Stand before a mirror and look at
both breasts.
 Check for anything unusual, such
as nipple retraction, redness,
puckering, dimpling or scaling of
the skin.
 Look for nipple discharge.

15.  Next, press hands firmly on
hips and lean slightly toward
mirror as you pull your
shoulders and elbows forward
with a squeezing or hugging
motion.
 Look for any change in the
normal shape of your breasts.

16.  Looking in the mirror, raise
arms and rest hands behind
head.
 This allows to see the
underside of the breasts

17.  Place left hand on waist,
roll shoulder forward and
reach into underarm area
and check for enlarged
lymph nodes
 Also check the area above
and below clavicle
 To be done on both sides

18.  Raise left arm.
 Use the pads of three or four fingers of right
hand to examine left breast.
 Use three levels of pressure (light, medium
and firm) while moving in a circular motion.
 Beginning at the outer edge of breast, use
flat part of fingers, moving in circles slowly
around the breast.
 Gradually make smaller and smaller circles
toward the nipple.
 Check behind the nipple as well

19. Lie flat on back with left arm over head and a
pillow or folded towel under left shoulder

22.  Breast health awareness programs
Breast cancer early detection: The goal of breast health awareness is to
educate women about the importance of diagnosing cancer at early stages when
treatment is easier and outcome is better. Advanced cancers demand more extensive
therapies and are more likely to spread (metastasize) to other organs at which point
they no longer can be cured.
Educational targets: 1) heightened cancer awareness in the community, 2)
increased breast evaluation training for frontline clinical staff, and 3) improved access
for breast cancer testing and treatment, which together can reduce mortality.
Cultural context: Breast cancer advocates, including but not limited to breast
cancer survivors, can play an important role in breast cancer awareness programs.
Efforts to increase general public awareness and openness, and reduce stigma about
breast cancer can result in more women who have breast cancer symptoms or breast
concerns seeking expeditious and reliable care.

23.  Breast health awareness and self-detection
-Most breast tumors are discovered by women themselves, although not necessarily
through formal breast self-examination. The critical component of breast health
awareness is “knowing your normal”. Health professionals should be prepared to
educate women about the risk factors and signs and symptoms of breast cancer as part
of breast health awareness.
 CBE as a diagnostic tool
Cultural context: A culturally sensitive approach to breast exams and breast
health counseling can reduce a woman’s discomfort and anxiety during a breast health
visit, and allow her to make informed decisions about her preferred breast health care.
Effectiveness of CBE: Studies on the effectiveness of CBE report a wide range
of data and suggest that CBE can find masses not reported by women (asymptomatic
cancers), but may also miss small tumors detectable by imaging modalities
Certain groups of women, such as obese women or younger women with more nodular
breast tissue, may receive less benefit from CBE.

24. A. Public awareness: Public awareness and
education campaigns may contribute
toward reducing stigma, myths and
misconceptions about breast cancer
detection and treatment.
B. Collaborative efforts: Determining the most
appropriate early detection method
requires joint efforts by hospital systems,
regional centers and ministries of health.
Other stakeholders including patients,
survivors, advocates, community leaders
and academic and financial institutions
should also be engaged in this process.

25. C. Optimizing primary care visits: Programs that
improve access to primary care providers and
expand referral networks can improve early breast
cancer detection, assuming that primary care
providers are educated in early detection
techniques such as CBE and are able to provide
access to breast diagnostic services for patients
with abnormal breast findings.
D. Optimizing referral services: Improving referral
networks, communication between providers and
timely access to care is essential to optimizing
early detection efforts.

26. E. Mixed methods for early detection: Mixed
screening strategies may be appropriate based on differences
in local availability of resources and expertise. For example,
a rural setting may be able to implement breast health
awareness programs, tissue biopsy followed by mastectomy
for definitive surgical treatment.
F. Data collection: Health professionals and health
ministers must work together to support the collection and
consolidation of data and tracking of indicators based on
national standards and goals.
G. Resource-stratified care pathways: Using a
resource-stratified pathway allows programs to begin with
breast cancer awareness, and diagnostic CBE, and move
along the pathway toward organized mammography screening
as more resources become available.

27.  Modify previous mentioned risk factors like:
 Reducing or eliminating alcohol consumption
 Maintaining ideal weight
 Exercising on a regular schedule
 Several drugs have been studied as chemo-
preventive agents.
 But the only agent for which mature data
from clinical trials are available is tamoxifen

28.  The results of the NSABP P-1 trial indicated that
tamoxifen reduced the rates of invasive and noninvasive
breast cancer by 49% and 50%, respectively in high risk
women
 Women with a history of atypical ductal hyperplasia had
an 86% risk reduction, and women with a history of LCIS
had a 56% risk reduction.
 Tamoxifen increased the risk of developing stage I
endometrial cancer (RR-2.53)
 Aromatase inhibitors are being tested (Letrozole,
Anastrazole and Exemestane)

29.  Bilateral total mastectomy or bilateral
salpingoophrectomy may be beneficial in
selective high risk groups.
 According to series done by several studies,
bilateral prophylactic mastectomy
there is 89.5% risk reduction in
breast carcinoma (p<0.001).

30.  Mrs. X is a 46-year-old woman who presents to
hospital for enquiry about breast cancer.
 She informs that her 51-year-old friend was
diagnosed with breast cancer one month ago and
that she is worried about getting breast cancer.
 On further inquiry, she gives history that she
delivered her only child when she was 32 years
of age and has no family history for breast
cancer.
 She does not perform breast self-examinations
and has never had a mammogram. Mrs. X asks
advice on breast cancer screening.

31.  Discuss the harms and benefits of screening,
and offer screening because she is older than
age 40.
 Mammography with clinical breast
examination every year.
 In general, the benefits of screening for
breast cancer increase as a woman becomes
older.

32.  Breast cancer awareness is a key component
of early detection efforts.
 It is essential that women know the most
common symptoms associated with breast
cancer, such as lumps and thickenings, and
understand that prompt evaluation and early
detection improves outcome.
 At a minimum, healthy systems should be
prepared to evaluate women who present
with breast complaints, and refer them for
timely diagnosis and treatment.

33.  Health professionals need to be trained in
clinical breast exams (CBE) and breast health
counseling, including culturally sensitive
patient-clinician communication strategies.
 Early detection screening methods should
realistically match available resources
(human resources, equipment, facilities) and
community support and access to care.
 Successful implementation of early detection
program, cognizant of local barriers, can
result in down-staging of breast cancer and
improved overall health outcomes