1. BSE and Mammography
Dr Sujata Mittal
Sr. Consultant – Gynec. Oncology
PARAS HOSPITALS, GURGAON
2. Foundational Science – Breast Anatomy
UOQ contains a greater volume of tissue than any other quadrant
3. Incidence of Breast Cancer in India (ICMR)
Number(#), Relative Proportion(%) & Rank(R) of leading sites of cancer
4. • Identify those who are going
to develop/early breast
cancer
• Low false positive rate
• Low false negative rate
• Inexpensive, reproducible
• RCT should reveal reduction
in mortality
• Available to masses
• Identify those who are going
to develop/early breast
cancer
• Low false positive rate
• Low false negative rate
• Inexpensive, reproducible
• RCT should reveal reduction
in mortality
• Available to masses
4
Cancer Control Screening
•Average Risk
•High Risk
•Average Risk
•High Risk
5. • BSE
• CBE
• Mammography
• MRI
• Tomography
• USG
• Thermal detection Monitors
• Proteomics
• BSE
• CBE
• Mammography
• MRI
• Tomography
• USG
• Thermal detection Monitors
• Proteomics
Modalities Available Controversies
• No SINGLE TEST (Combination)
(Opinion Vary)
• BSE ? BREAST AWARENESS
• MAMMOGRAPHY ? AGE
• No SINGLE TEST (Combination)
(Opinion Vary)
• BSE ? BREAST AWARENESS
• MAMMOGRAPHY ? AGE
Breast Cancer Screening
6. Breast self-exam (BSE) first introduced
American Cancer society (ACS)
initiated campaign Cancer’s Danger
Signals “Look for a lump or
Thickening in the Breast”
First studies evaluating BSE
presented. Women confused about
proper technique and relied on clinical
breast exam
Russian study found BSE did not
decrease Breast Cancer mortality
China study found no decrease of
Breast Cancer deaths after giving
women BSE instructions
Malaysia & other
countries where
Mammography is scarce,
declared women should
conduct monthly BSE
US Preventive Service Task Force
(USPSTF) recommended against
teaching BSE.
ACS recommended against BSE.
Several new studies directly refute the
China & Russia studies:
DUKE
Found 46.6% of the cancers diagnosed
were first found during the BSE &
limitation of Mammography
HARVARD
71% of cancers detected were first
detected by BSE in women under 40
MAYO CLINIC
Found that women under 50 were more
likely to find cancer by BSE than
detected by Mammography
Still mixed messages
Susan G. Komen no longer recommends monthly
BSE, but encourages women to become familiar with
the way their breast normally look and feel
(but, isn’t t hat a breast self-exam?)
7. USPSTF ACS ACOG
Recommends against
clinicians teaching women
how to perform Breast self-
examination
Recommends against
clinicians teaching women
how to perform Breast self
examination
Consider Breast self
examination instruction for
high-risk patients. Breast
self-awareness should be
encouraged and can include
Breast self-examination
Recommendations for Breast Cancer
Screening
8. • Breast Awareness empowers women to fight BC/disease
not in terms of statistics used for mortality but on the
qualitative effects of reductions in morbidity
• BSE in Conjunction with Mammography provide with
added layer of protection
• Breast Awareness empowers women to fight BC/disease
not in terms of statistics used for mortality but on the
qualitative effects of reductions in morbidity
• BSE in Conjunction with Mammography provide with
added layer of protection
Controversy continues
10. WOMEN SHOULD REMAIN INVOLVED IN THEIR
BREAST (HEALTH)
EMPOWERING WOMEN
AS EVERY WOMAN MATTERS / COUNTS
WOMEN SHOULD REMAIN INVOLVED IN THEIR
BREAST (HEALTH)
EMPOWERING WOMEN
AS EVERY WOMAN MATTERS / COUNTS
Message
14. USPTSF
• Biennial screening mammography beginning at age 50.(B Recommend)
• Evidence is insufficient for assessing the additional benefits of screening
mammography in women past age 74
• Biennial screening mammography beginning at age 50.(B Recommend)
• Evidence is insufficient for assessing the additional benefits of screening
mammography in women past age 74
• Annual screening mammography beginning at age 45 with an option to
begin at age 40. Transition to biennial screening at age 55 with option to
continue annual screening
• Continue biennial screening mammography for as long as a woman is in
good health and a life expectancy of has at least 10 years
• Annual screening mammography beginning at age 45 with an option to
begin at age 40. Transition to biennial screening at age 55 with option to
continue annual screening
• Continue biennial screening mammography for as long as a woman is in
good health and a life expectancy of has at least 10 years
• Annual Screening Mammography beginning at age 40
• Women aged 75 years and older should consult with their physicians to
decide whether or not to continue screening mammography
• Annual Screening Mammography beginning at age 40
• Women aged 75 years and older should consult with their physicians to
decide whether or not to continue screening mammography
Controversies in Mammography
ACS
ACOG
15. • Mammography Screening Increased detection of
precancerous lesions / In-situ
• 25% of newly diagnosed BC cases in screening is DCIS.(FEA,
ADH)
• Biological Significance and practical M/M Big challenge
and still unclear
• Trials/Individual studies No reduction to 30-45%
modest decrease in BC when screened every 1-2 years
• Mammography Screening Increased detection of
precancerous lesions / In-situ
• 25% of newly diagnosed BC cases in screening is DCIS.(FEA,
ADH)
• Biological Significance and practical M/M Big challenge
and still unclear
• Trials/Individual studies No reduction to 30-45%
modest decrease in BC when screened every 1-2 years
Controversies in Mammography
16.
17. • Despite Rising incidence of cancer breast
• Decrease in Absolute Number of deaths
• Not attributed to mammography screening
• Risk stratified screening is gaining momentum
• Despite Rising incidence of cancer breast
• Decrease in Absolute Number of deaths
• Not attributed to mammography screening
• Risk stratified screening is gaining momentum
Mammography debate / controversy
18. • The most well known and extensively used breast cancer risk
assessment model
• Well validated, modified and improved after original development
• Some limitations
• Provides estimated 5-year and lifetime breast cancer risk based on:
– Current age (>35 and <85)
– Age at menarche
– Age at 1st live birth
– Number of 1st degree relatives with breast cancer (0,1, >1)
– Number of previous breast biopsies (1, >1)
– History of atypical hyperplasia on prior breast biopsy
– Race
ACOG, 2011; NCCN, 2013; NCI, 2013; Amir, 2010
Gail Model (NCI-GAIL MODEL)
19.
20. • Breast cancer risk and BRCA mutation probability model
• Developed using data derived from the International Breast
Intervention Study and other epidemiologic data
• Only model to incorporate extensive family history,
reproductive/hormonal factors, genetic factors, AJ ancestry,
and benign breast disease in one comprehensive model
• Some limitations
• Breast cancer risk and BRCA mutation probability model
• Developed using data derived from the International Breast
Intervention Study and other epidemiologic data
• Only model to incorporate extensive family history,
reproductive/hormonal factors, genetic factors, AJ ancestry,
and benign breast disease in one comprehensive model
• Some limitations
TYRER-CUZICK (IBIS) MODEL
21. IBIS MODEL
• Provides estimated 10-year and lifetime breast cancer risk and probability of a BRCA1 or BRCA2
mutation based on:
• Current age
• Age at menarche/age at menopause
• Age at 1st birth
• Use of HRT
• BMI
• Abnormal breast biopsy findings
• History of ovarian cancer
• Family history of ovarian cancer, breast cancer (including
• affected 1st degree male relatives)
• AJ ancestry
• Also accounts for half-siblings, and affected cousins/nieces,
• Genetic test results of patient and family members
• Cuzick, 2013
05/14/16
21
22. • Should be used and start at the age of 40 years
• Majority of BC is preventable
• Chemoprevention is real possibility
• Should be used and start at the age of 40 years
• Majority of BC is preventable
• Chemoprevention is real possibility
Risk based stratification Screening for Breast Cancer
The breast parenchyma is made up of lobules which make milk, and the ducts that transport milk to the nipple. These structures are embedded in stroma containing fat and fibrous connective tissue. The upper outer quadrant of the breast contains a greater volume of tissue than any other quadrant.
Proteomics: Molecular profiling by gene expression
Looks like the radiologist didn’t have on reading glasses that day
There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
