Screening for breast cancer

Screening for Breast Cancer screening
It is a well known fact that breast cancer (or for that matter any cancer), when detected and treated in its early stage, is curable. The point is- how do we diagnose cancer in its early stage?
Screening has been promoted as an effective method to detect breast cancer early. What is screening? It is testing oneself for presence of disease in absence of disease related symptoms- essentially on a normal woman. Once a woman has developed symptoms (eg: breast lump, nipple discharge, lumps in the arm-pit etc), the tests performed are not screening in its true sense but an evaluation to confirm the presence or absence of disease.
It needs to be stressed that the currently available screening guidelines have been formulated in the United States of America or Europe and are in accordance with the prevalence of cancers in those regions. It is difficult to formulate India-specific guidelines due to diversity and volume of our population. Nevertheless, some of these can be applied in our context. We also need `India-Specific’ guidelines which would be more relevant to our population.
So when does a woman start screening herself for breast cancer?
Breast cancer is rare in young women. However, it makes sense in making a woman `Breast-Aware’ early in life. Self-breast-examination, a simple test which can be done at home from the 3rd decade of life (20+ years). It is best done a week after menstrual periods because some women may experience heaviness and pain in the breasts during menses. The ideal place and time to perform self-breast-examination is while bathing. Women should strip completely above the waist and observe their breasts in the mirror to look for any abnormalities of the nipple (retraction, deviation to one side) or obvious changes in size of the breast. Each breast then needs to be felt with the flat of fingers of the other hand starting from the nipple and going radially to the periphery. Women must look for lumps (both painless and painful) and thickening in the breast. In addition, the axilla (arm-pit) needs to be felt for any lumps. A video of this technique can be easily found on YouTube. This test needs to be done once a month and suspicious findings need to be reported to the doctor. It is quite natural for a young lady to find lumps in the breast. Often, these lumps are benign (not cancerous) and are a result of hormonal changes in breast. Nevertheless, every new lump in the breast must be examined by a trained professional. Benign breast lumps (fibroadenomas) do not require any treatment and usually do not progress to cancer.
A clinical examination of the breast (examination of the breast by a trained doctor) should be done at least once a year. A doctor, by virtue of his training, is likely to notice subtle abnormalities and can rule out false positive alarms.
Self-breast examination and a clinical breast examination are the only screening procedures recommended in women between the ages of 20 and 40 years. A mammography is not recommended routinely unless there is a strong suspicion of cancer, a strong family history of cancer and/or has been recommended by a doctor. Younger women often have dense breasts and a mammography may not yield accurate information. A magnetic resonance imaging (MRI) scan is preferred in such situations.
The incidence of breast cancer starts rising after the age of 40 years and this is the period when screening needs to be pursued diligently. For years, mammography was recommended for women above the age of 40 years. However, recently published studies have put a big question-mark on the efficacy of mammography in its ability to prevent breast cancer related deaths.
So what does a woman above the age of 40 years do? She should continue performing self-breast examination every month, undergo a clinical breast examination every year and discuss the pros and cons of doing a mammogram with her doctor.
For women above the age of 50 years, mammography is recommended once a year. In addition, the lady continues self-breast examination and clinical breast examination.
If screening is so easy, why is it not done routinely ? One reason is the lack of awareness about breast cancer screening. Many women believe that a mammogram is the screening modality. Mammography units now are available at several places in the city but not so at the taluka levels. However this should not pose a major problem as most big cities are well connected to the remotest places by road, rail or some other means of public transport. Travelling to a city once a year is not very taxing (physically and financially). Some organizations and hospitals have mobile mammography units which have the machine loaded on a vehicle which can reach smaller places. Mammography is done as a part of various health camps organized from time to time. So availability of mammography should not be a major hurdle. Secondly, it has to be understood that for screening to be effective, it needs to be done regularly. One normal mammogram is not a clean chit for the rest of the woman’s life. The incidence of breast cancer is higher among woman above the age of 50 years. Unfortunately, most Indian women lose interest in their own health after a certain age limit. Consequently, the most àt-risk’ population gets screened the least.
Self-breast examination is really very simple. It can be practiced by a woman herself at home at a time according to her convenience. It is to be done monthly so a woman needs to spend only a few minutes for it. Unfortunately, this simple, convenient and completely free breast examination test is largely ignored.
Most women do not screen themselves for breast cancer due to the fear that an examination may reveal something abnormal and it may lead them to the diagnosis of cancer. This fear is also responsible for women not reporting their breast lumps. This fear is the biggest mind block which prevents a woman form getting her screened. A woman needs to understand that a mammogram can detect a breast lump at a much earlier stage than the lump which is diagnosed when it produces overt symptoms. So, a woman whose breast lump is diagnosed by breast cancer screening (in a woman who has no symptoms of the lump)has a better chance of cure than a woman whose lump is diagnosed by virtue of the symptoms it has produced. A smaller breast lump essentially means reduced extent of surgery and in some cases, lesser treatment (viz. no chemotherapy, only hormonal therapy or no radiation therapy). Another misconception is mammography is a painful procedure. It is true that during mammography the breast is compressed between 2 plates but the pain is minimal and is further reduced by the newer mammography machines.
Screening is effective only if it is done on a periodic basis. One mammogram done as a part of a mass screening camp once in a while is meaningless and is a waste of resources. An annual mammogram, when combined with annual clinical examination and a monthly self-breast examination will yield the best results. This may result in a slightly increased incidence of early breast cancer (because these will be detected by screening) but it will result in a reduction in advanced cases of breast cancer and improve the overall cure rate.
Breast cancer screening has been hotly debated for the past few decades. There have been several articles for and against mammography and self-breast examination. Instead of attempting to decipher the statistical jargon it would be better if Indian women become more ‘breast –aware’. Today, the average time gap between a woman noticing a lump in her breast and she actually seeking medical attention is a few months. If this time span can be reduced(the lady reports to a doctor as soon as she notices a lump), we can diagnose at least a few breast cancers at an early stage and this will help improve the outcome of treatment.

- Oncologist in Pune | Cancer Specialist | Dr. Chetan Deshmukh