Dr Gita Devi
Breast cancer is the most prevalent malignancy in women worldwide, including in India. The incidence of breast cancer has significantly increased in India in every state. It has increased by 39.1% from 1990 to 2016. Breast cancer accounted for 13.5% of all cancer cases and 10.6% of all deaths in India in 2020. Moreover, trend in current time shows higher case occurrence at younger age. According to literature, people in India has a low level of breast cancer awareness. Most common barriers to screening include low rates of women’s education, low income, and low awareness about its benefits. In addition to this, lack of facility of mammography, fear of radiation risk, fear of cancer detection and self-effacing nature also discourage women from getting an early breast cancer screening in India. When detected in advanced stage the treatment of breast cancer becomes costly and morbidity as well as mortality increases as compared to lower treatment cost and better prognosis if diagnosed early. The Government of India launched a national programme for the prevention and control of non-communicable diseases (NCDs), and numerous more guidelines for breast cancer screening are available. Despite this, the general public, including healthcare professionals, lacks awareness about breast cancer screening. Therefore, there is a need to spread awareness about the process of screening for breast cancer, risk factors of breast cancer, and its management.
RISK GROUPS: The female population is split into two risk groups for breast cancer screening: High/intermediate risk and average risk.
HIGH RISK GROUP FOR BREAST CANCER: Women with a cumulative lifetime breast cancer risk of 20 percent are considered high-risk. Between 13 to 20 percent cumulative lifetime risk of breast cancer is considered intermediate risk group. These groups include:
* Women with the personal history of pre-cancerous lesions and/or breast cancer i.e., Lobular Carcinoma in Situ, Atypical Ductal Hyperplasia, Ductal Carcinoma in Situ, or invasive breast cancer or ovarian cancer.
* Women with the family history of breast cancer e.g., those who have suspected inherited predisposition of breast cancer.
* Women with known genetic predisposition of breast cancer: Women with breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2) mutations or untested but have first-degree relatives (mothers, sisters, or daughters) who are proven to have BRCA mutations.
* Women with the history of mantle or chest radiation therapy before the age of 30 years.
* Women with dense breasts.
AVERAGE RISK GROUP: Women with a cumulative lifetime breast risk of 13 percent are considered high-risk. Age is the most common risk factor here.
BREAST CANCER SCREENING TOOLS:
* Mammography including digital breast tomosynthesis (DBT)
* Magnetic resonance imaging (MRI)
* Ultrasound
* Clinical breast examination
* Breast self-examination.
MAMMOGRAPHY: Best screening tool for breast cancer. Majority of guidelines recommend screening of breast cancer with mammography in women aged 40 to 74 years every year and after that till the life expectancy reaches 10 years.National Comprehensive Cancer Network (NCCN) recommends screening for average-risk women ?40 years by mammography annually and in cases of a high-risk group, screening should start at 25 years.
MRI: For 25-30 years of age MRI should be preferred over mammography as the screening modality. In case lump detected in females below 25 years, ultrasound should be preferred over MRI as breast cancer screening tool. For 30-39 years of age either MRI or mammography can be utilized as the screening modality in high-risk group females.
ULTRASOUND: It is complimentary imaging tool for breast cancer diagnosis but is not recommended as a universal supplemental screening test in average risk population. In patients with dense breast screening USG is recommended as an adjunct to mammography. It is also recommended in patients who cannot tolerate MRI.
CLINICAL BREAST EXAMINATION (CBE) AND BREAST SELF-EXAMINATION (BSE): CBE and BSE are methods of screening breast cancer recommended in limited resource settings.
MAMMOGRAPHIC EXAMINATION PROCEDURE: Mammographic examination is performed in mammography room. Fasting is not needed prior to examination. Skilled female technologist helps in positioning and mammographic examination. The examination is tolerated well without any difficulty. Patients should avoid application of powders and deodorants in axillary regions before mammography examination. Patient should inform about pregnancy or breast implants etc.
MAMMOGRAPHIC SCREENING IN PREGNANCY: The American College of Radiology (ACR) cautions against utilising dynamic contrast-enhanced MRI in pregnant patients regardless of the patient’s risk profile. Routine screening mammography is recommended in pregnant women after 40 years of age (in average risk group), 30-39 years of age (in intermediate & high-risk group) and high-risk group women younger than 30 years of age. The increased breast density in pregnancy increases the likelihood of concealing the small lesions. In this group DBT benefits by reducing masking effects.
SCREENING BREAST CANCER AND MENSTRUAL CYCLE: For breast cancer screening MRI is recommended to be planned in the follicular phase (day 1 of menstrual bleeding till ovulation, approx.14th day)as in the luteal phase of the menstrual cycle (day of ovulation till the onset of menstrual bleeding) the fibro-glandular tissue is denser due to hormonal cyclical changes (stromal oedema, enlargement of lumens of ducts, venous congestion and active glandular tissue) than in the follicular phase. Though no significant evidence is there to schedule the screening mammographic examinations based on menstrual cycle, it is also better to plan it preferably in follicular phase for the same reason.
BREASTFEEDING AND MAMMOGRAPHY SCREENING: Women who undergo mammography during lactation can resume breastfeeding immediately after the procedure as milk is not affected by it.
MAMMOGRAPHY IN MALES: Incidence of breast cancer in males is low. So, screening mammography is not done in males. Mammography is done only for diagnostic purposes when indicated.
RADIATION RISK VS MAMMOGRAPHIC EXAMINATION: We all get exposure of small doses of radiation from the environment. Mammography also exposes to small doses of ionizing radiations but the benefits overweigh any possible harm. Additionally, modern mammography equipment uses latest technology to provide high-quality images while exposing patients to less radiation.
TAKE HOME MESSAGE: Breast cancer screening helps in early diagnosis, which results in less expensive, more effective treatment with wider options available and best prognosis. Be aware about breast cancer and come forward for breast cancer screening.
(The author is an Assistant Professor at, Department of Radiodiagnosis and Imaging, AIIMS, Vijaypur, Jammu.)
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