Amidst several guidelines, this is important to adapt them to Indian scenario and have wider applicability of indigenous guidelines

1. Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist)
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow
Screening of Breast Cancer

2.  1.62 Lakh new cases per year (Incidence): 50% deaths
 Commonest cancer among women (28%) and even in both sexes
combined (14%)
 4 lakh prevalent cases (62%)
Breast Cancer scenario: India

3. Why screening in breast cancer

4.  Health Insurance plan study (1963-1997)
 Randomization between three annual mammograms plus
CBE versus no screening
 30% reduction in 10-year breast cancer mortality and 25%
reduction at 18 years follow up
History of mammographic
screening

5. Evidence: Screening breast cancer

6.  Relative risk of breast cancer death reduced by 10-25% in
age group 40-75 years
 Risk benefit more favorable for 60-69 years versus 50-59
years
 Flaws and limitations:
 Most before modern era of adjuvant therapy
 Less advanced mammographic techniques
 Trial design flaws: randomization, contamination
Evidence: Screening breast cancer

7. o Clinical breast examination
o Breast self examination
Screening modalities

8.  Full length digital
mammography (FFDM)
 Less false positive
 Reduces the number of
women needing additional
imaging and biopsies
Newer screening technologies

9.  Digital breast tomosynthesis
 Increased sensitivities, lesser recall rates
Newer screening technologies

10.  Molecular breast imaging
 USFDA approved
 Uses intravenous Tc 99m-Sestamibi and gamma camera to image the
breast
 Better for screening dense breast
 Cellular metabolism as opposed to structure is visible
Newer screening technologies

11.  Abbreviated fast MRI (AB-MRI)
 Takes 3-5 mins
 Feasible, less costly and more
accessible
Newer screening technologies

12.  Contrast enhanced mammography (CEDM)
 Positron Emission Mammography (PEM)
 PET/MR Imaging
 Thermography
 Microwave imaging
Emerging screening technologies

13. Society Recommendations

14.  Screening with annual mammography and MRI starting at age 30 years
 Are known or likely carriers of BRCA mutation
 Have other high risk genetic syndromes like Cowden, Li-Fraumeni syndrome
etc
 Have been treated with radiation to the chest for Hodgkins disease
 Have 20-25% or greater lifetime risk of breast cancer risk by estimation
models
High risk screening

15. Additional Recommendations: USPSTF
 For teaching of BSE, there is moderate certainty that harms
outweigh benefits.
 For CBE as a supplement to mammography, evidence is
lacking, and balance of benefits and harms cannot be
determined.
 ACS does not recommend clinical breast examination for
breast cancer screening among average-risk women at any age
(qualified recommendation).

16.  No study has documented decreased mortality with BSE
 Chinese study on 2.66 lakh women showed no difference in
mortality, albeit increased incidence of benign breast diseases and
breast biopsies
 Russian study on 1.24 lakh women showed no difference in
mortality. BSE group had higher proportion of early stage tumors
and also significant increase in proportion of breast cancer
patients surviving 15 years after diagnosis
Breast self examination

17.  In women younger than 50 years: USG with CBE
 Resources available with Mammography: prioritize women 50-65
years
 Awareness and education starting at 30 years and CBE screening
(40-60 years) once in every 3 years
 Access to FNAC and Biopsy should be made available
 Combine education and CBE with cervical cancer at 30 years of age

19.  Best offered as an organized program
 Informed discussion with women: Benefits, limitations and harms
 False negative and false positives
 Additional imaging and need for biopsy
 Biologically indolent lesions
 Availability of treatment resources
Screening implementation

20. Breast Screening
 Risks of breast cancer screening tests:
 False-negative test results
 False-positive test results
 Anxiety from additional testing may result from false
positive results.
 Mammograms expose the breast to radiation.
 There may be pain or discomfort during a mammogram.
 Over diagnosis-a panel of experts concluded that over
diagnosis 11% to 19% does exist if breast cancers
diagnosed by screening

21.  Incidence of DCIS has increased five folds
 Heterogenous condition
 Uniformly subjected to treatment
 Increased rates of mastectomies/double
mastectomies
DCIS Trouble

22.  Screening mammography decreases breast cancer mortality
 Digital breast tomosynthesis and novel technologies
enhance the detection rates and decrease recall rates
 Guidelines need to be adapted as per regional
variations/resources
 Counselling and discussion with women desirous of
screening is a must before prescription of tests
Take home messages