breast cancer - Symptoms - Signs - Screening - Treatment

The association of HRT with an increased risk of breast cancer is well recognized but has attracted disproportionate attention following recent publications that have in turn resulted in conflicting advice from regulatory authorities. This has reduced health professional and patient confidence in HRT and triggered a dramatic decline in HRT prescribing.

In a few studies, reduced breast cancer mortality in women who used hormone therapy before diagnosis have been observed . Due to the high prevalence of past and current hormone use, it is important to investigate whether these preparations are related to breast cancer mortality.

To evaluate the influence of prediagnostic use of hormone therapy on breast cancer mortality, a prospective cohort of 12,269 women ages 50 years or more diagnosed with incident invasive breast cancer and residents of Wisconsin, Massachusetts, or New Hampshire were enrolled in three phases beginning in 1988. They were followed for death until December 31, 2005, using the National Death Index. During an average 10.3 years of follow-up, 1,690 deaths from breast cancer were documented. Cumulative mortality from breast cancer was lower among hormone therapy users, specifically current users at the time of diagnosis, and oestrogen/progestogen users, compared with nonusers. No association was observed for women who were former or current users of oestrogen-alone preparations. Although use of combined oestrogen/progestogen preparations increases breast cancer risk, in this study, use of these hormones before diagnosis was associated with reduced risk of death after a breast cancer diagnosis.⁰⁸⁰¹

Prediagnostic use of hormone therapy and mortality after breast cancer.(2008-01)

breast cancer and Early pregnancy loss

Anti-Termination of Pregnancy Groups have claimed that pregnancy termination increases the risk of breast cancer by 30%. There would appear to be no foundation for this contention according to a study by Michels et al.⁰⁷⁰¹ They found no increased risk of breast cancer in women with a history of pregnancy termination or spontaneous miscarriage.

Induced and spontaneous abortion and incidence of breast cancer among young women: a prospective cohort study.

breast cancer and the combined oral contraceptive pill.

Breast cancer is common with more than 600,000 new cases reported internationally each year. Many studies have been undertaken to determine whether the pill might place women at increased risk of breast cancer

The results of meta-analyses (Q33.23) are reasonably reassuring with at most a marginal increase. This must be balanced against several pill benefits including reduction in the risk of ovarian and endometrial cancer, fibroids, ovarian cysts, endometriosis, benign breast disease and ectopic pregnancy. Those women found to have breast cancer whilst taking the pill are usually diagnosed at an early stage so that the prognosis is relatively good.

breast cancer Statistics

Every three minutes a woman in the United States is diagnosed with breast cancer. In 2006, an estimated 212,920 new cases of invasive breast cancer were diagnosed, along with 61,980 new cases of non-invasive breast cancer. 40,970 women died in 2006 from this disease.

breast cancer is the leading cancer among white and African American women. African American women are more likely to die from this disease.

breast cancer incidence in women has increased from one in 20 in 1960 to one in eight today.

Although the incidence of breast cancer has been increasing, deaths have been falling - Figure 1

Figure 1 Incidence and mortality from breast cancer 1975 to 2005 in Great Britain.

(http://info.cancerresearchuk.org/cancerstats/mortality/timetrends/)

 

Cancer In Women	Risk Factors For breast cancer	Breast Cancer Statistics	Breast Cancer Screening	Breast Cancer Screening Benefits - Mammograph and Mammograms	Breast Cancer Cause
Breast Cancer and Family History		Breast Cancer Treatment		Breast Cancer Support Groups

 

 Interventions (PEPI) Investigators.(1999-01)

Breast Cancer Screening Benefits - Mammograph and Mammograms

Self-Examination:

• The majority of doctors would advocate self-checking on a regular basis. More than 90% of breast cancers are found by the woman herself. If any change is noted, early assessment by the doctor is to be highly recommended.
• The breast tissue becomes more nodular (lumpy) before each period so that it is best to undertake examination after a period.
• The breasts are composed of lobes of glandular tissue that can be felt between the thumb and the fingers by gentle squeezing this is therefore not the method to examine the breast for lumps or thickening.
• The hand should be closed and flat with the fingers being gently but firmly pressed in and moved to feel for swellings.
• Imagine each breast in four quarters and systematically check each of these areas.
• Other changes such as discharge or bleeding from the nipple should also be reported to your general practitioner.

The merits of a screening test are listed in screening tests. With reference to Q32.8:-

• Breast cancer is an important health risk (A). There are 24,000 new cases and 15,000 deaths reported annually in theUK .
• Breast cancer is the commonest cancer in women in theUK (B). One women in twelve (7.5%) will develop breast cancer at some time in her life.
• The majority of breast cancers are found in women over the age of 55 years. We know a lot about the natural history of the disease (C). When the tumour is limited to a duct or measures less than 1 cm, spread to the lymph glands is least likely to have occurred. Screening aims to detect this early stage of disease.
• The five year survival for stage 1 breast cancer (less than 2 cm) with appropriate treatment is 84% whereas it falls to 18% for stage 4 disease (D). TheUK screening programme (mammography) costs 37 million per year.
• An evaluation in 1986 found that the cost per quality-adjusted life year (a year of good health quality) achieved by screening compared favourably to other approved and established screening programmes (E).
• Mammography has
  • high specificity (low false negatives – (F)
  • and sensitivity (low false positives - G).

In the three years from 1992, 4,729,003 women aged 50-65 were offered mammography – 3,582,332 (75.8%) accepted (H). Breast biopsies were required for 24,651 women (0.69% of those having mammograms. breast cancer was identified 19,792 (0.55%). Cancer of 1 cm or less was found in 5,785 (0.16%).

It is not known if all invasive breast cancers begin as ductal carinoma in situ lesions (pre-malignant). Not all early abnormalities undergo calcification and mammography, looking for calcification, may not be the most effective way of diagnosing early lesions. A prospective study from Germany has compared mammography with MRI. The MRI proved more effective in diagnosing early lesions.⁰⁷⁰¹

Being screened for breast cancer reduced breast cancer deaths by 48% in a study in East Anglia following the introduction of screening in 1989.²⁰⁰⁸

It might be assumed that computer assisted detection of abnormality on mammography would enhance interpretation. In practice, the use of computer-aided detection is associated with reduced accuracy of interpretation of screening mammograms. The increased rate of biopsy with the use of computer-aided detection is not clearly associated with improved detection of invasive breast cancer.⁰⁷⁰²

The ideal interval for breast cancer screening has yet to be established. The UK was one of the first to offer national breast screening with mammography. All women aged 50 – 64 are offered screening at three year intervals. The Department of Health is currently assessing the potential of extending the upper limit of screening to the age of 69. Most European programmes screen at two year intervals. A British trial looking at this interval is due to report in 1998. The Cancer Research Campaign is evaluating the possible benefits of mammography starting at age 40.

The breasts in younger women are usually too dense for interpretation of x-ray mammography. Sonography (ultrasound examination of the breast) is accurate but the investigation requires considerable expertise and is time-consuming.

Compression of the breast during mammography can be painful but the discomfort is just for a short time.

Mammography involves radiation. Current evidence suggests that, at most, mammography could be the cause of cancer in one woman for every two million women screened.

Whereas cervical screening is designed to pick up cervical disease before it becomes malignant, breast cancer screening is designed to pick up the disease when it has already become active although hopefully early enough to provide curative treatment.

Nine out of ten women found to have an abnormality on mammography do not have cancer. If an abnormality is detected on the mammogram a sample of tissue is taken by the breast specialist often under local anaesthetic. A pathologist will then examine this biopsy microscopically to provide the definitive diagnosis. The emotive issues around breast screening, the need for quick evaluation and access to specialist consultation and treatment are being increasingly recognised by many units.