Question

Make a case for breast cancer screening with mammography before age 50 from a perspective of being a healthcare administrator of a large urban hospital. Include validity, reliability, sensitivity, specificity, positive predictive value and negative predictive value

Answer 1

Breast cancer (BCa) is the leading cause of cancer death in women worldwide. It is the main cause of cancer-related death in women in developing countries (where many have advanced disease at presentation), and it is the second-leading cause in women in developed countries. Breast cancer has one of the highest potential years of life lost: almost 137,000 years, reflecting the burden of BCa in younger women.

Community practice of screening may differ from the care provided within randomized clinical trials and is less often discussed in review articles. Reviews of breast cancer screening usually emphasize efficacy and results of randomized trials, particularly those involving screen-film mammography. Efficacy of a screening tool is measured in experimental studies under ideal circumstances. In contrast, effectiveness is defined as the extent to which a specific intervention “when deployed in the field in routine circumstances, does what it is intended to do for a specific population.”

The evaluation of screening modalities, especially in the community setting, is challenging for methodological, clinical, and ethical reasons. Randomized clinical trials are considered the gold standard for evaluating a new screening test. The long-term breast cancer mortality rate of women randomized to receive a new screening test is compared with that of women randomized to receive standard care. However, such trials are difficult to conduct. They require tens of thousands of women who need to be followed up for more than 15 years. Furthermore, because mammography screening has been shown to be effective in some trials, it would likely be even more difficult to demonstrate any additional efficacy of new tests. Finally, as treatment for breast cancer has improved over time, the impact of screening on breast cancer mortality may be increasingly difficult to establish. Because of these challenges, new screening tests are often first studied by establishing characteristics of the tests themselves, rather than by studying their effect on patient outcome such as breast cancer mortality. Important test characteristics include sensitivity, specificity, safety, cost, simplicity, and patient and clinician acceptability. It is important to determine the characteristics of a screening test in a community setting if the test is to be used in that setting. However, test characteristics of new modalities are usually evaluated among women for whom the rate of breast cancer is higher than average, such as women at increased risk of breast cancer or women in a diagnostic setting with breast symptoms or known breast abnormalities. The reported sensitivity and specificity of a test in these high-risk women may be different from the sensitivity and specificity of the same test used in a general screening population.

Women aged 50 to 54 years should get mammograms every year. Women aged 55 years and older should switch to mammograms every 2 years, or have the choice to continue yearly screening. Screening with mammography and clinical breast exam annually. For women aged 50 to 69 years, screening with mammography is recommended. Women with an average risk of breast cancer – most women – should begin yearly mammograms at age 45. Women should be able to start the screening as early as age 40, if they want to. It's a good idea to start talking to your health care provider at age 40 about when you should begin screening.

A mammogram is an x-ray of the breast. While screening mammograms are routinely administered to detect breast cancer in women who have no apparent symptoms, diagnostic mammograms are used after suspicious results on a screening mammogram or after some signs of breast cancer alert the physician to check the tissue.

Once A Month
Adult women of all ages are encouraged to perform breast self-exams at least once a month. “Forty percent of diagnosed breast cancers are detected by women who feel a lump, so establishing a regular breast self-exam is very important.” While mammograms can help you to detect cancer before you can feel a lump, breast self-exams help you to be familiar with how your breasts look and feel so you can alert your healthcare professional if there are any changes.

Breast Self-Exam
1) In the Shower
Using the pads of your fingers, move around your entire breast in a circular pattern moving from the outside to the center, checking the entire breast and armpit area. Check both breasts each month feeling for any lump, thickening, or hardened knot. Notice any changes and get lumps evaluated by your healthcare provider.

2) In Front of a Mirror
Visually inspect your breasts with your arms at your sides. Next, raise your arms high overhead. Look for any changes in the contour, any swelling, or dimpling of the skin, or changes in the nipples. Next, rest your palms on your hips and press firmly to flex your chest muscles. Left and right breasts will not exactly match—few women's breasts do, so look for any dimpling, puckering, or changes, particularly on one side.

3) Lying Down
When lying down, the breast tissue spreads out evenly along the chest wall. Place a pillow under your right shoulder and your right arm behind your head. Using your left hand, move the pads of your fingers around your right breast gently in small circular motions covering the entire breast area and armpit. Use light, medium, and firm pressure. Squeeze the nipple; check for discharge and lumps. Repeat these steps for your left breast

Mammogram
A mammogram is an x-ray that allows a qualified specialist to examine the breast tissue for any suspicious areas. The breast is exposed to a small dose of ionizing radiation that produces an image of the breast tissue. Mammograms can often show a breast lump before it can be felt. They also can show tiny clusters of calcium called microcalcifications. Lumps or specks can be caused by cancer, fatty cells, or other conditions like cysts. Further tests are needed to find out if abnormal cells are present. What Happens If My Mammogram Results Are Abnormal? If the mammogram shows an abnormal area of the breast, your doctor will order additional tests offering clearer, more detailed images of that area. Although lumps are usually non-cancerous, the only way to be certain is to perform additional tests, such as an ultrasound or MRI. If further tests show that the mass is solid, your radiologist may recommend a biopsy, a procedure in which cells are removed from a suspicious area to check for the presence of cancer.

Mammography
Mammography can detect tumors before they can be felt, so screening is key for early detection. But when combined with regular medical care and appropriate guideline-recommended mammography, breast self-exams can help women know what is normal for them so they can report any changes to their healthcare provider. If you find a lump, schedule an appointment with your doctor, but don't panic — 8 out of 10 lumps are not cancerous. For additional peace of mind, call your doctor whenever you have concerns.

Clinical Breast Exam
A clinical breast exam is performed by a healthcare professional who is trained to recognize many different types of abnormalities and warning signs. This in-office exam will most likely be completed by your family physician or gynecologist at your annual exam, whereas your breast self-exam is something every woman should do at once at month at home. During a clinical breast exam, your healthcare provider checks your breasts’ appearance. You may be asked to raise your arms over your head, let them hang by your sides, or press your hands against your hips. These postures allow your healthcare provider to look for differences in size or shape between your breasts. The skin covering your breasts is checked for any rash, dimpling, or other abnormal signs. Your nipples may be checked to see if fluid is expressed when lightly squeezed.

A Manual Check for Unusual Texture or Lumps

Using the pads of the fingers, your healthcare provider checks your entire breast, underarm, and collarbone area for any lumps or abnormalities. It is worth noting that some women have breast tissue that appears to be full of tiny fibrous bumps or ridges throughout the breast tissue, known as fibrocystic breasts. Overall lumpy tissue is something your provider will want to note but is unrelated to cancer.

A suspicious lump –the type your physician is checking for– is generally about the size of a pea before anyone can feel it in the breast tissue. The manual exam is done on one side and then the other. Your healthcare provider will also check the lymph nodes near the breast to see if they are enlarged.

An Assessment of Any Suspicious Area

If a lump is discovered, your healthcare provider will note its size, shape, and texture. He or she will also check to see if the lump moves easily. Benign lumps often feel different from cancerous ones, but any lump found will likely need to be examined with further diagnostic measures.

It may be helpful to know that lumps that appear soft, smooth, round, and movable are likely to be either benign tumors or cysts. A lump that is hard and oddly-shaped and feels firmly attached within the breast is more likely to be cancer, but further tests are needed to diagnose the problem.

The Value of Clinical Breast Exams

Clinical Breast exams are an important part of early detection. Although most lumps are discovered through breast self-exams, an experienced professional may notice a suspicious place that fails to register as a warning in the patient’s mind.