1.
 Breast cancer is the most frequent cancer among women, in both
developed and developing countries : affecting 2.1 million women
each year.
 RCC statistics
In 2015 : 2065 new cases registered
In 2016 : 2185 new cases registered

2.
 In order to improve breast cancer outcomes and survival,
early detection is critical.
Two early detection strategies for breast cancer:
 Early diagnosis
 Screening

3.
 Early diagnosis strategies focus on providing timely access to
cancer treatment by reducing barriers to care and improving access
to effective diagnosis services.
 Goal : increase the proportion of breast cancers identified at an
early stage, allowing for more effective treatment to be used and
reducing the risks of death from breast cancer.

4.
 Improve awareness
 Reducing stigma associated with cancer
 Building diagnostic capacity and improving access to care
 Financial ,logistic ,geographic barriers must be addressed

5.
 Defined as identification of unrecognized disease in an apparently
healthy ,asymptomatic population.
 By means of tests ,examination ,or procedures that can be applied
rapidly and easily to target population .

6.
1.Suitable screening test
a) Cheap and easy to apply
b) Valid:
 Sensitivity
 Specificity
 Positive predictive value
c) Safe and acceptable

7.
2.Suitable programme settings
a) Adequate infrastructure for diagnosis and treatment in health
services
b) Adequate trained manpower
c) Adequate financial resources
 Diagnosis & treatment should reduce morbidity & mortality
 Benefits should exceed harms

8.
 Increased cost to health care systems
 Anxiety
 Overdiagnosis

9.
• SELF BREAST EXAMINATION
• CLINICAL BREAST EXAMINATION
• MAMMOGRAM
• ULTRASONOGRAPHY
• MRI

10.
 Examination of breasts by women herself
to look for changes in her breast tissue.

11.
Steps 1-3 involve visual inspection of the breasts with the arms in different
positions. Step 4 is palpation of the breast. Step 5 is palpation of the nipple. Step 6
is palpation of the breast while lying down.

12.
 Simple and noninvasive test
 Women gain a sense of control over their health
 Detect breast changes early and thereby seek treatment

13.
 Increased number of health care visits
 Increased healthcare costs
 No benefit in reducing breast cancer mortality.
 Increase in benign breast biopsy
Kösters JP, Gøtzsche PC (2003). Kösters JP (ed.). "Regular self-examination or clinical examination for early detection of breast
cancer". Cochrane Database Syst Rev (2): CD003373. doi:10.1002/14651858.CD003373. PMID 12804462.
Magnitude of Effects on Health Outcomes: Biopsy rate was 1.8% among the study
population compared with 1.0% among the control group.

14.
 Is an examination of both breasts performed by a trained health
professional.
 CBE seems to be a promising approach for low resource settings.
Ongoing randomized trials (India , Egypt ), are designed to assess the efficacy of
screening CBE but have not reported mortality data. Thus, the efficacy of screening
CBE cannot be assessed yet.

15.
 False Positives with Additional Testing and Anxiety.
 False Negatives with Potential False Reassurance and Delay in
Cancer Diagnosis
Reference : Fenton JJ, Rolnick SJ, Harris EL, et al.: Specificity of clinical breast
examination in community practice. J Gen Intern Med 22 (3): 332-7, 2007.

16.
TBCS: Survival breast cancer patients in the control and intervention
groups
Trivandrum Breast Cancer Screening Study (TBCS)
0
255075
100
Proportion(%)
0 1 2 3 4 5 6 7 8 9
Follow-up time (years)
Control group CBE group
Sankaranarayanan et al., J Natl Cancer Inst. 2011;103:1476–80

17.
Control Intervention
Adjusted
hazard ratio
(95% CI)
Person-years of Observation (PYO) 592,204 555,473
Breast cancer incidence - cases 156 203
Age standardize rate (per 100,000 PYO) 27.2 37.7 1.4 (1.1 – 1.7)
Early stage (0-II) breast cancer incidence -
cases
73 108
Age standardize rate (per 100,000 PYO) 12.6 20.3 1.6 (1.2 – 2.1)
Advanced stage (III-IV) breast cancer incidence
- cases
66 69
Age standardize rate (per 100,000 PYO) 11.5 12.7 1.1 (0.8 – 1.5)
5-year absolute survival in breast cancer cases 65.9 72.9
Breast cancer mortality - cases 39 36
Age standardize rate (per 100,000 PYO) 6.9 6.6 1.0 (0.7 – 1.5)
Breast cancer incidence and mortality during 2006-2015
Trivandrum Breast Cancer Screening Study (TBCS)

18.
 Patient must be stripped to the waist
 Majority of examination is in the sitting position arms by side , arms
raised ,hands on hip and leaning forward

19.
BREAST
• Position
• Size and shape
• Any puckering or dimpling
• Swelling or ulcer – size ,
shape , surface
Skin over breast
• Colour and texture
• Dimple , puckering
• Engorged veins
• Peu de orange
• Nodules
• Ulceration and fungation

20.
 Palpate bilateral breast
 Examine axilla for lymphnodes
 Examine supraclavicular area for lymphnodes

21.
 Primary imaging modality for early detection of breast cancer :
found to decrease breast cancer-related mortality
 A mammogram involves exposing the breast to x-rays.
 The x-rays are attenuated based upon the characteristics of the
breast tissue then absorbed as latent images on the recording
device  The latent image is processed and displayed for
diagnostic purposes .

22.
Surveillance
Diagnostic
Screening

23.
 Mammographic screening was first introduced in 1950’s
 HIP(health insurance plan study )
first prospective, randomized clinical trial to formally assess its v
alue in reducing death from breast cancer screening
With 18 years of followup, those in the
screening arm had a 25% lower breast cancer mortality rate
Shapiro S. Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance
Plan. J Natl Cancer Inst Monogr 1997:27–30

24.
T
y
p
e
s

25.
 Craniocaudal (CC) view : the breast is lifted and positioned on the
plate and compression is applied from above.
 Mediolateral oblique (MLO) view : the breast is compressed and
imaged from the side.
 Breast positioning is critical.
Craniocaudal
Mediolateral
oblique
Typical views

26.
 Average adult effective dose : 0.4mSV (estimated equivalent dose :
20 chest xrays )
 The American Cancer Society :
dose of radiation received during a screening mammogram is =
amount of radiation a person gets from their natural surroundings
(background radiation) in an average 3-month period.

27.
Breast Calcification
Calcifications are small calcium deposits in breast that show up as white spots on
mammogram .Large ,round or well defined calcification are most likely to be
noncancerous (benign ) .Tight clusters of tiny irregularly shaped calcification may
indicate cancer.

28.
 OVERDIAGNOSIS
 False positives
 False negatives
 Possibility of radiation induced breast cancer

29.
 Abnormal even though no cancer is present.
 Usually followed by more tests
 More common in :
Younger women
Women who have had previous breast biopsies.
 more likely the first time screening mammography

30.
 Screening test results may appear to be normal even though breast
cancer is present.
 Overall screening mammogram miss 1/5 breast cancers
 can delay diagnosis and treatment.

31.
 Over diagnosis is a potential harm from screening mammogram .
 Over diagnosis describes tumors found on screening in
average risk women that would have never developed clinical
symptoms

32.
Causes ??
 mammographically detected cancers that
may have remained asymptomatic throughout the woman’s lifetime.
 although they are detected early, the woman dies of other causes
well before symptoms would have developed.

33.
 Some breast cancer are aggressive and grow rapidly ,but many
cancers are slow growing and would not be found if women did not
have a screening test .
 Some women may be treated for cancers that would never become
clinically significant .

34.
 Overall, 22% of screening detected invasive breast cancers were over-diagnosed,
representing one over-diagnosed breast cancer for every 424 women who
received mammography screening in the trial.
, A. B., Wall, C., Baines, C. J., Sun, P., To, T., & Narod, S. A. (2014). Twenty five year follow-up for breast cancer incidence and mortality of the
Canadian National Breast Screening Study: randomised screening trial. BMJ (Clinical research ed.), 348, g366. doi:10.1136/bmj.g366

35.
“The woman would only experience the harmful effects of early
diagnosis and treatment without the opportunity to benefit due
to the invasive procedures involved and the
physical & psycho-social impact of the treatment”

36.
 Not a primary screening modality.
 Useful in women with dense breast tissue
“there is little evidence to support the use of ultrasound in population
breast cancer screening at any age”
Teh W, Wilson AR: The role of ultrasound in breast cancer screening. A consensus statement by the European Group for
Breast Cancer Screening. Eur J Cancer 34 (4): 449-50, 1998.

37.
 Widely available
 Non invasive
 Cost effective
 USG guided FNAC

38.
 MRI has been promoted as a screening test for breast cancer
among women at elevated risk of breast cancer based on BRCA1/2
mutation carriers, a strong family history of breast cancer, or
several genetic syndromes, such as Li-Fraumeni syndrome or
Cowden disease.
Breast MRI is more sensitive but less specific than screening
mammography

39.
Figure 1. Example of a mammographically occult invasive ductal
carcinoma in the left breast of a woman at high risk of developing breast
cancer. The images were acquired on a 1.5T scanner. The invasive
ductal carcinoma presented as a mass (arrows) was well visualized with
both (A) the maximum intensity projection subtraction image and (B) the
T1-weighted postcontrast image. This study had homogeneous fat
suppression (B) and no interscan patient motion (A), which aided in the
visibility of the lesion.

40.
 Recommended annually based on evidence
BRCA mutation carrier
Untested first degree relative of BRCA carrier
Lifetime risk > 20%-25% defined by family history models
 Recommended Based on Expert Consensus Opinion
Radiation to chest from age 10-30 year
Li Fraumeni syndrome and first degree relatives
Cowden syndrome (and variant ) and first degree relatives

41.
 Insufficient Evidence to recommend for or against
Lifetime risk 15%-20%
Lobular carcinoma in situ
Dense breast on mammography
Personal history of intraductal or invasive breast cancer
 Recommendation against based on Expert Consenses
Lifetime risk < 15%

42.
BREAST CANCER
SCREENING GUIDELINES

43.
Evidence on screening interval
Evidence of the effect of the screening interval on breast cancer-specific
mortality was obtained from data from RCTs and modelling.
•Screening intervals in the RCTs ranged from 12 to 33 months over a median of 11
years and suggested no difference in breast cancer mortality for screening
intervals less than 24 months compared to those of 24 months and longer.
•Results from modelling
showed that screening every two years seems to provide the best trade-off
between benefits and harms.

44.
•Screening biennially from age 50 years to 69 years achieved a median 16%
reduction in breast cancer deaths compared to no screening.
•Biennial screening at age 40 years versus 50 years
reduced mortality by an additional 3%, but it consumed more resources
and yielded more false-positive results.
•Biennial screening after the age of 69 years yielded some additional mortality
reduction in all models, but overdiagnosis increased substantially at older ages.

45.
Women aged 50−69 years
Limited resource
settings with weak
health systems
Limited resource
settings with
relatively strong
health systems
Well-resourced
settings
screening interval of two years.
(Conditional recommendation
based on low quality evidence)
screening interval of two years.
(Conditional recommendation
based on low quality evidence)
Clinical breast examination
(a low-cost screening method)

46.
Women aged 40−49 years
Limited resource
settings with weak
health systems
Limited resource
settings with
relatively strong
health systems
Well-resourced
settings
Population based screening programme
after research and shared decision
making strategies (Conditional
recommendation
based on moderate quality evidence)
WHO IS AGAINST IMPLEMENTATION OF
POPULATION BASED SCREENING PROGRAMMES
(Conditional recommendation
based on moderate quality evidence)
Clinical breast examination
(a low-cost screening method)

47.
Women aged 70−75 years
Limited resource
settings with weak
health systems
Limited resource
settings with
relatively strong
health systems
Well-resourced
settings
Population based screening programme after
research and shared decision making strategies
(Conditional recommendation
based on moderate quality evidence)
WHO IS AGAINST IMPLEMENTATION OF
POPULATION BASED SCREENING PROGRAMMES
(Conditional recommendation
based on moderate quality evidence)

48.
Conclusion …
• Screening mammogram is effective in decreasing breast cancer related
mortality
• However, mammography screening does have limitations

49.
• Because screening requires substantial investment and carries significant
potential personal and financial costs, the decision to proceed with
screening should be pursued only after
(1) basic breast health services including effective diagnosis and timely
treatment are available to an entire target group
(2) its effectiveness has been demonstrated in the region
(3) resources are available to sustain the programme and maintain quality.

50.
• Irrespective of the type of setting, access to objective, evidence-based
information about the benefits and harms of breast cancer screening
should be explained
• In well-resourced settings with good infrastructure and workforce
population screening programmes maybe implemented
• Limited resource settings with weak health systems where the majority of
women are diagnosed in late stages should prioritize early diagnosis
programmes based on breast awareness , self breast examination and
clinical breast examination for detection of early signs and symptoms and
prompt referral to diagnosis and treatment.