Thiruvananthapuram

Breast cancer: limited role for mammography in early detection

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Many tumours can easily be detected by proper clinical breast examination

The young woman in her 30s, sitting in front of the doctor, was still in a state of shock. Delivering a diagnosis of breast cancer is never easy. But it is doubly difficult for the surgeon to deliver the message when the said patient has been through an ‘executive check-up’ and has had a screening mammography done six months ago and is convinced that she cannot be having breast cancer.

“The lump that could be palpated in her breast was only about 1 cm. With appropriate management, the chances of a cure was almost 100%. She was supposed to come to us for surgery. But she disappeared and when I saw her after an year, the cancer had metastasised (spread to distant locations),” says Paul Augustine, Head of Surgical Oncology, Regional Cancer Centre.

“If the breast cancer incidence in Kerala has been spiralling, it is not just because of the delays in early detection, it is also due to delays in decision-making. The problem is that even when detected early, women sit on it, and come back to us when there is little that anyone can do for them,” says Dr. Augustine.

Regular screening and early detection are the keystones of reducing mortality due to breast cancer. Though a number of screening tools, from clinical and self breast examination to mammography, genetic screening and MRI are available, early detection and cure seem to elude a significant population of women.

For a long time, women have been told to do regular self examination s to detect any unusual lumps. But self examination has not offered any mortality reduction benefit.

Today, self awareness and regular clinical breast examination (CBE) by a surgeon or a trained volunteer with sufficient expertise are considered to be effective in early detection. While mammography, which can detect tiny tumours which are not palpable (felt) is a superior screening tool, its utility and cost effectiveness for population-based breast cancer screening is today an area of major controversy.

Overdiagnosis

Screening mammograms often detect invasive and non-invasive cancers, most of which would never have progressed to life-threatening cancer or created a problem in a woman’s lifetime.

Canadian National Breast Screening Study published in 2014, after following up a screening group of 44,925 healthy women for 25 years, said that there was no difference in survival among mammographically screened women and the control cohort, and that screening mammography resulted in harm by overdiagnosing cancers in 22% of women.

It found that 106 of the 484 screen-detected cancers were overdiagnosed and these healthy women were treated for breast cancer unnecessarily.

Also, a Cochrane review of 10 trials involving more than 6,00,000 women showed there was no evidence suggesting an effect of mammography screening on overall mortality (New England Journal of Medicine, April 2014).

The benefit of mammography for women aged 40 to 49 years is uncertain and in 6% to 46% exams, mammography might not detect invasive breast cancer.

“Many tumours which may be missed by mammography in women with dense breasts (especially in those less than 40 years age) can be easily detected at 1 cm through a proper clinical breast examination (CBE). The expertise of the clinician is crucial here,” says Dr. Augustine.

Imparting training in CBE to primary care physicians and gynaecologists becomes very important as these are the first point of care for most women.

C. Maya

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Printable version | Dec 16, 2019 10:07:57 AM | https://www.thehindu.com/news/cities/Thiruvananthapuram/breast-cancer-limited-role-for-mammography-in-early-detection/article29892366.ece

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