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| {{Breast cancer}} | | {{Breast cancer}} |
| {{CMG}}; {{AE}} [[User:Jack Khouri|Jack Khouri]] | | {{CMG}}; {{AE}} {{Soroush}}[[User:Jack Khouri|Jack Khouri]], {{MGS}} |
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| ==Overview== | | ==Overview== |
| Breast cancer screening is an attempt to find unsuspected cancers. The most common screening methods include: self and clinical breast exams, x-ray [[mammography]], breast [[magnetic resonance imaging]] (MRI), ultrasound, and genetic testing. | | According to the the U.S. [[Preventive medicine|Preventive]] Service Task Force (USPSTF), screening for breast cancer by [[Mammography|mammogram]] is recommended for women aged 50-74 years, twice a year. |
| | ==Screening== |
| | Three tests are used by health care providers to screen for breast cancer:<ref name="Screening">Breast Cancer. National Cancer Institute (2015) http://www.cancer.gov/types/breast/patient/breast-screening-pdq#section/_13 Accessed on January 15 2016 </ref> |
| | ===Mammogram=== |
| | *[[Mammography]] is the most common [[Screening (medicine)|screening test]] for [[breast]] [[cancer]]. A mammogram is an [[X-rays|x-ray]] of the breast. This test may find tumors that are too small to feel. Mammograms are less likely to find breast tumors in women younger than 50 years than in older women. This may be because younger women have denser breast tissue that appears white on a [[Mammography|mammogram]]. |
| | *The following may affect whether a mammogram is able to detect (find) breast cancer: |
| | :*Size of the [[tumor]] |
| | :*How dense the is breast tissue? |
| | :*The radiologist knowledge and expertness |
| | *Women aged 40 to 74 years who have screening mammograms have a lower chance of dying from breast cancer than women who do not have screening mammograms. |
| | ===Clinical breast exam=== |
| | *A clinical breast exam is an exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual. It is not known if having clinical breast exams decreases the chance of dying from breast cancer. |
| | *Doing breast self-exams '''has not been shown''' to decrease the chance of dying from breast cancer. |
| | *'''The USPSTF recommends against ''teaching'' [[breast self-examination]] (BSE). There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.''' |
| | ===MRI=== |
| | *[[Magnetic resonance imaging|MRI is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body.]] [[Magnetic resonance imaging|MRI]] does not use any [[x-rays]]. |
| | *MRI is used as a screening test for women who have one or more of the following: |
| | :*Certain [[gene]] changes, such as in the [[BRCA1]] or [[BRCA2]] genes. |
| | :*A [[family history]] (first degree relative, such as a mother, daughter or sister) with breast cancer. |
| | :*Certain genetic syndromes, such as [[Li-Fraumeni syndrome|Li-Fraumeni]] or [[Cowden syndrome]]. |
| | *[[Magnetic resonance imaging|MRI]]<nowiki/>s find breast cancer more often than [[Mammography|mammogram]]<nowiki/>s do, but it is common for MRI results to appear abnormal even when there isn't any cancer. [[Type I and type II errors|(False positive)]] |
| | ==The New Recommendations== |
| | * Women should begin yearly mammogram by the age of 45 years. |
| | * At age 55 years, women should have mammogram every other year should continue as long as the women is in good health. |
| | * Breast exams are no longer recommended.<ref>Breast cancer guidelines. American cancer society (2016). http://www.cancer.org/cancer/news/news/american-cancer-society-releases-new-breast-cancer-guidelines Accessed on March 8, 2016</ref> |
| | * Because of variation in life style, genes as well as the other risk factors of breast cancer, national studies in each country is warranted in order to precisely determine the cut of point for age of starting screening. |
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| ==X-Ray Mammography== | | ==U.S. Preventive Service Task Force (USPSTF) screening for breast cancer== |
| [[Image:Mammo breast cancer.jpg|thumb|right|Normal (left) versus cancerous (right) mammography image.]]
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| Mammography is still the modality of choice for screening of early [[Breast cancer|breast cancer]], since it is relatively fast, reasonably accurate, and widely available in developed countries. Breast cancers detected by mammography are usually much smaller (earlier stage) than those detected by patients or doctors as a breast lump.
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| Due to the high incidence of breast cancer among older women, screening is now recommended in many countries. Recommended screening methods include [[breast self-examination]] and [[mammography]]. Mammography has been estimated to reduce breast cancer-related mortality by 20-30%.<ref>{{cite journal | author = Elwood J, Cox B, Richardson A | title = The effectiveness of breast cancer screening by mammography in younger women. | journal = Online J Curr Clin Trials | volume = Doc No 32 | issue = | pages = [23,227 words; 195 paragraphs] | year = | id = PMID 8305999}}</ref> Routine (annual) mammography of women older than age 40 or 50 is recommended by numerous organizations as a screening method to diagnose early breast cancer and has demonstrated a protective effect in multiple clinical trials.<ref>{{cite journal | author = Fletcher S, Black W, Harris R, Rimer B, Shapiro S | title = Report of the International Workshop on Screening for Breast Cancer. | journal = J Natl Cancer Inst | volume = 85 | issue = 20 | pages = 1644-56 | year = 1993 | id = PMID 8105098}}</ref> The evidence in favor of mammographic screening comes from eight randomized clinical trials from the 1960s through 1980s. Many of these trials have been criticised for methodological errors, and the results were summarized in a review article published in 1993.<ref name=Fletcher_1993>{{cite journal | author = Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S | title = Report of the International Workshop on Screening for Breast Cancer | journal = J. Natl. Cancer Inst. | volume = 85 | issue = 20 | pages = 1644-56 | year = 1993 | pmid = 8105098 | doi = | accessdate = 2007-05-26}}</ref>
| | {| class="wikitable" |
| | ! colspan="2" | |
| | == '''Breast cancer screening: summary of recommendations''' == |
| | ! |
| | |- |
| | !Population |
| | !Recommendation |
| | !Grade |
| | (please refer to the next table below) |
| | |- |
| | |Women, Age 50-74 Years |
| | |The USPSTF recommends biennial screening mammography for women 50-74 years. |
| | |B |
| | |- |
| | |Women, Before the Age of 50 Years |
| | |The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. |
| | |C |
| | |- |
| | |Women, 75 Years and Older |
| | |The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older. |
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| Improvements in mortality due to screening are hard to measure; similar difficulty exists in measuring the impact of [[Pap smear]] testing on [[cervical cancer]], though worldwide, the impact of that test is likely enormous. Nationwide mortality due to cancer before and after the institution of a screening test is a surrogate indicator about the effectiveness of screening, and results of mammography are favorable.
| | Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement. |
| | |I |
| | |- |
| | |All Women |
| | |The USPSTF recommends against ''teaching'' breast self-examination (BSE). |
| | |D |
| | |- |
| | |Women, 40 Years and Older |
| | |The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. |
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| ===Clinical Practice Guidelines===
| | Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement. |
| There is a discrepancy among breast cancer screening guidelines regarding the age at which screening mammography should begin. The 2009 [[Uniteds States Preventive Services Task Force]] (USPSTF) guidelines for screening for breast cancer recommended screening mammography every two years beginning at the age of 50,<ref name="pmid19920272">{{cite journal| author=US Preventive Services Task Force| title=Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 716-26, W-236 | pmid=19920272 | doi=10.7326/0003-4819-151-10-200911170-00008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920272 }} </ref> an age cut-off point that used to be 40 in the 2002 [[USPSTF]] guidelines.<ref name="NCI_MMG_Screening">{{cite web |url=http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional |title=NCI Statement on Mammography Screening - Breast Cancer Screening (PDQ®) |accessdate=2014-09-24 |format= |work=}}</ref><ref name="NCI_MMG_Screening2002">{{cite web |url=http://www.cancer.gov/newscenter/newsfromnci/2002/mammstatement31jan02 |title=NCI Statement on Mammography Screening - National Cancer Institute |accessdate=2014-09-24 |format= |work=}}</ref> While the 2009 USPSTF recommends biennial screening mammography among women between the age of 50 and 74 years (grade B recommendation),<ref name="pmid19920272">{{cite journal| author=US Preventive Services Task Force| title=Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 716-26, W-236 | pmid=19920272 | doi=10.7326/0003-4819-151-10-200911170-00008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920272 }} </ref> the 2003 American Cancer Society guidelines for early breast cancer recommends that screening mammography begins at the age of 40.<ref name="pmid12809408">{{cite journal| author=Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP et al.| title=American Cancer Society guidelines for breast cancer screening: update 2003. | journal=CA Cancer J Clin | year= 2003 | volume= 53 | issue= 3 | pages= 141-69 | pmid=12809408 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12809408 }} </ref>
| | |I |
| | |- |
| | |All Women |
| | |The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. |
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| In the UK, women are invited for screening once every three years beginning at age 50. Women with one or more first-degree relatives (mother, sister, daughter) with premenopausal breast cancer should begin screening at an earlier age.
| | Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement. |
| | |I |
| | |} |
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| It is usually suggested to start screening at an age that is 10 years less than the age at which the relative was diagnosed with breast cancer.
| | {| class="wikitable" |
| | | ! |
| ===Criticisms of Screening Mammography===
| | ! colspan="2" | |
| Several scientific groups however have expressed concern about the public's perceptions of the benefits of breast screening.<ref>{{cite news | first= | last= | coauthors= | title=Women 'misjudge screening benefits' | date= Monday, 15 October, 2001 | publisher= | url =http://news.bbc.co.uk/1/hi/health/1601267.stm | work =BBC | pages = | accessdate = 2007-04-04 | language = }}</ref> In 2001, a controversial review published in [[The Lancet]] claimed that ''there is no reliable evidence that screening for breast cancer reduces mortality''.<ref>{{cite journal |author=Olsen O, Gøtzsche P |title=Cochrane review on screening for breast cancer with mammography |journal=Lancet |volume=358 |issue=9290 |pages=1340-2 |year=2001 |pmid=11684218}}</ref> The results of this study were widely reported in the popular press.<ref>{{cite news | first= | last= | coauthors= | title=New concerns over breast screening | date= Thursday, 18 October, 2001 | publisher= | url =http://news.bbc.co.uk/1/hi/health/1607113.stm | work =BBC | pages = | accessdate = 2007-04-04 | language = }}</ref>
| | == '''Grade definitions after July 2012''' == |
| | | |- |
| False positives are a major problem of mammographic breast cancer screening. Data reported in the UK Million Woman Study indicates that if 134 mammograms are performed, 20 women will be called back for suspicious findings, and four biopsies will be necessary, to diagnose one cancer. Recall rates are higher in the U.S. than in the UK.<ref name="pmid15814020">{{cite journal |author=Smith-Bindman R, Ballard-Barbash R, Miglioretti DL, Patnick J, Kerlikowske K |title=Comparing the performance of mammography screening in the USA and the UK |journal=Journal of medical screening |volume=12 |issue=1 |pages=50-4 |year=2005 |pmid=15814020 |doi=10.1258/0969141053279130}}</ref> The contribution of mammography to the early diagnosis of cancer is controversial, and for those found with benign lesions, mammography can create a high psychological and financial cost.
| | !Grade |
| | | !Definition |
| ===Mammography in Women Less than 50 Years Old===
| | !Suggestions for Practice |
| Part of the difficulty in interpreting mammograms in younger women stems from the problem of breast density. Radiographically, a dense breast has a preponderance of glandular tissue, and younger age or [[estrogen]] [[hormone replacement therapy]] contribute to mammographic breast density. After menopause, the breast glandular tissue gradually is replaced by fatty tissue, making mammographic interpretation much more accurate. Some authors speculate that part of the contribution of [[estrogen]] [[hormone replacement therapy]] to breast cancer mortality arises from the issue of increased mammographic breast density. Breast density is an independent adverse prognostic factor on breast cancer prognosis.
| | |- |
| | | |A |
| A [[systematic review]] by the [[American College of Physicians]] concluded "Although few women 50 years of age or older have risks from mammography that outweigh the benefits, the evidence suggests that more women 40 to 49 years of age have such risks".<ref name="pmid17404354">{{cite journal |author=Armstrong K, Moye E, Williams S, Berlin JA, Reynolds EE |title=Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians |journal=Ann. Intern. Med. |volume=146 |issue=7 |pages=516-26 |year=2007 |pmid=17404354 |doi=}}</ref>
| | |The USPSTF recommends the service. There is high certainty that the net benefit is substantial. |
| | | |Offer or provide this service. |
| ===Enhancements to Mammography===
| | |- |
| In general, digital mammography and computer-aided mammography have increased the sensitivity of mammograms, but at the cost of more numerous false positive results.
| | |B |
| | | |The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. |
| [[Computer-aided diagnosis]](CAD) Systems may help radiologists to evaluate X-ray images to detect breast cancer in an early stage.{{Fact|date=September 2007}} CAD is especially established in US and the Netherlands. It is used in addition to the human evaluation of the diagnostician.
| | |Offer or provide this service. |
| | | |- |
| ==== Digital Mammography ====
| | |C |
| ===== Overview =====
| | |The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. |
| In digital mammography, the processes of image acquisition, display, and storage are separated, which allows optimization of each. Radiation transmitted through the breast is absorbed by an electronic detector, the response of which is faithful over a wide range of intensities. Once this information is recorded, it can be displayed by using computer image-processing techniques to allow arbitrary settings of image brightness and contrast, without the need for further exposure to the patient.<ref name="pmid15670993">Pisano ED, Yaffe MJ (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15670993 Digital mammography.] ''Radiology'' 234 (2):353-62. [http://dx.doi.org/10.1148/radiol.2342030897 DOI:10.1148/radiol.2342030897] PMID: [http://pubmed.gov/15670993 15670993]</ref>
| | |Offer or provide this service for selected patients depending on individual circumstances. |
| Several approaches have been taken in the development of digital mammography systems: (a) slot scanning with a scintillator and a charge-coupled device (CCD) array, (b) a flat-panel scintillator and an amorphous silicon diode array, (c) a flat-panel amorphous selenium array, (d) a tiled scintillator with fiberoptic tapers and a CCD array, and (e) photostimulable phosphor plates (computed radiography).<ref name="pmid15537982">{{cite journal |author=Mahesh M |title=AAPM/RSNA physics tutorial for residents: digital mammography: an overview |journal=[[Radiographics : a Review Publication of the Radiological Society of North America, Inc]] |volume=24 |issue=6 |pages=1747–60 |year=2004 |pmid=15537982 |doi=10.1148/rg.246045102 |url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=15537982 |accessdate=2011-12-02}}</ref>
| | |- |
| | | |D |
| ===== Advantages =====
| | |The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. |
| *Better contrast resolution for dense breasts
| | |Discourage the use of this service. |
| *reduction in recall rates
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| *potential for reduction in radiation dose
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| *increased patient throughput, post-processing capability, and digital acquisition<ref name="pmid15537982">{{cite journal |author=Mahesh M |title=AAPM/RSNA physics tutorial for residents: digital mammography: an overview |journal=[[Radiographics : a Review Publication of the Radiological Society of North America, Inc]] |volume=24 |issue=6 |pages=1747–60 |year=2004 |pmid=15537982 |doi=10.1148/rg.246045102 |url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=15537982 |accessdate=2011-12-02}}</ref>
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| As mentioned above, a film mammography's sensitivity for detecting breast cancer in women with radiographically dense breast tissue is limited. A study, which was published in the New England Journal of Medicine, aimed at assessing the role of digital mammography in screening for breast cancer in women with dense breasts. The study concluded that the overall diagnostic accuracy of digital and film mammography as a means of screening for breast cancer is similar, but digital mammography is more accurate in women under the age of 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women.<ref name="pmid16169887">Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16169887 Diagnostic performance of digital versus film mammography for breast-cancer screening.] ''N Engl J Med'' 353 (17):1773-83. [http://dx.doi.org/10.1056/NEJMoa052911 DOI:10.1056/NEJMoa052911] PMID: [http://pubmed.gov/16169887 16169887]</ref>
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| ==Breast MRI==
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| [[Magnetic resonance imaging]] (MRI) has been shown to detect cancers not visible on mammograms, but has long been regarded to have disadvantages. For example, although it is 27-36% more sensitive, it is less specific than mammography.<ref>{{cite journal | author = Hrung J, Sonnad S, Schwartz J, Langlotz C | title = Accuracy of MR imaging in the work-up of suspicious breast lesions: a diagnostic meta-analysis. | journal = Acad Radiol | volume = 6 | issue = 7 | pages = 387-97 | year = 1999 | id = PMID 10410164}}</ref> As a result, MRI studies will have more [[Type I and type II errors|false positives]] (up to 5%), which may have undesirable financial and psychological costs. It is also a relatively expensive procedure, and one which requires the intravenous injection of a chemical agent to be effective.
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| Proposed indications for using MRI for screening include:<ref>{{cite journal | author = Morrow M | title = Magnetic resonance imaging in breast cancer: one step forward, two steps back? | journal = JAMA | volume = 292 | issue = 22 | pages = 2779-80 | year = 2004 | id = PMID 15585740}}</ref>
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| *Strong family history of breast cancer
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| *Patients with BRCA-1 or BRCA-2 oncogene mutations
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| *Evaluation of women with breast implants
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| *History of previous lumpectomy or breast biopsy surgeries
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| *Axillary metastasis with an unknown primary tumor
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| *Very dense or scarred breast tissue
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| However, two studies published in 2007 demonstrated the strengths of [[MRI]]-based screening:
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| *In March 2007, an article published in the ''[[New England Journal of Medicine]]'' demonstrated that in 3.1% of patients with breast cancer, whose [[contralateral]] breast was clinically and mammographically tumor-free, [[MRI]] could detect breast cancer. [[Sensitivity (tests)|Sensitivity]] for detection of breast cancer in this study was 91%, [[Specificity (tests)|specificity]] 88%.<ref>{{cite journal | author = Lehman CD, Gatsonis C, Kuhl CK, Hendrick RE, Pisano ED, Hanna L, Peacock S, Smazal SF, Maki DD, Julian TB, DePeri ER, Bluemke DA, Schnall MD | title = MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer.| journal = N Engl J Med.| volume = 356 | issue = 13| pages = 1295-1303| year = 2007 | id = PMID 17392300}}</ref>
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| *In August 2007, an article published in ''[[The Lancet]]'' compared [[MRI]] breast cancer screening to conventional mammographic screening in 7,319 women. [[MRI]] screening was highly more sensitive (97% in the MRI group vs. 56% in the mammography group) in recognizing early high-grade [[Carcinoma in situ| Ductal Carcinoma in situ (DCIS)]], the most important precursor of invasive carcinoma. Despite the high [[Sensitivity (tests)|sensitivity]], MRI screening had a [[positive predictive value]] of 52%, which is totally accepted for cancer screening tests.<ref>{{cite journal | author = Kuhl CK, Schrading S, Bieling HB, Wardelmann E, Leutner CC, Koenig R, Kuhn W, Schild HH| title = MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study| journal = The Lancet | volume = 370 | issue = 9586 | pages = 485-492 | year = 2007 | id = PMID }}</ref> The author of a comment published in the same issue of ''The Lancet'' concludes that "MRI outperforms mammography in tumour detection and diagnosis."<ref>{{cite journal | author = Boetes C, Mann RM| title = Ductal carcinoma in situ and breast MRI| journal = The Lancet | volume = 370 | issue = 9586 | pages = 459-460 | year = 2007 | id = PMID }}</ref>
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| === The American Cancer Society Guidelines for Breast Cancer Screening with MRI as an Adjunct to Mammography ===
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| According to the American Cancer Society guidelines, screening MRI is recommended for:<ref name="pmid17392385">{{cite journal |author=Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA |title=American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography |journal=[[CA: a Cancer Journal for Clinicians]] |volume=57 |issue=2 |pages=75–89 |year=2007 |pmid=17392385 |doi= |url= |accessdate=2011-12-05}}</ref>
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| *Women with a strong family history of breast and ovarian cancer
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| *Carriers of the BRCA mutation
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| *Women with a history of chest radiation between the ages of 10 and 30 years for Hodgkin disease
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| *Women with a lifetime risk greater than 20% to 25% as defined by risk predication models dependent on family history
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| There are several risk subgroups for which the available data are insufficient to recommend for or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography.
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| ==Breast Ultrasound==
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| [[Medical ultrasonography|Ultrasound]] alone is not usually employed as a screening tool but it is a useful additional tool for the characterization of palpable tumours and directing image-guided biopsies. U-Systems is a US-based company that is selling a breast-cancer detection system using ultrasound that is fully-automated. Using an ultrasound allows a look at dense breast tissue which is not possible with digital mammmography. It is closely correlated with the digital mammography. The other significant advantage over digital mammography is that it is a pain-free procedure.
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| ==Breast Self-Exam==
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| [[Breast self-examination]] was widely discussed in the 1990s as a useful modality for detecting breast cancer at an earlier stage of presentation. A large clinical trial in China reduced enthusiasm for breast self-exam. In the trial, reported in the ''Journal of the National Cancer Institute'' first in 1997 and updated in 2002, 132,979 female Chinese factory workers were taught by nurses at their factories to perform monthly breast self-exam, while 133,085 other workers were not taught self-exam. The women taught self-exam tended to detect more breast nodules, but their breast cancer mortality rate was no different from that of women in the control group. In other words, women taught breast self-exam were mostly likely to detect benign breast disease, but were just as likely to die of breast cancer.<ref name="pmid12359854">{{cite journal |author=Thomas DB, Gao DL, Ray RM, ''et al'' |title=Randomized trial of breast self-examination in Shanghai: final results |journal=J. Natl. Cancer Inst. |volume=94 |issue=19 |pages=1445-57 |year=2002 |pmid=12359854 |doi=}}</ref> An editorial in the Journal of the National Cancer Institute reported in 2002, "Routinely Teaching Breast Self-Examination is Dead. What Does This Mean?"<ref name="pmid12359843">{{cite journal |author=Harris R, Kinsinger LS |title=Routinely teaching breast self-examination is dead. What does this mean? |journal=J. Natl. Cancer Inst. |volume=94 |issue=19 |pages=1420-1 |year=2002 |pmid=12359843 |doi=}}</ref>
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| ==BRCA Testing==
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| ====Approach to Genetic Testing====
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| {{Family tree/start}}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|A1|A1=<div style="float: left; text-align: left; height: 5em; width: 45em; padding:1em;"> '''Assess women with:'''
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| ----
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| ❑ No previous diagnosis with BRCA related cancer, and <br> ❑ Absence of signs and symptoms of any BRCA related cancer</div>}}
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| ----
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|B1|B1=<div style="float: left; text-align: left; height: 15em; width: 45em; padding:1em;">'''Risk assessment: is ANY of the following history factors present?'''<br>
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| ----
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| ❑ Family members with breast, ovarian, tubal or peritoneal cancer<br>
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| ❑ Breast cancer diagnosis before age of 50 years<br>
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| ❑ History of bilateral breast cancer<br>
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| ❑ Presence of both breast and ovarian cancer<br>
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| ❑ Breast cancer in one or more male family members<br>
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| ❑ Multiple breast cancer cases in the family<br>
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| ❑ One or more family members with two primary types of BRCA related cancers<br>
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| ❑ Ashkenazi Jewish ethnicity
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| </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C2| C2=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;"> '''Yes?'''</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C1|C1=<div style="float: left; text-align: left; height: 10em; width: 45em; padding:1em;">'''Screening with ANY of the following:'''
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| ----
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| ❑ [[Risk stratification tools for BRCA related cancers#Ontario Family History Assessment Tool|Ontario Family History Assessment Tool]]<br>
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| ❑ [[BRCA screening tools#Manchester Scoring System|Manchester Scoring System]]<br>
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| ❑ [[BRCA screening tools#Referral Screening Tool|Referral Screening Tool]]<br>
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| ❑ [[BRCA screening tools#Pedigree Assessment Tool|Pedigree Assessment Tool]]<br>
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| ❑ [[BRCA screening tools#FHS-7|FHS-7]]<br>
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| </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C2| C2=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;"> '''High risk of potentially harmful BRCA mutation based on screening?'''</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|D1|D1=<div style="float: left; text-align: left; height: 10em; width: 45em; padding:1em;">'''Genetic counseling'''
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| ----
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| ❑ Risk assessment for presence of potential BRCA mutation <br>❑ Educating patients about the possible genetic testing results <br>❑ Risk assessment of family members to identify suitable candidates for genetic testing<br>❑ Discussion about risk reducing interventions <br>❑ Post-test counseling </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|E1|E1=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;">'''BRCA mutation genetic testing'''</div>}}
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| {{Family tree/end}}
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| Algorithm based on the 2013 [[US Preventive Services Task Force]] recommendation statement.<ref name="pmid24366376">{{cite journal| author=Moyer VA| title=Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. | journal=Ann Intern Med | year= 2013 | volume= | issue= | pages= | pmid=24366376 | doi=10.7326/M13-2747 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24366376 }} </ref>
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| | |
| ==Screening Guidelines==
| |
| {|Class="wikitable"
| |
| |- | | |- |
| |'''Organisation'''||'''Year of the Issued Guidelines''' || '''Mammography''' ||'''Clinical Breast Examination''' || '''Breast Self-Examination''' || '''Imaging''' | | |I |
| |- style="height:75px"
| | |The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. |
| |USPSTF||2009 ||Age 50-74 years: every 2 years <br> Age 40-49 or >75: individualize decision <br> (every 2 years if performed)||Insufficient evidence for recommendation || Not recommended || Insufficient evidence for recommendation | | |Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. |
| |- style="height:75px"
| |
| |American Cancer Society ||2010||Age >40 years: annually||Age 20-39 years: every 3 years<br>age >40 years: annually ||Optional ||MRI annually in high risk women<br> (20% lifetime risk of breast cancer,<br> positive BRCA mutations, <br> history of radiation therapy)
| |
| |- style="height:75px" | |
| |American College of Obstetricians and Gynecologists ||2011||Age >40 years: annually ||Age 20-39 years: every 3 years <br> >40 years: annually ||Encouraged ||Not recommended
| |
| |} | | |} |
|
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|
| ==Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement (DO NOT EDIT)<ref name="pmid24366376">{{cite journal| author=Moyer VA| title=Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. | journal=Ann Intern Med | year= 2013 | volume= | issue= | pages= | pmid=24366376 | doi=10.7326/M13-2747 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24366376 }} </ref>== | | {| class="wikitable" |
| ===Clinical Summary of U.S. Preventive Services Task Force Recommendation=== | | ! colspan="2" | |
| {|class="wikitable"
| | == '''Level of certainty''' == |
| |- | | |- |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Screen women whose family history may be associated with an increased risk for potentially harmful BRCA mutations. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. ''([[USPSTF guidelines classification scheme#Evidence Quality Rating|Grade B]])''<nowiki>"</nowiki>
| | !Level of Certainty* |
| | !Description |
| |- | | |- |
| |} | | |'''High''' |
| | | |The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. |
| {|class="wikitable"
| |
| |- | | |- |
| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Do not routinely recommend genetic counseling or BRCA testing to women whose family history is not associated with an increased risk for potentially harmful BRCA mutations. ''([[USPSTF guidelines classification scheme#Evidence Quality Rating|Grade D]])''<nowiki>"</nowiki> | | |'''Moderate''' |
| | |The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: |
| | * The number, size, or quality of individual studies. |
| | * Inconsistency of findings across individual studies. |
| | * Limited generalizability of findings to routine primary care practice. |
| | * Lack of coherence in the chain of evidence.As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. |
| |- | | |- |
| | |'''Low''' |
| | |The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: |
| | * The limited number or size of studies. |
| | * Important flaws in study design or methods. |
| | * Inconsistency of findings across individual studies. |
| | * Gaps in the chain of evidence. |
| | * Findings not generalizable to routine primary care practice. |
| | * Lack of information on important health outcomes.More information may allow estimation of effects on health outcomes. |
| |} | | |} |
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| [[Category:Breast]] | | [[Category:Breast]] |
| [[Category:Hereditary cancers]] | | [[Category:Hereditary cancers]] |
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