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Screening and Early Diagnosis of Breast Cancer

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Screening and Early Diagnosis of Breast Cancer CLINICAL REVIEW Screening and Early Diagnosis of Breast Cancer Garey L. McLellan, MD Jacksonville, Florida Long-term survival in breast cancer currently rests on detection and appropriate therapy at the earliest possible stage, with survival being excellent in patients whose cancers are discovered at a small size and without dissemination. Discov­ ery of lesions at the smallest possible size is therefore desirable. Of the available imaging modalities, only modern mammography has been shown consistently to detect small breast lesions. The efficacy of screening mam­ mography in asymptomatic women has been demonstrated in large-scale trials in women older than 49 years of age and has been strongly supported by follow-up results in the Breast Cancer Detection and Demonstration Project in women aged 40 to 50 years. Mammographic screening has been advocated by the American Cancer Society (ACS) beginning at 40 years of age, while the National Cancer In­ stitute recommends mammographic screening beginning at 50 years of age. The ACS recommends also that breast self-examination begin at 20 years of age. Unfortunately, a great majority of women do not practice breast self-exami­ nation, nor do they know that mammography is useful in detecting breast cancer. Further, only a minority of physicians recommend screening mammography, al­ though most recommend breast self-examination and perform physical examina­ tion of the breast. Physicians are therefore urged to recommend regular screening to their patients. or women, breast cancer remains the most prevalent ten-year survival in patients with minimal cancer (local­ F cancer in America and is surpassed only by lung can­ ized, invasive lesions of 0.5 cm or less in diameter or car­ cer as the leading cause of cancer death. It is estimated cinomas in situ)9,10 or “early” breast cancer (invasive tu­ that in 1987 this disease will be diagnosed in 135,000 mors of 5 cm or less in diameter without axillary nodal women and about 41,000 will die as result of it.1 Unfor­ or distant metastasis7,1') is approximately 92 to 95 percent9 tunately, the death rate has remained essentially un­ and 70 to 85 percent,7,9 respectively, while the ten-year changed for the past 50 years, whereas the overall incidence survival in more advanced disease is 40 percent or less. and prevalence has been increasing slowly.2,3 Long-term survival or cure is therefore attainable only if The means to prevent breast cancer has yet to be found, methods for the earliest possible detection and diagnosis leaving improvement in diagnosis and therapy the only are developed, utilized, and followed by prompt, effective methods of decreasing the death and sulfering associated therapy.7,11 with this devastating disease. Although over the past 20 The following discussion will review pertinent aspects years patients have been presenting with breast cancer of the epidemiology, risk-factor assessment, pathology, earlier in the course of the disease,4 the positive axillary screening guidelines, and patient and physician attitudes lymph node rate has remained high, in the range of 40 to toward breast cancer screening. 55 percent.5'6 Patients without positive regional lymph nodes or metastases have much better prospects for long­ term survival than those having such lesions.7,8 Specifically, RISK FACTORS The general risk factors known for breast cancer are sex, age, and geography. It is well known that breast cancer is Submitted, re vise d , January 8, 1988. much more common in women than men,1 with an in­ I Pram the Department of Radiology, University of Florida, Jacksonville Health cidence of less than 0.5 percent in the latter.1,12 The in­ Education Programs, Jacksonville, Florida. Requests for reprints should b e ad­ cidence of breast cancer among American women in­ dressed to Dr. Garey L. McLellan, Department of Radiology, University Hospital creases sharply with age. Women aged 30 years have a it Jacksonville, 655 West Eighth Street, Jacksonville, FL 32209. © 1988 Appleton & Lange ________________________________________________ 561 THE JOURNAL OF FAMILY PRACTICE, VOL. 26, NO. 5: 561-568,1988 EARLY DIAGNOSIS OF BREAST CANCER Several subgroups have been identified who are at in­ TABLE 1. BREAST CANCER INCIDENCE RATES BY AGE creased risk of developing breast cancer. Women with a PER 100,000 POPULATION family history of breast cancer carry an overall relative Age (years) Incidence per 100,000 risk estimated to be about two to three times that of sim­ ilarly aged women in the general population.14,20 Further, 25 <10 30 20 Anderson18,21-23 has shown that age, kinship, and laterality 35 40 have considerable value in estimating risk. For a patient 40 80 whose mother and sister have had premenopausal bilateral 45 120 breast cancer, there is about a 30 percent lifetime risk of 50 180 breast cancer.18 Cancer development also is seen at earlier 55 210 60 240 ages than the general population in these familial groups.18 65 270 If the cancer is found postmenopausally and unilaterally, 70 290 the relative risk in a first-degree relative is 1.2, only slightly 75 310 higher than the 2.3 percent rate in the control group.1823 80 330 These and other studies suggest hereditary factors are im­ From Seidman and Mushinski12 portant in premenopausal breast cancer,22,24 while he­ reditary factors are thought to have a lesser role in postmenopausal disease with environmental factors pre­ rate of 20 per 100,000 while women aged 40 to 50 years dominating.12 have rates of 80 and 180 per 100,000.12 Thereafter the Women with previous breast cancer, either invasive or incidence increases at a slower rate12 (Table 1). in situ, are at increased risk. If the patient has had invasive Marked differences exist in the incidence of breast can­ breast cancer, the risk in the contralateral breast is about cer worldwide, with the highest rates in North America four to five times the risk of women of comparable age and northern Europe, intermediate rates in southern Eu­ in the general population.14,25,26 Women with carcinoma rope and South America, and the lowest rates in Asia and in situ can be separated into two groups: those with lobular black Africa.13 Further, in low-incidence areas such as carcinoma in situ (LCIS), and those with intraductal car­ Japan, the rate actually declines postmenopausally.14 Al­ cinoma in situ (IDCS). These groupings are based on dif­ though genetic factors may have some role, environmental ferences in tumor pathology as well as differences in tumor factors appear to predominate,14 as illustrated by breast behavior. Lobular carcinoma in situ is considered a cancer rates in Japanese immigrants to the United States. preinvasive lesion, characteristically being multicentric The immigrant group developed disease at rates similar and bilateral.27,28 Twenty-five to 33 percent of women to the low levels found in Japan15; however, first-gener­ with LCIS will develop invasive cancer with an equal ation offspring demonstrated higher rates, and second and chance of occurrence in either breast.28 Development may third generations attained an incidence similar to the gen­ occur many years after the initial diagnosis, with 50 per­ eral American population.16 cent occurring after 15 years and 38 percent after 20 Discussions of breast cancer risk factors generally in­ years.27,28 Patients with biopsy-proven IDCS have about volve an estimate or calculation of the relative risk of a 40 percent chance of developing invasive breast can­ women developing breast cancer when these women cer.29,30 These cancers are located predominantly in the manifest the specific risk factor. These relative risks are quadrant of the initial biopsy, with an average latent pe­ usually derived by comparing the breast cancer rates of riod prior to diagnosis of about ten years.29,31 IDCS lesions women with the risk factor with the rates of women in a are often multicentric and predominantly unilateral. specific base or control population.17-19 Cancer risk in Another important risk factor is proliferative epithelial these control or reference groups is usually on the order breast disease as demonstrated by biopsy.3,17 A large ret­ of 2 to 4 percent,17-19 a rate considerably less than the rospective study by Dupont and Page17 found that women cumulative lifetime risk of 9 percent now calculated for with atypical lobular or atypical ductal hyperplasia and the overall American female population.12,19 This 9 per­ women with atypical hyperplasia and a family history of cent figure includes all women and thus encompasses all breast cancer had about five times and 11 times, respec­ risk groups.19 Because baseline risks used in many studies tively, the risk of women with nonproliferative disease. are often for specified periods, such as 20 to 30 years, and Specifically, women with atypical hyperplasia and women in women who have not completed their life span17'18 with atypical hyperplasia and a family history of breast when a relative risk is stated, it must be used only in the cancer had a 10 percent and 20 percent incidence, re­ context of the referenced study. For example, if the control spectively, of cancer 15 years after biopsy, while women population cancer risk is 2 percent, then a two times rel­ with biopsy-proven nonproliferative lesion had only a - ative risk would be 4 percent. A second method in general percent incidence over the same period.17 use is to state risk compared with similarly aged controls. The presence of one or more of the foregoing risk factors 562 THE JOURNAL OF FAMILY PRACTICE, VOL. 26, NO. 5,198® Early d ia g n o s is o f b r e a s t c a n c e r generally places the women who manifest them into the sequent embolization transforms a local process into a major- or high-risk category requiring regular follow-up potentially devastating systemic disease.37-40 It is this sys­ with physical breast examination and mammography be­ temic dissemination that is the overriding factor in breast • 39-42 ginning at the time of the appearance or discovery of the cancer prognosis.
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