Evidence Based Answers CLINICAL INQUIRIES from the Family Physicians Inquiries Network

Patricia Goodemote, MD, and Deana Mitchell, DO What is the best way to screen Eglin Air Force Base Family Medicine Residency, for cancer in women Eglin AFB, Fla William Nichols, MLS Eglin Air Force Base, Fla with implants?

Evidence-based answer is best. It is considered as recommendation [SOR]: B, limited number effective for screening women who have of retrospective and prospective cohort undergone augmentation mammoplasty studies). This question has not been well as those who have not (strength of studied, however. ® Dowden Health Media ❚ Evidence summary dence interval [CI], 29.3%–61.5%) than BreastCopyright augmentationFor personal is one of the mostuse thoseonly without (66.8%; 95% CI, 60.4%– popular plastic in the United 72.8%); P=.008).2 Similarly, in symptom- States; an estimated 291,350 such pro- atic women diagnosed with breast can- cedures were performed in 2005.1 Breast cer (41 augmented, 145 nonaugmented), FAST TRACK cancer occurs in 1 of every 8 women; a screening sensitivity was lower in the aug- Mammography projected 32,000 women who received mented women (73.2%) than the non- breast implants in 2003 will develop can- augmented women (81.4%)—although is considered cer.1 Available research has focused on the results weren’t signifi cant P( =.25). as effective for retrospective and prospective designs be- Despite lower screening sensitivity, screening women cause of the ethical limitations of experi- breast tumors in asymptomatic women, who have breast mental designs. No US studies directly whether augmented or not, had similar compare mammography with alternate characteristics, except for larger tumor implants as for screening methods, such as sonography size (3 mm) at diagnosis in augmented those who do not or magnetic resonance imaging. women. Symptomatic women with breast implants had cancers that were smaller, With implants: Lower screening lower-grade, and more likely to be es- sensitivity but similar prognosis trogen receptor dependent and invasive Studies show that augmentation decreas- (P=.052) compared with nonaugmented es the sensitivity of screening mammog- women. The authors concluded that aug- raphy but doesn’t affect mentation doesn’t infl uence the prognostic prognosis.2 A 2004 prospective cohort characteristics of tumors, and they recom- study of 986,270 women found that, mended screening mammography at ap- among asymptomatic women diagnosed propriate intervals. with breast cancer (40 augmented, 238 Two other prospective cohort studies nonaugmented), the sensitivity of screen- produced similar fi ndings. A 2006 study ing mammograms was lower in women of 4082 breast cancer patients conclud- with breast implants (45%; 95% confi - ed that mammography yielded a false-

482 VOL 57, NO 7 / JULY 2008 THE JOURNAL OF FAMILY PRACTICE

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482_JFP0708 482 6/18/08 2:24:13 PM negative rate of 41.4% in augmented pa- survival rates are no different.1-3,6 This is tients compared with 8.8% in nonaug- true whether a screening mammogram or mented patients (P<.0001).3 However, diagnostic mammogram is used. In any both augmented (n=129) and nonaug- case, all available fi ndings suggest that mented (n=3953) women had a compa- clinicians who perform mammography rable prognosis at diagnosis. The authors should be trained in imaging the aug- of the studies suggested diagnostic mam- mented breast.6-8 mography for augmented patients and correlation with physical exam fi ndings. Recommendations An earlier study of 2956 cancer The National Cancer Institute indi- patients found that mammography cates that the best screening method for detected an abnormal breast mass in augmented women is mammography 66.3% of augmented women compared performed at a facility with employees with 94.6% of nonaugmented women trained in implant imaging.7 The Ameri- (P=.001).4 No signifi cant differences can College of Radiology’s practice were noted in cancer characteristics at guidelines affi rm that mammography diagnosis or survival rates (P=.78). The is the best imaging tool available.8 The authors of this study concluded that American College of Obstetrics and Gy- mammography should be used for aug- necology and the US Preventive Services mented women until a more effective Task Force don’t comment on screening screening tool is found. augmented women. ■

Sonography vs mammography: Acknowledgments The jury is still out The opinions and assertions contained herein are the private views of the author and not to be construed as Although studies comparing screening offi cial, or as refl ecting the views of the US Air Force methods have not been performed in the Medical Service or the US Air Force at large. United States, a small Taiwanese study directly compared ultrasound to mam- References mography in 105 women without breast 1. Tuli R, Flynn RA, Brill KL, et al. Diagnosis, treat- FAST TRACK ment, and management of breast cancer in previ- implants. This retrospective cohort study ously augmented women. Breast J. 2006;12:343- Breast found sonography to be a more useful 348. 2. Miglioretti DL, Rutter CM, Gellar BM, et al. Effect augmentation diagnostic tool than mammography in of on the accuracy of mam- Taiwanese women.5 Sonography had the mography and cancer characteristics. JAMA. decreases highest sensitivity (87.5%) compared to 2004;291;442-450. 3. Handel N, Silverstein MJ. Breast cancer diagnosis the sensitivity physical examination (50.0%) and mam- and prognosis in augmented women. Plast Recon- of screening mography (25.5%). str Surg. 2006;118:587-593. 4. Skinner KA, Silberman H, Dougherty W, et al. mammography Sonography was recommended as the Breast cancer after augmentation mammoplasty. imaging tool for Asian women with small- Ann Surg Oncol. 2000;8:138-144. but doesn’t er, denser . However, it is unclear 5. Hou M-F, Ou-Yang F, Chuang C-H, et al. Com- parison between sonography and mammography affect breast whether this result applies to US women for breast cancer diagnosis in oriental women af- ter augmentation mammaplasty. Ann Plast Surg. cancer prognosis or women who have undergone breast 2002;49:120-126. augmentation . 6. Hoshaw SJ, Klein PJ, Clark BD, et al. Breast im- plants and cancer: causation, delayed detection, and survival. Plast Reconstr Surg. 2001;107:1393- Training in implant imaging 1407. is needed 7. National Cancer Institute. Screening Mammo- grams: Questions and Answers. September 4, Mammography appears to be the most 2007. Available at: www.cancer.gov/cancertopics effective screening method for women /factsheet/Detection/screening-mammograms. with breast implants. Despite the small Accessed November 2, 2007. 8. American College of Radiology. ACR Practice differences in cancer characteristics at di- Guideline (amended 2006). Available at: www.acr. org/SecondaryMainMenuCategories/quality_safe- agnosis between augmented and nonaug- ty/guidelines/breast/screening_mammography. mented women, overall prognosis and aspx. Accessed November 2, 2007.

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