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Breast Cancer Surveillance

Disclaimer

Disclaimer: The most accurate medical advice requires a complete history and physical with a personal consultation. This is rendered only as general information and is not medical advice. This information is not meant to be comprehensive. This information is not clinical advice on breast screening. This information may not be the most recent information on breast cancer screening. Medical advice can only be obtained by personal contact with a qualified professional. This response does not establish a physician patient relationship. The information below is based on the medical literature, personal communications with colleagues, and personal opinion based on over 25 years of clinical experience.

Breast cancer affects about 1 out of 8 women in the United States (about 12% of women). Breast cancer screening is a very important part of general medical care. Breast cancer screening is routinely provided by primary care physicians, including Family practice, Internal medicine, and Obstetric-Gynecology physicians. Routine (on a regular basis) breast cancer screening is usually not provided by Plastic surgeons. Breast cancer screening is provided by Plastic surgeons as a part of the work up for breast surgery including breast augmentation. The main reason that Plastic surgeons do not routinely provide breast cancer screening is continuity of care. It is important that breast cancer screening be provided in a consistent, organized, and methodical manner, and breast screening records are archived in one location. This is because it is just as important to understand if anything has changed in the breast tissue as it is to understand the existing breast architecture. If an area in the breast is “stable” in the breast, this is another piece of information in some circumstances to make a decision. In general, changes in the body may raise suspicion to a level that further investigation is indicated.

The process of breast screening involves many different elements and all are important. The first important element is patient awareness of the screening process and the patients responsibility to seek breast screening. The first responsibility of the patient is the self breast exam. A treatise on self breast exam is beyond the scope of this document. The American Cancer Society published that “it is acceptable for women to choose not to do BSE (breast self exam) or to do BSE (breast self exam) occasionally”. The United States Preventive Services Task Force published that for all women they “recommend against teaching breast self examination (BSE)”. Both these groups are apparently advocating for the concept of “body unawareness” and that changes in the body are unimportant, which defies the most basic level of common sense. These recommendations are likely based on “statistics” which many very experienced clinical physicians think are a great disservice to the public in this circumstance. Because a “study” shows that self breast exams does not reduce breast cancer mortality (deaths) does not mean that a woman should ignore her breasts. Many very experienced clinical physicians believe that the self breast exam is a very important part of breast cancer surveillance. The American Cancer Society published that the “harms” of the self breast exam leads to “more breast biopsies and diagnosis of more benign breast lesions”. The “harm” in this circumstance appears to be healthcare dollars. While there are many ways to save money in the United States healthcare system, skimping on breast biopsies is not one of them. Nor is limiting imaging procedures based on healthcare dollars. Patients should discuss the self breast exam with their primary care physician for guidance on this screening exercise. One should always be very aware of changes in the body, and should seek medical advice when any concerns arise.

Breast imaging is a well known screening tool for breast cancer. The mammogram is the most well known breast imaging procedure. The mammogram is a type of x-ray that is used to detect masses and/or micro calcifications. The mammogram is not a perfect breast cancer screening tool, but it is a front line imaging tool used to detect breast cancer. The amount of radiation received from a standard mammogram using modern technology is very small, and approximates the amount of radiation exposure from natural surroundings in about 7 weeks. There has been controversy about the best age at which to start breast imaging (mammograms). The United States Preventive Service Task Force rejected “routine screening mammograms” for women 40-49. The recommendations issued by the USPSTF regarding screening mammography have not been adopted by the majority of professional societies or federal agencies.
They later “updated the language of their recommendation regarding women under 50 years of age to clarify their original and continued intent”. Their “conclusions” were thought to be flawed based on many issues, as chronicled by The Sibley Group of Johns Hopkins Medicine (link to reference below).

Facts

  1. There is universal agreement that mammography saves lives.
  2. 75% of breast cancers occur in women who are not at high risk for breast cancer.
  3. 25% of breast cancers occur in women in their forties.
  4. The most number of years of life lost to breast cancer are for women who develop breast cancer in their forties.
  5. Mammography does decrease breast cancer deaths for all age groups screened, including women in their forties on the order of 30% based on real experience in the US and Europe as well as based on the majority of randomized control trials.
  6. Mammography finds cancers at an earlier more curable stage.
  7. Most (75%) women who die from breast cancer do not have mammographic screening.
  8. There is agreement that more women will die of breast cancer if the screening interval for women 50-74 is extended from annual to biennial intervals. Allowing a cancer to grow for an additional year will result in more aggressive and morbid treatments. Earlier cancers are more favorable and can be treated with less cost.
  9. Women and physicians should rely on American Cancer Society Guidelines to inform them of the best screening options available.

Flaws

  1. There were no breast cancer experts on the 16 member panel. Three members are associated with insurance companies including the Medical Director of Group Health Cooperative, Medical Director/CEO of Health Partners, and a member of the Blue Cross Blue Shield Medical Advisory Group.
  2. The panel is a government sponsored body, not independent.
  3. The panel ignored actual experience and randomized control trials and relied on mathematical models to draw conclusions.
  4. The panel commissioned its own computer models, not subjected to critical peer review. They ignored hundreds of respected journal articles and rejected both randomized control trials and already existing modeling studies.
  5. The panel disregarded evidence that digital mammography is more accurate in women in their forties. Data are based on film screen mammography which is being used less and less in this country. Sibley uses all digital mammography.
  6. The cost to screen and diagnose breast cancer for women in their forties should not be considered a “harm.”
  7. Actual harms are minimal and acceptable. The additional biopsies generated by screening mammography do not affect women in their forties as much as other age groups.
  8. Although this panel cites the use of evidence based medicine their recommendations are not based on evidence. Despite documented decreased deaths from breast cancer for women in their forties they withdraw support for screening mammography. Despite admitting there will be more deaths from breast cancer for women screened biennially ages 50-74 they withdraw support for annual screening. Despite having no evidence for or against screening women 75 and older they withdraw support. Despite having no scientific evidence that screening only high risk women (who account for only 10-25% of breast cancer cases) will decrease breast cancer mortality they support screening this population.
  9. Health and Human Services has so far rejected plans to modify their recommendations for screening based on this panel’s recommendations.

Read the Johns Hopkins reference here

Comparison of USPSTF and ACS Screening Guidelines

USPSTF
ACS
Biennial screening mammography beginning at age 50.
Annual screening mammography beginning at age 40.
Evidence is insufficient for assessing the additional benefits of screening mammography in women past age 74.
Continue annual screening mammography for as long as a woman is in good health.
Recommends against clinicians teaching women how to perform breast self-examination.
Breast self-examination is optional. Women who choose to do breast self-examination should receive instruction from their health providers.
Evidence is insufficient for assessing the additional benefits of clinical breast examination beyond screening mammography in women 40 years and older.
Recommends clinical breast examination at least every three years for women in their 20s and 30s, and annually for women aged 40 and older.
Evidence is insufficient for assessing the additional benefits and harms of MRI as a screening method for breast cancer.
In addition to screening mammography, annual MRI screening is recommended for women with greater than 20% lifetime risk of breast cancer.

Screening guidelines for high risk patients are different (more rigorous) than screening guidelines for the “normal population”.

Supplemental screening is also used in high risk patients and patients that have had a mammogram and need further study. Magnetic Resonance Imaging (MRI) uses magnetic field, radio frequency pulses and a computer to form images of the body to create multiple images of the body, in this case the breast. MRI is not good for the detection of micro calcifications which can be seen in mammograms. MRI is also used to study high risk patients, including those that have the BRCA gene or patients with a strong family history. MRI is not recommended as a primary screening tool because it can fail to show some breast cancers that would be detected on a mammogram. Ultrasound is another type of exam that is used for secondary screening. Ultrasound uses high frequency sound waves to develop images of the body. Like MRI, ultrasound is not a primary screening tool but is used to study an abnormality already found in a mammogram. Ultrasound can also be used to guide a biopsy of the breast which improves accuracy and can also minimizes the unnecessary removal of normal breast tissue.

Many new breast screening tools are on the horizon. Digital tomosynthesis is a new type of breast imaging that uses multiple x-rays that are compiled and analyzed by a computer. The initial studies with digital tomosynthesis are promising. Technology changes and improves very rapidly in Radiology and will continue to improve in the future.

Patients that have gotten a breast augmentation should receive breast cancer screening, the same screening as for patients that have not had a breast augmentation. Initial concerns that patients getting a breast augmentation could be at greater risk for breast cancer are unfounded, with the possible exception of anaplastic large cell lymphoma (with a slight increase, see section below). There have been numerous studies that show a lower risk of breast cancer in patients that have received breast augmentation. One study showed a “significant” reduction in the risk for breast cancer. Studies have also shown that there is not an increase in other cancers as a result of breast augmentation. Some cancers are slightly increased in patients that have had breast augmentation but those increases appear to be the result of lifestyle rather than the breast implants per se. Breast implants are not thought to affect the general physical health of patients.

There is substantial evidence that patients with breast implants have a slight increase in risk for anaplastic large cell lymphoma of the breast. The chances of developing anaplastic large cell lymphoma is very small and this entity appears to have a more indolent course than other types of anaplastic large cell lymphoma. Some of the cases reportedly resolved when the breast implant was removed. It was reported that most of the cases of anaplastic large cell lymphoma were in patients with textured implants.

In the work up of patients considering breast augmentation, cancer risk and cancer screening is considered. While there is no single set of definitive guidelines for breast cancer screening, the guidelines of the American Cancer Society are a good reference and starting point for guidance.

Read the United States Preventive Services Task Force breast screening recommendations here

Read the American Cancer Society breast cancer information here