1. Breast cancer screening 93.07.23

4. Recommendations for breast cancer screening چه شواهدی برای خطر وجود دارد؟ برای غربالگری چه باید کرد؟

5. Evidence about the risk of the condition:

6. The incidence of breast cancer in developed countries is high compared to under-developed countries: o USA 2014, Estimated new cases; 232,670 o USA2014, Estimated Death; 40,000 o 89.7 per 100,000 women in Western Europe. o 19.3 per 100,000 women in Eastern Africa The incidence of breast cancer is increasing in the developing world due to: o Increase life expectancy, o Increase urbanization and o Adoption of western lifestyles. o Risk reduction with prevention, cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages. o Breast cancer survival rates vary greatly worldwide, 80% or over in North America, Sweden and Japan 60% in middle-income countries Below 40% in low-income countries o Although breast cancer is thought to be a disease of the developed world, almost 50% of breast cancer cases and 58% of deaths occur in less developed countries Why Screening? Early detection to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.

7. How? Population-based cancer screening Done in the context of high-standard programmes Target all the population at risk in a given geographical area with high specific cancer burden Everyone who takes part being offered the same level of screening, diagnosis and treatment services WHO promotes breast cancer control within the context of national cancer control programmes and integrated to noncommunicable disease prevention and control. Cost-effective when started early.

8. RISK FACTORS

10. Breast cancer risk management

11. Family history of premenopausal bilateral breast cancer or Family history of premenopausal bilateral breast cancer or Premenopausal breast cancer in a mother and sister, Premenopausal breast cancer in a mother and sister, Breast and ovarian cancer in close relatives, Breast and ovarian cancer in close relatives, Evidence of genetic susceptibility in mutations of BRCA1 or BRCA2 (and p53) (35-85%, lifetime), Evidence of genetic susceptibility in mutations of BRCA1 or BRCA2 (and p53) (35-85%, lifetime), Personal history of lobular carcinoma in situ, atypical hyperplasia, Personal history of lobular carcinoma in situ, atypical hyperplasia, Mammographic density occupying more than 75% of the breast volume. Mammographic density occupying more than 75% of the breast volume.

13. Weak risk factors (risk up to two times normal) are: o Family history of postmenopausal breast cancer, o High socioeconomic status, o Nulliparity, o Later age at first birth (>30 years versus <20 years), o Later age at menopause (>55 years versus <45 years), o Early age at menarche ( 15 years), o Postmenopausal obesity, o Alcohol consumption (daily versus never), and diet.

14. Breast cancer risk prediction tools

15. Breast Cancer Screening Tests are used to screen Tests are used to screen o Three tests are used by health care providers to screen for breast cancer: Mammogram ( Mammogram ( Film mammography, Full-field digital mammography), Clinical breast exam (has not been shown to decrease the chance of dying from breast cancer). MRI MRI (in women with a high risk of breast cancer) Newer tests, such as tomography, are under evaluation

16. Ultrasonography (used for diagnostic follow-up of an abnormality seen on screening mammography, to clarify features of a potential lesion, scanning of a questionable findings) Ultrasonography ( Thermography Tomosynthesis (a modification of digital mammography, three-dimensional images, using a moving x-ray source and a digital detector). Tissue sampling (Fine-needle aspiration, Nipple aspiration, Ductal lavage). Tissue samplingFine-needle aspirationaspiration Ductal lavage Other screening tests are being studied in clinical trials.

17. Effectiveness of mammography Systematic reviews of randomized controlled trials of mammography screening in women ages 40 to 69 years found a long-term 15 to 20 percent decrease in breast cancer mortality. Because most of these studies were begun before 1990, there is increasing concern that the trials do not reflect modern therapy. More recent modeling and community studies suggest that breast cancer screening may be less effective than in the past because of increasingly effective therapy.

18. MRI or (NMRI), is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. MRIradio waves 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.gene A family history with breast cancer.family history Certain genetic syndromes, such as Li-Fraumeni, ataxia-telangiectasia, Peutz-Jeghers syndrome or Cowden syndrome.syndromesLi-FraumeniCowden syndrome MRIs find breast cancer more often than mammograms do, but it is common for MRI results to appear abnormal even when there isn't any cancer (more sensitive but less specific than mammography). abnormal. MRI (magnetic resonance imaging) in women with a high risk of breast cancer

19. Does breast cancer screening save lives or do harm? One of the great controversies at present is the issue of breast cancer screening and overdiagnosis.

20. Breast cancer screening 'may not reduce deaths'

21. HARMS FROM SCREENING Women should understand the possibility of both benefits and harms from screening.  False-positive results  Discomfort  Radiation risk:  Mammograms expose the breast to radiation.(1.86 vs. 2.37mGy for digital vs. screen film)  Overdiagnosis:  Refers to disease that is detected by screening that would not have caused morbidity or mortality if it had not been found and lead to: Unnecessary testing and treatment, Psychological consequences (Anxiety) Other consequences of being diagnosed with and treated for cancer.

22. Bilateral mammograms Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. BSE: is an option for women starting in their 20s. Women should be counseled on the benefits and limitation of breast self-examination and should know how their breasts normally look and feel and report any breast change promptly to their health care provider. CBE: about every 3 years for women in their 20s and 30s and every year for women 40 and over. For high risk women, CBE every 6 months is recommended at age 30.

23. MRI High risk women (greater than 20% lifetime risk) should undergo MRI and mammography every year (started at age 30) (The number of women who fall into this category is small: less than 2% of all the women in the US.) ( or for high risk women, screening begins 5-10 years earlier than the age of index case) Medium risk women (15%-20% lifetime risk) should talk to their health care professional about the benefits and limitations of adding MRI to their yearly mammographic screening. low risk women (less than 15% lifetime risk) are not recommended to undergo additional MRI screening. Screening and counselling for families who have the appropriate history but fail to demonstrate BRCA1 or BRCA2 mutations should be exactly the same when the mutations are found.

24. Genetic testing Genetic testing: Genetic tests can be done to look for mutations in the BRCA1 and BRCA2 genes (or some other genes linked to breast cancer risk). BRCA1 and BRCA2: Breast cancer & ovarian cancer ATM: ataxia-telangiectasia & breast cancer. TP53: Li-Fraumeni syndrome & breast cancer. CHEK2: CHEK2: with or without the Li-Fraumeni & breast cancer. PTEN: Cowden syndrome & breast cancer. CDH1: diffuse gastric cancer, & invasive lobular breast cancer. STK11: Peutz-Jeghers syndrome & breast cancer.

25. The American Geriatric Society recommends annual or at least biannual mammography for women up to age 75 years, and after that age every 2-3 years, if the woman has a life expectancy of more than 4 years. ACS “2014” are recommended yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Age to stop Screening

26.  A detailed family and personal history is an important step in the evaluation of an individual woman’s risk of developing breast cancer.  For high-risk women who have an inherited predisposition due to mutations in BRCA1 or BRCA2, genetic testing will stratify that person’s risk further. Knowing whether her risk is high, moderate, or low allows a woman to make decisions regarding appropriate risk-reducing interventions, strategies, and lifestyle changes.  Moderate-risk women should be encouraged to have an increased awareness of their risk and could benefit from participating regularly in breast screening programs as well as clinical trials evaluating breast cancer risk-reducing strategies.  Low-risk women should follow the breast screening guidelines for the general population.  All women should be advised that there are beneficial effects from a lifestyle that includes: o moderate exercise, o a low-fat high-fibre diet, and o low alcohol consumption.  For high-risk women, management options include: Intense screening Surveillance protocols or Prophylactic mastectomy.