MAMMOGRAPHY SCREENING

About?
Breast Cancer briefly
Screening methods briefly
Mamography Screening Protocols
Efficiency and Recent Discussions

Breast
Mass: benign / malignant

Ductal carcinoma
Ductal carcinoma in situ
Papilloma
Lobular carcinoma in situ
Fibrocystic changes
Fibroadenoma
Sclerosing adenosis

Breast Cancer
Significant health concern of women
Most commonly diagnosed
Second leading cause of cancer death

Risk increases
with age
Screening; our
only option

SCREEING
Complicated
Self examination : noninvasive. Has not beneficial effect. Increases
the number of biopsies performed.
Mamography : 1963-80 studies decreased risk of breast cancer
death. Now being questioned as a screening method
MRI : better at ruling out breast cancer but more likely to produce
false positive results. Suggested for high risk women
USG : suggested for younger high risk women However European
Group for Breast Cancer Screening : no evidence to support its use
as a screening at any age!
Scintimammography no role as a screening method
PET : no clear advantage over others. High cost

Back to MAMMOGRAPHY
X-ray examination of breast

Some breast cancers

identified 2 years before
they reach a size detectable by palpation

American College of Radiology

"Detection, characterization
and evaluation of findings
suggestive of breast cancer
and other breast disease"

Mammography
Protocols: diagnostic / screening
Diagnostic briefly ;
Complaints/symptoms
Implants
Previous history of breast cancer follow up

Screening :
Age
Asymptomatic

MAMMOGRAPHY AS SCREENING
A) Women <40 who are asmptomatic
but considered HIGH RISK;
Group1: Personal/family history of mutations of BRCA1 or BRCA2 genes
Group2: Very strong family history of breast cancer
2 cases of close family relatives diagnosed below 50
30. s
:
e
ag ogram
3 or more cases in close family relatives with at
g
tin mam
r
a
t
least one diagnosed below 50.
***S nnual
***A

Group3: History of chest radiation received between ages of 10-30. Starts

8 years after but above the age 25.
Group4: Biopsy proven lobular neoplasia, atypical ductal hyperplasia,
ductal carcinoma in situ, invasive breast cancer, ovarian cancer yearly,
regardless of age.

MAMMOGRAPHY AS SCREENING
B) Asymptomatic women age 40 and older
who are at avarage risk for breast cancer
C) Self requesting
women
D) Women with
breast
augmentation

MAMMOGRAPHY AS SCREENING
Adequate craniocaudal (CC) and
mediolateral oblique (MLO) views of each
breast
There is no defined upper
age limit at which annual
mammography screening
should end.
Most effective between ages
50 and 59

Recent Discussions
SWISS MEDICAL BOARD, 2013
Benefits of mammography screening
overweighed the harms
20% risk reduction in mortality BUT at a cost
of repeated mammographies, subsequent
biopsies and overdiagnosis !
21.9% overdiagnosis !
Unneccessary treatments,
surgical interventions,
radiotherapy, chemotherapy and negative psychological effects

Recent Discussions - Shock goes

on...
10 year course of annual screening :
73% likely to have false positive mammogram
14-20% undergoes unneccessary biopsies
0.6-2.8 % underdiagnosed with breast cancer

Recent Discussions
Swiss Medical Board emphasizes; women are too
pessimistic about their chance of developing breast
cancer.
Do women really know the efficiency of mammography?
Not Really; Most are overoptimistic! According to a
survey; only 20% women estimated the relative risk
reduction of mammography truelly. The rest thought
that it reduces mortality by 50-75%

WHAT IS THE CORRECT ESTIMATE?

Recent Discussions
Another study - Elmor and
Carney; studied the computer
aided detection of breast
cancer . Sensitvity of
mammogram decreases and
false positive results increase !

Overdiagnosis

Overdiagnosis in Cancer, Welch and Black, 2009

Recent Discussion
Peter C. Gotzsche; No relation between
breast cancer mortality and screening
effectiveness. The effect of screening is
not clear since the size of bias is similar
to the estimated effect. But it seems like
biases are in favor of screening.

NHS; psyhological
consequences of false positives
Psychological distress for 3 years
affecting mood and functioning
Prevents 3% women from attending
their next screening

What else NHS says?

Sufficient information must be given
about their recall/procedures but
not too detailed to make them
scared and distressed.

On the other hand

Researchers and medical staff are
concerned that if women are fully informed
on efficacy of mammography, participation
to screening will reduce and this will affect
screening programs considerably.
However all agrees that women should be
educated and informed about the facts,
benefits and harms sufficiently to make
their own decisions.

What to do now?
Apart from informing
women about efficiency
of mammography, there
is not much to do since
it is the only justified
way of screening and
detection of early
breast cancer and
diseases.
Some experts think that
overdiagnosis and false
positives are better
than missdiagnoses.

What to do now?
Reccomendations by Swiss Medical
Board:
No new systematic mamography
screening programs should be
introduced
A time limit should be placed on
existing programs
Quality of all forms of mammography
screening should be evaluated
Clear, balanced information should be
provided to women regarding the
benefits and harms of screening

Summary
Mammography
High density of breast is contraindication
Compared to other methods, best way of
detecting early cancer.
Mortality reduction: 20%
But high rates of overdiagnosis and false
positives : unneccessary biopsies, surgeries,
chemotherapies and radiotherapies.

Better method of screening is needed.

THANK YOU FOR YOUR

PATIENCE !