Breast cancer incidence has been on the rise in India and currently it has the highest footprint in our country among all cancers. One in 28 Indian women develop breast cancer in their lifetime and mortality rates are as high as 50%. It is more common in urban areas (1 in 22) as compared to rural areas (1 in 60).
This data emphasises the need for improving awareness and screening. The goal of screening is early cancer detection to improve outcomes and reduce mortality. Randomised control trials in the west have reported a 30 per cent mortality reduction and 70 per cent of their cancers present at Stage I and II. In India, more than 70 per cent of cancers present at an advanced stage. Screening in India is largely opportunistic and currently there are no screening guidelines for asymptomatic women.
SCREENING MODALITIES
Self-breast examination: Periodic self-inspection of your breasts so that one may seek medical attention when a change is noted Clinical breast examination: Breast examination by a health care professional Mammography: Low dose X-ray picture of the breast. It is the only test that has proven to save lives Ultrasonography: Good adjunct to mammography in assessing dense breasts Magnetic resonance imaging: Not a routine screening tool but may be useful in high risk patients
WOMEN AT HIGH RISK FOR BREAST CANCER
Carriers of genetic mutations
Strong family history of breast cancer without a mutation
History of chest-wall radiation therapy Personal breast cancer history
Personal history of premalignant conditions (Atypical Ductal Hyperplasia, Atypical Lobular Hyperplasia and Lobular Carcinoma In Situ) If you consider yourself at high risk for breast cancer, please discuss the appropriate screening recommendation for you with your health care provider.
SCREENING GUIDELINES FOR AVERAGE RISK WOMEN
There is no consensus on the ideal screening guideline.
AMERICAN CANCER SOCIETY
Annual mammography from 40 – 55 years of age
Biennial mammography after 55 years of age until the individual is in good health (Life expectancy of 10 years)
NATIONAL HEALTH SERVICES (UK)
Mammography every three years from 50 – 71 years of age Breast Cancer incidence peaks at 40-50 years in Indian women which is a decade earlier in comparison to women in the west. It would be appropriate to consider screening annually from 40-55 years of age and biennially after 55 years in our population.
DISADVANTAGES OF SCREENING
The major harm of screening is overdiagnosis (10 – 20% of screen detected cancers) which is the diagnosis of a disease that will never cause symptoms or death during a patient’s expected lifetime. Patients may be subjected to harmful treatments without significant benefit.
Radiation risk is minimal. The dose (4mGy) is similar to that received by an individual over seven weeks from natural surroundings.
False positives will warrant further workup and turnout to be non-cancerous, resulting in unnecessary biopsies, anxiety and cost.
Interval cancers are a limitation of screening and become apparent in the period between two screenings. These include fast growing and mammographically occult cancers.
Routine screening has been successfully implemented in western countries and has proven to save lives and detect cancers early, improving outcomes. Though nationwide standardised screening cannot be implemented in India due to various resource, cultural and socioeconomic constraints, promoting awareness and opportunistic screening can significantly improve breast cancer outcomes.
