Tag: breast cancer

Screening mammography – is it harmful or helpful?

Hard to think that it could be harmful when so many women go through the procedure.

In Medicine Hat, 1989 was the first full year of mammography when 1046 mammograms were done at the Medicine Hat Regional Hospital (MHRH). These were mostly for screening (women with no palpable breast lump or symptoms) and some were diagnostic (women with breast lumps or with symptoms).

In the last four years, MHRH has transferred mammography services to the private clinic (Blair Stubbs and Associates Radiology Inc.). In 2001, Blair Stubbs did total of 5229 mammograms. In 2002, they did 7454 mammograms (screening 5857, diagnostic 1597).

An article in the New England Journal of Medicine (NEJM) says that 71 per cent of women in the United States who were 40 years of age or older have undergone mammography during the previous two years – an increase from 54 per cent in 1989.

Good news is that since 1973, mortality from breast cancer has been decreasing steadily. Is this due to treatment or due to early diagnosis from screening? Experts are not sure. Could be due to both.

For almost 20 years, there is a uniform agreement among the experts that screening mammography saves lives (20 to 35 per cent reduction in mortality) among women in their 50s and 60s, although the disagreement persisted about the usefulness of screening mammography in other age groups, says the NEJM article.

For many years, there has been controversy over the use of screening mammography for women in their 40s. Analysis of multiple studies show that screening in this age group decreased 15-year mortality from breast cancer by about 20 percent.

What about older women? Studies in the Netherlands found that screening women between 65 and 74 years of age led to a 55 percent decrease in mortality from breast cancer, says the NEJM article.

Sounds wonderful. But are there any risks associated with mammograms?

False positive mammograms and over diagnosis can be harmful. Here are the numbers:

-An average of 11 percent of screening mammograms is read as abnormal and necessitates further diagnostic evaluation.

-Breast cancer is found in about three percent of women with an abnormal mammogram (representing 0.3 percent of all mammograms).

-On average, a woman has about a 10.7 percent chance of a false positive result with each mammogram.

-After 10 mammograms, about half of women will have had a false positive result, which will have led to a needle biopsy or an open biopsy in 19 percent of cases.

-False positive mammograms increase patients’ anxiety.

-12 months after a false positive mammogram, women initiated more health care visits for both breast-related and non–breast-related problems.

Some women find mammography painful, there is a small radiation exposure, and false negative interpretations are possible in about 15 per cent of mammograms.

Like any screening and diagnostic test, mammography is not a perfect science. It should be interpreted with care in combination with clinical examination, needle biopsy, and any other tests which may become necessary to come to a diagnosis.

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“The secretion of fluid from the nipple of a newborn baby or any mature woman is not unusual, nor is it a sign of breast pathology,” says a textbook, Breast Diseases.

Nipple discharge is not an uncommon complaint. At one breast clinic, using a special suction device, researchers were able to demonstrate nipple secretion in 83 per cent of the consecutive breasts examined.

Statistically, only five percent of the patients with breast problems present with nipple discharge. But it is the third most common complaint after breast lumps and pain. Breast lumps – with or without pain – account for 70 to 80 per cent of complaints.

What information a physician wants when a patient presents with nipple discharge?

1. Is it spontaneous or elicited? If it is elicited then probably it is benign. To be significant, nipple discharge should be true, spontaneous, persistent and non-lactational.

2. Is it from one nipple or both nipples? If it is from both nipples then the chances of serious pathology is small.

3. Is it from one duct or multiple ducts? Discharge from one duct is of more concern than from multiple ducts.

4. What is the color and consistency of the discharge? If it is milky (galactorrhea), multicolored and sticky, or pus then it is probably benign. Pus needs to be drained and infection taken care of. Galactorrhea should be investigated for a pituitary tumor. A multicolored and sticky secretion is usually due to dilated ducts (duct ectasia) near the nipple.

5. Is the discharge surgically significant? Yes, if it is clear (watery), serous (yellowish), pink (blood stained) or bloody. It may indicate presence of a polyp in a duct, fibrocystic changes, pre-cancerous changes or cancer.

What about investigations?

A smear from the discharge can be sent for microscopic examination to see if there are any cancer cells. But it is not a very reliable test in this type of situation. A mammogram may or may not pick up a lump. Special x-ray of the nipple with dye in the duct (ductogram) can be helpful if it picks up a lump.

So, how do we know if the discharge is due to cancer? Quite often one can never be sure. But certain signs and symptoms may suggest presence of cancer in the breast if:
-the discharge is watery, serous, pink, or bloody
-it is accompanied by a lump
-it is from one nipple
-it is from one duct
-if mammogram is abnormal
-and if a woman is over 50 years of age.

In one series of 249 patients with nipple discharge, only four per cent of the patients had cancer of the breast. Nipple discharge due to cancer is not that common – but one can never know until appropriate investigations, including surgical biopsy, says there is no cancer.

What is the surgical management?

Most surgeons will recommend breast biopsy for all women with persistent spontaneous single duct nipple discharge, whether it is serous or bloody. However there are exceptions, in pregnant women and women on birth control pill usually secretion is not pathological.

Spontaneous multiple duct nipple discharge may occur in several benign conditions. Surgery is usually recommended to relieve profuse discharge.

Although nipple discharge is often due to benign conditions, it should not be ignored. Appropriate consultation and investigation should be undertaken to make sure a serious pathology is not missed.

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Dear Dr. B: Is there a pill to prevent breast cancer? Yours: Ms. Worried.

Dear Ms. Worried: There is no straight answer to this question. Studies have shown that, in some women, tamoxifen can prevent breast cancer.

Recently, an article was published on this subject in the Canadian Medical Association Journal. It is a joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative’s Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

The objective of the guideline is to assist women and their physicians in making decisions regarding the prevention of breast cancer with tamoxifen and raloxifene.

Raloxifene is a drug used for prevention and treatment of osteoporosis in
post-menopausal women. Current evidence does not support the use of raloxifene for prevention of breast cancer.

Tamoxifen is a drug used for certain categories of women who have had breast cancer. It has shown to reduce the recurrence of cancer in the same breast, reduce the occurrence of new breast cancer in the other breast, and reduce the risk breast cancer spreading to other parts of the body (metastasis).

Tamoxifen has been found to be effective in preventing breast cancer. On that basis the Task Force has made recommendation in the use of Tamoxifen for prevention of breast cancer.

How do I know tamoxifen will help me prevent breast cancer?

First, you need to determine your risk. This is not easy. You have to go on the internet and check the Gail risk assessment index. This is a model used to estimate an individual woman’s risk of breast cancer.

The index uses a series of risk factors (age, age at first period, age at first live birth, number of breast biopsies, family history and ethnic origin) to calculate a “baseline risk.” The article says that the Breast Cancer Risk Assessment Tool, which is based on the Gail index, is available online: http://bcra.nci.nih.gov/brc. This will calculate percentage risk for you.

Once you have done that, then check the following recommendations to see if they apply to you:

1. Women at low or normal risk of breast cancer (Gail risk assessment index less than 1.66 percent at 5 years): There is fair amount of evidence to recommend against the use of tamoxifen in this group.

2. Women at higher risk of breast cancer (Gail index equal to or more than 1.66 percent at 5 years): Evidence supports counselling women in this group on the potential benefits and harms of breast cancer prevention with tamoxifen.

Examples of women in the second group would be – two first-degree relatives with breast cancer, a history of breast biopsy showing lobular carcinoma-in-situ, or atypical hyperplasia. Tamoxifen reduces the risk of breast cancer by 50 percent or in atypical hyperplasia by 86 percent.

Use of tamoxifen is not without side effects like stroke, blood clots in the lung or leg veins, cancer of the uterus, hot flashes and vaginal dryness. The article says that the side effects increase with a woman’s age.

So, Ms Worried, tamoxifen will do the trick for you if you are the right candidate. And remember, the benefits are not without side effects. “The benefit of protection against breast cancer is more likely to outweigh the risks on women aged 35 to 50 years”, says the Canadian Task Forces’ guideline.

Good luck, Ms. Worried.

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