SCREENING AND EARLY DIAGNOSIS
What are the differences between screening and early diagnosis?
Screening is defined as the mammograms carried out on women with no symptoms of breast cancer in order to detect the possible presence of a hidden breast cancer. This isPART of the public campaigns that recruit thousands of women, generally between the ages of 50 and 65.
In contrast, a mammogram used for early diagnosis is carried out on women who have some sort of abnormality in the breast (a lump that can be felt, a bloody discharge from the nipple, etc) but with no other symptoms. Thus, a mammogram would show if there was a tumor in the breast.
What part does the breast self exam play in early diagnosis?
The biggest problem with BSE is that most women do it wrong. A number of studies reveal that only 3% of the women studied do the BSE properly. This means that 97% of the women do not get the full benefit of BSE because they don’t do it correctly.
Here we are speaking about something that can be extremely important. Studies that included more than 8,000 women with breast cancer show that the women who used BSE had smaller tumors and few affected ganglia than those who did not.
What we have, then, is a problem of information and of training.
Returning to topic of screening, is it recommended only for women without symptoms between the ages of 50 and 65?
It was started in this age bracket, primarily because the mammogram is much easier to read after menopause, when the glandular milk secreting tissue (very difficult for X-rays to penetrate) has been substituted for fatty and fibrous tissue, that x-rays can pass through easily. In contrast, a younger woman’s breast is denser, and thus tumors often are not detected by a mammogram. In contrast, it is quite difficult to miss a tumor in a mammogram of the less dense breast of a post menopausal woman.
For this reason the ideal age bracket for screening is between 50 and 65.
And what about woman over 65?
Nowadays many screening campaigns include women up to 69 years old. So what happens with women over 70? The life expectancy of women in the western world forces us to re-examine the complicated and conflictive subject of age limits. The facts speak for themselves: people are living longer and longer And there are more and more incidence of cancer, and greater necessity to detect it in time.
What are the results of the screening process?
Very significant. Several studies of groups of women between 50 and 65 with no symptoms of cancer have demonstrated that participating in screening reduces mortalityRATE by 30%.
What part does treatment play in this advance?
The two things go together: early diagnosis and better treatment. But only if treatment is not delayed. There must be maximum coordination between screening campaigns and hospitals. It would be pointless to have early diagnosis and afterwards a delay in treatment.
And what about screening in younger women?
This is a controversial subject. Some groups affirm that screening in women between 40 and 50 years old reduces deathRATES by 17%, while others say that it doesn’t work.
As we have mentioned, the interpretation of the mammogram in this age bracket is more difficult, and thus the efficacy of screening is at least doubtful.
Probably the most practical approach is to use mammograms to screen those women between 40 and 50 who have one or more of the risk factors described above.
And women with a family history of breast cancer?
Familial breast cancer has the tendency of appearing earlier in each generation. Thus, women with a family history of breast cancer should have their first mammogram ten years before the age when the family member with the earliest case of breast cancer was diagnosed. For example, if the mother was diagnosed at 45, the daughter should begin mammograms at 35.
How is the diagnosis carried out?
Most of the diagnosis of suspicion are carried out by the patient herself. In other cases cancer is detected in a gynecological checkup, or in a early diagnosis campaign.
What are the suspicious signs and symptoms that a woman should look for?
With the increasingly widespread use of mammography, breast cancer is being detected with increasing frequency in women with no symptoms of cancer.
When symptoms do appear, the most frequent is the discovery of a lump in the breast or under the arm (65-76% of all the cases). Frequently the woman affected makes the first diagnosis, when she is having a shower, for example.
Other possible symptoms are pain in the breast, thickening in one area or in all the skin covering the breast, and a bloody discharge from the nipple.
What should be done when there are grounds for suspecting breast cancer?
When a suspicious tumor is found, a biopsy (removal of a tissue sample) to be examined under a microscope is necessary.
What about the biopsy?
It can be carried out in two ways:
a) Fine needle aspiration biopsy (FNAB), guided manually or with ultrasound.
Another technique is the use of stereotactic needle biopsy, where a computer uses mammograms taken from two angles to map the exact location of the mass . Then the computer guides the needle to the right spot.
If the tumor is solid, a larger needle than the one used in the FNAB is needed. In this case a small cylinder of tissue is removed from a breast abnormality
b) Surgical biopsy To get the entire tumor or abnormal area, the mass is surgically removed, along with an area of normal breast tissue from around the tumor.
What happens after the diagnosis?
Once the diagnosis has been established, a series of examinations are carried out, as described below:
A complete blood analysis determines if the patients blood has the number and correct proportion of the different types of blood cells.
Classifying the hormonal receptors (see hormonal treatment) helps in selecting the treatment.
If the cancerous breast cells don’t have these receptors, scientists classify them as “estrogen-negative receptors” (ER-negative) or progesterone-negative receptors (PR-negative) tumors, or simply hormone receptor negative.
However, if ER and PR are positive, the cancer cells will most likely respond to hormonal treatment.
EVALUATION OF HER-2/neu
HER-2/neu is the name of the gene that produces a type of receptor which helps cells growth. Breast cancer cells with a large number of HER-2/neu tend to grow exceptionally rapidly.
IDENTIFYING THE S-PHASE (percentage of cancer cells in the process of dividing)
The S-phase fraction (SPF) is the percentage of cells in a sample that are replicating their DNA. A low SPF indicates a tumor that is dividing slowly, and a high SPF shows the cells are dividing rapidly.
TUMOR MARKERS CEA and CA 15.3 are the ones used most in breast cancer.
Using them together gives the biggest chance to diagnose how aggressive the breast cancer is, and to select the correct treatment for it.
These markers should be checked, though a simple blood test, before the first treatment is given, since they are not present at high levels in all women with breast cancer.
Thus, in the follow up of the disease after treatment, the markers allow the recurrence of breast cancer to be discovered, but only in those women who are positive to begin with.
Not analyzing the markers before treatment, but doing so after treatment, means an expenditure of resources and an annoyance (periodic blood sample extraction) for women with breast cancer that might well have tested negative from the start.
We must insist that the markers be determined in the first diagnosis, and always before starting treatment.
RADIOLOGICAL SCANS OR NUCLEAR MEDICINE
What are they used for?
The aim is to determine the third dimension of the tumor, the presence or absence of metastasis or distant spread colonies. It’s best to carry out the examinations described below before local treatment of the breast is begun. This is the only way to fully know the clinical situation of the patient. A diagnosis of the extension or spread of the cancer must be made after local treatment is carried out, if it has not been done before But systemic therapy, a complement (or adjuvant) to surgery (see below), must never be given before the diagnosis of the extension has been carried out..
So chest x-rays must be made before treatment begins?
Yes, in order to see if cancer cells have spread to the lungs.
And what about ultrasound?
Radiologists sometimes use this painless technique to distinguish between fluid filled cysts and simple cysts.
They are also carried out in the diagnosis of the extent of the disease to see if the liver has been affected.
And the bones?
They are examined with bone scans, a nuclear medicine procedure where the patient is given a radioisotope (a radioactive isotope, usually technetium that is attracted to diseased bone cells throughout the entire skeleton. This technique provides important information about the bones, including the location of any cancer that might have spread there. There is no danger to the patient or to their family, since radioisotopes with a very short wavelength are used (they don’t leave the body) with a very short half-life (about 6 hours), which means that the radiation disappears rapidly.
Why do some doctors ask for a CAT?
Doctors ask for a CAT (computed axial tomography) of the abdomen to see if the breast cancer has spread to organs such as the liver, internal lymph glands, or the suprarenal glands (located above both kidneys). Others prefer an ultrasound of the abdomen or the liver.
And the resonance?
Nuclear magnetic resonance imaging uses radio frequency signals and magnets to produce a detailed study of the internal organs without using x-rays.
DIAGNOSIS OF EXTENSION (TNM or stages)
What is staging?
Cancer has three dimensions, the T or tumor, the N, or lymph nodes, and M or metastasis. The combination of these three dimensions, depending if they are affected or not, and on the size and number affected, give rise to numerous combinations called the diagnosis of the extent of the disease, and are classified using one of two system, TNM or stages. Normally the classification by stages (staging) is used.
The stage indicates how the breast cancer has spread inside the breast, to nearby tissues, and to other organs.
The stage of the cancer is one of the most important factors to be considered in selecting the treatment.
What are the stages of breast cancer?
They are the following:
1.- Stage 0
Non invasive or in situ breast cancer
a) Ductal carcinoma in situ (DCIS), The cancerous cells are localized inside a duct, and the surrounding fatty tissue hasn’t been invaded.
b) Lobular carcinoma in situ (LCIS): The abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules.
2.- Stage I
The tumor is less than 2 centimeters in diameter. It has not spread to areas outside the breast.
3. Stage II
Stage II is separated into IIA and IIB
a) Stage IIA There are three varieties. Tumor is not palpable, with axillary lymph nodes positive but movable, not attached to each other; a tumor 2 centimeters or less with axillary lymph nodes positive and movable, and tumors between 2 and 5 centimeters with axillary lymph nodes negative.
b) Stage IIB There are two varieties: Tumors between 2 and 5 centimeters in diameter, with axillary lymph nodes positive but movable; tumors more than 5 centimeters in diameter, with axillary lymph nodes negative.
4. Stage III
This stage is divided into IIIA and IIIB
a) Stage IIIA It consists of the following varieties: Tumors that are not palpable, tumors 2 centimeters or less, and tumors between 2 and 5 centimeters, which have axillary lymph nodes positive, attached to one another, or have invaded other structures of the axila. Or tumor more than 5 centimeters in diameter with any type of positive axillary lymph node.
b) Stage IIIB Breast cancer of any size that has extended to the chest wall, to the skin covering the breast, or to the chest wall and skin, or inflammatory carcinoma of the breast. Or any size tumor with positive lymph nodes in the internal mammary nodes on the same side as the tumor.
5. Stage IV
The cancer, regardless of its size, has spread to distant organs such as bone, liver, or lung, or to lymph nodes far from the breast.