2007 Update

Guideline for The Early Detection of Breast Cancer

Administered by the Alberta Medical Association

This guideline was written to provide guidance about the appropriate use of screening tools for breast cancer and to help physicians and patients make informed decisions about screening for breast cancer in asymptomatic women of all ages. Due to the addition of important research related to breast screening, this guideline will continue to be reviewed on an anuual basis.

Mammography Screening in Women aged 50 to 69

Women aged 50 to 69 years should have a screening mammogram at least every two years. Annual mammography screening should be considered in circumstances of increased risk.

RECOMMENDATIONS
Screening Procedures
Mammography, clinical breast examination and breast self-examination can be used as screening procedures. Breast ultrasound and MRI are not currently recommended for routine screening.

Mammography Screening in Women Over 70 Years

The risk of breast cancer in this group is high. Mammography screening every two years should be continued taking into account individual health factors and estimated life expectancy.

Exclusions
The recommendations in this guideline do not apply to: Women with signs and symptoms suggesting breast cancer; Women with a personal history of breast cancer; Men.

Mammography Screening in Women with a Genetic Predisposition to Breast Cancer

Some experts suggest that mammography screening among this population should commence five to ten years prior to the age of onset of breast cancer in their family member. Consideration may be given to referral to the Cancer Genetics Research Clinics. (See Background & Appendix 1).

Mammography Screening in Women Under 40 Years

Routine mammographic screening for women under 40 is not recommended.

Clinical Breast Examination and Breast Self Exam

CBE and BSE should be seen as complementary examinations to mammography. (For CBE See Appendix 2) Primary care physicians should discuss breast self examination with all women by age 30.

Mammography Screening in Women aged 40 to 49

Women aged 40 to 49 should have the opportunity to access screening mammography. Physicians should discuss with patients, the benefits and risks of screening. There remains controversy regarding the degree of benefit of screening mammography in this age group. (See Background) If a woman chooses to participate in mammography screening, the recommended interval between screens in this age group is one year.

Breast Implants
Women with breast implants should be referred for diagnostic mammography at age appropriate intervals.

The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.

BACKGROUND
Epidemiology
Breast cancer is one of the most serious health concerns of Canadian women and is the most common form of cancer in women excluding non-melanoma skin cancer. Breast cancer accounts for 30% of all new cancer cases.1,2,3,4 In 2001, 1,644 Alberta women were diagnosed with invasive breast cancer and 425 women died of the disease.5 Breast cancer accounts for nearly 21% of all cancer deaths in Alberta women.1

Definition of Screening for Breast Cancer used in this CPG

Breast cancer screening refers to the application of a procedure to asymptomatic women for the purpose of detecting unsuspected breast cancer at a stage when early intervention can affect the outcome.

Mammography Screening
A normal screening mammography does not rule out breast cancer in the presence of persistent palpable abnormalities. Further evaluation may still be required.

Risk Factors
The lifetime risk for breast cancer is one in nine. The risk however, varies over a womans lifetime. Table 1 reflects the age specific risk of breast cancer for women.6
Table One Probability of Developing Breast Cancer in the Next Five Years, by Age, for Women Who Reside in Alberta and Currently Do Not Have Breast Cancer Age 35 Probability 1/384

Screening in Women Under 40 Years

Randomized controlled studies have not included women in this age group.9 Routine screening is not recommended.

Screening in Women Aged 40 to 49 Years

In women aged 40 to 49, breast cancer is the single leading cause of death.3,4 Some of the reservations about making population-based recommendations for women in this age group, are based on limitations in the scientific evidence available to date. While there is emerging evidence of benefit from some combined analyses of the randomized trials, the benefit is smaller than in older women, and is of borderline statistical significance.10,11 There has been a lot of debate in the literature regarding the reasons for the apparent decreased benefit of screening. Evidence to date suggests that screening mammography is less sensitive for women in their forties than for older women.12 It has also been suggested that due to more rapid growth of tumours in this age group that the interval between screens in some studies has been too long to show a benefit.13 Data suggests that annual mammography in this age group will be required 14in order to detect breast cancer at its earliest stages and achieve a reduction in breast cancer mortality similar to that seen in older women.14,15 Finally, there may be statistically insufficient numbers of women in this age group included in the controlled trials to definitively show a benefit.16 Concerns have also been raised about the decreased positive predictive value of any of the three breast screening procedures in women in their forties when compared to older women. In other words, the probability that a younger woman would have a benign biopsy as a consequence of screening is higher than for older women.

40 45 50 55 60 65 70

1/208 1/128 1/109 1/94 1/78 1/70 1/65

Increasing age, being born in North America and northwest Europe, and having two or more first degree relatives with a history of breast cancer are identified as the strongest risk factors. There are many other identifiable risk factors, but few are amenable to change. It is estimated that up to 80% of women who develop breast cancer have no risk factors other than being female, and in a higher risk age group.7 Evidence from the WHI8 studies indicate that in any single year, 0.08 percent more women in the HRT group developed breast cancer than women in the placebo group, suggesting that the effect of HRT on the risk of breast cancer is small.

Women Aged 50 to 69 Years

Many studies have shown the efficacy of mammography screening for breast cancer for women aged 50 to 69 years. Regular mammographic screening in this age group is estimated to reduce mortality from breast carcinoma by approximately one third. Because additional benefit with annual screening has not been demonstrated, screening every two years is often recommended.9

Factors Affecting the Acceptance of Screening Recommendations

The strongest stimulus for a woman to participate in mammography screening is the recommendation from her physician. Studies indicate that many factors affect a womans choice to participate in breast cancer screening. Adverse factors include age, i.e., younger (40-49) and older (70 plus) women; socioeconomically disadvantaged; limited contact with a physician; single martial status; unemployed and retired; country of birth and fewer years since immigration, i.e., Asia, South and Central America, Caribbean and Africa; lower educational attainment; and, rural residence.19,20,21 Physicians should ensure that all women who would benefit from screening be informed of its potential advantages.

Women Over 70 Years

The incidence of breast cancer increases with age, and therefore women over 70 years continue to be at high risk. Although no randomized clinical trials have specifically addressed the efficacy of screening in this age group, it should be continued in the context of individual health factors and life expectancy.

SELECTED REFERENCES
1. National Cancer Institute, Canadian Cancer Statistics, 1997. 2. Statistics Canada. HEALTH REPORTS. Catalogue 82.003XPB.1997;9(1). 3. Gaudette LA, Silberger C, Altmayer CA et al. Trends in breast cancer incidence and mortality. HEALTH REPORTS. Statistics Canada, Catalogue 82.003- XPB. 1996;8(2):29-37. 4. Bondy M, Luskbader E, Halabi S, et al. Validation of a breast cancer risk assessment model in women with a positive family history. Journal of the National Cancer Institute 1994;86:620-25. 5. Alberta Cancer Board. Alberta cancer registry (2003). Cancer statistics 6. Bryant HE, Brasher PMA. Risks and probabilities of breast cancer: short term versus lifetime probabilities. CMAJ 1994;150(2):211-216. 7. Alberta Cancer Board. A Snapshot of Cancer in Alberta. 1996. 8. Womens Health Initiative. NIH Publication No. 02-5200 October 2002. 9. Tabar L, Faberberg G, Day N, et al. What is the optimum interval between mammographic screening examinations? An analysis based on the latest results of the Swedish two-county breast cancer screening trial. International Journal of Cancer, 1987; 55: 547- 551. 10. Smart C, Hendrick R, Rutledge J, Smith R. Benefit of mammography screening in women ages 40 to 49. Current evidence from randomized controlled trials. Cancer, April 1995; 75(7): 1619-1626. 11. American Cancer Society. Workshop on Guidelines for Breast Cancer Detection. Chicago, March 1998.

Women a Genetic Predisposition for Breast Cancer

Women with a strong family history of breast cancer should be advised of the availability of counselling and information provided by the Cancer Genetics Research Clinics. (See Appendix 1 for referral criteria) The recommended screening interval for women in this group is yearly beginning at age 40 or 5 - 10 years prior to the age of onset of breast cancer in a first degree family member. Additional screening tools for this group of women are currently being studied including MRI, ultrasound, and Sestamibi Nuclear Medicine Scans.

Radiation Risk
The risk of mammographically-induced cancer is generally considered to be negligible. Some experts have expressed concern over the theoretical risk of radiation-induced breast cancers, especially among younger women. However, the studies which have raised this concern involved much higher levels of radiation than are found in present day mammography.17,18 The radiation dose delivered by mammography is lower than that of an ordinary chest X-ray.

12. Kerlikowske K, Grady D, Barclay J, et al. Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA, July 1996; 276(1): 33-38. 13. Feig S. Determination of mammographic screening intervals with surrogate measures for women aged 40-49 years. Radiology, 1994; 193: 311-314. 14. Duffy S, Chen H, Tabar L, et al. Sojourn time, sensitivity and positive predictive value of mammography screening for breast cancer in women aged 40-49. International Journal of Epidemiology, 1996; 25(8): 1139-1145. 15 Tabar L, Fagerberg G, Chen H, et al. Tumour development histology and grade of breast cancers: prognosis and progression. International Journal of Cancer, 1996; 66: 413-419. 16. Kopans D, Halpern E, Hulka C. Statistical power in breast cancer screening trials and mortality reduction among women 40-49 years with particular emphasis on the national Breast Screening Study of Canada. Cancer 1994; 74: 1196-1203. 17. Mettler F, Upton A, Kelsey C, et al. Benefits versus risks from mammography: a critical reassessment. Cancer, March 1996; 77(5): 903-909. 18. NIH Consensus Statement. Breast Cancer Screening of Women Ages 40-49. January 1997; 15(1). 19. Dodd GD. Screening for Breast Cancer. CANCER SUPPLEMENT. August 1, 1993; 72(3):1038-1042 20. Maxwell CJ, Parboosingh J, Kozak JF, Desjardins-Denault SD. Factors Important in Promoting Mammography Screening among Canadian Women. Canadian Journal of Public Health,Sept 1997; 88(5):346-350. 21. Gentleman JF, Lee J. Who Doesnt get a Mammogram? Statistics Canada, Catalogue 82-003-XPB, Health Reports, Summer 1997. Vol.9, No.1 22. Bates B. A Guide to Physical Examination and History Taking. (pp317-328) 4th Edition, 1987 J.B. Lippincott Company, Philadelphia.

Toward Optimized Practice (TOP) Program

Arising out of the 2003 Master Agreement, TOP succeeds the former Alberta Clinical Practice Guidelines program, and maintains and distributes Alberta CPGs. TOP is a health quality improvement initiative that fits within the broader health system focus on quality and complements other strategies such as Primary Care Initiative and the Physician Office System Program. The TOP program supports physician practices, and the teams they work with, by fostering the use of evidence-based best practices and quality initiatives in medical care in Alberta. The program offers a variety of tools and out-reach services to help physicians and their colleagues meet the challenge of keeping practices current in an environment of continually emerging evidence.

TO PROVIDE FEEDBACK
The Early Detection of Breast Cancer Working Group is a multidisciplinary team composed of a family physician, general practitioners, radiologists, general surgeons, a gynecologist, oncologist, pathologist, epidemiologist, Medical Officer of Health, nurse, medical student, public representatives, the Canadian Cancer Society, and Breast Cancer Policy Council representatives. The Working Group encourages your feedback. If you need further information or if you have difficulty applying this guideline, please contact: Clinical Practice Guidelines Manager TOP Program 12230 - 106 Avenue NW Edmonton AB T5N 3Z1 Phone: 780.482.0319 or toll free 1.866.505.3302 Fax: 780.482.5445 Email: [email protected] Website: www.topalbertadoctors.org

Early Detection of Breast Cancer - April 1999 Reviewed - August 2000 Reviewed - March 2002 Reviewed - November 2004

APPENDIX 1: CANCER GENETICS CLINICS

CANCER GENETICS CLINIC
Contact Information
Cross Cancer Institute and Edmonton/Calgary Genetics Clinics. By Mail: Edmonton Genetics Clinic Clinical Sciences Building B-139 University of Alberta Edmonton, Alberta T6G 2B7 Cancer Genetics Research Clinic Tom Baker Cancer Centre 1331-29th Street NW Calgary, Alberta T2N 4N2 Note: Referrals MUST be made by a physician and are preferred by mail. Appointments will be made with patient(s) after initial work up completed.

By Telephone: Cross Cancer Institute (780) 432-8422 Edmonton Genetics Clinic (780) 407-7333 Cancer Genetics Research Clinic (403) 670-2438

Referral Criteria
The following are offered as considerations for selecting women who may benefit from genetic counselling. The criteria do not necessarily define women at increased risk of developing breast carcinoma who merit earlier or more frequent mammographic screening.

Personal or close family history of breast cancer < 35 years; ovarian cancer < 50 years; bilateral breast cancer

- first onset < 50 years; or breast and ovarian cancer Two related family members with breast cancer and/or ovarian cancer with onset in both < 50 years Three or more related family members with breast and/or ovarian cancer, one onset < 50 years Four or more related family members with breast and/or ovarian cancer, any age Ashkenazi descent, breast and/or ovarian cancer, any age Any case of male breast cancer Known mutation in a cancer susceptibility gene such as the BRCA1 or BRCA2 gene is present in a family member Families which may not meet the above criteria, but have a strong family history suggestive of the presence of a mutated cancer susceptibility gene

APPENDIX 2: CLINICAL BREAST EXAMINATION

Clinical breast examination (CBE) may detect some breast cancers which are not evident on mammography. However, the effectiveness of CBE depends upon systematic examination of all quadrants of both breasts and all regional lymph nodes. One systematic approach is illustrated below.22

Region Examined
BREASTS

Examination Skills and Focus

Inspection BREAST, AREOLA, NIPPLE

Procedures and Techniques

Client in SITTING position disrobed to waist. Inspect breast, areola and nipple bilaterally from anterior and lateral view: 1. With arms at side 2. With arms raised over head 3. With hands pressed against hips or With hands squeezed together at shoulder level 4. DO ONLY IF breasts are pendulous or very large: inspect with client leaning forward. Inspects skin of axillae with arms raised over head Supports clients L hand and wrist with L hand to examine L axilla and reverses for R axilla. Cup fingers together. Reaches as high as possible into axilla 1. Brings fingers down over ribs and feels for CENTRAL nodes 2. Feels inside anterior axillary folds (PECTORAL) 3. Feels inside posterior axillary folds (SUBSCAPULAR) 4. Feels against humerus (LATERAL) Palpates bilaterally for INFRACLAVICULAR nodes in 1st interspace with finger pads Palpates bilaterally for SUPRACLAVICULAR nodes above clavicle with finger pads Client SUPINE, with pillow removed from under head. Uses small pillow under clients shoulder on side examined to shift breasts medially (NO PILLOW IF BREASTS ARE SMALL) 1. Inspects breasts. Palpates each breast: 1. Asks client to move arm away from chest on side being examined 2. Uses flat of 4 fingers, in a rotary motion to compress breast tissue 3. Flexes, from the wrist, not the fingers 4. Applies moderate pressure, keeping constant contact with skin 5. Moves back and forth across breast in straight lines, making constant small circles 6. Slides hand down 1 finger width for each pass 7. Covers full area from below clavicle to 3 cm below breast from anterior axillary line to midsternal line: a) glandular tissue c) nipple b) areolar area d) Tail of Spence

AXILLAE AXILLARY LYMPH NODES

Inspection AXILLAE Palpation CENTRAL, PECTORAL, SUBSCAPULAR, LATERAL LYMPH NODES

INFRACLAVICULAR LYMPH NODES SUPRACLAVICULAR LYMPH NODES BREASTS

Palpation INFRACLAVICULAR Palpation SUPRACLAVICULAR Inspection BREAST, AREOLA, NIPPLE (same as above) Palpation BREAST, AREOLA, NIPPLE and TAIL OF SPENCE

Adopted and reproduced with permission from: Skillen DL & Day R. (Eds). 1998. A syllabus for adult health assessment (pp.61-62). Edmonton: University of Alberta, Faculty of Nursing.