Mammographic screening for breast cancer: An invited review of the benefits and costs

Mammographic screening for breast cancer: An invited review of the benefits and costs
Jon M. Greif
The Breast 2010. 19;4:260-267

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Mammographic screening is a proven method for reducing breast cancer mortality for women 40 years of age and older, but the best method for implementation of mammographic screening, particularly in the age group 40–49, remains controversial. The author, in an invited review, summarizes the data and offers guidance based on the best information available for women at risk for breast cancer, and their care providers, with particular emphasis on costs and benefits

Breast cancer is a global public health problem and the reader can decide for him or her self if the costs and benefits outweigh the risks associated with breast health screening programs. Many governments will continue to debate the costs and the pros and cons; however without population based screening, many women will continue to suffer needlessly throughout the world. Thus, I would like to offer the following conclusions based on one surgeon’s analysis of the literature regarding the benefits and costs of mammographic screening for breast cancer:

1. Women invited to participate in a regular program of mammographic screening, beginning at age 40 and continuing annually for as long as a woman is healthy can be expected to have a 19% reduction in breast cancer mortality compared with women not invited to participate in systematic mammographic breast cancer screening. In fact, 75% of all breast cancer deaths occur in the 20% of women not undergoing periodic screening mammography. Breast cancer screening saves lives, and, when considering the monetary costs to society of treating advanced breast cancer, may actually save money.

2. Screening mammography is less than 100% sensitive or 100% specific for detection of breast cancer, and so there will be false negatives and false positives. Following rigorous quality control guidelines will minimize the incidence of false negatives and false positives. Combining annual screening mammography with annual professional clinical breast exams and encouraging women to become familiar with their breasts through monthly breast self exam are likely also to reduce the impact of the falsely negative mammogram, and should be encouraged.

3. It may be desirable to examine alternatives to current screening strategies, but, hopefully, this does not translate into less effective breast cancer screening strategies that aim to simply reduce costs in the future. Improving efficiency in mammographic screening practices may be a successful cost saving strategy that does not sacrifice benefit.

4. The perfect breast cancer screening tool would be 100% sensitive and 100% specific, inexpensive and not harmful. Mammography is not that perfect tool, but, for now, is a very satisfactory and evidence-based procedure which can save lives, and should be made accessible to all women at risk for developing this dreaded disease.

Risk assessment, screening and prevention of breast cancer: A look at cost-effectiveness

Risk assessment, screening and prevention of breast cancer: A look at cost-effectiveness
Gail S. Lebovic, Alan Hollingsworth, Stephen A. Feig
The Breast 2010. 19;4:260-267
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Following consideration of the above review, it is clear that the cost-effectiveness surrounding the many clinical areas as they relate to breast cancer are difficult, if not impossible to fully assess. However, within the literature we begin to see an important framework for the future. This includes the importance of risk assessment for stratification of women of various ages, preventive measures including lifestyle, chemoprevention and surgery, as well as the continued support for the essential component of mammographic screening according to present guidelines. It is these measures taken together as a whole that ultimately will save lives with the most effective, efficient and most cost-effective approach to breast cancer throughout the world

Role of magnetic resonance imaging in managing selected women with newly diagnosed breast cancer

Role of magnetic resonance imaging in managing selected women with newly diagnosed breast cancer
S. Scomersi, M. Urbani, M. Tonutti, F. Zanconati, M. Bortul
The Breast 2010 19;2:115-119

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The purpose of this study is evaluation of therapeutic impact of magnetic resonance imaging (MRI) in breast cancer patients that cannot be imaged adequately with traditional radiology: dense breasts, microcalcifications suspicious for carcinoma in situ or discordance between mammography and ultrasound. A review was performed of 493 patients’ records: determination of breast MRI effect on clinical management was made for the selected 70 cases by analysing pre-MRI and post-MRI therapeutic plans. Analysis of final pathology was useful to determine if the change in surgical plan prompted by MRI was appropriate. 

Breast MRI added clinical information in 52.9% of patients that resulted in 44.3% of management changes that were judged as appropriate in 83.9% of cases. Breast  MRI provides additional useful information, but causes more extensive surgery (40%) with no proven prognostic benefit. MRI should be considered optional in the clinical staging  of breast cancer and performed in selected cases.

Freehand versus ultrasound-guided core biopsies of the breast: reducing the burden of repeat biopsies in patients presenting to the breast clinic

Freehand versus ultrasound-guided core biopsies of the breast: reducing the burden of repeat biopsies in patients presenting to the breast clinic
S.T. Ward, J.A. Shepherd, H. Khalil
The Breast 2010 19;2:105-108

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In our breast unit a significant proportion of core biopsies are performed freehand sometimes necessitating a repeat biopsy under image guidance. The aims of this study were to establish the proportion of patients undergoing freehand core biopsies who proceeded to a repeat procedure and to determine any factors associated with a missed freehand biopsy. Four hundred and ten core biopsies over 21 months were included in the analysis. Demographic details, position and size of the lump, breast volume and lesion depth were recorded.

Twenty-four percent freehand biopsies were repeated under ultrasound guidance. The histological classification of two-thirds of the repeat biopsies were upgraded, suggesting that the lesion had been previously missed. Multivariate analysis showed that missed freehand biopsies were strongly associated with deep lesions. If all lumps sited at a depth of 6 mm or more were selected for US-guided core biopsy, the workload for the ultrasound department would increase by just less than a half and would have the effect of reducing the freehand biopsy miss rate by almost two-thirds.

Core biopsies should be performed under ultrasound guidance. A freehand technique could be limited to superficial lesions. Depth is more predictive for a missed biopsy than lesion size or breast volume

Long-term follow-up-findings in mammography and ultrasound after intraoperative radiotherapy (IORT) for breast cancer

Long-term follow-up-findings in mammography and ultrasound after intraoperative radiotherapy (IORT) for breast cancer
M. Ruch, J. Brade, C. Schoeber, U. Kraus-Tiefenbacher, A. Schnitzer, D. Engel, F. Wenz, M. Sütterlin, S.O. Schoenberg, K. Wasser
The Breast Volume 18, Issue 5, October 2009, Pages 327-334

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In early postoperative follow-up studies the radiologist is confronted with large and partially organized wound cavities in most cases after IORT. In further follow-ups, fat necroses arise from those cavities, and about 60% of patients show likewise large oil cysts on late follow-up mammograms. As a frequent phenomenon wound cavities appear sonographically as liquid lesions with pronounced polypoid inner wall thickening. Furthermore, a prolonged parenchymal scarring has to be expected after IORT. No specific factors were found, which might influence the incidence or the value of these structural alterations after IORT

Comparison of interval breast cancer rates for two-versus single-view screening mammography: A population-based study

Comparison of interval breast cancer rates for two-versus single-view screening mammography: A population-based study
A. Seigneurin, C. Exbrayat, J. Labarère, M. Colonna
The Breast Volume 18, Issue 5, October 2009, Pages 284-288

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Two-view mammography for first and subsequent screens is associated with lower rates of interval breast cancer. This is at the expense of an increased number of women being recalled for further assessment after subsequent screens