Comparison of breast mammography,sonography and physical examination for screening women at high risk of breast cancer in taiwan

Recommended surveillance for screening breast cancer, which includes regular mammography and clinical breast examination, has long been established in Western countries. This strategy may be too costly and unnecessary for countries with low incidences of breast cancer. The purpose of the present study is to compare breast mammography, sonography and physical examination in screening female relatives of breast cancer index cases from the hospital, and their relative efficiency. A total of 935 women over 35 years old, who were relatives of breast cancer patients, were invited to an annual screening by means of a combination of mammography, sonography and physical examination on a single day. A biopsy was performed when any of the three investigations indicated a possibility of malignancy. A total of 21 breast cancers, including sixteen invasive cancers and 5 noninvasive cancers, were detected among the 935 high-risk women. Of the cancers, 18, including 16 invasive cancers and 3 noninvasive cancers, were detected by sonography. In contrast, only 11 invasive cancers were detected by mammography, and 7 by physical examination. There were only 14 cancers detected by a combination of mammography and physical examination. The 7 (33.3%) additional cancers were detected when sonography was added. The sensitivity of sonography was 90.4%, which was higher than mammography (52.4%) and physical examination (33.3%), or even a combination of these two modalities (66.7%). This indicates that sonography is a more accurate screening tool for breast cancer in the high-risk group. Although breast sonography has not yet been recommended as a routine screening tool for breast cancer in Western countries, it may be superior to mammography and physical examination for the screening of Taiwanese high-risk female relatives of breast cancer index cases. If it should also be considered as a routine adjunct screening modality for Taiwanese women with lower rates of breast cancer will need further study.     

Imaging of the breast: techniques and results

Procedures for imaging of the breast have increased in number substantially in the past 30 years. Mammography, currently the most important breast imaging technique, was introduced at the Mayo Clinic in 1961. In 1988, more than 36,000 mammographic procedures were done. Breast ultrasonography is also a valuable examination, particularly for determining whether mass lesions are cystic or solid. The use of mammography for screening is increasing. Screening mammography allows the detection of breast cancer before it is palpable and while it is still in a stage known as minimal breast cancer. Lesions metastatic to axillary lymph nodes are less common in women with nonpalpable breast cancers than in women with palpable lesions. Nondiagnostic mammography should not delay the biopsy of a mass that is suspicious on physical examination. A special breast imaging center for performance of screening studies and evaluation of breast problems has been established at the Mayo Clinic.     

Cancer screening in public health clinics: the importance of clinic utilization.

OBJECTIVES: To determine how screening for breast and cervical cancer in public health clinics was associated with overall clinic utilization. METHODS: Evidence of screening and clinic visits between June 1989 and May 1992 was obtained by medical record audit for a random sample of 1825 women aged 40 to 75 attending eight public health clinics in the San Francisco Bay Area. RESULTS: With an average number of visits (4 per year), women who did not receive a physical examination were much less likely than those who did to obtain a clinical breast examination (OR = 0.03), mammography referral (OR = 0.1), or a mammogram (OR = 0.4) within 2 years, or a Papanicolaou smear (OR = 0.1) within 3 years. Without a physical examination, the odds of screening or referral increased with the first visit (OR = 1.2 for referral, breast examination, and Pap; 1.3 for mammography), but with a decreasing marginal effect of each additional visit (ratio of successive one-visit OR values = 0.992 for referral and breast examination; 0.995 for Pap; 0.98 for mammography). With a physical exam, visits were associated with mammography only (first visit OR = 1.2; OR ratio = 0.992). CONCLUSIONS: In public health clinics, screening is associated either with receipt of routine care or repeated visits for treatment. Women who fall through the cracks are those who come to the clinic with a medical problem but otherwise receive few services. Interventions in public health clinics need to facilitate the provider's ability to use medically related visits as opportunities to increase adherence to screening recommendations.     

Radiographers’ Reflections on Women With High Breast Density Tissue—An Interview Study

Women aged between 40 and 74 years are called to do mammography screening in Sweden with the aim of early detection of breast cancer, which is the most common type of cancer in women. Women with dense breast tissue are more likely to develop breast cancer, and mammography is not an optimal diagnostic method for them because of reduced sensitivity. Radiographers who work in mammography departments are exposed to ethical dilemma daily, which is whether they should inform women about the density of their breast. The purpose of the study is to illustrate thoughts that radiographers have on breast density during mammography examination. The study was performed with qualitative method, where semistructured interviews were conducted. The material from the interviews was analyzed, condensed into different units and afterward in different codes that became different categories. The informants had separate opinions about if women in Sweden should be informed about breast density. On the other hand, radiographers considered that women should not be informed if there are no guidelines for the assessment and follow-up of breast density. With regard to supplementary examinations, all informants consider that it would be good for women with high-dense breast tissue to be offered supplementary examinations during mammography screening.     

提高乳腺X线摄影对致密型腺体乳腺癌检出率的方法探讨

乳腺X线检查在乳腺癌的筛查及早期诊断中具有重要价值。但对于致密型乳腺,乳腺X线检查假阴性率高,早期检出病灶困难,易延误患者的最佳诊疗时机,影响患者预后。本文旨在从提高乳腺X线摄片的质量、BI-RADS分类的应用、辅助手段检查的应用等方面,对提高乳腺X线摄影对致密型腺体乳腺癌检出率的方法进行综述。     

An assessment of the quality of mammography care at facilities treating medically vulnerable populations

BACKGROUND: Women in medically vulnerable populations, including racial and ethnic minorities, socioeconomically disadvantaged, and residents of rural areas, experience higher breast cancer mortality than do others. Whether mammography facilities that treat vulnerable women demonstrate lower quality of care than other facilities is unknown. OBJECTIVES: To assess the quality of mammography women receive at facilities characterized as serving a high proportion of medically vulnerable populations. RESEARCH DESIGN: We prospectively collected self-reported breast cancer risk factor information, mammography interpretations, and cancer outcomes on 1,579,929 screening mammography examinations from 750,857 women, aged 40-80 years, attending any of 151 facilities in the Breast Cancer Surveillance Consortium between 1998 and 2004. To classify facilities as serving medically vulnerable populations, we used 4 criteria: educational attainment, racial/ethnic minority, household income, and rural/urban residence. RESULTS: After adjustment for patient-level factors known to affect mammography accuracy, facilities serving vulnerable populations had significantly higher mammography specificity than did other facilities: ie, those serving a higher proportion of women who were minorities [odds ratio (OR): 1.32; 95% confidence interval (CI): 1.01-1.73], living in rural areas (1.45; 1.15-1.73), and with lower household income (1.33; 1.05-1.68). We observed no statistically significant differences between facilities in mammography sensitivity. CONCLUSIONS: Facilities serving high proportions of vulnerable populations provide screening mammography with equal or better quality (as reflected in higher specificity with no corresponding decrease in sensitivity) than other facilities. Further research is needed to understand the mechanisms underlying these findings.     

Breast cancer screening. Benefits, risks, and current controversies

Mammography is the best tool available for screening for breast cancer. Although the data supporting clinical breast examination are not as strong, this procedure continues to be widely used in the United States. To maximize accuracy of results, women who undergo screening during their premenopausal years should attempt to schedule mammography during the follicular phase of the menstrual cycle. All women should be educated about the benefits and the harms of screening, including the risk of being called back for further testing.     

How should we screen for breast cancer? Mammography, ultrasonography, MRI

Of the imaging techniques currently available to evaluate women for breast disease, mammography remains the mainstay of breast cancer screening, but recent guidelines have included magnetic resonance imaging (MRI) for the screening of some women at high risk. Whole-breast ultrasonography for screening has not been established as useful and so should not be offered routinely to patients.     

Common breast problems

A palpable mass, mastalgia, and nipple discharge are common breast symptoms for which patients seek medical attention. Patients should be evaluated initially with a detailed clinical history and physical examination. Most women presenting with a breast mass will require imaging and further workup to exclude cancer. Diagnostic mammography is usually the imaging study of choice, but ultrasonography is more sensitive in women younger than 30 years. Any suspicious mass that is detected on physical examination, mammography, or ultrasonography should be biopsied. Biopsy options include fine-needle aspiration, core needle biopsy, and excisional biopsy. Mastalgia is usually not an indication of underlying malignancy. Oral contraceptives, hormone therapy, psychotropic drugs, and some cardiovascular agents have been associated with mastalgia. Focal breast pain should be evaluated with diagnostic imaging. Targeted ultrasonography can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older. Treatment options include acetaminophen and nonsteroidal anti-inflammatory drugs. The first step in the diagnostic workup for patients with nipple discharge is classification of the discharge as pathologic or physiologic. Nipple discharge is classified as pathologic if it is spontaneous, bloody, unilateral, or associated with a breast mass. Patients with pathologic discharge should be referred to a surgeon. Galactorrhea is the most common cause of physiologic discharge not associated with pregnancy or lactation. Prolactin and thyroid-stimulating hormone levels should be checked in patients with galactorrhea.     

上海市普陀区3436名妇女乳腺钼靶普查分析

目的为了做好乳腺常见病的早发现早诊断早治疗,我院对3436名妇女进行乳腺钼靶普查,本文对普查结果进行分析总结。方法2004年9月至10月份对3436名普陀区妇女进行双乳钼靶检查。结果经普查共检出1759例乳腺常见病例,其中包括乳腺增生病1648例,钙化73人,纤维瘤或囊肿36人,乳腺癌2例。结论钼靶X线检查目前仍是乳腺病变最简便及有效的检查方法。     

Screening for breast cancer: current recommendations and future directions

Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older.     

Comprehensive breast cancer screening. Programs now include individual risk assessment

A comprehensive breast cancer screening program needs to include risk assessment in addition to clinical breast examination and mammography. Women identified as being at increased risk should have an individualized schedule of screening mammography and a proven prevention program tailored to their level of risk. In this article, Drs Cardenas and Frisch review risk factors, screening methods, and individual risk assessment, then explain how to use them in conjunction to identify tumors at an earlier, more curable stage.     

The regulation of mammography

There has been a long history of public and professional concern about the safety and quality of mammography. Whereas concerns about radiation dose levels dominated the 1970s, the type of equipment used in mammography was the focus of the 1980s. In the early 1990s, there was a lack of confidence in the overall quality of mammography. These problems have stood in the way of the widespread utilization of mammography to reduce mortality from breast cancer. The Mammography Accreditation Program of the American College of Radiology, state regulations, and the Mammography Quality Standards Act of 1992 came about to ensure a minimum level of quality that would encourage women to participate in breast cancer screening programs. Designing regulations that ensure quality mammography for women, without burdening mammography facilities with unnecessary costs and depletion of their resources, is one of the most difficult challenges facing the U.S. Food and Drug Administration.     

1502名社区女性钼靶筛查行为现状及影响因素研究The status and influencing factors of mammography screening behavior for 1502 women in community 陈乐英 吴怡颖 郁骐襄 沈坤炜 方琼*

目的 调查社区女性实施乳腺钼靶筛查行为的现状,并分析影响其实施的相关因素。方法 2012年对上海16个社区共1502名女性进行问卷调查。结果 调查中≥40岁的女性中,有544人（占49.5%）从未做过乳腺钼靶检查,仅有284人（占25.8%）每年参与乳腺钼靶检查;乳腺疾病史、是否有机会参加乳腺健康检查、是否知道乳腺自我检查方法、医院是否有专业检查人员及设备是重要影响因素（F=34.427 P＜0.001 R2=0.468）。结论 目前社区女性参与乳腺钼靶筛查行为处于较低水平,医护人员需要从其影响因素着手,探索并研究如何提高女性参与乳腺癌早期筛查率的方法。     

中国女性乳腺癌筛查现状及适宜模式探索

乳腺癌已成为中国女性最常见的恶性肿瘤, 但目前尚无规范的筛查标准和流程。欧美国家普遍采用以乳腺X线摄影为主要手段的乳腺癌普查模式, 但中国经济发展水平和女性的乳腺癌发病特点与欧美国家存在较大差别, 故其筛查模式并不适合中国。结合当前现有的针对中国女性乳腺癌筛查模式的研究和实践提示, 先采用乳腺癌风险模型进行评估, 对高危女性首选查体联合超声进行筛查, 成本效益较高, 且可提高早期诊断率, 是更适宜中国女性的乳腺癌筛查模式。     

Breast cancer screening.

Breast cancer, as the second leading form of cancer death among women, causes significant morbidity and mortality. The primary care physician can help raise the survival rate of women with breast cancer by providing important screening procedures that will lead to early diagnosis and treatment. Screening mammography and regular breast physical examinations are the current screening procedures of choice. Although there is still considerable debate over the age and interval at which women should undergo screening (see Table 1 for recommendations from various organizations), the primary care physician's recommendation is the single most important factor and will certainly lead to a higher screening rate for women in the greater at-risk age groups. Judicious use of these screening procedures should allow primary care physicians to catch more breast cancers at an early, curable stage.     

Assessment of mammography and ultrasound examination in the diagnosis of breast cancer

Objective: The aim of the present study is to evaluate the significance of the fine needle aspiration biopsy (FNAB) compared to the histological diagnosis and to compare the reliability of the X-ray mammography versus the reliability of ultrasonic mammographic examination of the breast. Methods: The material was collected during 1992 and 1993, a total of 2964 breast examinations were performed. The X-ray mammography was performed in 1711 patients and was the only examination in 565 cases. The US breast examination was performed as the only examination in 1253 cases and both the X-ray mammography and the US breast examination were performed in 1146 patients. The total number of FNAB performed was 855 and in 85 cases the samples from the breast masses or the structural changes were reported as Papa-classes III-V and needed surgical evaluation. An additional three cases needed surgical evaluation, the samples were reported as Papa-class II and the cytologist recommended a histological diagnosis. Among these 88 cases 76 breast cancers were found. Results: In the present material the sensitivity of mammography was 75% and the sensitivity of US examination 100%. The sensitivity of FNAB was 90% with no false negative cytological result in the group of the operated patients. One false positive report (1.3%) was given and in the cases reported as Papa-classes III-IV 42% of the lesions were benign. A malignant tumor was found in 87% of the operated patients. This study revealed that a breast cancer ∼ 60% in diameter smaller could be evaluated on the ultrasound breast examination than on the X-ray mammography. It could also be possible to visualize a breast cancer on the ultrasound mammography several years before doing so on X-ray mammography. The cost of diagnosing and treating a breast cancer patient was 8640 USD. Conclusion: According to the results of this study, the US breast examination seems to be the best method for diagnosing breast cancer.     

Women with cerebral palsy and breast cancer screening by mammography

Women with cerebral palsy and breast cancer screening by mammography. We emphasize the need to identify specific barriers to participation in breast cancer screening by mammography experienced by women with cerebral palsy (CP). Mammography screening has been found to reduce mortality rates by 30%, but women with disabilities such as CP underuse this important preventive medicine facility, potentially leading to delay in diagnosis of breast cancer and a less favorable prognosis. Because equity in health care is compromised through underutilization by these women, barriers to participation and successful outcomes must be investigated. Barriers such as appropriate information, transport, and assistance prevent women with CP from getting to the facility. Once there, communication difficulties, physical limitations, psychologic barriers, and staff attitudes become barriers to a successful outcome. Education for health personnel as well as adaptation of the mammographic technique to suit the physical limitations of women with CP are critical to increasing participation and ensuring successful outcomes. Importantly, there is a need to identify women for whom having a mammogram is not an option and for whom alternative breast screening methods should be provided.     

Quebec breast cancer screening program: A study of the perceptions of physicians in Laval, Que

OBJECTIVE

To identify physicians’ perceptions of breast cancer prevention in order to generate strategies to increase women’s participation in the Quebec breast cancer screening program (QBCSP).

DESIGN

Qualitative study using archival data and in-depth interviews.

SETTING

Laval, Que, a suburban city north of Montreal.

PARTICIPANTS

Twenty family physicians and 1 gynecologist practising in Laval who had received at least 1 screening mammography report in 2004 or 2005.

METHODS

Archival data were obtained in order to refine our understanding of the QBCSP. In-depth individual interviews were conducted with participating physicians until data saturation was reached in order to determine physicians’ knowledge of, beliefs and attitudes about, and behaviour toward preventive breast cancer practices, as well as their suggestions for enhancing patient compliance. The interviews were recorded, transcribed, and coded, and the content was analyzed.

MAIN FINDINGS

Respondents indicated that the screening age groups, the age for beginning clinical breast examination, and the instructions to patients about breast self-examination should be harmonized. Letters to patients should be shortened, simplified, and endorsed by physicians. Screening mammography reports should include more details and be clearer about patient follow-up. The need for patients to sign authorization forms for transmission of information related to their participation in the QBCSP should be reinforced by their physicians. Following abnormal mammogram results, services and procedures should be simplified and delays in appointments decreased. Referral for “orphan patients” (ie, patients without family physicians) should be supervised by nurse practitioners, with physician consultations when needed.

CONCLUSION

This study provides a qualitative understanding of improvements or modifications needed in order to reach a screening mammography participation rate sufficient to reduce breast cancer mortality in women.