Guidelines (1).pdf

8/14/2019 Guidelines (1).pdf

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The above recommendations are systematically developed statements to assist practitioner and patient

decisions about appropriate health care for specic clinical circumstances. They should be used as an

adjunct to sound clinical decision making.

Guideline for

The Early Detection of Breast Cancer

Administered by the Alberta

Medical Association

2007 Update

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 wom-

en 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.

RECOMMENDATIONS

Screening Procedures

Mammography, clinical breast examination and breast

self-examination can be used as screening procedures.

Breast ultrasound and MRI are not currently recommendedfor routine screening.

Exclusions

The recommendations in this guideline do not apply to:

Women with signs and symptoms suggesting breastcancer;

Women with a personal history of breast cancer;

Men.

Mammography Screening in Women Under 40 Years

Routine mammographic screening for women under40 is not recommended.

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 benets and risks of

screening.

There remains controversy regarding the degreeof benet of screening mammography in this agegroup. (See Background)

If a woman chooses to participate in mammogra-phy screening, the recommended interval betweenscreens in this age group is one year.

Mammography Screening in Women aged 50 to 69

Women aged 50 to 69 years should have a screeningmammogram at least every two years.

Annual mammography screening should beconsidered in circumstances of increased risk.

Mammography Screening in Women Over 70 Years

The risk of breast cancer in this group is high.

Mammography screening every two years shouldbe continued taking into account individual health

factors and estimated life expectancy.

Mammography Screening in Women with a Genetic

Predisposition to Breast Cancer

Some experts suggest that mammography screeningamong this population should commence ve to tenyears prior to the age of onset of breast cancer intheir family member. Consideration may be givento referral to the Cancer Genetics Research Clinics.

(See Background & Appendix 1).

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.

Breast Implants

Women with breast implants should be referred for

diagnostic mammography at age appropriate intervals.


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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.1,2,3,4In

2001, 1,644 Alberta women were diagnosed with invasive

breast cancer and 425 women died of the disease.5Breast

cancer accounts for nearly 21% of all cancer deaths in

Alberta women.1

Risk FactorsThe lifetime risk for breast cancer is one in nine. The risk

however, varies over a womans lifetime. Table 1 reects

the age specic risk of breast cancer for women.6

Table OneProbability 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 Probability

35 1/384

40 1/208

45 1/128

50 1/109

55 1/94

60 1/78

65 1/70

70 1/65

Denition 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.

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.3,4Some of the reservations about

making population-based recommendations for women in

this age group, are based on limitations in the scientic evi-

dence available to date. While there is emerging evidence

of benet from some combined analyses of the rand-

omized trials, the benet is smaller than in older women,

and is of borderline statistical signicance.10,11

There has been a lot of debate in the literature regarding

the reasons for the apparent decreased benet of screen-

ing. Evidence to date suggests that screening mammog-raphy is less sensitive for women in their forties than

for older women.12It 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 benet.13 Data suggests that annual mam-

mography in this age group will be required14in order to

detect breast cancer at its earliest stages and achieve a

reduction in breast cancer mortality similar to that seen in

older women.14,15Finally, there may be statistically insuf-

cient numbers of women in this age group included in

the controlled trials to denitively show a benet.16

Concerns have also been raised about the decreased

positive predictive value of any of the three breast screen-

ing 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 conse-

quence of screening is higher than for older women.

Increasing age, being born in North America and

northwest Europe, and having two or more rst degree

relatives with a history of breast cancer are identied as

the strongest risk factors.

There are many other identiable risk factors, but few

are amenable to change. It is estimated that up to 80% ofwomen 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.


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Women Aged 50 to 69 Years

Many studies have shown the efcacy of mammog-

raphy 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 car-

cinoma by approximately one third. Because additional

benet with annual screening has not been demonstrated,screening every two years is often recommended.9

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

specically addressed the efcacy of screening in this

age group, it should be continued in the context of indi-

vidual health factors and life expectancy.

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 rst degree fam-

ily member. Additional screening tools for this group of

women are currently being studied including MRI, ultra-

sound, 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. How-

ever, the studies which have raised this concern involved

much higher levels of radiation than are found in present

day mammography.17,18The radiation dose delivered by

mammography is lower than that of an ordinary chest

X-ray.

Factors Affecting the Acceptance of Screening Recom-

mendations

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.19,20,21Physicians should ensure that all

women who would benet from screening be informed of

its potential advantages.

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 statistics6. 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. Benet

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.


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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 ts within the broader health systemfocus on quality and complements other strategies such as Pri-

mary Care Initiative and the Physician Ofce 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 multi-

disciplinary team composed of a family physician, general practi-

tioners, radiologists, general surgeons, a gynecologist, oncologist,

pathologist, epidemiologist, Medical Ofcer 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 fur-

ther information or if you have difculty 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

12. Kerlikowske K, Grady D, Barclay J, et al. Effect

of age, breast density, and family history on the

sensitivity of rst 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 ofCanada. Cancer 1994; 74: 1196-1203.

17. Mettler F, Upton A, Kelsey C, et al. Benets 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 PublicHealth,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 His-

tory Taking. (pp317-328) 4th Edition, 1987 J.B. Lip-

pincott Company, Philadelphia.


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APPENDIX 1: CANCER GENETICS CLINICS

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.

Referral Criteria

The following are offered as considerations for selecting women who may benet from genetic counselling. The

criteria do not necessarily dene 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- rst onset < 50 years; or breast andovarian 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 ofa mutated cancer susceptibility gene

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

CANCER GENETICS CLINIC

Contact Information

Cross Cancer Institute and Edmonton/Calgary Genetics Clinics.

By Telephone:

Cross Cancer Institute (780) 432-8422

Edmonton Genetics Clinic (780) 407-7333

Cancer Genetics Research Clinic (403) 670-2438


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APPENDIX 2: CLINICAL BREAST EXAMINATION

Region

Examined

Procedures and Techniques

BREASTS Inspection

BREAST, AREOLA, NIPPLE

Client in SITTING position disrobed to waist. Inspect breast, areola an

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.

Examination

Skills and Focus

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

AXILLAE Inspection

AXILLAE

Inspects skin of axillae with arms raised over head

AXILLARY LYMPH

NODES

Palpation

CENTRAL,

PECTORAL,

SUBSCAPULAR,

LATERAL LYMPH NODES

Supports clients L hand and wrist with L hand to examine L

axilla and reverses for R axilla. Cup ngers together. Reaches as

high as possible into axilla

1. Brings ngers 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)

INFRACLAVICULAR

LYMPH NODES

Palpation

INFRACLAVICULAR

Palpates bilaterally for INFRACLAVICULAR nodes in 1st interspace

with nger pads

SUPRACLAVICULAR

LYMPH NODES

Palpation

SUPRACLAVICULAR

Palpates bilaterally for SUPRACLAVICULAR nodes above clavicle

with nger pads

BREASTS Inspection

BREAST, AREOLA,

NIPPLE (same as above)

Client SUPINE, with pillow removed from under head. Uses small

pillow under clients shoulder on side examined to shift breasts medi-

ally (NO PILLOW IF BREASTS ARE SMALL)

1. Inspects breasts.

Palpation

BREAST, AREOLA,

NIPPLE and

TAIL OF SPENCE

Palpates each breast:

1. Asks client to move arm away from chest on side being examined

2. Uses at of 4 ngers, in a rotary motion to compress breast tissue

3. Flexes, from the wrist, not the ngers

4. Applies moderate pressure, keeping constant contact with skin5. Moves back and forth across breast in straight lines, making

constant small circles

6. Slides hand down 1 nger 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

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.

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