Forrest (1986) reminds us about the high proportion of mortality rates from breast cancer back in early 1980s which effected in 62.5% deaths (24000 diagnosed each year versus 15000 deaths from the disease). His recommendations were based on previous trials, which proved about 30% improvement in mortality rates from screening (Tabar et al, 1985). Because the statistics proved breast cancer to be significant health concern, working group, chaired by Mr Forrest, recommended population screening programme in the UK. For the program to be successful it should meet the ten principles for population screening (appendix 1) (Wilson and Jungner, 1968).
Breast cancer screening helps to diagnose cancer in early stage and population screening is a process of identifying the healthy population who have a potential risk of developing some condition or disease (Public Health England, 2015). It refers to group of people with common characteristics, such as all men and women aged 60 to 74 (bowel cancer screening) or all women aged 50 to 70 (breast cancer screening).
The condition screened for should be an important health problem, showing in its frequency and severity.
The risk of developing breast cancer in UK is 1 in 8 for women and 1 in 868 for men (Cancer Research UK, 2012) and breast cancer is one of the most common causes of death in women in age groups 50-64 (Chetlen et al, 2016). In UK death rates from breast malignancy in 2014 went up to 163444, which is 45% of all cases diagnosed (Cancer Research UK, 2017).
Some might think that innovations in health care, including breast screening, are not necessary linked with the improvement of mortality rates, but they believe that reduced mortality rates are associated with innovation of drugs, such as tamoxifen (Hoffmann et al, 2014).
The NHS Breast Screening Programme (NHSBSP) in England offers all women between the age of 50-70 routine breasts screening every three years and studies prove the reduction of 28% in mortality rates for women in that age group (Duffy et al, 2010). Screening women younger than recommended age does not show significant difference in mortality rates (Fedewa et al, 2016). Recently, the UK screening program has been extended for females between the ages 47-73. The new phased extension will effect 1.5 million women having offered mammography in the new age group, they will be compared in terms of breast cancer diagnosis and mortality, with another 1.5 million women not offered the screening (UK Clinical Trials Gateway, 2016). Those findings might suggest new screening age and screening intervals. Some countries implemented more frequent screening and out of thirty national mammography based screening programmes, only the UK have screening intervals every 3 years (Youlden et al, 2012). Screening intervals are influenced by lead time, which is the time from the initial diagnosis to the time when the cancer would be clinically felt. Andersson et al (1988) in their Malmo trial found that screening women every 18-24 months showed 36% reduction in breast cancer mortality with average follow up of 15.5 years. Similarly, the Gothenburg trial showed significant, 44% improvement in breast carcinoma mortality reduction for those screened every 18 months at 14 years follow up (Bjurstam et al 2003.) However Canadian National Breast Cancer Screening Study (CNBSS) showed no reduction in breast cancer mortality for women aged 40-59 from annual mammography (Miller et al, 2014).
For screening to be effective it must distinguish an early stage of the disease, where cure is highly possible; in breast it means using specific test to eliminate disease before it causes any symptoms, such as lump (Cancer Research UK, 2017). Bansal et al (2013) report that tumours found at the earlier stage of their natural history are less likely to spread and require less aggressive treatment. About 20% of newly diagnosed breast cancers are early stage, non-invasive and too small to be clinically evident, which means they are less likely to metastasis to distant organs such as lymph nodes, bones or brain (Symonds et al, 2012). Moreover, Spencer et al (2004) found association with smaller tumour size, lower stage at presentation, and less mortality in women who underwent routine mammographic screening.
Currently, NHSBSP spends about £96 million per annum (NHSBSP, 2013). Any screening programme that is introduced to the public must be cost effective and well balanced in terms of benefits it provides. This is why other cancers, such as prostate cancer, do not qualify for national screening programme even though it is an important health problem. Risks of over diagnosis are too high and outweigh the potential 20% reduction in mortality (Prostate Cancer Risk Management Programme, 2013).
Duffy et al (2010) state that between 2 and 2.5 lives are saved for 1 over diagnosed case, which proves the benefits of screening. However, over diagnosis is considered to be the major harm from screening (Cancer Research UK, 2017). This is where a malignancy is detected, but it would not have come in the woman’s lifetime (Public Health England, 2012).
Some argue that starting age of 45-46 versus 50-51 increase the higher risks of false positive (Salas et al, 2011).
In 2015-16, 4.2% (88654 women) of women aged 45 and over had abnormalities found on their screening mammograms and was then called back for further assessment. Out of those women, 79.3% had no cancer diagnosis. This shows that the percentage of all women diagnosed with abnormality but not having breast cancer following further assessment was 3.3% (NHS Digital, 2017). The uncertainty comes from not knowing which cancers might or might not cause a patient a life threatening condition or present but not detected cancers; this effect in false positive and false negative diagnosis (Public Health England, 2016).
One of the factors that can limit the success of screening program is low compliance, which could be affected by misconceptions about the screening programme, travel or unpleasant experience from previous mammograms (Chetlen et al, 2016). The number of women accepting the screening invitation has fallen over the last few years. In 2014-15, 71.3% attended, where 72.1% attended in 2013-14. Similarly, in 2014-15, 63.3% of women who received their first invitation, were screened, where in 2013-14 it was 65.8% and even more back in 2004-05, 70.1% (NHS Digital, 2016). Whelehan et al. (2013) suggested that pain associated with mammograms increases poor re-attendance. Hence, it is crucial to adapt pain-reducing intervention in mammography.
Any person with suspected abnormality in breast that requires investigation and/or treatment, has access to facilities in a specialist breast clinic. In the UK, women can enter the breast clinic via GP referral (with symptomatic problems) or recall from screening where abnormality found requires further assessment. Most patients attending breast clinic will be undergoing triple assessment (TA). It means the patient will be clinically examined by breast care nurse (BCN) in assessment clinic. Furthermore, diagnostic imaging, either mammographic picture or ultrasound (US), might be performed followed by the biopsy if suspicious mass is found (Aslam et al, 2015). The results are sent to histology department and discussed at the multidisciplinary meeting (MDT) where further steps/ treatment are put in place. The estimated clinic cost to diagnose one cancer is about £1962 (Wooler et al, 2014).
During clinical breast examination (CBE) BCN will examine patient’s both breast and nodes in the axillae, supraclavicular and infraclavicular areas. Shen et al (2011) reported that negative nodes were associated with a significant increase in 5-year survival. Similarly, the Swedish two counties trial proved that women diagnosed at earlier stage of disease progression, where no nodes were involved, have even better survival rates (Tabar et al, 2011). Additionally, those women with mammography detected cancer (MDC) had a significantly lower incidence of having a positive nodes than those with non-mammography detected cancers (NMDC) (24.78% vs. 55.92%).
BCN provides clinical opinion and more detailed lump/ mass description (benign/ malignant). Some suggest that CBE can detect cancers not visualised on mammograms (Kearney et al, 2009). However, this is only when high standards of clinical training are provided and systematic search pattern as well as appropriate length of examination is applied (Miller et al, 2011). CBE by itself is not a reliable diagnostic method in breast cancer investigation and its accuracy is between 60-85% (Buccimazza, 2010).
The image modality that is available to everyone, regardless their age is US. US is radiation free and has very high localisation precision. The scan is quick to perform and it is targeted to small area rather that the whole breast. In study done by Ji et al (2012) diagnostic sensitivity of US alone, mammography alone and combined US and mammography were 57.4, 79.6 and 92.6%. Other authors found that US combined with mammography improves cancer detection by 10-20%, but, it is operator dependant (Madjar, 2010). Patients with denser breast, under 40 years old, will be offered ultrasound above mammogram. Patients with suspected lymph nodes involvement will have US to the axilla (Bansal et al, 2013). US increases the specificity and clinical findings, however it is better in diagnosis of cysts and lobular masses rather than visualise calcification (Candelaria et al, 2013). More advanced form of ultrasound is elastography, which measures tissue stiffness and it can reduce the number of benign biopsies (Bansal et al., 2013).
Mammography is the only available population-level screening method that shows significant reduction in mortality rates (Glasziou and Houssami, 2011). This quick procedure can investigate both breasts at the same time and it is available to broad range of women. Digital mammography (DM), in particular brought lots of advances in practice. Firstly, it detects significantly higher numbers of DCIS and low grade invasive cancers (Nederend et al, 2012). Secondly, Shen et al (2011) reported that MDC was smaller in size than NMDC (20.68 vs. 30.38mm) and it correlated with better survival prognosis. The average detected tumour size dropped from 3.5cm in 1950 to 2cm in 2006 and the size reduction benefit was one of the factors that implemented mammographic screening (Cady et al, 2011). Mammography has sensitivity of nearly 90% in women age 50 and over but cannot detect all cancers because some cancers and normal tissue have similar mammographic density (Osborn, 2013). Hence, it is easier to visualise mass in fatty breasts and when cancers show distortion or calcifications (Tardivon et al, 2010).
More advanced form of digital mammography is digital breast tomosynthesis (DBT). It shows microcalcification in more depth by performing multi sliced image. Tomosynthesis has its benefits in clearer demonstration of an area of interest. It also detects more cancers than standard mammogram and provides more detail hence it could be used in diagnosing invasive breast cancers (Hwang et al, 2016). However, more research is required to confirm this statement. The radiation dose associated with DBT screening and running costs are slightly higher compared to standard 2D mammograms. Also, more slices will require more reading time, putting extra pressure on radiologists. Ciatto et al (2013) in their STORM study found that integrated 2D and 3D mammography improves detection of breast malignancy and potentially it can reduce false positive recalls by one fifth. Similarly, Oslo trial found increase in detection of invasive breast cancers by 40%, increase in the detection of all cancers: invasive and in situ (27%) and decrease in false-positive (15%) (Hologic, 2017). DBT is beneficial in finding multifocal diseases but it cannot tell the actual tumour size. For that, it is more common to use contrast enhanced spectral mammography (CESM) (Bhavika et al, 2017). CESM is used for ladies over the age of 35. As much as applying contrast is great in detailed localisation of cancerous mass, it is not safe to use in all cases.
MRI is used mainly for some ladies with breast implants, dense breasts, high-risks young women and imaging axillary node cancers (Schenberg et al, 2015) but it is not part of TA. It is great in detecting invasive malignancy and has no radiation risks. Some suggest that MRI should be implemented as a screening tool due to its high sensitivity. However, its specificity is lower than mammography (Jatoi, 2005).
Though mammography remains the gold standard diagnostic tool for breast cancer, there are some limitations. First of all, sensitivity of the device reduce from 85% to 68% in ladies with dense breast and negative biopsies for abnormal findings, lead to unnecessary anxiety and extra costs (Fedewa, 2009). Biopsy is required in patient with suspicion of malignancy to confirm the findings and its grading/ staging. This provides information on the tumour types, size and hormone receptor status which can contribute to the management options and help predict prognosis (Bateman and Shaw, 2016). Biopsy is performed under ultrasound guide or stereotactic guide, which are more accurate and stored images can be used during the MDT (Bansal et al, 2013). Moreover, Reynolds (2009) agrees that guided biopsies are more cost effective, quicker and less invasive for the patient compared with surgery.
Fine needle aspiration cytology (FNAC) is very quick, simple procedure and it can get to difficult areas and provide information on status of the malignancy. However, it cannot always predict hormone receptor status and differentiate between in-situ and invasive carcinoma, hence core biopsy (CB) is the preferred method over FNAC (O’Flynn et al, 2010). Apesteguia et al (2011) suggest that best results are achieved when 14G needle is inserted several times to take samples with sensitivity of 97.5% and there is low false negative rate of around 5%. However, micro-calcifications are difficult to be seen on ultrasound and this can lead to incorrect sampling and histological under-estimation (O’Flynn et al, 2010). This is why X-ray guided stereotactic vacuum-assisted biopsy (SVAB) is currently the gold standard for calcification sampling. It can remove larger volume of tissue for analysis and in some cases, it can remove the whole abnormality. The specimen is normally X-rayed to confirm the successful removal of calcification and then a marker clip is inserted to highlight the area affected and guide wire insertion at the latter date (Lacambra et al, 2012). CB is cheaper under US guide: 56% decrease in the cost of diagnosis in comparison with surgical biopsy and some believe it is even more if compared with stereotactic assistance (Schueller, 2008).
All findings will be discussed at the multidisciplinary team meeting (MDT) to establish best management. Previously, patient pathway was organised by an individual consultant-led service, which took several weeks from referral and diagnostic process to treatment. There was poor communication and no discussion between different professions until 2000, where MDT was implemented in UK with the NHS Cancer Plan and it is now compulsory for treatment recommendation in all newly diagnosed/ suspected cancers. Specialists have now dedicated time to attend meetings and they are supported with administrative assistance, infrastructure investment into meeting rooms with videoconferencing facilities to allow communication between different specialist centres and hospitals (English et al, 2012)
MDT meetings take place every week and surgeons, oncologists, radiologists and pathologists are present to discuss their findings. They are supported by specialist nurses, radiographers and administrative staff (Bateman and Shaw, 2013). Combination of different professions allows sharing of broad range of expertise and knowledge, which effects in improved clinical outcome (Tang, et al, 2010).
Kesson et al (2012) found that MDT meetings led to improved patients diagnostic and treatment planning outcome. They also confirmed that survival was partially dependent on MDT rather than purely on treatment advances. Prades et al (2015) undertook systematic review of 51 papers from 2005 to 2012 and they found that MDTs resulted in much better clinical and process outcomes for patients with improved survival in cancer patients.
However, it is not clear how to evaluate and monitor the outcome of MDT performance and some state that about 20% of all decisions made by MDT need revision after the meeting (English et al, 2012). The reason behind it could be not included patient’s comorbidity or patient’s choice (Blazeby et al, 2006). Audit done by English et al (2012) showed that 6.5% of MDT decisions were not implemented as patient preferred less or more aggressive form of treatment. However, this study does not say how many MDT decisions were actually performed in practice or whether there was another factor that affected final procedure. Arguably, the treatment decisions agreed during MDT could be different if the panel was not aware that it was monitored by external body/ audit.
Each MDT meeting lasts between 30min to 2hours and the costs are estimated to be around £822057 per year; the cost to discuss each individual patient is £36.6 (Fosker and Dodwell, 2010). The costs however, might be higher as those are only estimates based on salary of professionals potentially present at the meeting. They do not include preparation time and time of junior doctors and other professions as well as non-salary costs.
Saini et al (2011) suggest that MDTs provide a good opportunity for education and training of junior doctors as well as they are good information source to other professions present. Some believe that MDTs can be specifically designed to teach about a certain procedure, ex. breast reconstruction (oncoplastic MDT) to facilitate training and teaching in these techniques (Lawn and Johnson, 2014).
Hamilton et al (2016) believe that patients should be presented with well-balanced options of their treatment rather than comply with the speaker’s assessment of “best” intervention. Lanceley et al (2008) add, that patient centred factors should be included in MDT hence they see the benefit of implementing staff with nursing or psychosocial background as they might have relevant information about patient centred issues.
Even though all papers highlight the importance of MDTs none of them mentioned whether MDT management are of benefit to all patients or only some. Also, some teams are more confident with using advanced IT system to communicate between hospitals but not all MDT participants make the most out of the current digital advances. None of citied articles included patients in MDT. It could be due to limited time as well as data protection of other patients. Also, advanced medical terms used during MDT can make patients struggle with the language and this can delay the procedure (Keeson et al 2012). A good solution to this might be a discussion with the patient prior to MDT, as this will support the principle of “no decision about me without me”.
Summarising, it has been demonstrated that breast cancer meets the criteria for population screening and investigation process plays a major role in detecting breast cancers.
It has been shown that screening prolongs lives, however age-specific effect of mammographic intervention and the use of different imaging modalities can lead to many debates. More research and audits are needed to understand the behaviour of breast cancers to be able to distinguish which cancers might not need treatment; this might minimise the highest disadvantage of screening which is false positives.
Triple assessment plays a vital role in non-operative diagnosis for most of the patients with minimally invasive procedures, however its best benefit is seen when all of its aspects are combined together followed by multidisciplinary discussion in cases where cancerous mass has been confirmed.
The growing population number that brings growing breast cancer numbers will put extra pressure on breast clinics and MDTs, hence it is vital to continue with research and audits to test and provide most effective diagnostic tools and treatment options for all affected by breast malignancy.
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- The condition sought should be an important health problem
- There should be an accepted treatment for patients with recognized disease, and treatment should be better at an earlier stage
- Facilities for diagnosis and treatment should be available
- There should be a recognizable latent or early symptomatic stage
- There should be a suitable test or examination
- The test should be acceptable to the population
- The natural history of the condition, including development from latent to declared disease, should be adequately understood
- There should be an agreed-upon policy on whom to treat as patients
- The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole
- Case-finding should be a continuing process and not a “once and for all” project