Post screen-detected breast cancer within the Screening Mammography Program of British Columbia

Tactile imaging of an imbedded palpable structure for breast cancer screening

Apart from texture, the human finger can sense palpation. The detection of an imbedded structure is a fine balance between the relative stiffness of the matrix, the object, and the device. If the device is too soft, its high responsiveness will limit the depth to which the imbedded structure can be detected. The sensation of palpation is an effective procedure for a physician to examine irregularities. In a clinical breast examination (CBE), by pressing over 1 cm(2) area, at a contact pressure in the 70-90 kPa range, the physician feels cancerous lumps that are 8- to 18-fold stiffer than surrounding tissue. Early detection of a lump in the 5-10 mm range leads to an excellent prognosis. We describe a thin-film tactile device that emulates human touch to quantify CBE by imaging the size and shape of 5-10 mm objects at 20 mm depth in a breast model using ∼80 kPa pressure. The linear response of the device allows quantification where the greyscale corresponds to the relative local stiffness. The (background) signal from <2.5-fold stiffer objects at a size below 2 mm is minimal.

Breast cancer screening recommendations: is mammography the only answer?

Early detection of breast cancer is important to reduce mortality and morbidity. Traditionally, three methods of breast screening were recommended: mammography, clinical breast examination (CBE), and breast self-examination (BSE). At present, BSE and CBE are no longer widely recommended, while mammography is still broadly promoted in the Western world. The primary intent of this article is to examine whether current health policy recommendations related to breast cancer screening are informed by evidence. The issue of whether women are adequately aware of the potential benefits and risks of breast screening methods to make informed decisions is also discussed. It is argued that it is premature to caution women against BSE and CBE because the current evidence is inconclusive or incomplete. Moreover, women should be better informed about the potential harms associated with mammography screening. Recommendations for research and health policy are also discussed.

Commentary - Evidence Against Breast Self Examination is not Conclusive: What Policymakers and Health Professionals Need to Know

Breast cancer is a serious health concern and a disease that is not well understood. Early detection remains the best way to prevent debilitation and death. Traditionally, mammography, clinical breast examination (CBE), and breast self examination (BSE) have been accepted as legitimate breast screening modalities. Over the past 5 years, academics, health professionals, and policymakers have seriously questioned the usefulness of BSE after influential organizations such as the Canadian Task Force on Preventive Health Care downgraded their BSE recommendation citing fair evidence of no benefit and good evidence of harm. We briefly review the three large BSE trials, highlighting methodological weaknesses limiting their ability to evaluate its effectiveness, as well as critique the 2001 Canadian Task Force on Preventive Health Care report on BSE. We argue that it is premature to conclude that BSE is ineffective. Given that most women find their own breast cancer, this article cautions policymakers and health professionals that a prudent approach to BSE promotion should be taken.

Increasing our understanding of breast self-examination: women talk about cancer, the health care system, and being women

The author engaged 13 women, aged 30 to 59, in a collaborative research project over several months to explore the meaning of breast self-examination (BSE) to them. Through a series of 11 group discussions, the women developed a critical consciousness of the commonality of their personal experiences in relation to BSE. Although these women valued BSE, their reluctance to perform it was influenced by their perceptions of breast cancer as a lethal disease, the perceived threat it posed to their femininity, and their ability to negotiate an increasingly medical and technological health care system. This study provides insight into the importance of the social environment and shared understandings in influencing women's individual behavioral choices for BSE. It also illustrates the particular value of collaborative health research.

Provider case volume and outcome in the evaluation and treatment of patients with mammogram-detected breast carcinoma

BACKGROUND

Practice volume may affect the outcome of patients with breast carcinoma. Defining factors that influence the relation of volume and outcome for the diagnosis and treatment of breast carcinoma is important, because breast carcinoma is common, and care is decentralized.

METHODS

Community-wide diagnosis and treatment of mammogram-detected breast carcinoma was examined using claims data from a single insurer representing 25% of the regional population. Among 1001 mammogram-directed breast biopsies, the rate of breast carcinoma diagnosed by stereotactic core needle biopsy (SCNB) or excisional biopsy with needle localization (EBNL) and the rate at which breast-conserving surgery (BCS) was used were analyzed. Outcome and practice volume were examined for surgeons, radiologists, and medical centers.

RESULTS

Two hundred twenty-four tumors were diagnosed by EBNL (604 diagnoses) and SCNB (397 tumors), for a 22.4% positive biopsy rate. The median number of procedures per physician was one. Positive biopsy rates for radiologists, surgeons, and medical centers did not correlate with practice volume. Positive biopsy rates for high-volume physician providers and medical centers ranged from 9% to 46%. The BCS rate was 45% and 64% for surgeons treating one or more than one claim, respectively. Tumor stage and surgeon case volume were the only independent predictors of BCS (P < 0.05).

CONCLUSIONS

There is wide variation in diagnosis and treatment outcomes for patients with mammogram-detected breast carcinoma. Overall, practice volume was correlated with the use of BCS but not with the rate of positive biopsy. A wide variation in the positive biopsy rate among high-volume providers and medical centers suggests that volume of practice is not a surrogate for quality in the diagnosis of breast carcinoma.

Palpable breast cancers are inherently different from nonpalpable breast cancers

BACKGROUND

We examined the clinicopathologic profile of T1 cancers to determine whether palpable cancers are different from nonpalpable cancers.

METHODS

A prospective database was reviewed. Palpable T1 cancers were compared with nonpalpable T1 cancers. Initial significance was determined by chi2 analysis. Factors found to be significant were then reanalyzed. controlling for tumor size by logistic or linear regression, as appropriate.

RESULTS

Of 1263 T1 cancers treated between 1981 and 2000, 857 (68%) were palpable and 401 (32%) were nonpalpable. Palpability correlated with pathologic tumor size, mitotic grade, nuclear grade, high S-phase, lymphovascular invasion, nodal positivity, and lack of extensive intraductal component, multifocality, and multicentricity. There was no significant difference in estrogen receptor, progesterone receptor or Her-2/neu status, ploidy, or DNA index. Breast cancer-specific survival was worse for patients with palpable cancers.

CONCLUSIONS

Palpable cancers are inherently different from nonpalpable cancers, with a less diffuse growth pattern, higher metastatic potential, higher proliferative activity, more nuclear abnormalities, and a worse prognosis.

The effect of structured training on breast self-examination search behaviors as measured using biomedical instrumentation

BACKGROUND

Although breast self-examination (BSE) has long been recommended by health care practitioners as a complement to mammography and clinical breast examination, only a small percentage of U.S. women report doing monthly BSE, and an even smaller number of women perform this procedure proficiently.

OBJECTIVES

To measure the effect of a structured training protocol on improving two dimensions of BSE technique (depth of palpation and search time) in each of two search patterns (vertical strip and concentric circle) using biomedical instrumentation.

METHODS

For this study, 41 young women participated in a structured training protocol for BSE instruction. The dependent variable was thoroughness of search, for which there were two measures: depth of palpation (displacement of the sensors) and duration of the examination. An instrumented breast model designed by the investigator provided quantitative measurements of examination behaviors and was used to test outcomes of the instruction.

RESULTS

Multivariate analyses demonstrated an overall difference across examinations (F = 28.03; p = 0.0001). Univariate tests showed treatment effects for both dependent variables: depth of palpation and duration of examination.

CONCLUSIONS

Individual training in BSE with guided practice improved two measures of thoroughness of search: depth of palpation and duration of search time. Biomedical instrumentation represented a novel approach to the collection of quantitative performance data.

Waiting for a diagnosis after an abnormal screening mammogram. SMPBC diagnostic process workgroup. Screening Mammography Program of British Columbia

BACKGROUND

Women with abnormal screening mammograms require diagnostic assessment and experience anxiety until a diagnosis is established. This report evaluated the timeliness of diagnosis after an abnormal screening mammogram in the Screening Mammography Program of British Columbia (SMPBC).

METHODS

Information on diagnostic interventions following an abnormal screen (N = 10,314) provided through 11 regional SMPBC services between January 1, 1993 and June 30, 1994 were abstracted and analyzed.

RESULTS

The median time from abnormal screen to diagnosis was 3.4 weeks with regional variation of 2.0 to 4.7 weeks; 10% waited 8.7 weeks or longer. For the 19% of women proceeding to open biopsy, the median diagnostic interval was 7.1 weeks with regional variation of 4.6 to 9.3 weeks; 10% waited 13.1 weeks or longer.

INTERPRETATION

After an abnormal screening mammogram, women waited many weeks for a definitive diagnosis, especially those proceeding to open biopsy. Opportunities for process improvement were identified.

Breast cancer screening

Breast cancer is the most common malignancy among women in the United States; however, recent data demonstrates a decline in the mortality rate, which may be attributed to early detection from screening programs combined with effective therapies for early stage disease. As a result of the prevalence of breast cancer and its association with highly emotional issues, screening recommendations have aroused debate in the scientific, public, and legislative domains. A general consensus supports breast cancer screening among women between the ages of 50 and 70; however, much controversy exists regarding screening for women age 40 to 49 or above age 70. This article explores the issues involved in determining breast cancer screening recommendations among asymptomatic women with average risk in the United States.

Prognosis, treatment, and recurrence of breast cancer for women attending or not attending the Screening Mammography Program of British Columbia

Breast cancer screening programs have been initiated in many countries in the past decade. To determine the impact of the Screening Mammography Program of British Columbia (SMPBC), disease and treatment outcomes for women with breast cancer diagnosed in BC between 1989 and 1996 were compared on the basis of attendance at the SMPBC. An SMPBC attender was a women diagnosed with breast cancer within three years of an SMPBC screen, regardless whether the cancer was detected as a result of that screen. Of the 13,636 women aged 40-89 years diagnosed with breast cancer in BC during the study period, 2,647 (19.4%) were SMPBC attenders. 73.5% of SMPBC attenders (N = 1,946) and 74.2% of non-attenders (N = 8,149) were referred to the BC Cancer Agency and had pathology, staging, treatment, and outcome information available. SMPBC attenders compared with non-attenders were more likely to have in situ disease alone, and those with invasive cancers had smaller tumors which were less likely to have grade III histology and less likely to have spread to axillary lymph nodes (all P < 0.001). SMPBC attenders were more likely to be treated with breast conservation and less likely to receive adjuvant chemotherapy or tamoxifen (P < 0.001). Log-rank tests showed local (P = 0.017), distant (P < 0.001), and overall (P < 0.001) disease-free survival were better for SMPBC attenders. These favorable surrogate endpoints suggest that the benefits of breast screening as demonstrated by randomized trials can be translated into community practice by an organized breast screening program.

Development of a competency-based curriculum for training women in breast self-examination skills

It is expected that there will be 178,700 new cases of breast cancer diagnosed in American women during 1998. This corresponds to a new breast cancer diagnosis every 3 minutes. In the absence of any preventive measures at this time, control of breast cancer morbidity and mortality must be sought through early detection and treatment. A competency-based training curriculum in breast self-examination was developed that incorporated three specific skill components: a systematic pattern of search; palpation topography discrimination training; and use of appropriate finger pressure for examination. A computer-assisted breast model was built and piloted for use in this study. The design, implementation, and validation of this program as a platform to train women and advanced practice nurses in breast self-examination is described.