Presentation and screening

Breast lumps

In up to 75% of cases, women present to their family practitioner having detected a lump in their breast, most frequently in the upper outer quadrant.

In recent years, however, screen-detected cases have become more important with the widespread adoption of public screening programs.

The presence of a breast lump does not always indicate cancer – up to 90% of breast lumps are benign; the commonest causes being cysts, fibroadenomas or areas of fibroadenosis.

Without laboratory investigation it is impossible for a doctor to know for certain whether a lump is benign or malignant. Consequently, after confirming its presence the clinician should subject the lump to further investigation, regarding it with suspicion (i.e. a possible malignancy) until it is proven benign. Signs that indicate a lump may be malignant include:

• findings of a radiological opacity (microcalcification) with radiating fibrous strands
• a change within the breast that is noticed by the patient
• signs of locally advanced or metastatic disease, including a large mass, tethering to the skin and/or chest wall, lymph node enlargement, peau d’orange (‘orange peel skin’), nipple inversion and skin infiltration.

Other forms of presentation

Not all women having breast cancer present with a lump, other possible presenting signs and symptoms include:

• breast pain or tenderness (in around 15% of cases)
• change in breast shape or size
• dimpling, flaking or thickening of the skin on the breast
• peau d’orange
• nipple inversion, rash or discharge
• swelling of the upper arm or in the armpit.

Alternatively, the patient may present with symptoms arising from secondary disease, for example in the spine or brain. The symptoms may include pain in the back, due to vertebral metastases causing vertebral collapse and/or spinal cord compression. Focal neurological signs and raised intracranial pressure are frequent findings in patients with cerebral metastases. General symptoms such as lassitude and anorexia may reflect advanced and widespread disease, particularly liver involvement.

In women identified to be at increased risk of the disease due to the presence of one or more risk factors, it may be appropriate to use screening to detect a developing cancer at the earliest stage possible.

Breast cancer screening

Early detection of breast cancer is a potentially important strategy for reducing mortality from the disease and has been the goal of breast cancer screening programs since the mid-1970s.

The most commonly used methods for early detection of breast cancer are mammography (x-ray examination of the breast) and physical examination performed by a skilled healthcare professional. Self-examination of the breast has been shown to be of questionable value since it does not appear to reduce breast cancer mortality.

Mammography allows the identification of very small breast cancers (<1cm in diameter), before they can be detected by physical examination, however, debate has ranged as to whether the earlier detection and treatment of these tumors will reduce mortality.

Overall there is general agreement that for women aged 50–69 years, mammographic screening is both beneficial and cost-effective, however, for younger women mammographic screening remains a controversial issue.

National screening programmes have now been adopted in a number of countries including USA, UK, Canada, Sweden, Finland and The Netherlands for women of certain age groups.

In most countries women are screened between 50 and 69 years of age, however, in the USA women from 40 years onwards are screened every 1-2 years.

Following the introduction of the UK national screening program in 1988, a marked increase in incidence of breast cancer was observed in the screened age group. Since that time a significant decrease in mortality in this same age group has been observed, thought to have been brought about by a number of factors including screening and the widespread adoption of adjuvant systemic therapies.

Risk vs. benefit . Whilst the contribution of screening towards the overall reduction in mortality from breast cancer cannot be ignored, this must be balanced against the known risks of cancer associated with ionizing radiation. However, studies assessing the benefit versus risks from mammography confirm that radiation risk does not represent a valid reason for not recommending screening.

For a woman beginning annual mammographic screening at age 50 years and continuing to age 75 years, the benefits have been shown to outweigh the radiation risk by a factor of almost 100.

Costs vs. benefits . The surgical treatment of small, invasive tumors (usually <1cm in diameter) detected by mammographic screening only, with or without radiotherapy, is frequently very successful and in many cases avoids the subsequent need for systemic therapy.

However, national screening programs carry with them considerable economic implications. As a result, efforts are continuously directed towards increasing the effectiveness of screening and reducing costs, in order to obtain a satisfactory cost-benefit ratio in health economic terms. Further studies are necessary to determine the optimal mode of early detection and the frequency of screening in the various age groups.

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