|Year : 1996 | Volume
| Issue : 1 | Page : 7-9
Breast cancer and early detection
Osama M Koriech
Oncology Department, Armed Forces Hospital Member, Board of Directors, National Cancer Registry PO Box 7897, Riyadh 11159, Saudi Arabia
|Date of Web Publication||31-Jul-2012|
Osama M Koriech
Oncology Department, Armed Forces Hospital Member, Board of Directors, National Cancer Registry PO Box 7897, Riyadh 11159
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Koriech OM. Breast cancer and early detection. J Fam Community Med 1996;3:7-9
The incidence and pattern of cancer is changing worldwide due to the unprecedented changes in social habits, industrialization and medical diagnosis advancements. In developed countries, cancer is the second cause of death after cardiovascular disease. Over the last few decades, the increase in incidence appears to be faster in developing countries due to the additional factors of improvement in health care services with a fast drop in other causes of morbidity and mortality and improvement in diagnostic facilities.
Yet in spite of the advancement of clinical science, the improvement in the overall cure rate over the last few years, with few exceptions of infrequent cancers, have been small. A significant prognostic factor in most cancers is the stage at presentation.
In some cancers it is possible to improve the overall survival with early detection of malignancy or identification of precancerous conditions. This is possible with the increasing awareness of the individual at risk of the early signs and symptoms of the specific disease, setting up of screening programs and a routine periodic clinical examination of apparently healthy individuals.
The concept of screening has developed over the last few decades with results supportive of its implications in some cancers and its inefficiency in others. In setting up these programs financial implications and cost effectiveness of the procedure is not infrequently an essential issue.
Effective screening programs should have adequate sensitivity and specificity. The screening programs have inherent biases including lead time, the time by which diagnosis is advanced by screening; length bias, the tendency of screening to detect cases of disease with a more prolonged natural history and a better prognosis than normal; selection bias, reflecting the recruitment of volunteers to screening who tend to have different risks of disease or death from disease than the general population; and overdiagnosis, the tendency of screening to bring to light and label as disease lesions that might never have been diagnosed in the patient's lifetime.
Treatment of cancer precursors reduces the reported incidence of disease in the screened population. However, if the cancer is detected through screening, the incidence of the disease is increased because of overdiagnosis. 
The introduction of screening necessitates the presence of adequate facilities for diagnosis and effective treatment of the detected abnormalities and observed diseases. The programs introduced should be monitored to ensure that they achieve the expected benefits and if changes are required in their organization.
Early detection of cancer or a precursor can result in less radical treatment and improved prognosis of some cancers. Less radical treatment for early disease is less expensive with substantial resource savings. Screening also reassures those with negative test results.  Many people participate in screening programs for reassurance.
Screening and early detection is not beneficial for all cancers. In some cancers early detection does not alter the prognosis, and just prolongs the period of morbidity. Some abnormalities discovered by screening might never have been recognized without a positive screening test, and some patients with borderline abnormalities will be overtreated. A serious disadvantage of screening is false reassurance with false-negative screening tests. Subsequent symptoms may be ignored causing delayed diagnosis. In addition, false-positive screening tests can cause morbidity and expenses of the diagnostic tests, and its potential hazard.
Breast cancer is the most frequent female cancer in developed and many developing countries. The overall incidence is rising and the risk factors are well recognized. A number of screening studies have been completed or are in progress in most developed countries.
Studies confirmed that the 5-year mortality results was significantly reduced in women between 50 and 64 years old. The benefit for younger women reported at 18 years of follow up was controversial as the accrual numbers for the different age groups were small. , Most studies used mammography with or without physical examination s The radiation dosage required for mammography has fallen substantially to an acceptable dose of 0.6 to 0.2 cGy. The benefit derived from low-dose modern mammography substantially exceeds any possible hazard, especially for women older than 40.  In the Breast Cancer Detection Demonstration Project (BCDDP) thermography was not sensitive nor specific enough to be a viable screening test.
Skillful interpretation of mammograms to localize and diagnose impalpable lesions is essential. It is recommended that screening every 1-2 years of women older than 50 is satisfactory. For younger women shorter intervals are desirable. Possible factors for the age difference include reduced sensitivity of the screening tests in younger women with the high density of the breast endocrine tissue, biologic difference in the natural history, and the relative poor prognosis in younger women. Whatever the reason, breast cancer screening in younger women is less cost effective than in older women. This conclusion is confirmed by the failure of the more recently published studies to show a benefit in younger women.  American institutions , recommend that mammography be offered every 1 to 2 years for women age 40 to 49. The Canadian working group made no recommendation for screening this age group.
In Saudi Arabia breast cancer is the most frequent malignancy in females and most patients present at an advanced stage. Patients present at a younger age group in the West.  The implications of these two factors are essential in deciding on early detection programs.
The benefit of Breast Self Examination (BSE) in the West has not been confirmed, though ongoing studies may eventually provide the evidence needed.  This could be due to the relatively low incidence of large lesions at presentation. Delay in presentation is the most important factor in the advanced presentation. The causes of delay might not vary between countries or regions. Cancer is a taboo whether you are in the East, West, North or South. For womanhood fear of breast cancer can persuade women to invent excuses not to seek medical advice early enough. Fear of loosing the breast can be alleviated if the public are informed that mastectomy is not the only treatment choice available. Preservation of the breast with good cosmetic results without affecting the cure rate is now frequent if diagnosed early. Mastectomy is indicated for large tumors, relatively large tumors in small breasts or if the patient prefers it. Some women believe that if cancer is diagnosed then there is nothing can be done, and delay reporting to their doctor. This view should be abandoned.
In developing countries, such as Saudi Arabia, breast cancer presents at an advanced stage. Further epidemiological and prognostic information will be available through the recently established National Cancer Registry. It is conceivable that BSE and breast awareness as a part of whole body awareness, might reduce the incidence of advanced stage disease presentation. The World Health Organization have determined that only BSE can provide early diagnosis of breast cancer in many parts of the world. 
In this issue of the Journal of Family & Community Medicine, Kashgari  have looked into the knowledge of BSE in the Saudi women. Their findings reflect the long held, but unconfirmed, views that public knowledge of BSE is limited. Before publicizing the possibility of early detection, it is necessary to identify institutions where women can get the optimal diagnosis and treatment on defining an abnormality. Patients should be encouraged to find their problems and immediately bring them to the doctor. The doctor should have the knowledge and the facilities to manage the condition promptly.
A further significant issue that will be brought forward indirectly in these patients is informing patients of the findings of cancer and the details of its treatment and its implications. Data from the West suggests that the patients who are informed of their disease are more cooperative and less anxious.
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