Evaluation and management of breast abnormalities

Article Abstract:

While mammography and physical examination hold promise for the earlier diagnosis of breast cancer, they have not relieved the clinician of difficult challenges in making the most prudent recommendations to the patient. Neither mammography nor physical examination result directly in a diagnosis of breast cancer, but only in an indication that some abnormality exists. The decisions about when and how abnormal findings should be followed by biopsy are still complex, though a systematic approach should aid good clinical judgement. Patients may be classified into three major categories: those with a palpable mass and normal mammogram, those with an abnormal mammogram and no palpable mass, and those with both a palpable mass and an abnormal mammogram. A normal mammogram can not be reason to disregard a palpable mass, as the best mammographic techniques will miss at least 10 percent of breast cancers. In patients with nothing in their medical history or mammogram to suggest that a mass is malignant, aspiration biopsy can be useful in confirming clinical impressions. Aspiration biopsy can produce false negative results, although no more than 5 percent of breast cancers will be missed by this technique. Among patients with abnormal mammograms without a palpable mass, careful analysis of the mammogram is necessary or the patient will be exposed to the risks and costs of needless biopsy. There is a strong tendency to lean towards biopsy for any apparent lesion, but surgeons should resist this tendency and attempt a reasonable malignancy-to-benign ratio. Often, observation and follow-up mammography may be more appropriate than biopsy for an inconclusive mammogram. The presence of a palpable mass greatly aids the interpretation of a mammogram; for this reason, physical examination should always accompany mammography. This is more important now that many women make appointments on their own at mammography clinics; they should be referred for physical examination as well. One study has estimated that 16 percent of minimal breast cancer would be missed if mammography alone were used. Care should be taken to confirm that the palpable mass is identical to the mammographic lesion. However, regardless of the mammogram, all clinically suspicious masses should be biopsied. (Consumer Summary produced by Reliance Medical Information, Inc.)

Management, Evaluation, Abnormalities, Biopsy, Breast biopsy

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Mammographic screening of women with increased risk of breast cancer

Article Abstract:

Numerous studies have demonstrated that the use of screening mammography improves the prognosis of breast cancer, and that more widespread use of mammographic screening would not only save many lives but would also permit greater numbers of women to be treated with breast-conserving therapy. Nevertheless, the majority of women of appropriate age have not adopted routine mammography into their health care programs, and physicians do not widely recommend mammography to their patients. Clearly, any understanding of the behavioral impediments to routine mammography may have large payoffs in terms of public health. Indeed, in an era of otherwise skyrocketing costs of medical care, the benefits which may be achieved through mammographic screening are quite cost-effective. In an effort to evaluate the reasons for seeking or not seeking mammography, researchers studied 1,002 women. These women consisted of 501 subjects who were at high risk for breast cancer, most often because one or more first-degree relatives had breast cancer, and 501 matched controls. Although it might be expected that women at increased risk would take greater advantage of opportunities for early diagnosis, this was not the case. This failure to obtain mammographic screening was not due to a failure to perceive the increased risk. Seventy-nine percent of the high-risk women perceived themselves as high-risk, in contrast to 54 percent of the controls. Nevertheless, there was no statistically significant difference between the groups regarding the number of mammograms received. Curiously, among the women in either group who had not had a mammogram, the lack of a physician's order to do so was given as a major reason, but among the women who did have a mammogram, a physician's order was less important and major reasons given for deciding on mammography included media publicity. The results indicate that members of families with a high incidence of breast cancer should continue to be sought out and encouraged to participate in regular breast cancer screening programs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Psychological aspects, Usage, Testing, Medical screening, Health screening

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Revisions in the risk-based breast cancer screening program at Group Health Cooperative

Article Abstract:

The increased uses of mammography and breast physical examination are part of the early detection objectives of the National Cancer Institute and have become a national priority. However, there are limitations in resources, mammographic equipment, and trained personnel. One approach has been to limit mammographic screening to women who belong to increased risk groups. Unfortunately, research has shown this technique to be ineffective, since it fails to include a large number of women who are likely to develop breast cancer. A more workable solution is to vary the recommended interval of mammographic screening, depending upon the risk category of the individual. This method has several advantages. More women are recommended to have mammographic screening, and yet the total number of screenings need not increase. In addition, the small but finite risks of mammographic screening are more concentrated among the women who are also the most likely to benefit. (The risks of the screening itself are, in fact, smaller than the risks involved with following up what would otherwise turn out to be false positives reports.) Such a program of risk determination has been instituted in a large northwest health maintenance organization (HMO) serving 400,000 members. After completing a questionnaire and noting such factors as age of first menstruation, nulliparity, first birth over 30, breast cancer in a first degree relative, and so forth, the woman is assigned to one of four risk categories. Women in the lowest category have mammography only when referred by their physician. In the next three categories, women are suggested to have mammographic exams at five-, three-, and one-year intervals. The net result is that within this HMO the number of mammographic exams has not increased, but the percentage of women over 40 who are eligible for mammography has risen from 57 to 83 percent. (Consumer Summary produced by Reliance Medical Information, Inc.)

Economic aspects, Risk factors

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