Guest Post: ‘Be Breast Aware’ – Maltese Radiologist Shares Advice During Cancer Awareness Month
Breast cancer is the most common cancer in women with more than two million women being diagnosed worldwide every year.
In Europe, breast cancer is the most frequently occurring cancer, accounting for about 30% of all new cancer cases in women. More than 500,000 breast cancers are diagnosed every year in Europe, and about one woman in every eight will be diagnosed with breast cancer during her lifetime.
Improvements in diagnosis and treatments together with the establishment of breast cancer early detection programs, have significantly reduced breast cancer mortality in the last three decades.
Risk factors
Risk factors can be non-modifiable (risk factors you cannot change) and modifiable (risk factors you can change). Known non-modifiable risk factors include age, sex, genetic mutations, reproductive history, having dense breasts, family history of breast or ovarian cancer, a personal history of previous breast cancer or certain noncancerous breast disease and previous treatment using radiation therapy to the chest or breasts before the age of 30.
Modifiable risk factors include not being physically active, being overweight or experiencing obesity after menopause, hormone replacement therapy, drinking alcohol and smoking.
Know your breast density
Breasts contain glandular tissue, fibrous connective tissue and fat. Breast density is a term used to describe the relative amount of these different tissue types as seen on mammography.
Breast density is classified into four categories, from A to D, with Category A being of lowest density and Category D being of highest density. Categories C and D are considered “dense” and about 40 – 50% of women fall under these categories. Dense breasts are thus common, however, women with dense breasts have a 2.9 – 6-fold increased risk of developing breast cancer compared to women with predominantly fatty breasts.
The sensitivity of mammography also decreases with increasing breast density, therefore supplemental screening with breast US and/or MRI is recommended in these cases.
The rationale behind screening
The aim of breast cancer screening is to reduce breast cancer mortality through the expedited diagnosis of smaller, asymptomatic breast cancers which are less likely to have spread beyond the location where they originated. Treatments remain less effective in the case of advanced-stage disease, and mortality reduction is still significantly related to the tumour size and lymph node involvement at diagnosis, thus screening for breast cancer to pursue an early diagnosis is important.
Mammography meets the characteristics of a screening test: it is rapidly and easily performed, is widely available, and studies have shown that it demonstrates an estimated
breast cancer relative risk reduction of 20%.
Malta National Breast Screening Program
The Malta National Breast Screening program currently invites women between 50 and 69 years of age for a full field digital 2D mammogram (FFDM) once every two years. During 2023, 14,651 screening mammograms were performed.
Each mammogram is double-read by two breast radiologists independently. If the mammogram is reported as normal by both readers, the patient will be invited for her next mammogram after two years. If only one of the two readers reports a positive finding, the mammogram will be further read by a third reader who then decides the outcome.
If both readers report a positive finding, the woman is recalled for further investigations such as digital breast tomosynthesis (DBT)/3D mammogram, ultrasound (US) and magnetic resonance imaging (MRI). In some cases, a core biopsy is also performed.
Personalising breast cancer screening
By means of regular mammographic screening early cancer diagnosis can be achieved however, breast cancer still remains the leading cause of cancer death among women worldwide, thus further improvements are sought.
Screening programs defined by age alone, allow for little to no personalisation, both when considering the choice of the imaging technique and the age boundaries, save for specific groups of high-risk women. This almost “one-size-fits-all” paradigm currently characterises most European strategies, with only few exceptions.
Moving towards a personalised risk-stratified screening could improve the performance of a screening program by reducing underdiagnosis, false positives, and overdiagnosis as well as improving cost-effectiveness.
Artificial intelligence (AI) also represents a real game changer in breast cancer imaging. Applications include assisted detection of tumour to increase diagnostic accuracy; non-invasive tumour characterisation to plan targeted therapy and follow-up; predictive applications regarding response to treatment, risk of relapse and overall survival; and lastly risk stratification, in order to achieve individualised screening programs through AI risk prediction modes.
Be Breast Aware
Women are encouraged to be familiar with their breasts, check their breasts periodically and seek medical advice if they detect any unusual changes.
Signs to look out for are new lumps in the breast or armpit, change in size or shape of the breast, breast redness, swelling of all or part of the breast, skin dimpling and puckering, nipple inversion and bloody-nipple discharge.
With regards to screening, women should seek breast specialist advice so that individual screening recommendations including when to start and how often to get screened is discussed, based on a personalised risk assessment.
Lara Sammut is a Consultant Radiologist specialised in Breast Imaging at Mater Dei Hospital and St James Hospital.
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