BREAST CANCER SCREENING

 I recently attended a webinar on breast cancer screening, presented by a radiologist. It had a lot of new information on screening guidelines for women. As an OBGYN I am not equipped with clear guidelines to inform the reproductive age patients about their breast cancer risk and screening intervals. Breast cancer screening is focused on identifying malignancies in asymptomatic women to detect disease at an early, highly treatable stage. While the clinical utility of early detection is universally acknowledged, specific screening protocols, modalities, and initiation ages vary slightly across international and regional guidelines.

Mammography remains the gold standard for population-based screening and the only modality clinically proven to reduce breast cancer mortality. Mammography employs low-dose X-ray imaging to visualize architectural distortions, microcalcifications, and soft tissue masses.

Increasingly preferred over conventional 2D mammography, particularly for dense breast tissue, 3D mammography reduces recall rates and improves the detection of invasive cancers by capturing multiple cross-sectional images.

Other modalities are utilized for specific clinical indications and are not recommended as standalone screening tools for average-risk individuals:

Breast Ultrasound: Primarily used to evaluate palpable masses or targeted findings on a mammogram. It serves as a supplemental screening tool in women with dense breast tissue (BI-RADS C or D), where dense parenchymal tissue can mask small lesions on an X-ray.

Magnetic Resonance Imaging (MRI): Utilizes intravenous gadolinium contrast to detect neoangiogenesis associated with malignancy. It features high sensitivity but lower specificity, and is reserved for high-risk screening algorithms.

Screening schedules are strictly dictated by an individual’s risk category, typically determined using validated risk assessment models.  Tyrer-Cuzick is a software risk calculator that can identify high-risk women who may require annual screening. 

I went and reviewed my mammogram report again, which made more sense to me, realizing that I have type C breast density. which explains why radiologists are required to supplement their screening with an ultrasound. 

Most average-risk women have no personal history of breast cancer, no family history, and no genetic mutations. 

Defined as women with a calculated lifetime risk of breast cancer greater than 20%, a known pathogenic germline mutation (e.g., BRAC1, BRCA2, TP53, PTEN), an untested first-degree relative with a mutation, or a history of therapeutic chest radiation (e.g., for Hodgkin lymphoma) received between the ages of 10 and 30. This category of high-risk patients requires combined annual screening mammography and annual contrast-enhanced breast MRI. The screening typically begins at age 25 to 30, or 10 years earlier than the youngest affected first-degree relative (but generally not before age 25 for MRI and age 30 for mammography due to radiation sensitivity of young breast tissue).

Implementing a screening program requires a balanced evaluation of its epidemiological advantages against potential diagnostic complications.

The benefits include

• Significant reduction in breast cancer-specific mortality.

• Increased likelihood of identifying early-stage disease (Stage 0 or I), allowing for breast-conserving surgery rather than mastectomy and lowering the necessity for aggressive adjuvant systemic chemotherapy.

As with any screening test, there may be false positive results, which may lead to unnecessary health care costs, psychological distress, and tissue biopsies. 

This made me a bit worried to know that high breast density decreases mammographic sensitivity and independently increases breast cancer risk. Clinical practice increasingly incorporates mandatory reporting of breast density to guide decisions regarding supplemental screening.

Routine physical examination alone is no longer recommended as a primary standalone screening method due to a lack of clear mortality benefit; clinicians emphasize "breast self-awareness." Patients should remain familiar with their baseline breast topography and promptly report clinical changes, such as skin tethering, nipple retraction, or new focal asymmetry.
 

WE ALL KNOW HOW THIS ENDS

 This was the title of the latest book I have read. It really touched my heart. As a doctor, we aim to keep patients alive, and, most importantly, in my profession as an obstetrician, we assist women in giving birth. This book has a great number of topics that are not discussed in everyday life and are often avoided. These are topics around death, the end of life, funerals, and dealing with grief. We are mostly unprepared and unable to plan accordingly. In all these affairs, the presence of an end-of-life doula becomes handy. The author Anna Lyons points out tips to help people who are interested in this profession to step into this path. Tips such as working in a hospice or as a healthcare assistant, and she introduces several useful websites and links.

Training as an end-of-life doula teaches us that death is a normal and natural part of life, dying is still living, and death is a transition. She points out that a good doula listens to her clients and asks all the important questions. They remember all the important facts, and at the same time maintain confidentiality. They are not there to be your friend, judge, or impose their own beliefs, or befriend you. 

Throughout the book, there were numerous stories of death and loss and how the family members handled it, from stillbirth to death in the COVID pandemic, or loss of a small child who had been unwell from birth. There were some interesting reads about various funeral plans. It really got me thinking about how I have not really bothered to plan my own funeral. I am of muslim faith, and most of the time, the family does the burial the following day after the death, the body is washed and wrapped in a white cloth, and buried with no coffin. Sometimes I feel like a cremation would be a better option, but I am fearful to make such drastic decisions. 

My first experience with the death of a family member was in 2008, when my great-grandmother was transferred to a specialist cardiology hospital after collapsing in a nursing home. I was a curious medical student then. She was taken for a pacemaker insertion, but the procedure failed, and she was transferred to the ward, intubated, while someone was giving breaths through the ambu bag. She demised the following day. My uncle and I were there all along. I unfortunately missed the burial due to my duties and classes.  Grandpa, whom I have always loved more than my parents, passed away in August 2018. I got the news of his passing while driving to work. I cried in the car, wiped the tears and went to work. I am crying now as I am typing… I flew back home for the 40th, and my family and I went to his grave, mourned, cried, and paid our respects. I have a small picture frame of him, looking handsome in a tie and suit, on my parents’ wedding day. I talk to him most of the time, especially when I am sad with my medical work, and things are not going well. He was so proud of me when I made it to medical school.

Towards the end of the book, I came across Dr Liz O’Riordan’s story. She was a qualified breast surgeon who was diagnosed with stage 3 breast cancer. She has had two episodes of local cancer recurrence. She is an author and, through multiple social media channels, educates the public on cancer awareness and her own personal experience with cancer treatment. She is open about how her cancer treatment caused her to lose her career as a surgeon and her ability to have children. I was extremely touched by her resilience and her extraordinary work. 

No matter what happens in life, we all know that death is the one true inevitability. There is nothing more certain in this world than our mortality.