Follow Up of Abnormal Clinical and Imaging Findings of the Breast: Five Self-Study Modules for Primary Care Clinicians

 

Preface

Breast cancer is the most common cancer to occur among women in the United States, and 13.2% of all US women are expected to develop this malignancy in their lifetime.[1] In the National Cancer Institute's SEER Program for the years 1998-2002, the median age at diagnosis of breast cancer in women was 61 years. Women dying of breast cancer lose an average of 19.0 years of life. About 1 in 4 women with breast cancer is younger than 50 years at the time of diagnosis, an age at which women are commonly raising children and the social burden of treatment and mortality are greatest.

For most women, especially those not in a high-risk group (and these are the women who contribute the majority of new cases of breast cancer), screening mammography is the first line of defense against a late diagnosis. Breast cancer screening programs of mammograms with or without clinical breast exams (CBE) have been demonstrated to reduce mortality from breast cancer.[2,3] The American Cancer Society, the Susan G. Komen Foundation, the Centers for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the National Cancer Institute, the American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force all recommend regular mammograms for women ages 40-74. Regular breast cancer screening, early diagnosis and treatment, is the accepted clinical and public health approach to reducing treatment morbidity and mortality from breast cancer.

The survival rate is 98% for localized disease, 81% for regional disease, and 26% for distant-stage disease.[4] The treatment options for earlier-stage cancers are generally more numerous, include less invasive alternatives, and are usually more effective than treatments for later-stage cancers.[5]

For primary care clinicians, the presentation of women with breast problems (eg, breast mass, abnormal screening mammogram, pain, spontaneous nipple discharge) remains one of the most common and challenging issues in clinical practice. Fortunately, many of these women have benign breast disease. However, delays in breast cancer diagnosis do occur with sufficient frequency and constitute the most common reason for professional liability litigation in the United States.[6] Clinician factors that contribute to delays in breast cancer diagnosis include: (1) not ordering appropriate diagnostic follow-up when a suspicious CBE finding has a diagnostic imaging result reported as Category I-Negative, and placement of the patient on "routine re-screening"; (2) failure to distinguish normal CBE breast changes from suspicious findings that may be breast cancer; and (3) inadequate tracking and follow-up systems to assure that patients receive timely and appropriate follow-up as indicated.

The challenge for primary care clinicians is to optimize detection and management of early breast cancer and to provide reassurance to women with benign disease. Toward this goal, clinicians must stay current with an ever-growing body of clinical evidence and generally accepted protocols and guidelines. This curriculum reviews the latest knowledge and research findings on the presentation and management of common breast problems, with particular emphasis on assessment and early diagnosis.

The CDC Division of Cancer Prevention and Control has joined with the American College of Obstetricians and Gynecologists (ACOG) and the US Food and Drug Administration (FDA) to update its 1999 educational packet, entitled "Follow-up of Abnormal CBE and Mammographic Findings." Although originally published for grantees of CDC's NBCCEDP, this redesigned curriculum is intended to give any clinician who provides primary care to women the knowledge needed to provide appropriate and timely care to women with abnormal clinical and imaging findings. The format is designed to promote self-study and to be updated regularly in order to reflect new clinical research and advances in technology.

Breast Cancer Diagnostic Algorithms for Primary Care Providers (Algorithms) -- presented in Modules II, III, and IV -- is the product of the California Department of Health Services Cancer Detection Section (CDS). The Breast Expert Workgroup, a volunteer panel of California clinicians (primary care physicians, radiologists, surgeons, pathologists), provided leadership and consultation to CDS on clinical quality issues. These algorithms provide guidelines and are based on an informal consensus development process. The algorithms do not represent the only medically or legally acceptable approaches, but rather, they are presented with the recognition that there are alternate and acceptable approaches. Deviation under appropriate circumstances does not necessarily represent a breach of a medical standard of care. New knowledge and technologies, clinical or research data, and clinical experiences may provide sound reasons for alternative approaches.

The Centers for Disease Control and Prevention has obtained permission to reproduce certain previously published and unpublished material as noted in the text. Users are advised that any further reproduction of these materials requires copyright permission. All other materials in this self-study are in the public domain and may be used or reproduced without permission; however, citing the source is requested.

References

  1. Ries LAG, Eisner MP, Kosary CL, et al, eds. SEER Cancer Statistics Review, 1975-2002, National Cancer Institute. Bethesda, Md. Available at: http://seer.cancer.gov/csr/1975_2002/. Based on November 2004 SEER data submission, posted to the SEER Web site 2005. Accessed November 7, 2006.
  2. Shapiro S, Venet W, Strax P, Venet L. Periodic Screening for Breast Cancer: The Health Insurance Plan Project and Its Sequelae, 1963-1986. Baltimore, Md: The Johns Hopkins University Press; 1988.
  3. Humphrey LL, Helfand M, Chan BKS, Woolf SH. Breast cancer screening: summary of the evidence. Ann Intern Med. 2002;137:344-346.
  4. ACS Breast Cancer Facts and Figures: 2005-2006.
  5. Smith R, Saslow D, Sawyer W, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA Cancer J Clin. 2003;53:141-169.
  6. Saslow D, Hannan J, Osuch J, et al. Clinical breast examination: practical recommendations for optimizing performance and reporting. CA Cancer J Clin. 2004;54:327-344.