Transcript Breast Screening

Breast Screening
NHS Breast Screening Programme
• Introduced in 1988
• Invites women from 50-70 age group for
screening every 3 yrs.
• Age extension roll-out in progress includes ages
47-73.
• Due for completion 2016.
• Women over 70 can request screening every 3
yrs at their local unit.
• Why every 3 years?
– Higher number of false positives with annual screening leading to unnecessary
investigations.
• Why the lower age limit?
– Only 15% breast cancers occur before age 45. Mammography more difficult to
interpret in younger age group due to density of breast tissue.
• Why upper age limit?
– May pick up latent cancers which would not have presented clinically within
the woman’s lifetime. Leading to unnecessary intervention.
• Screening does not prevent cancer developing
(unlike Ca cervix)
• But may detect cancers earlier- giving a better
prognosis.
• For more info on statistics and cancer detection
rates see:
Breast Screening Programme Report 2008-09:
link available from NHS Breast Screening
website.
Breast Cancer
• Population risk is about 1:12
• 5% genetic predisposition
• Genes that predispose can be inherited by both
sexes but not expressed to same degree. High
penetrance.
• BRACA1 & BRACA2, TP53 gene mutations.
• May get clusters of cancers which are not
explained by identifiable genetics.
How do we assess genetic risk?
• Family hx is most reliable way of assessing.
• Important to identify those at risk as may
require increased frequency of screening.
• Prophylactic mastectomy decreases risk of ca
breast by up to 90%.
What to ask the patient:
• Who in the family was affected?
• Need to look over 3 degrees of relatives
• What type of cancer was it?
• The more detail the better: breast, ovary,
endometrium, prostate
• At what age?
• don’t forget males in a family who may be carriers but not
express the gene- male with a mother and sister affected
counts as an affected relative.
Genetic Clues in the FH
• Two or more closely related people (1st, 2nd degree)
with same type cancer.
• Unusual combinations of cancers in a family. Or
more than one in an individual eg: breast & ovary,
colorectal & endometrial
• Same cancer in successive generations
• Cancer at unusual young age- breast/colorectal <40.
NICE Guidelines
• Who should be referred to secondary or tertiary
care?
Tertiary Care:
– If a faulty gene has been identified within the family:
should refer straight to tertiary care for specialist genetic
counselling services
– May include surveillance: mammography/ MRI (in younger
women), genetic testing, prophylactic surgery.
What is raised risk?
Is there one of the following present in the family
history?
Applies to female breast cancers only:
• One 1st degree relative diagnosed before age 40.
• One 1st degree relative and one 2nd degree relative
diagnosed after average age 50.
• Two 1st degree relatives diagnosed after average age 50.
What is more than raised risk?
• Is there at least one of the following present in the family history? A 'yes'
to any indicates a positive referral.
• Female breast cancers only
• One 1st degree relative and one 2nd degree relative diagnosed before
average age 50.
• Two 1st degree relatives diagnosed before average age 50.
• Three or more 1st or 2nd degree relatives diagnosed at any age.
• Male breast cancer
• One 1st degree male relative diagnosed at any age.
• Bilateral breast cancer
• One 1st degree relative where 1st primary diagnosed before age 50.
• For bilateral breast cancer, each breast has the same count value as one
relative.
• Breast and ovarian cancer
• One 1st or 2nd degree relative with ovarian cancer at any age and one 1st
or 2nd degree relative with breast cancer at any age (one should be a 1st
degree relative).
NICE guidelines cont..
• So what NICE is saying is that women aged 4049 who are at ‘raised’ or ‘more than raised’ (ie:
high) risk should be offered annual screening.
• However:
– Women aged under 40 at increased risk would
usually only be offered increased screening as part of
a national research programme or audit
– Women aged 50+ at increased risk would usually not
be offered any additional screening ie: they would
cont with the normal 3 yearly screening programme
as per the rest of the population.
Summary
• Genetic predisposition to Ca breast is actually small –
5%, but important to identify
• FH most important in assessing genetic risk
• Gather information from patient- usually over more
than one consultation.
• If unsure use NICE pathway to decide whether to
manage in primary care or to refer.
• Find out what your local services are so you know
what you can offer the patient!