#234 The Breast Lump, and Breast Cancer Screening

Turns out, it’s more complicated than we thought…but we got you

Master your breast cancer screening spiel, cultivate your approach to the breast mass, and empower your patients with empathetic shared decision-making (which we know you’re all already fabulous at)! On this fantastic episode, we are joined by Dr. Nancy Keating @NancyKeatingMD, policy wonk and primary care doc extraordinaire at Brigham and Women’s Hospital. This episode is rife with drama, as the ACS butts heads with the USPSTF and the ACR, and you have to figure out what’s right for the patient by talking with them–almost as exciting as that moment on Grey’s when Izzie cuts the…anyway, I won’t ruin a key plot point in the most excellent medical show of all time, all in a day’s work, here at The Curbsiders. Enjoy!

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

Credits

Producer and Writer: Nora Taranto MD
Show Notes: Nora Taranto MD, Isabel Valdez PA
Infographic: Nora Taranto MD
Cover Art: Kate Grant, MBChb, MRCGP
Hosts: Stuart Brigham MD, FACP; Matthew Watto MD, FACP; Paul Williams MD, FACP, Nora Taranto MD
Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
Reviewer: Arielle Medford MD
Guest: Nancy Keating MD, MPH

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VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

How to Claim VCU CME Credit

Time Stamps

Sponsor – Provider Solutions & Development www.psdrecruit.org/curbsiders.
Sponsor – VCU Health Continuing Education
00:30 Intro & Guest Bio
03:27 Guest one-liner
05:27 Best Advice for Women in Medicine
07:34 Picks of the Week
Sponsor – Provider Solutions & Development www.psdrecruit.org/curbsiders.
10:00 Case 1: Brenda Cantwell and Breast Lump DDx
13:39 Clinical Breast Exam vs Self Breast Exam
17:26 Practical Tips for the Clinical Breast Exam
21:50 Imaging to Evaluate the Breast Lump
26:36 Demystifying BIRADS
28:36 Epidemiology Potpourri
33:02 Breast Pain without a Mass
34:30 Case 2: Mammie Gram and Breast Screening
46:03 Average Risk vs High Risk Screening
47:18 Breast Risk Prediction Tools
48:51 Breast Density
53:16 Imaging Modalities
61:28 Shared Decision Making in Screening
68:04 Case 3: Ms Britta Lumpworth and When to Stop Screening Mammograms
74:42 Take Home Points and Outro
Sponsor – VCU Health Continuing Education

Breast Lumps and Cancer Screening Pearls

Malignancy causes a minority of palpated breast masses, but is important to rule out, especially as women age.
Perform a clinical breast exam for any breast complaint (even though there’s mixed evidence for its utility in screening)
Evaluate the breast lump initially with ultrasound in women younger than 30, and with both diagnostic mammogram and ultrasound in women thirty or older. You may need to follow up with an aspiration or core needle biopsy, depending on the results.
In some patients (younger, few risk factors, no red flags on exam), it’s appropriate to observe and re-evaluate in several months if imaging does not reveal a mass.
To decide when to start screening: Use the National Cancer Institute, Breast Cancer Surveillance Consortium (BCSC) Risk Calculator, taking into account Individual Risk factors, to assess whether patients are average or high risk for the development of breast cancer.
Mammogram Screening Recommendations for average risk women differ from society to society. The ACS recommends yearly from age 45 to 54 and every other year starting at age 55. The USPSTF recommends mammography every other year from 50-75.
The harms of mammogram include false positives and unnecessary testing, overdiagnosis of disease that is not and would not become clinically significant, and anxiety about having a diagnosis of cancer that proves to be unfounded.
Engage in shared decision-making with your patients to decide when to start screening mammography, and when to stop.
Consider stopping mammography screening when the patient has less than 10 estimated life years (use ePrognosis).

Dr. Keating’s Mammogram Spiel: It’s important to know that mammograms are not perfect tests. They’re the best test we have right now, but they are still limited. The benefits of mammograms are a small decrease in the risk of dying from breast cancer. You can use the numbers here, if you want: If you were to screen 10,000 women every year throughout their forties, you would save 3 women from dying of breast cancer. Many women will still be diagnosed with and treated for breast cancer, and will do well whether or not they had the mammogram.

Language to Use Around False Positives: There are also harms to mammograms, most notably false positives and unnecessary biopsies, which are incredibly common (over 6000 false positives in that same cohort of 10,000 women above, for average risk women from aged 40-50). Expect to be called back for more testing at some point when you are getting mammograms; and if a callback does happen, don’t think of it as a definitive cancer diagnosis. Think of it as just another part of the test that you need to complete.

Evaluation of the Breast Lump, and Breast Cancer Screening: Show Notes

Part 1: Approach to the Breast Lump

Must-Ask Questions on History

Is the lump painful or not painful? Is the mass new, or is there a history of breast mass in the past, or recurrence over time? Does the mass change over time? Is the mass associated with menses, or trauma? Has the patient had a recent pregnancy? Does the patient have a family history of any cancer—but particularly breast cancer, endometrial cancer, ovarian cancer, or colorectal cancer, which have been associated with genetic syndromes that include breast cancer? If so, at what age?

What are the patient’s other risk factors for breast cancer (most specifically age, but also considering family history, known gene mutation, ethnicity, nulliparity, alcohol use, prior breast biopsy, history of radiation exposure at a young age, ACOG Practice Bulletin 179).

Differential Diagnosis for the Breast Lump:

Malignancy, while present in 10% or fewer lumps (though this percentage increases with age, which is important to consider), is the most important diagnosis to find or rule out (Elmore 1998). Benign cysts, fibroadenoma, and nodular breast tissue (likely bilateral) are all quite common. Acute concerns should be raised if the patient has fevers, swelling or redness, including abscess or galactocele, particularly in recently pregnant patients. Consider fat necrosis, especially if noticed after trauma from an accident.

The Evidence for the Breast Exam: Self vs Clinical

Self-Breast Exam

The Self-Breast Exam is not recommended in part because studies found no decrease in breast cancer mortality with utilization (Thomas 2002, Semiglazov 2003). It can increase the risk of false positives and unnecessary diagnostic testing (Fuller 2015).

Clinical Breast Exam

The clinical breast exam is indicated if there is concern about a breast mass being present. As a screening tool, it has not yet been found to reduce breast cancer mortality by RCT, though there is a study ongoing in India, the results of which should be coming to press in the next year or two. Since 2015, The American Cancer Society (ACS) has recommended against annual clinical breast exam (ACS Breast Cancer Screening Recommendations, 2020) because of risk of unnecessary diagnostics and the lack of evidence to support it, and the USPSTF recommendation has remained neutral towards it, stating since 2016 that there is insufficient data to recommend for or against the clinical breast exam (USPSTF Screening Recommendations, 2016). All that said, the clinical breast exam can still be done at the discretion of both the patient and the clinician.

Dr. Keating’s Expert Advice: About 10-15% of palpable breast masses do not show up on mammogram (Chan 2015), and some of the trials show some potential indirect benefit of breast exam. Dr. Keating therefore still does the breast exam once a year in women.

Practical Tips for the Clinical Breast Exam

Step 1- Inspect

Start with the patient sitting, then have the patient lie supine, with arm behind head. Inspect the breast for dimpling, retraction, nipple inversion, color or skin changes.

Step 2- Palpate

Palpate the entire rectangle of breast tissue, including both breast and axilla. Be sure to examine the axillary, supraclavicular and cervical lymph nodes. Approaches include the radial or “wheel spoke” method, the circumferential approach, or the lawnmower approach. Apply light, medium and deep pressure to the breast tissue with the finger pads (not the tips), feeling for discrete masses. The exam could be done with the patient both sitting or lying down, especially if there is a complaint. Doing the exam while the patient is lying down for screening purposes is acceptable.

Step 3- Feel

Feel for a discrete mass with its own edges within the nodularity of the breast. It is helpful to describe the mass as fixed or mobile, spongy or firm, tender or non-tender. (Check out this 2020 StatPearls for more tips on Breast Exam Techniques!)

Bonus tip (from the Breast Surgeons out there): You can inspect for asymmetry, dimpling, and skin retractions the patient sitting with hands on hips, and then internally rotating the shoulders, allowing the breasts to suspend in front of the patient.

N.b. What if the patient is complaining only of pain, not of a lump?:

Pain is not a typical presenting sign of breast malignancy, in the absence of a mass. Take a thorough history and do a complete exam. Remind women of other possible contributors to pain including menopause, diet, menstruation, heavy lifting, or ill-fitting bra. Breast pain does not typically require further imaging unless the patient has other concerning symptoms.

Imaging to Evaluate the Breast Lump

Patients < 30 years old

Ultrasound is preferred for patients under the age of 30 because younger women have denser, more fibrous breast tissue that is not as well characterized on mammogram (Kolb 2002). Communicate the location of the mass using the “clock method” (Mammogram Interpretation, Chapter 2) to the radiologist. The radiologist can help determine if mammography is needed in addition, or whether to jump directly to core needle biopsy (if solid or complex mass), or cyst aspiration, whatever the case may be.

If no mass is identified on ultrasound but a mass is present: If the patient is young and healthy, you can observe the patient at home for 2 menstrual cycles and then reassess the patient by ultrasound and physical exam. Many of these masses will resolve. If it does not go away, or the patient is not menstruating, you should refer to a breast surgeon for consideration of biopsy based solely on feel.

Patients > 30 years old

Order both a diagnostic mammogram and an ultrasound, as 10-15% of breast cancers are not detected by mammogram alone. Ultrasounds are a good complement to help improve diagnosis with a palpated mass (Flobbe 2003) and further help distinguish a fluid-filled cyst from a solid mass.

Biopsy Needs

Radiology reads will help determine the need for follow-up imaging or biopsy based on the concern for malignancy. Typically, cystic masses can be aspirated. Solid or complex masses require biopsies, most typically core needle biopsy (not fine needle aspiration).

Mammogram scoring- Demystifying BIRADS

Breast Imaging Reporting and Data System, aka BIRADS, is the standard scoring scale used by breast radiologists.

Score	Meaning	Action
0	Insufficient data to characterize.	More imaging is needed
1	Normal	Routine Imaging
2	Some benign changes	Routine Imaging
3	Changes likely benign, but of unknown consequence	Close follow up recommended at 6 months
4	Suspicious lesion	Core-needle biopsy
5	Highly suspicious lesion	Core-needle biopsy
6	Known malignancy	Continue with treatment (Used for monitoring treatment progress)

For further details see Guide to Mammography Reports: BIRADS Terminology, Bittner 2010.

Mammogram Centers

Mammogram centers are reliable in their patient outreach, particularly for follow up imaging or biopsies because they are regulated by the FDA. Primary care providers can play an active role in reminding patients to complete the follow up recommended by mammography centers.

Epidemiology Potpourri

One in eight women will develop breast cancer in their lifetime, making it one of the most common cancers diagnosed among women (Seer Cancer Statistics Review, 2020). Risk increases with age. While younger women tend to have a lower incidence of breast cancer, younger women can have more aggressive cancers (Anders 2011). Breast cancer is highly curable such that only 1 in 38 women will die of breast cancer in their lifetime (ACS 2020; SEER Lifetime Risk (%) of Dying from Cancer by Site and Race/Ethnicity: Females, Total US, 2014-2016), compared to 1 in 3 women who will die from heart disease (Garcia 2017). For more statistics on breast cancer incidence, see the Cancer Statistics Center’s page on Breast Cancer.

Dr. Keating’s pearl: Counsel women on lowering breast cancer risk, and heart disease risk, at the same time! They can do tis by increasing exercise and weight loss and avoiding excess alcohol.

Part 2: Guidelines for Breast Cancer Screening

Why screen to begin with?

The purpose of screening is to identify cancers early to be able to intervene earlier on cancers that would cause clinically meaningful disease and therefore lower mortality. At the same time, we must balance catching cancers early with overdiagnosis, the harms of unnecessary testing, and false positives.

Overdiagnosis: When we find cancer or disease that we would not have found without screening, and this cancer would not be clinically significant or cause mortality or morbidity.

There has been evidence of overdiagnosis in breast cancer screening, as well as evidence of false positives on mammograms that lead to unnecessary biopsies and anxiety about diagnoses (Independent UK Panel on Breast Cancer Screening 2012).

Current Breast Cancer Screening Guidelines:

First of all, know that the recommendations vary among different societies and task forces, and these have changed over time. See the 2020 CDC Summary of Society Guideline Recommendations. Also of note, there are multiple new imaging modalities on the horizon that may upend some of the recommendations for standard diagnostic mammogram–though this currently is the gold standard in general.

American Cancer Society, 2015

Screening is recommended yearly from age 45 to 54 and is subsequently done every other year starting at age 55. There is no age cutoff, but a general recommendation for screening to stop when life expectancy is 10 years or less. Women aged 40 to 44 should have the option to screen annually, knowing the benefit to harm ratio is less than with older women.

USPSTF, 2016

The US Preventive Services and Task Force recommends screening women every other year from age 50-75 (Grade B). Women 40 to 49 years should discuss their need for mammography with their providers.

American College of Radiology, 2018

The ACR continues to recommend that women start screening at the age of 40.

N.b. The screening guidelines in the United States are much more aggressive than those in Europe, Canada or Australia. The Canadian Task Force recommends mammography every 2-3 years between 50-74, and the UK NHS recommends it every 3 years from 50 to 71. Most notably, The Swiss Medical Board recommended the abolishment of mammography screening programs to maximize resource utilization (Biller-Andorno 2014).

What’s the data to support mammography screening?

First, there have been several large clinical trials looking at the benefit of mammography screening that find that mammography screening lowers the risk of dying from breast cancer. However, there is some uncertainty as to how well these studies which were conducted in the 1960s-1990s generalize to today. It is possible that the benefits may be better due to improvements in imaging technology. It is also possible that the benefits may be less due to the dramatic improvement in breast cancer treatment that has occurred over the same time frame.

Looking at the meta-analyses of these trials, the overall benefit of mammogram screening may be somewhat smaller than we had hoped for. There is a 21% reduction in the likelihood of dying from breast cancer (Nelson 2016). This risk reduction is not a benefit in overall mortality, but is breast-cancer mortality specific. In short, it’s not huge.

Furthermore, the benefit of this risk reduction varies by age. The risk reduction for women in their forties is about 8%, for women in their fifties is 14% and women in their sixties is 33% (Nelson 2016). The most recent trial looking at the utility of mammograms did not show benefit (Miller 2014). (Expert Opinion: Dr. Keating thinks there’s probably some benefit, though it is likely small).

Absolute risk reduction: In a population of 10,000 women that we screen every year for 10 years, we can look by age bracket. For women in their 40s, in that 10,000 woman bracket, we are likely to save 3 deaths from breast cancer (99.99% not benefiting from that). For women in their 50s, it’s about 10. For women in 60s, it’s about 43, and in their 70s, it’s about 20. But these numbers are still fairly small. See the Table in Dr. Keating’s 2018 JAMA Update on Breast Cancer Screening for the full Absolute Risk Reduction data.

Breaking Down the Imaging Types

Two-Dimensional Mammography: the standard diagnostic mammogram

Tomosynthesis/Three-Dimensional Mammography: This will give a clearer picture, with more pictures that gives you more visualization (1 to 3 additional cancers per 1000 women). But it takes longer for the radiologist to read, and double the radiation of a typical mammogram. Some institutions are replacing Two-Dimensional Mammography with Tomosynthesis completely for screening purposes.

Breast MRI: The Breast MRI can also identify more cancers, but higher rate of false positives, and done with gadolinium enhancement.

Mammography and Whole Breast Ultrasound: Not generally recommended. Downsides include: it’s time intensive, results in an increase in false positives and unnecessary biopsies.

Insurance will cover diagnostic mammography. The Affordable Care Act also mandated covering at no cost sharing any screening test recommended by the USPSTF. Insurance companies still cover it with no cost sharing for anyone over the age of 40, and for diagnostic purposes. The coverage of other tests is slightly less consistent, tomosynthesis and breast MRI for high-risk patients typically covered. Whole Breast Ultrasound for screening is frequently not covered.

Deciding When to Screen the Patient in Front of You

Differentiate Average vs. High Risk Women

Women with a genetic predisposition for breast cancer should get screened earlier and with different modalities, typically with both mammogram and breast MRI.

In the absence of that, we think about their risk factors affecting breast cancer risk include age, family history, early menarche, late menopause, nulliparity or late childbearing, obesity alcohol use, use of hormone replacement therapy, and mantle/chest radiation (ACOG 2017).

For women without particularly notable risk factors (e.g. chest radiation in youth), you can use risk assessment tools to identify average versus higher risk patients (though they are better for predicting risk in populations of patients than in individual patients). If a woman’s risk is substantially greater than average, consider earlier or more regular screening.

Good Risk Assessment Tools: National Cancer Institute, Breast Cancer Surveillance Consortium (BCSC) Risk Calculator (FYI): You need to know breast density to use the BCSC calculator)

What about Breast Density?

Breast density is a mammographic appearance. There is a four level scale to denote breast density on mammogram, and now federal legislation to notify patients of their breast density: Fatty, Scattered fibroglandular tissue, Heterogeneously dense, Extremely dense.

Women with dense breasts have an elevated risk of breast cancer, and breast density can obscure cancers on mammogram. That said, there are no different screening recommendations based on breast density alone. There is some evidence to suggest that doing tomosynthesis may be more useful in women with dense breasts, or that they may benefit from more frequent imaging.

It’s all about Shared Decision Making

In your conversation and risk evaluation, start with the patient’s age, their individual risk, and what the current guidelines would recommend for that age bracket. This conversation should generally start when women are in their forties.

After that, ask what their preferences are. You can ask them how they would feel if they didn’t have a mammogram and then were diagnosed with breast cancer, and also how they would feel having a mammogram and then extra testing and stress that turned out to be unnecessary? This conversation, eliciting their preferences, will typically lead to a relatively clear decision about when to start screening, and how frequently.

Tip for the Primary Care Doc: Give your patients decision making tools to use at home. Several options include the Healthdecision.org/University of Wisconsin Decision Tool and the Harding Center for Risk Literacy Fact Box. Find more in the Supplement Box in Dr. Keating’s 2018 JAMA Clinical Update on Breast Cancer Screening

When To Stop Mammogram Screening

We do not have a lot of guidance because there have been no randomized clinical trials done in women older than 75, and we have only observational data. Older women have a lower risk of false positives because they have less dense breasts, but have a higher risk of overdiagnosis because they often have comorbidities that will prove more clinically significant than a newly found breast cancer.

Start phasing out mammography screening when life expectancy is less than 10 years, certainly less than 5 years, and then have a conversation from there. To do this, you can use life tables or ePrognosis.

Take-Home Points

Engage your patients in shared decision making to decide how and when to start screening for breast cancer.
The mammogram is not a perfect test.
It’s important for the patient to understand the harms and benefits.

Links*

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will learn how to evaluate a breast lump in the primary care clinic, what the guidelines recommend for asymptomatic breast cancer screening, and how to engage a patient in shared-decision making given the data available on mammograms.

Learning objectives

After listening to this episode listeners will…

Triage and evaluate the Breast Lump
Perform breast cancer risk assessment
Recall the Guideline Recommendations for Breast Cancer Screening and how they vary
Engage patients in conversation about breast cancer screening
Perform Shared-Decision Making in deciding when to start mammogram screening and when to stop

Disclosures

Dr. Keating reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Taranto, N, Keating, NL, Williams PN, Brigham SK, Valdez I, Medford A, Watto MF. “#234 The Breast Lump, and Breast Cancer Screening”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. Final publishing date: September 28, 2020.

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