Breast cancer in asymptomatic women

Breast cancer is today a major health and social problem. One in eight women will suffer from breast cancer in her lifetime. The inability to carry out primary prevention, since most of the risk factors do not allow it, forces us to launch screening campaigns, campaigns aimed at the population – supposedly healthy – who may be suffering from the disease without it having manifested itself.

For this purpose, there is a suitable test or examination: mammography. The controversy about the possible risk of irradiation has been resolved with the use of “quality mammography” with the requirement of adequate equipment and execution and interpretation by specialists.

In breast cancer, the impossibility of knowing the factors that produce it (establishing a direct cause-effect relationship), together with the fact that most of the risk factors are not susceptible to prevention, obliges us to perform examinations on asymptomatic women who may be suffering from the disease without it having manifested itself. Knowledge of the natural history of the disease and its biological behavior has enabled us to establish criteria which, as we shall see later, reduce mortality.

Breast cancer is undoubtedly the most frequent oncological condition in women. Its incidence is progressively increasing due to the increase in the average age of life and social welfare, which has led to changes in daily life habits.

Risk factors for breast cancer

The factors that increase the risk of breast cancer are:

  • Sex: breast cancer is mainly a female cancer.
  • Age: infrequent before the age of thirty-five; thereafter, its incidence increases rapidly until the age of sixty-five.
  • Family history: there is an increased incidence of breast cancer in women whose mother, grandmother or sister has had a breast neoplasm.
  • Intrinsic causes related to sexual activity: early menarche, late menopause and pregnancies after the age of thirty. All of them related to a more prolonged hyperstronism.
  • Diet: an important cause proven by Haagensen (1981), who compares the incidence of breast cancer in the Japanese population living in Japan with Japanese women living in America, showing that it increases the incidence of breast cancer to equal that of American women in the first generation.

It is recognized that the diet rich in animal fats originates a cholesterol fixed to low density proteins (LDL-cholesterol) that Mettelin (1984) relates to breast cancer, since it is a hormone-dependent carcinoma conditioned by hyperstronism, which is produced by the increase of cholesterol, the pregnane derived from the previous one and the aromatization of androgens in peripheral tissue. Recently, researchers at New York University Medical Center have found bile in blood reaching the breast that could damage the cell, thus diet plays an important role.

  • Hormonal states: there are those that produce an increase in pituitary hormones, such as prolactin, somatotropin, pituitary gonadotropins and ACTH, since they stimulate tumor growth, as has been proven by stopping the growth of breast cancer metastases in one third of the cases, after hypophysectomy and adrenalectomy.
  • Environmental causes: they produce stress or depression, which lead to a deficient immunological and hormonal status, as a consequence of their depletion or decrease, as known from physiological scientific evidence by Houssay (1960).
  • Causes related to previous mammary diseases. Fibrocystic mastopatia of large elements that increases the risk of breast cancer by four times, as well as adenosis, multiple papillomatosis, phylloides tumor, etc.

These risk factors do not allow for primary prevention, so it is necessary to resort to secondary prevention, that is, the reduction of mortality rates based on early diagnosis and prompt treatment of the disease.

The importance of early diagnosis of breast cancer

The survival and quality of life of women who have had breast cancer is increased by early diagnosis. Three important changes have resulted from this:

  • Increased life expectancy
  • Cure of a greater number of patients
  • Reduced mortality
  • Less aggressive treatments

In our society there are a number of factors that interfere with the regular practice of breast screening. For example, poor or insufficient information sometimes causes patients to go late or at inappropriate times to the specialist in the diagnosis of breast pathology, due to unjustified cancerophobia. Other times they reject an indicated examination, such as mammography, for fear of cancerogenesis.

It is well known that tumor size is an important prognostic factor. On the other hand, the capacity for tactile discrimination does not allow the identification of tumors smaller than 1 cm, and it is these tumors that can benefit most from early diagnosis. Mammography in asymptomatic patients is most useful for them.

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Breast cancer treatment: decalogue of effectiveness criteria

When we consider the early diagnosis of breast diseases, we must take into account the decalogue of effectiveness criteria for the implementation of a screening program, first formulated in 1968 by Wilson and Jungner for the WHO:

  • The condition or disease screened for must be a major health problem.
  • The natural history of the disease must be adequately understood and known.
  • The latent or early period of the disease must be identifiable. The longer the preclinical phase of the tumor, the greater the interest in screening.
  • Treatment of the disease in an early period should be more beneficial than treatment started in a later period. This reduces mutilations, adjuvant treatments and mortality.
  • There must be an adequate test or examination. In the case of breast cancer, mammography, due to its sensitivity and specificity, is the only test to be evaluated. Mammography detects about 80%-90% of breast cancers, with a specificity of 95% in prevalent screening.
  • Such a test should be acceptable to the population. The effectiveness of the program is highly dependent on the attendance rate of women. Various scientific evidences carried out in New York show that 65% of women attended and it was shown that it was sufficient, although not ideal, to have an impact on mortality (the higher the participation, the greater the benefit).
  • Adequate means must be available for the diagnosis and treatment of detected abnormalities. The screening test is not diagnostic, but classifies the population into positive and negative. Women with positive mammography should be diagnosed; diagnosis and treatment should be diverted to the corresponding specialists.
  • In diseases of insidious onset, screening should be repeated at intervals determined by the natural history of the disease. In principle, an annual periodicity is recommended for at-risk ages.
  • There should be unified criteria for the population to be screened. The population to be included should be those at risk for the disease.
  • The cost of a screening program should be offset by the benefit it produces. Benefit in terms of reduced mortality and yield gains.

Cost-utility analyses are used to value breast cancer screening in terms of cost per extra year of life gained, and cost per year of life adjusted for quality of life gained.

Mammography as an effective method of breast cancer diagnosis

In view of the experience and results obtained by the different working groups, we can affirm that breast cancer detection and diagnosis campaigns in early research have shown that the mortality rate can be reduced by at least 30%, especially thanks to mammography.

Let us not forget that mammography is capable of detecting 80%-90% of breast cancers, with a specificity of 95%. However, there are still countries or geographical areas where these screening campaigns have not yet been implemented.

Physicians in general, and in particular general practitioners, occupational physicians and gynecologists, are becoming more and more aware of the frequency and seriousness of this disease.

Campaigns for early detection of breast cancer in other age groups

In women under 45 years of age, the use of mammography in screening campaigns is currently a hotly debated issue. There are campaigns in which the call includes women between 35 and 45 years of age if they have a family history of breast cancer in the first degree.

Conclusions

For all these reasons, breast screening should be a routine event, since the social and health benefits are very important. It is our responsibility to transmit the need for mammography screening at risk ages, as well as to make it easier for them to undergo it, since this is the only method with real effectiveness in breast screening. Currently, and in spite of the unanimous recommendations made by the National Health Organizations and the WHO that all women at risk should have an annual screening, not all of them do it. It is, therefore, a priority that physicians, administration, society…. make the maximum effort to improve the results in the fight against breast cancer.