Discovery of Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are They Found?

Sirs, as regards breast cancer prevention and bedside detection, I think that some interesting actual paramount knowledges unfortunately are overlooked by physicians all around the world. Using breast cancer risk assessment tools (e.g. breast physical examination) and going through the process of assessing breast cancer real risk by this way, can answer many women's questions about what puts them at relatively higher or lower risk (1). Certainly such as evaluation is expensive for NHS, and not appliable for all women (and men!, of course). In fact, for all women (and men!), in my opinion, an original clinical assessement may be desirable that in a easy, quantitative and reliable manner allows doctor to recognize the possible presence of maternally- inherited Oncologial Terrain, and then oncological "real risk", conditio sine qua non of cancer in one or mor mamma quadrant (2), without to follow with genetic testing, but ascertaining also breast cancer;real risk; in well-defined breast quadrant(s). In addition, testing for mutations of breast cancer susceptibility genes or for their diminished expression adds to our ability to assess breast cancer risk at an individual level. Really, we cannot localise in a (or more) mamma quadrant the possible breast cancer risk in BRCA 1 and BRCA 2 positive women (and men!). Biophysical Semeiotics (http://www.semeioticabiofisica.it, Breast Cancer in Practical Application, and Oncological Terrain) allows doctor to recognize firstly Oncological Terrain in a quantitative way, and then, but not in all cases, of course, breast cancer real risk: individuals with Oncological Terrain do not show necessarily also breast cancer real risk (1-6)

1. Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1995 2. Stagnaro S., Auscultatory percussion of the cerebral tumour: Diagnostic importance of the evoked potentials, Biol. Med., 7, 171-175, 1985. 3. Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 4. Stagnaro S. Genes and Cancer: a clinical view-point. The Oncological Terrain. BioMed Central Informatics. http://www.biomedcentral.com/1471- 2105/5/21/comments#10454 5. Stagnaro Sergio. Clinical tool reliable in bedside early recognizing pancreas tumour, both benign and malignant. World Journal of Surgical Oncology 2005, 3:62 doi:10.1186/1477-7819-3-62. 6. Stagnaro Sergio. "Genes, Oncological Terrain, and Breast Cancer" World Journal of Surgical Oncology., 2005, http://www.wjso.com/content/3/1/45/comments#205475 7. Stagnaro Sergio. Reale Rischio Semeiotico-Biofisico. Ruolo Diagnostico e Patogenetico dei Dispositivi Endoarteriolari di Blocco neoformati- patologici, tipo I, sottotipo a) e b).

Ed. Travel Factory, Rome, in press.

Competing interests:   None declared

Dr. Carney and colleagues present some interesting information about missed cancers and in the process point out the importance of recognizing and evaluating breast lumps.(1) While Dr. Carney emphasizes the importance of women seeking evaluation if they find a lump after a negative mammogram, the same message is good for physicians as well.

The main concern is that physicians must take breast lumps seriously to achieve optimal care for patients, and there is evidence that physicians fail to evaluate adequately in 40% of women with lumps and a negative mammogram.(2) The background reality is that litigation for a breast-cancer related problem is 20 times more frequent in primary care than breast related problems themselves.(3) A lump in the breast doubles or triples the odds of cancer being present at the time of a mammogram.(4). Evaluation of breast lumps is difficult and ultimately persistent lumps need a definitive explanation by ultrasound, aspiration, and/or biopsy.(5)

In addition to pointing out the need to pay attention to lumps, this article by Carney et al reinforces the reality that screening mammography is an imperfect test that may miss 20 to 25 % of breast cancers present in women with good mammographic images read by the best eyes. Fully 40% of late-stage breast cancers in 10 managed care organizations occurred after negative mammograms.(6)

Despite mammography’s limitations, it remains the best technology to reduce the morbidity and mortality due to breast cancer.(7) The best estimates are that it has accounted for about half the mortality reduction now appearing in the United States.(8) The point that Carney raises is that women must respond to lumps even when there is a negative mammogram and I would reinforce that physicians evaluating them must listen and respond appropriately when women present.

References:

1: Carney PA, Steiner E, Goodrich ME, Dietrich AJ, Kasales CJ, Weiss JE, MacKenzie T. Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found? Ann Fam Med. 2006 Nov- Dec;4(6):512-8.

2: Haas JS, Kaplan CP, Brawarsky P, Kerlikowske K. Evaluation and outcomes of women with a breast lump and a normal mammogram result. J Gen Intern Med. 2005 Aug;20(8):692-6.

3: Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004 Apr;13(2):121-6.

4: Aiello EJ, Buist DS, White E, Seger D, Taplin SH. Rate of breast cancer diagnoses among postmenopausal women with self reported breast symptoms. J Am Board Fam Pract. 2004 Nov-Dec;17(6):408-15.

5: Kerlikowske K, Smith-Bindman R, Ljung BM, Grady D. Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern Med. 2003 Aug 19;139(4):274-84. Review.

6. Taplin SH, Ichikawa L, Yood MU, Manos MM, Geiger AM, Weinmann S, Gilbert J, Mouchawar J, Leyden WA, Altaras R, Beverly RK, Casso D, Westbrook EO, Bischoff K, Zapka JG, Barlow WE. Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow- up? J Natl Cancer Inst. 2004 Oct 20;96(20):1518-27.

7: Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Sep 3;137(5 Part 1):347-60.

8: Berry DA, Cronin KA, Plevritis SK, Fryback DG, Clarke L, Zelen M, Mandelblatt JS, Yakovlev AY, Habbema JD, Feuer EJ; Cancer Intervention and Surveillance Modeling Network (CISNET) Collaborators. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 2005 Oct 27;353(17):1784-92.

Competing interests:   None declared