Breast Cancer: Guidelines, Screening & Treatment Options (2023)

Despite the advances in modern medicine, healthcare providers are still struggling to learn more about the early diagnosis and prevention of locally advanced and early-stage breast cancer, along with the best care for people already diagnosed with this disease.

Technological advances and ongoing studies are focusing on ways to enhance the current screening options as well as educate the masses regarding preventive care.

Why is breast cancer so prevalent in Pakistan?

Sadly, one in every eight women in Pakistan has this disease, and this rate is expected to rise exponentially if this bull is not taken by the horns.

Research with functional time series models shows that in the past, the age group impacted by breast cancer was in the range of 60 to 64 years. This range expanded to 50 to 64 years in recent years, and the prevalence of breast cancer (23%) recorded in the year 2020 is expected to climb to 60.7% by the year 2025. In other words, prevalence would be higher in the post-menopausal group and the younger age group of 30 to 34 years by the year 2025.

A number of reasons are attributed to the high mortality of breast cancer in Pakistan, with the leading reason being late diagnosis. The latter is a consequence of a multitude of socio-economic and educational barriers when it comes to breast diseases.

Individual and cultural factors

In terms of factors dependent on the individual, lack of awareness plays a major role. Discussions and talks about breast cancer are discouraged in general, as they are perceived as sexual organs by women in Pakistan.

This inhibits awareness about potential medical issues, with the majority being unaware of self-examination and screening tests. Research interviewees reveal how they don’t know where to get help if they feel a big lump in the breast and there is no one to guide them.

Women living in rural areas far away from treatment centers think that cancer is a terminal diagnosis and don’t want to engage in treatment for fear of medical complications and the expenses incurred by the family. Such women also lack the emotional and social support of the family and prefer to waste away in isolation rather than seek treatment.  

Guidelines for Breast Cancer – 2023

The trusted screening guidelines from the American Cancer Society, American College of Physicians, and the United States Preventive Services Task Force (USPSTF) are:

• For women between the ages of 50 and 74 years, the current guidelines recommend mammography every two years.

• For women between the ages of 40 and 49 years, there should be an individualized approach based on input from the clinician, the risk of disease, and the woman’s own preference. The clinician weighs the potential benefits and the harms of the screening test along with the risk of cancer before recommending mammography.

• In women younger than 40 years or older than 75 years, there is insufficient evidence to make a recommendation.

In the current guidelines, there are no clear recommendations on the benefits of breast self-examination or clinical breast examination.

The French College of Gynecologists and Obstetricians (CNGOF) recommends screening with mammography and ultrasonography to investigate a clinical mass, mastitis, or nipple discharge.

Screening options

Screening options are best for women who are at risk of cancer—such as those with positive family history—before there are evident signs of disease. While screening does not prevent cancer, it does improve the chances of treatment success through early diagnosis.

Screening tests are available in clinics, labs, and hospitals. Following are the types of screening tests recommended for breast cancer detection:

Mammography

• Mammography is a type of X-ray of the breasts. For early lesions, this investigation is recommended. For women in the screening age, regular mammograms decrease the risk of dying from cancer.
• 3-D mammography or tomosynthesis uses the same x-ray technology to create three-dimensional images of the breast, allowing more detailed imaging and easier viewing of abnormalities. Instead of films, a computer records the images.

Ultrasound of the breast

• In addition to the mammogram, ultrasonography of the breast improves the chances of cancer detection. In comparison to mammography alone, physician-performed ultrasound and mammography combined offer a higher sensitivity.
• Ultrasound-guided needle aspirations are useful in cases of breast abscesses.

MRI

• Magnetic resonance imaging (MRI) is helpful in select cases.
• The confirmatory investigation for breast cancer is a biopsy, combined with imaging tests.

Treatment options

Cancer needs multidisciplinary management—involving a surgeon, oncologist, radiologist, pathologist, and palliative care specialist. Depending on the sub-type of cancer, stage of cancer, genomic markers of the tumor, and the overall health of the patient, the treatment is planned by the multidisciplinary team.  

1. Surgery

In most types of breast cancer, like DCIS, surgery precedes other treatments. The idea is to remove most of the tumor and perform radiation or chemotherapy, thereafter. For larger cancers, surgery is performed after systemic therapy with chemo and radiotherapies.

2. Adjuvant therapy

After the surgery, the goal is to lower the risk of recurrence and to get rid of microscopic leftovers of the tumor. This is done through adjuvant therapy, involving: chemotherapy, hormonal therapy, and radiation.

3. Radiation therapy

Uses high-energy x-rays to destroy cancer cells. The radiation oncologist may use external-beam radiation or intra-operative radiation for the tumor. Alternatively, brachytherapy is used, by placing radioactive sources into the tumor.  

4. Inoperable tumors

Cancers that are not treatable with surgery are termed ‘inoperable’ and are managed with adjuvant therapy first.

5. Reconstruction

Plastic surgery for reconstruction is for women who have undergone tumor resection. This surgery reconstructs the breast using synthetic implants or tissue is taken from another part of the body.

To get a cancer-risk assessment, book an appointment with an Oncologist in Lahore.