1. Breast Cancer Screening

2. Introduction Breast cancer is a fatal disease at advanced stages; however, it can be controlled through prevention and early detection. Breast cancer strikes women at all ages; indeed, its incidence seems to drastically increase at the age of forty.

3. Global Perspective Globally, breast cancer is the most frequently diagnosed cancer in women, it is also the leading cause of cancer death among women worldwide (ACS, 2011; International Agency for Research on Cancer (IARC), 2008). About half of the new cases were expected to occur in developing countries. Rates were high in North America, Australia and Northern and Western Europe. However, low rates were observed in large parts of Africa and Asia (ACS, 2011).

4. Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 36 (about 3%). Death rates from breast cancer have been declining since about 1989, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier detection through screening and increased awareness, as well as improved treatment.

5. Breast Cancer In USA Breast cancer is the most common cancer among American women, except for skin cancers. About 1 in 8 (12%) women in the US will develop invasive breast cancer during their lifetime. About 40,000 women die from breast cancer After increasing for more than 2 decades, female breast cancer incidence rates began decreasing in 2000, then dropped by about 7% from 2002 to 2003.

6. Breast Cancer In Jordan In Jordan, cancer is the second leading cause of death, preceded only by cardiovascular diseases. It is reported that the first cause of death in Jordan is cardiovascular diseases representing (35.9%) of all deaths in Jordan, followed by Neoplasms which constitute (14.6%) (Ministry of Health, 2012).

7. In the year 2009 the number of deaths due to neoplasm was 2164 (14.6%), in males 1237 (14.4%) and in females 927 (14.9%) with male to female ratio of 1.3:1; among females, breast cancer has the highest mortality rate when compared to other types of cancer (MOH, 2012).

8. In 2009 breast cancer was ranked the first of all cancer types accounting for 19.6 % of all new cancer cases (MOH, 2012). Furthermore, it was ranked the first among cancer affecting women accounting for 36.8 %, of the diagnosed women, less than one third (3% and 26%) were diagnosed at a stage of zero and one respectively (MOH, 2012).

9. Can breast cancer be prevented? Lowering your risk by changing those risk factors that can be changed: Body weight, physical activity, and diet have all been linked to breast cancer, so these might be areas where you can take action. Both increased body weight and weight gain as an adult are linked with a higher risk of breast cancer after menopause. Alcohol also increases risk of breast cancer. Even low levels of alcohol intake have been linked with an increase in risk. Many studies have shown that moderate to vigorous physical activity is linked with lower breast cancer risk. A diet that is rich in vegetables, fruit, poultry, fish, and low-fat dairy products has also been linked with a lower risk of breast cancer in some studies. But it is not clear if specific vegetables, fruits, or other foods can lower risk. Most studies have not found that lowering fat intake has much of an effect on breast cancer risk.

10. At this time, the best advice about diet and activity to possibly reduce the risk of breast cancer is to:  Get regular, intentional physical activity.  Reduce your lifetime weight gain by limiting your calories and getting regular physical activity.  Avoid or limit your alcohol intake.  Women who choose to breastfeed for at least several months may also get an added benefit of reducing their breast cancer risk.  Not using hormone therapy after menopause can help you avoid raising your risk.  It’s not clear at this time if environmental chemicals that have estrogen-like properties (like those found in some plastic bottles or certain cosmetics and personal care products) increase breast cancer risk. If there is an increased risk, it is likely to be very small.  Still, women who are concerned may choose to avoid products that contain these substances when possible.

11. For women who are or may be at increased risk If you are a woman at increased risk for breast cancer (for example, because you have a strong family history of breast cancer, a known genetic mutation of a BRCA gene, or you have had DCIS, LCIS, or biopsies that have shown pre-cancerous changes), there may be some things you can do to reduce your chances of developing breast cancer. Before deciding which, if any, of these may be right for you, talk with your doctor to understand your risk and how much any of these approaches might lower this risk.

12. Genetic testing for BRCA gene mutations Breast cancer chemoprevention Preventive surgery for women with very high breast cancer risk For the few women who have a very high risk for breast cancer, surgery to remove the breasts or ovaries may be an option.  Preventive (prophylactic) mastectomy  Prophylactic oophorectomy (ovary removal)

13. Can breast cancer be found early?

14. Breast Cancer Screening Guidelines Recent breast cancer screening recommendations are emphasizing mammography (every one to two years) as the most effective modality for early detection of the disease among women at average risk (ACS, 2013; Jordan Breast Cancer Program (JBCP), 2011; US Preventive Services Task Force (USPSTF), 2009).

15. American Cancer Society Guidelines

16. Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram will miss some cancers, and it sometimes leads to follow up of findings that are not cancer, including biopsies. Women should be told about the benefits, limitations, and potential harms linked with regular screening.

17. Mammograms can miss some cancers. But despite their limitations, they remain a very effective and valuable tool for decreasing suffering and death from breast cancer. Mammograms for older women should be based on the individual, her health, and other serious illnesses, such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate-to-severe dementia. Age alone should not be the reason to stop having regular mammograms. As long as a woman is in good health and would be a candidate for treatment, she should continue to be screened with a mammogram.

18. Clinical Breast Exam Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, at least every 3 years. After age 40, women should have a breast exam by a health professional every year.

19. CBE is a complement to mammograms and an opportunity for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman's history that might make her more likely to have breast cancer. There may be some benefit in having the CBE shortly before the mammogram. The exam should include instruction for the purpose of getting more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast self-exam (BSE). Breast cancer risk is very low for women in their 20s and gradually increases with age. Women should be told to promptly report any new breast symptoms to a health professional.

20. Breast Self-Exam Breast self-exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

21. Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Women who choose to do BSE should have their BSE technique reviewed during their physical exam by a health professional.

22. Women at high risk for breast cancer based on certain factors should get an MRI and a mammogram every year. This includes women who:  Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tools that are based mainly on family history  Have a known BRCA1 or BRCA2 gene mutation  Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, but have not had genetic testing themselves  Had radiation therapy to the chest when they were between the ages of 10 and 30 years  Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan- Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

23. The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%. There is not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15% to 20% according to risk assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as:  Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH).  Having dense breasts (“extremely” or “heterogeneously” dense) as seen on a mammogram

24. If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because while an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

25. For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited about the best age at which to start screening, this decision should be based on shared decision making between patients and their health care providers, taking into account personal circumstances and preferences. Several risk assessment tools, with names like the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk.

26. National Guidelines National efforts to promote universal screening for Jordanian women are led by the JBCP; recommendations for early detection of breast cancer in Jordan are consistent with the international ones (ACS, 2013; USPSTF, 2009).

27. The JBCP recommends mammography every one to two years for women at an average risk between 40 and 52 year-old, and every two years for those who are 52-year old and above. Clinical Breast Exam (CBE) is recommended for women at an average risk between the ages 20-40 every 1-3 years, whereas women at an average risk at the age of 40 and above should have it yearly. Moreover, BSE is recommended to be performed every month starting at the age of twenty (JBCP, 2012).

28. References http://www.cancer.org/acs/groups/cid/documents/webconte nt/003090-pdf.pdf