Introduction:

Breast screening refers to the examination of a woman’s breast to facilitate the detection of breast problems such as diseases or breast malignancies. When regularly done, breast screening forms an early entry point for the diagnosis, care and treatment of disease conditions affecting a woman and further preventing complications that may arise from them. In some countries, breast screening is done individually to the woman seeking the services while in others; it involves the running of organized programs. These invite the women for breast cancer screening, reminding them about the services, notifying the participants of their results, tracing them to avoid defaulters, and checking the quality of the service provided to these participants. This paper discusses the various breast screening programs; the imaging modalities utilized in the diagnosis and their advantages, as well as their limitations. It also explains the multidisciplinary approach to the breast cancer screening, diagnosis as well and the role of the stakeholders.

Breast screening programs:

Currently, the NHS runs a breast cancer screening program that provides breast screening at an interval of three years for women aged fifty (50) years and above. The program provides screening for free, although with both invitations and personal appointments, with an age extension of 47 to 73 years. According to NHS (2014), this program has contributed to a reduction in deaths of women aged 55 to 69 years. The Ontario breast screening program is run by the Ontario cancer care that screens women at risk of breast cancer of the age extension 50 to 74 years. It also screens the women at high risk of breast cancer, especially those aged between 30 to 69 years. Through this program, the women receive quality mammograms and breast MRIs. They are also referred to the necessary facilities for continued care, and, for care for those who are diagnosed with breast cancer, arrangements are made for follow-ups (Cancer Care Ontario, 2014). In Canada, the Nova Scotia breast screening program carries out a cost effective breast screening to Nova Scotia women at the age extensions between 50 and 69 years. It promotes the guidelines for the policies of decentralized breast screening services in Scotia, and it also provides clinical services (Nova Scotia Breast screening Program, 2014). In the British Columbia, the BC Cancer Agency runs a breast screening program with the goal of reducing breast cancer through early detection. It also ensures that screening policies are up to date and carries out regular screening mammograms to women aged 40 years. According to its statistics, about 7% of the women require further tests to confirm breast problems (BC Cancer Agency, 2014). The Saskatchewan Cancer Agency carries out a screening program for women aged between 50 to 69 years. The centers for disease control and prevention has come up with a program called “the national breast and cervical cancer early detection,” which provides screening for underinsured women of low income aged between 40 to 64 years.

Triple assessment in breast cancer screening and diagnosis:

The screening process involves the use of varied methods, ranging from simple to advanced. The procedures are done in a systematic manner, leading to a continuum of investigations that build on one another, building a pool of clinical data available about cancer, and helps in easier diagnosis and management (Heusner et al., 2011). As commonly referred to as triple assessment, it involves a set of screening tests, which are done to people who are with the aim of detecting malignant breast cancer cells as early as possible for early initiation of management. These include techniques such as self-breast examination and clinical breast examinations (CBE), done through inspection of the breast that allows for the visualization of breast changes such as color of the breast skin, as well as the difference in sizes of the two breasts. Palpation is another commonly used screening procedure which helps in the detection of the presence of breast lumps (Heusner et al., 2011). Although it may outline the breast masses, it is limited to the provision of in-depth explanation of their nature in terms of composition, extend of other tissue and organ involvement, as well as the stage of the breast cancer. Mammograms remain a key screening test for women. When done regularly, or at a given interval, a present breast cancer can be managed early. This is because mammography provides a high definition of the breast condition and more detailed and reliable information compared to the other screening methods (Heusner et al., 2011)

Breast imaging modalities, their advantages and disadvantages:

Upon screening, diagnostic tests form the second part of triple assessment. They involve people who are suspected to have breast cancer and can be based on screening tests or the signs and symptoms in people presenting with breast malignancies. They can be non-invasive or invasive methods involving the breast cell mass (Cuhl, et.al., 2005). Noninvasive methods include breast imaging, which involves the use of x-rays mostly done on the chest for the affected breast to visualize the breast tissue. The x-rays remain vital in indicating the sizes of the masses, as well as their degree of extent in relation to the surrounding tissues and organs. They possess the advantage of being easy to use and readily available, though they are sometimes costly and repeated exposure may have an adverse health effect on the recipient (Cuhl, et.al., 2005). Other modalities include the use of ultrasonography techniques to image the breast. Breast ultrasounds provide a more detailed picture of the breast masses in-terms of the quadrants and lobular locations as well as measurements of the malignancies. For the user, ultrasounds can be costly and not easily accessible compared to x-rays. However, they are relatively safer upon repeated exposure.

Breast Magnetic Resonance imaging (MRI) is another form of imaging modality involving the use magnets and radio waves to give detailed images of the breast tissue and its surrounding structures. As opposed to the x-rays and ultrasound, MRI gives clearer images that can be used to differentiate between normal and abnormal breast masses. It doesn’t involve radiation exposure, hence remains safer compared to other imaging modalities. However, it is expensive, leaving most clients unable to afford, and it is not available in most health centers, making it not easily accessible to the patients (Cuhl, et.al., 2005)

Computerized Tomography Scans (CT scan) are also commonly used for the imaging of breasts during diagnosis for the confirmation of the nature of the masses present in the breast tissue. Though they are not routinely used, breast CT scans play a key role in indicating whether the malignant breast cancer cells or tissues have spread to the neighboring organs such as the lymph nodes, liver, kidneys or lungs. It also remains relevant when there is a possibility of going for a mastectomy (Warner, 2011). Though a CT scan provides key information on the extent of the breast malignancy, some of the clients are sensitive to the dye used to guide the procedure. The dye used can also damage the kidney, and kidney tests may be required during the preparation period for the CT scan. It is also relatively expensive, and some clients may not afford it.

Positron Emission Tomography in breast cancer diagnosis can be used for obtaining images of the functioning cells (Warner, 2011). It shows the areas of high-cell activity since malignant cells have a higher activity compared to normal cells; hence images can be interpreted, and areas with cancerous cells are known. Breast thermography, as a breast imaging technique utilizes infrared rays to determine temperature changes in the breast skin as an effect of an underlying tumor. Compared to the other methods of imaging, breast thermography is less sensitive and may not provide adequate clinical information to guide diagnosis due to its reduced sensitivity (Warner, 2011).

Breast biopsies form the third part of the triple breast assessment done for the diagnosis of breast cancers and involve the collection of tissue or fluid samples from the breast tissue, which is later analyzed microscopically to determine whether the cells are cancerous or not (Warner, 2001). It is the definitive investigation and confirms the absence or presence of breast cancer in a suspected person. The types of biopsies used include fine needle aspirate (FNA), which involves the collection of fluid samples from the breast mass for histological examinations (Liberman, 2006). Through the laboratory examination of the collected specimen, the form of the cells found in the malignancy can be detected and analyzed to provide data that can guide the specific management of the breast condition. Fine needle aspirates can also tell the degree of other tissues and organ involvement like, the lymph nodes or other organs proximal to the involved breast. This in turn guides the process of staging for the breast mass, thus ensuring adequate data, and guidance in selecting the forms of management as per that particular stage (Liberman, 2006; Parker et al., 2001).

A core needle biopsy is used for the collection of some little samples of tissue from the suspicious breast with a large core needle. To ease pain from the procedure, it is done under local anesthesia and may involve the installation of some marker for guidance purposes in case surgery is thereafter required. The biopsy can be done as a free-hand core needle biopsy, where the mass can be clearly felt through the skin or as an ultrasound guided biopsy, especially where the mass cannot be located by feeling it via the skin (Taber, 2002). The tissue collected is later examined microscopically for any cancerous cells. Surgical biopsy can also be performed on clients who have suspected abnormal breast masses. Through it, an incision is made on the breast with a removal of part or whole of the abnormal breast tissue. This is then investigated using a microscope for histology to determine the type of the cells. The current use of vacuum-assisted biopsy (VAB) allows for the collection of a sample of breast tissue through a single-skin incision, making it less invasive compared to the other methods of biopsies. It remains advantageous because of its ability to collect specimens from different breast sites easily and within a short period as well as, causing minimal harm to the individual undergoing the procedure (Flessing et al., 2006)

Principles in population screening:

In community screening for breast cancer, various principles have to be adhered to, to ensure that the best outcome of the given program. Awareness should be created for the people involved in the screening about the program, including the procedures to expect, adverse effects from the procedures and any need for informed consent during the process. The condition or disease being screened should be of importance to the community in that there should bea serious health concern to warrant the screening. This includes deathsin the community as well as poor health to the people affected just like breast cancer does (Cancer Council of Australia, 2014)

For the condition being screened, it should have evident recognizable signs and symptoms at the latent and early phases of the disease development. This can include breast colour changes, breast size differences as well as presence of breast masses that can be detected through clinical breast examination (Flessing et al., 2006). The condition must have a natural history of disease progression in an individual. This includes the pre-disease or the latent phase, the disease period where the condition is confirmed and the recovery period, where the disease clears from the individual following treatment. In population screening, there must be an acceptable treatment for the people diagnosed with the disease condition. For example, in breast cancer, there must be a clear way of treatment once it is diagnosed and confirmed in a suspected individual. These may include chemotherapy or mastectomy either radical or partial as well as specific follow-up care following the successful management (Cancer Council of Australia, 2014).

The principle of having a suitable test or examination of high accuracy to confirm the diagnosis must hold in the population screening. For example, in breast cancer screening, breast biopsy has a higher accuracy in determining the presence or absence of breast cancer. This should be utilized with the other methods to avoid making the wrong diagnosis, which may lead to wrong management of the patient. The test should be acceptable within the population, that is, the procedures being done on the clients must conform to the community’s approved socio-cultural principles. This promotes easy engagement of the community and ease of participation in running the program (Cancer Council of Australia, 2014)

The screening program must have an agreed policy on whom to treat as patients. The policy strategies should be in line with those of international health organizations like the WHO policies on cancer treatment as well as international cancer treatment organizations guidelines. The centers for treatment and the diagnosis of the condition under screening must be available (Robinwots, 2004). There must be adequate hospitals or health centers with the necessary equipment, such as imaging machines, laboratories as well as drugs for the treatment of the diagnosed cases. All these facilities must be within reach for the age extensions targeted by the program. The cost of the screening must be economically balanced in order to benefit the individuals and not to strain the organizations providing the program. This includes the costs of treatment, expenses of diagnosis and the follow-up care. During the screening, the process should be a continuing one to cater for the people joining a certain age extension yearly or as per the programs specified intervals of the screening. It should not be a one timeproject, since it may not subsidize a large pact of the Population (Cancer Council of Australia, 2014).

Multidisciplinary approach in breast cancer screening and diagnosis:

According to Flessing et al. (2006) breast cancer screening involves multi-disciplinary teams approach from the time of disease suspicion to its treatment and follow-up care of the individual. This allows for the catering of the patient’s concerns as a whole, thus allowing optimal health. During the diagnosis stage, health educators are of need to the participants. They ensure that clients receive adequate information on breast cancer screening services and their benefits, thus creating a good awareness about the condition (Robinwots, 2004). Public relation officers also serve a key role during this process since they play an important role in creating a link between the individuals and the health facilities, as well as, persuading them to join the program and disseminating information concerning the program.

The team should include an oncology radiologist mostly involved in the radiological examinations such breast ultrasounds, breast MRIs, and breast x-rays. These play a paramount role in the diagnosis and guiding the whole process of cancer care and treatment. A medical oncologist remains a crucial member of the multidisciplinary team because he or she provides the medical guidance in relation to the breast cancer diagnosis, staging as well as proving the best treatment modality that can benefit the patient. They also play a pivotal role in the follow up care of the patient, including their reactions to the drugs being administered or any other treatments (Robinwots, 2004)

A breast care nurse remains critical in the breast cancer screening, treatment and evaluation process. He/she prepares the client for the procedures and maintains close monitoring during and post the procedure. In case of any complications, the nurse remains the first person to respond to the client’s needs. During hospitalization for the client post-surgery or post-procedures, the breast care nurse implements the specific and general nursing care required for such a patient. The nurse also promotes the process of the patient’s recovery through other procedures such surgical dressing and infection control measures since infection to the surgical site may hinder the process of client recovery.

An oncology surgeon is important in the management of a breast cancer patient. He/she utilizes surgical skills in the removal of confirmed breast cancer masses and decides the surgical modality to utilize in the process of the cancer treatment. The surgeon also acts as a linkage to the laboratory examinations by collecting the necessary specimens during an operation. In case of recurrence, he/she remains critical in the surgical re-evaluation of the clients. A pathologist should be present in the whole process. He /she evaluates the specimens collected to determine whether the cells have pathological changes brought by the effects of the breast cancer. It is through these pathological examinations that the diagnosis of the cancer is confirmed or ruled out.

Psychosocial support to a patient with breast cancer plays a pivotal role in the recovery of the a patient. Counseling the client promotes the psychological well being and ensures the client copes well with bodily changes and loss that comes with surgery following breast cancer. It also promotes good coping for the family of the affected individual (Perlet, et al., 2006). Nutritionists also play an important part of the team work in the management of this patient by providing the nutritional support to promote the recovery of such an individual. This is because cancer causes emaciation and increased body energy requirements due to the high metabolism of the cancer cells. Physiotherapy services are also highly required to enable the individual to regain the ability to use the affected side in performing duties. It also helps prevent complications like contractures that may arise from the disuse of the affected side (Perlet, et al., 2006). All these services combined; the multidisciplinary approach promotes a successful management of the breast cancer as well as promoting quicker recovery and optimal functioning of the affected individual

In conclusion, the diagnosis of cancer requires many steps, and each particular method has advantages and disadvantages. Among the sophisticated modern methods for breast cancer screening include magnetic resonance imaging, computed tomography scans, thermography and mammographies among others. After diagnosis and confirmation of breast cancer, the treatment follows. Treatment for breast cancer is a multidisciplinary process, and every stakeholder is very important in the care.

References

“Nova Scotia Breast screening Program”. (2014) Retrieved fromhttp://breastscreening.nshealth.ca/

BC Cancer Agency. 2014. Screening Mammography Program (SMP) of British Columbia. Retrieved from http://www.bccancer.bc.ca/PPI/Screening/Breast/default.htm

Cancer Care Ontario. 2014. About the Ontario breast cancer screening program. 2014. Retrieved from https://www.cancercare.on.ca/pcs/screening/breastscreening/obsp/

Cancer Council of Australia. 2014. National Cancer Prevention Policy. Principles of screening. 2014. Retrieved fromhttp://wiki.cancer.org.au/prevention/Principles_of_screening

Cuhl, C K., Schrading, S., Leutner, C.C., Morakkabati, S.N., Wardelmann, E., Kuhn, W., & Schidi, S. 2005.Mammography, Breast Ultrasound, and Magnetic Resonance Imaging for Surveillance of Women at High Familial Risk for Breast Cancer .American society of clinical oncology.Vol. 23 No. 33, PP.8469-8476.

Fleissing, A., Jenkins, V., Catt, S., & Fallowfield, L. .2006.Multidisciplinary teams in cancer care: are they effective in the UK?The lancet oncology, Vol 7, No 11, pp. 935-943.

Heusner T.A., Hahn, S., Jonkmans, C., Kuemmel, S., Otterbach, F., Hamami, M., …& Antoch, G. 2011.Diagnostic accuracy of fused positron emission tomography/magnetic resonance mammography: initial results British Journal of Radiology,Feb 1, 2011:126-135.

Lieberman, L. 2006.Breast MR imaging in assessing the extent of disease. Magnetic imaging clinics of North America. The Clinics, Vol 14, pp. 33-49).

NHS. 2014. NHS Breast screening report, 2014. Retrieved from;http://www.cancerscreening.nhs.uk/breastscreen/

Parker, H. S., Clausiz, A. J., Patrick, J., Weiz, M. ., Cathy, J., Tommy, E…. & Jay,K. 2001. Sonographically Guided Directional Vacuum-Assisted Breast Biopsy Using a Handheld Device. American Journal of Roentgenlogy. Vol 177, No 2,pp. 405-408.

Perlet C., Haywang, S., Heing, A., Sittek, H., Casselman, J… & Taourel, P. 2006. Magnetic resonance guided vacuum assisted biopsy. Results from a European multicenter study of 538 lesions. Cancer, Vol. 106. PP. 982.

Rabinowitz, B. 2004. Interdisciplinary breast cancer care: declaring and improving the standard.Oncology Services Meridian Health,Vol 18, No10, pp. 1263-8.

Tabár , L. Faqerberq, CJ., Gad, A., Bardetop, L., Lundstrom, B., Manson, JC., & Eklund, G. 2002. Reduction In Mortality From Breast Cancer After Mass Screening With Mammography: Randomized Trial from the Breast Cancer Screening Working Group of the Swedish National Board of Health and Welfare. The lancet.Vol.325.

Warner E.2011.Impact of MRI surveillance and breast cancer detection in young women with BRCA mutations. Annals of Oncology, Jan 1, 2011:i44-i49

Warner, E.2001.Comparison of Breast Magnetic Resonance Imaging, Mammography, and Ultrasound for Surveillance of Women at High Risk for Hereditary Breast Cancer. Journal of Clinical Oncology, Vol. 19 no. 15 3524-3531

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