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Guidelines for breast cancer screening in Lebanon Public Health Communication.


Guidelines for breast cancer screening in Lebanon Public Health Communication.

Abstract
The accumulation of national epidemiological data since the late 1990s has led to the adoption of evidence-based guidelines for breast cancer screening in Lebanon (2006). Almost 50% of breast cancer patients in Lebanon are below the age of 50 years and the age-adjusted incidence rate is estimated at 69 new cases per 100,000 per year (2004). This official notification calls for breast self-examination (BSE) every month starting age 20, and a clinical breast examination (CBE) performed by a physician every three years between the ages of 20 and 40 years. Starting age 40, and for as long as a woman is in good health, an annual CBE and mammography are recommended. Women with known genetic family history of breast cancer should start screening 10 years earlier than the first young patient in the family, or earlier depending on medical advice. The Breast Cancer National Task Force (BCNTF) recommends certification of mammography centers and continued training of personnel to assure high quality mammograms, and to minimize unnecessary investigations and surgeries.It recommends that a national program should record call-backs of women for annual screening and follow-up data on abnormal mammograms. BCNTF encourages the adoption of these guidelines and monitoring of their results, as well as follow-up of breast cancer epidemiology and registry in Lebanon, and scientific progress in early breast cancer detection to determine needs for modifications in the future.

http://www.ncbi.nlm.nih.gov/pubmed/19623881

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السنة السادسة

from UpToDate 19.3:
Quote:
BREAST PALPATION

Clinical breast examination — Because several randomized trials included both mammography and clinical examination, the extent of independent contribution of these methods is not clear. In these studies, mammography detected approximately 90 percent of screen-detected cancers and clinical breast examination approximately 50 percent. There is some but not total overlap.

Only one study compared the effects of careful clinical breast examination (CBE) alone with CBE plus mammography on subsequent breast cancer mortality in women in their 50s [71,72]. After 13 years of follow-up, breast cancer mortality was the same in both groups [72]. The CBE used was standardized and took an average of 10 minutes, far different than typical clinical practice. A review of controlled trials and case-control studies in which CBE was at least part of the screening modality estimated CBE sensitivity to be 54 percent and specificity 94 percent [73]. A subsequent study found that CBE plus mammography (with CBE performed by trained nurses) had greater sensitivity than mammography alone, but a higher false positive rate (12.5 versus 7.4 percent) [74]. Among 10,000 women screened with CBE and mammography, there were 55 additional false positive screens for each additional cancer detected by CBE. A 2009 literature review concluded that the effectiveness of CBE has not been proven by well-designed large trials [32].

A key factor is the quality of each examination: mammography is better standardized than CBE. The preferred technique for CBE includes: proper patient positioning (to flatten the breast tissue against the chest); examining in vertical strips beginning in the axilla and extending in a straight line down the midaxillary line to the bra line, with the fingers then moving medially and continuing up and down between the clavicle and the bra line; making circular motions with the pads of the middle three fingers and examining each breast area with three different pressures; examining each breast for at least three minutes [73].

CBE sensitivity in community practice appears to be substantially lower than that reported in randomized trials. The National Breast and Cervical Cancer Early Detection Program, which studied the value of CBE in the community setting where procedural guidelines for performing the examination were not dictated, found that CBE still detected about 5 percent of cancers that were not visible on mammography [75]. Despite good specificity in women without symptoms (96.2 percent), the sensitivity was low (36.1 percent). In another community-based study, the specificity of screening CBE in average risk women was even higher (99.4 percent), suggesting a lower sensitivity; specificity was slightly lower in women at increased risk (97.1 percent) and for diagnostic, rather than screening, examinations [76].

These studies suggest that CBE may modestly improve early detection of breast cancer, but at potential significant expense (in terms of clinician availability and time, as well as work-up of false positives) when performed as an adjunct to mammography. CBE alone may be a reasonably cost effective screening strategy, however, in developing countries where the relative cost of mammography is prohibitive for population screening [77].

Breast self-examination — There are few randomized trials of breast-self examination [78]. One study performed in China randomly assigned 266,064 women to a breast self-examination instruction group or a control group [79]. The instruction group received initial instruction in breast self-examination, reinforcement sessions one and three years later, supervised self-examination every six months for five years, and ongoing reminders. Over ten years, there was no difference between the two groups in breast cancer deaths. More benign breast lesions were diagnosed in the self-examination group.

A review of eight other studies also failed to show a benefit of regular breast self-examination in rates of breast cancer diagnosis, breast cancer death, or tumor stage or size [80]. In addition, several studies found the rate of breast biopsy for benign disease was significantly higher among women taught breast self-examination [81].

The results of two case-control studies suggest that technique is important in breast self-examination:

A nested case-control study comparing Canadian women who died of breast cancer or had metastatic disease with control women found increased risk for death or metastatic disease (OR 2.20, 95% CI 1.30-3.71) in women who did not perform technically correct breast self-examination [82].
A case-control study showed no overall effect of breast self-examination on detecting breast cancer at an earlier stage [83]. The small number of women, however, reporting more thorough examinations had about a 35 percent decrease in advanced-stage breast cancer compared with women not performing breast self-examination.

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