Диагностика рака молочной железы

[Dokukina_SV]

Одним из традиционных направлений в профилактике рака молочной железы (имею в виду санпросветработу) является обучение женщин самообследованию молочных желёз. А тут наткнулась на такую ссылочку:
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Как можно сформулировать алгоритм профилактического обследования молочных желёз у женщин с учётом возраста?

С уважением, врач акушер-гинеколог Докукина С.В.

[yananshs]

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[yananshs]

Breast cancer

Mammography

AAFP Every 1 to 2 years, ages 50 to 69; counsel women ages 40 to 49 about potential risks and benefits of mammography and clinical breast examination.
ACOG Every 1 to 2 years starting at age 40, yearly after age 50
ACS Annually after age 40
AMA Every 1 to 2 years in women ages 40 to 49; annually beginning at age 50
CTFPHC Every 1 to 2 years, ages 50 to 59
NIH Data currently available do not warrant a universal recommendation for mammography for women in their 40s; each woman should decide for herself whether to undergo mammography.
USPSTF Every 1 to 2 years, ages 50 to 69

Clinical Breast Examination

AAFP Every 1 to 2 years, ages 50 to 69; counsel women ages 40 to 49 about potential risks and benefits of mammography and clinical breast examination.
ACOG Yearly (or as appropriate) general health evaluation that includes examination to detect signs of premalignant or malignant conditions
ACS Every 3 years, ages 20 to 39; yearly after age 40; monthly breast self-examination beginning at age 20
AMA Continuation of clinical breast examinations in asymptomatic women older than age 40
CTFPHC Yearly, ages 50 to 69
USPSTF Insufficient evidence to recommend for or against using clinical breast examination alone; optional every 1 to 2 years, ages 50 to 69

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[yananshs]

Screening Recommendations for Low-Risk Patients
CTFPHC recommends screening by mammography every year in women ages 50 to 69. Evidence suggests that such screening is associated with a significant decrease in mortality in this age group.3 USPSTF recommends mammography every one to two years, with or without clinical breast examination, in women ages 50 to 69.4

The American College of Radiology supports annual mammography and clinical breast examinations starting at age 40.5 The American College of Obstetricians and Gynecologists (ACOG) recommends annual clinical breast examinations accompanied by mammography every one to two years in women from 40 to 50 years of age and annually after age 50.6 The American Medical Association (AMA) recommends mammograms and clinical breast examinations annually in women 50 years and older and mammography and clinical breast examinations every one to two years in women between 40 and 49 years of age.7

The American Cancer Society (ACS) recommends mammography annually after age 40; clinical breast examination is recommended every three years in women between 20 and 39 years of age and annually after age 40.2 The American Academy of Family Physicians (AAFP) recommends mammography and clinical breast examination every one to two years in women ages 50 to 69.8

Screening Recommendations for High-Risk Patients
USPSTF does not specifically recommend mammography or clinical breast examination in women younger than 50 years who are at increased risk of breast cancer, but leaves it up to the discretion of the patient and physician. However, such screening may be recommended for a patient at high risk of breast cancer based on the patient's and physician's preferences and the higher frequency of a positive predictive value of screening in the high-risk group.4
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[aberzoy]

Сообщение от Dokukina_SV

Одним из традиционных направлений в профилактике рака молочной железы (имею в виду санпросветработу) является обучение женщин самообследованию молочных желёз.

Здесь вообще, для начала, есть смешение понятий.

Ни один из методов диагностики не является "профилактикой рака молочной железы!
Ни самообследование, ни маммография, ни МРТ и прочее.
Это всё - методы диагностики.

К профилактике относятся - приём тамоксифена, овариоэктомия, профилактическая мастэктомия.

Теперь по самообследованию.
Да, самообследование не снижает смертность от рака молочной железы, поэтому и пересмотрено сейчас мнение о его "обязательности".
По статистике, 80% опухолей женщины находили самостоятельно, а сейчас в странах, где организован сплошной скрининг, значительное количество случаев выявляется на доклиническом этапе по маммографии.
У нас же, по прежнему, находят сами... :-(
Поэтому отказываться от самообследования - рано, но акцент должен быть не на "выявление рака" (при самообследовании), а на своевременное обращение к врачу при обнаружении изменений.

Алгоритм рекомендую такой:
1. Оценка факторов риска (семейный анамнез РМЖ)
2. Рекомендовать самообследование для своевременного обращения к врачу при возникновении изменений. Сразу отметить, что 80% самостоятельно выявленных изменений - не рак.
3. Ежегодный клинический осмотр врача (гинеколог, хирург)
4. Женщинам старше 40 лет рекомендовать маммографический скрининг раз в 1-1,5 года (или по рекомендации рентгенолога).
5. Женщинам старше 60 - раз в 2 года (или по рекомендации рентгенолога)
6. Женщинам старше 75 лет - по желанию/настоянию пациентки.
7. Кровным родственницам больных МГ ежегодно с 35 лет или на 5 лет раньше возраста заболевшей.
8. В случае нескольких родственниц с РМЖ обсудить генетическое тестирование мутаций BRCA1/BRCA2 и выбор метода профилактики.

При рекомендации маммографического скрининга, акцент делать на необходимости регулярного его проведения, а не "от случая, к случаю" (как чаще всего происходит).

[yananshs]

Role Of Breast Self-Examination Changes In Guidelines
Focus On Awareness Rather Than Detection

Article date: 2003/05/15


For years, the American Cancer Society has recommended monthly breast self-examination (BSE) for women age 20 and older to aid in the early detection of breast cancer. The Society’s guidelines have been updated, and BSE is now optional.

The shift is sure to be controversial, as there are various groups and individuals who believe breast self-exams are important to women’s health. But expert opinion is divided on whether there is a benefit to BSE, said Debbie Saslow, PhD, director of breast and gynecologic cancer for ACS.

Recent studies, including a trial with more than 250,000 women in Shanghai, China, have not shown that BSE reduces deaths from breast cancer.

“We don’t think there’s a strong reason not to do BSE, but there’s no strong reason to do it, either. BSE is an option for women starting in their 20s,” Saslow said.

An Evolution Of Thinking
Under the new guidelines, BSE is being recognized as a way for women to know how their breasts normally feel and to notice any changes. This approach focuses on the importance of self awareness compared to early detection.

“There are two ways to think about breast self-examination,” said Amy Langer, executive director of the National Alliance of Breast Cancer Organizations (NABCO). “One is as a particular technique that has to be learned, has to be demonstrated, has to be practiced and done consistently and correctly.”

Most women don’t do BSE in that structured, formal way, Langer said, because they don’t have confidence that they’re doing it right -- and that makes them feel anxious.

“Another way to think of BSE … is being familiar with the landscape of your breasts. It’s knowing that you already have a bump here, a wrinkle there, and that that freckle by your nipple has always been there, so that you get a sense in your mind and in your hands of what feels normal for you,” Langer said. “That’s less overwhelming for women.”

Benefits Of BSE Uncertain
One of the main reasons for the change to the BSE guideline is the lack of evidence over the benefits of breast self-examination.

Mammography is so far the only screening method that has been consistently proven to reduce deaths from breast cancer. It is considered the gold standard of screening, while BSE is, at best, a supplement to regular mammograms and breast exams by a doctor.

While a number of earlier studies found that BSE helped women detect cancers earlier, most of those studies were conducted before mammography was available as a screening tool. However, even in those studies, many of the women who detected their own cancers did not find them while performing BSE; they found them incidentally, while dressing or bathing, for instance.

And as mammography has become more common, the number of cancers detected by women themselves has dropped.

“An increasing number of cancers are detected at early stages, at a size that is too small to be found not only by BSE, but by a clinical exam,” said Langer, who is herself an 18-year breast cancer survivor.

A breast lump has to be about one inch in diameter, or about the size of a quarter, for a woman to feel it herself. A mammogram can reveal an abnormality as small as a pencil eraser.

Moreover, teaching and promoting BSE takes up numerous resources that may be better used to promote mammography, which has proven life-saving benefits, Saslow said.

Another potential problem is the guilt many women feel because they don’t do regular BSE. Such guilt is misplaced, said Saslow, because evidence is lacking that BSE has benefits beyond self awareness.


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