Evaluation of Breast Symptoms

Breast symptoms may suggest a diagnosis of breast cancer. During a 10-year period, 16% of 2,400 women aged 40 to 69 years sought medical attention for breast symptoms at their health maintenance organization.[1] Women younger than 50 years were twice as likely to seek evaluation. Additional examinations were performed in 66% of patients, with 27% undergoing invasive procedures. Cancer was diagnosed in 6.2% of patients with breast symptoms, most being stage II or III. Of the breast symptoms prompting medical attention, a mass was most likely to lead to a cancer diagnosis (10.7%) and pain was least likely (1.8%) to do so.

Pathologic Diagnosis of Breast Cancer

Breast cancer is diagnosed by pathologic review of a fixed specimen of breast tissue. The breast tissue can be obtained from a symptomatic area or from an area identified by a screening test, usually mammography. A palpable lesion can be excised surgically or biopsied with fine-needle aspirate or core needle biopsy (CNBx). Nonpalpable lesions can be excised by surgical needle localization under x-ray guidance (SNLBx). Alternatively, a CNBx of a mammographically suspicious area can be obtained with use of stereotactic x-ray or ultrasound. In a retrospective study of 939 patients with 1,042 mammographically detected lesions who underwent CNBx or SNLBx, sensitivity for malignancy was greater than 95% and the specificity was greater than 90%. Compared with SNLBx, CNBx resulted in fewer surgical procedures for definitive treatment with a higher likelihood of clear surgical margins at the initial excision.[2]

Fine-needle aspiration, nipple aspiration, and ductal lavage are three methods of obtaining cells from breast tissue or ductal epithelium for cytological examination (see Tissue Sampling [Fine-Needle Aspiration, Nipple Aspirate, Ductal Lavage]).

None of these technologies has been tested in controlled trials of screening or compared with other breast cancer screening modalities.

Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS) is a noninvasive condition that can progress to invasive cancer, with variable frequency and time course. While some authors include DCIS with invasive breast cancer statistics, it has been suggested that the term DCIS be replaced by a classification system of ductal intraepithelial neoplasia (DIN), similar to those used to grade cervical and prostate precursor lesions. DCIS is usually diagnosed by mammography, so it is rare in unscreened women. In the United States in 1983, the prescreening era, 4,900 women were diagnosed with DCIS, compared with 67,770 that will be diagnosed in 2008.[3]

The natural history of untreated DCIS is poorly understood because women diagnosed with DCIS undergo surgery, with or without radiation and hormone therapy. According to data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute on women with newly diagnosed DCIS treated between 1984 and 1989, 1.9% died of breast cancer within 10 years of diagnosis.[4] Development of breast cancer after treatment of DCIS varies according to treatment. One large randomized trial found that 13.4% of women treated by lumpectomy alone developed ipsilateral invasive breast cancer by 90 months, compared with 3.9% of those treated by lumpectomy and radiation.[5] Another series of 706 DCIS patients, however, allowed definition of the University of Southern California/Van Nuys Prognostic Scoring Index, which defines the risk of recurrence based on age, margin width, tumor size, and grade.[6] The low-risk group, comprising a third of the cases, experienced few DCIS recurrences (1%) and no invasive cancers, regardless of whether radiation was given. The moderate- and high-risk groups had higher recurrence rates, with a beneficial preventive effect of radiation. Nonetheless, only approximately 1% had death from breast cancer. The addition of tamoxifen also reduces the incidence of invasive breast cancer after excision of DCIS.[7] Because all these studies include excision of mammographically detected DCIS, the natural history of this condition remains unknown.