STRATEGY for BREAST CANCER SCREENING in TAIWAN

Breast cancer (BC) has become a global disease among women. Cost-effective strategies in reducing mortality caused by BC are highly desirable. Here, we suggest a working program based on an overall evaluation of the shortcomings and advantages of the current strategy for BC screening in Taiwan. From 1995 to 2002, cervical cancer was the most frequent cancer in women in Taiwan. However, invasive BC has moved from the second-most to the most frequent cancer since 2003. The incidence of BC increased by 14.69% between 2003 and 2008. In the same time interval, the incidence of cervical cancer decreased by 4.59%. Age analysis for BC incidence showed that 11% were at a relatively young age (30e39 years) and the peak incidence was in the group aged 40e49 years. Furthermore, only 31% of patients were at stage I according to data for newly diagnosed patients at National Taiwan University Hospital for 2004-2009. With the increase in pregnancy at an advanced maternal age, obstetrician egynecologists should be alert to the possibility of coexisting BC and pregnancy. To facilitate early detection of BC, a campaign for “Three points examined together” {uterine cervix and 2 breasts} should be implemented. Obstetrician-gynecologists should perform breast examination including palpation and ultrasound examination at the same time as the annual Pap smear. Mammography should be performed every 2-3 years or when indicated. If suspicious lesions are found, patients should be referred to a breast imaging laboratory, where a definitive diagnosis can be established. For confirmed cases of BC, appropriate surgery, chemotherapy and radiotherapy should be mammography or ultrasound provided. In short, active participation of obstetrician-gynecologists is a must in the campaign against BC in Taiwan.

Mammography or ultrasound

Although far from being a perfect tool, mammography has been the mainstay of BC screening. Mammography can detect microcalcification in breast lesions for stage 0 BC patients. However, it involves ionizing radiation. It is not applicable in women under 40 years of age in general. It has to be performed in rooms shielded with lead. Many studies have documented that the morphological view of breast tissue in Asian women is denser than that in Caucasian women. The pain and discomfort caused by compression during the mammography have deterred many women from BC screening programs. In fact, the acceptance rate for mammography in Taiwan has been as low as 17%. In addition, microcalcification in breast lesion is difficult to be detected by mammography for Asian compared to Caucasian women.

By contrast, ultrasound is not ionizing in nature. It is widely acceptable and available in Taiwan and it is performed in an OB/GYN clinic setting where Pap smears are performed. Thus, it is possible for “Three points examined together” to become more than a slogan. When a suspicious breast lesion is found, an experienced physician can undertake fine needle aspiration or core biopsy to make a definitive diagnosis right on site.

Taken together, these considerations indicate that the best strategy for BC detection might be to perform both mammography and ultrasound examinations without an additional charge at each visit. For women not at high risk of BC, mammography can be performed every 2-3 years, while breast ultrasound is performed annually together with Pap smears.

If we can convince 2000 obstetricianegynecologists in Taiwan to actively participate in BC detection, we believe that the BC mortality rate in Taiwan could be markedly reduced within a few years via early detection and management of disease. A good example is the maternal serum screening campaign for Down syndrome (Fig. 4) [19]. With the right strategy and a collaborative team consisting of patients, obstetrician-gynecologists and other medical care providers, the Down syndrome live birth rate decreased by 70% in 3 years. It was estimated that at least 200 families in Taiwan each year would benefit from this campaign.

Framework for a BC screening campaign in Taiwan

We suggest that the following framework should be established without delay in the fight against BC, the most frequent female cancer in Taiwan:

(1) First line. Physical breast examination should be performed followed by breast ultrasound examination at the time of annual Pap smears. Mammography can be performed every 2-3 years in the radiology department. Whether cases have family history of BC or not should be carefully scrutinized. If a patient has a family history of BC, extra caution should be exercised.

(2) Second line. Breast imaging laboratories should be established in regional hospitals and medical centers and operated by experienced radiologists or breast physicians. When a suspicious breast lesion is found during first-line screening, the patient should be referred to this breast imaging laboratory, where an expert can  use breast ultrasound, mammography, or MRI coupled with aspiration cytology or core biopsy to establish a definite diagnosis.

(3) Third line. Breast surgeons should be available to perform adequate surgery for confirmed BC cases.

(4) Fourth line. High-quality pathological diagnosis, radiotherapy, chemotherapy, and genetic counseling should be provided.

Experience in NTUH

A breast imaging laboratory was established in NTUH in 2003 and has been functioning effectively since then. The laboratory has actively engaged in training for breast ultrasound imaging. Physicians from surgery, obstetrics and gynecology, and family medicine can receive 3-month fellowship training in the laboratory. A 1-week introductory course on breast ultrasound is also available for members in Taiwan Society of Obstetricians and Gynecologists. The breast imaging laboratory at NTUH is a successful model that other hospitals in Taiwan can duplicate. We hope that this type of breast imaging laboratory will become available in an increasing number of hospitals all over Taiwan.

Conclusion

The incidence of female BC in Taiwan increased by 14.69% from 2003 to 2008 and some 8136 women were newly diagnosed with BC in 2008. The incidence of female BC at NTUH increased by 62.02% in 2009 compared with 2004 (Fig. 5). The peak incidence was in the group aged 40-49 years and 11% of cases occurred in the group aged 30-39 years. The percentage of early BC detected annually is pproximately 30%, a figure much lower than that in Western countries.

The following steps are suggested to boost early detection of BC in Taiwan:

(1) The health authority should implement a policy of “Three points examined together” by establishing a workable scheme. Thus, Pap smears and BC detection can be performed at the same site during the same visit.

(2) Active participation of obstetricianegynecologists is absolutely necessary for a successful BC detection campaign.

(3) The Taiwan Society of Obstetricians and Gynecologists and all teaching hospitals should gear up in establishing an educational program in breast medicine for residents and attending physicians to provide adequate care for breast disorders.

(4) Facilities to provide Pap smears and breast examinations simultaneously should be available at as many OB/GYN clinics and hospitals as possible.

(5) Easily accessible breast imaging laboratories should be set up at regional hospitals and medical centers to provide a definite diagnosis for patients with suspicious lesions found in first-line clinics.

(6) The health authority and relevant medical societies should work together to run quality assurance programs to familiarize doctors with various breast examinations.

(7) Active public campaigns should be implemented to raise public awareness of BC detection strategies.

Over the years, obstetricians and gynecologists in Taiwan have used Pap smear screening and screening of maternal serum for Down syndrome to great effect. This has resulted in marked reductions in cervical cancer cases and live births affected by Down syndrome. If a widespread screening program is set up involving first-line clinics and a good breast imaging laboratory, we may soon witness another miracle in BC screening in terms of early detection of (pre) cancerous lesions.