Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada
Abstract
:1. Introduction
Story 1.In 2019, a 46-year-old finds a lump in her breast and speaks to her family doctor. She is referred for a mammogram and ultrasound, then booked in for a biopsy of an 8 cm lump; within a few weeks, she is diagnosed with Triple Positive de novo stage IV breast cancer. This is after being denied regular mammograms by her family doctor at the age of 40 because the screening program in the province where she resides, Alberta, requires a requisition for the first screen of patients in their 40s and only begins self-referralat the age of 50. This is also after being repeatedly monitored using mammography for one existing lump when she lived in British Columbia in her 30s, and after practitioners had paperwork showing that her Volpara Breast Density Score is D, meaning a decreased sensitivity of mammography to identify cancerous masses and an increased risk of breast cancer. If this woman had not moved from the province of British Columbia to Alberta, she could have self-referred for screening from the age of 40 and possibly learned she had cancer before the Triple Positive breast cancer had spread to her lymph nodes, spine, sternum, and ribs. She would also be aware of her breast density category and the risks associated with this, as they are reported on the patient-facing screening documentation. Therefore, it is unlikely she would have been given a 22% prognosis of living for the next five years. That was three years ago. She has 2 children, aged 5 and 8.
2. Marrying Stories and Science
2.1. The Impact of Outdated and Inconsistent Screening Guidelines
Story 2.In 2020, a woman in Ontario feels a thickening of her breast tissue. She is 47. She thinks it is likely due to premenopausal changes. It develops into a dimple, so she visits her family doctor for an exam. He refers her for a mammogram. She is called back the next day for another mammogram and a biopsy. She has no history of breast cancer in her family and is shocked at the callback. The lumpectomy and sentinel node biopsy reveal stage I grade 3 breast cancer. Radiation treatment and tamoxifen are planned. At her preradiation CT scan, two additional tumours are found in her lungs and pancreas. She has an extensive Whipple procedure (pancreaticoduodenectomy) to remove the tumour in her pancreas, which also removes part of her small intestine, gall bladder, and pancreatic duct. The pathology reveals that the pancreas and lung tumours have metastasized from the breast cancer. Her diagnosis is updated to de novo stage IV breast cancer. It takes six months to recover from her surgery. She stops her career as an intensive care nurse and goes on long-term disability. She also has surgery to remove her ovaries, which pushes her into the menopause. She takes the drugs Letrozole and Ibrance, which cause fatigue and mouth sores. She experiences ongoing digestive issues. She loses contact with many friends. Check-ups show that the cancer has stabilised. The median survival rate for women with metastatic breast cancer is three years. Her diagnosis was two years ago.
2.2. Differences between Provincial and Canadian Task Force Breast Cancer Screening Guidelines Create Confusion for Medical Practitioners and Patients
Story 3.A 50-year-old woman originally from Brazil moves to Canada at the age of 40. She is aware of her breast density, has a history of finding benign cysts in her breasts, and has had regular mammograms, starting at the age of 35, until she moves to Canada. On multiple occasions, she speaks to her family doctor in British Columbia about screening mammography, but is repeatedly discouraged and quoted the Canadian Task Force screening guidelines that recommend mammograms every 2 years from the age of 50, rather than the provincial guidelines in British Columbia, which allow for self-referral at the age of 40. She has had progressively worsening hip pain from the age of 47 and repeatedly visits the family doctor for this reason; she is referred to a physiotherapist and told to practice yoga. Upon a worsening of the symptoms and seeing a different physician, she has an X-ray then CT scans and biopsies, which reveal stage IV breast cancer with two nodules in her right breast, multiple lesions in the pelvic bones and greater destruction to the hip socket, iliac, and ischium bones as well as multiple nodules in her lungs.
2.3. Geographical Inequities in Screening across Jurisdictions Mean Several Women Risk a Late Diagnosis Based on Where They Live
Story 4.A 50-year-old mother of three in Ontario finds a lump in her left breast before she is scheduled for her first mammogram, which is available for women in Ontario from the age of 50. She has previously inquired about mammograms in her 40s due to a family history of breast cancer (maternal and paternal aunts, and a first cousin who was diagnosed premenopausal), but has been informed that she “did not qualify under the rules and, by implication, should not worry”. After discovering the lump, she has a mammogram, which detects a vague architectural distortion. She has an ultrasound that shows three masses and an MRI, which reveals five. The post-surgical pathology reveals that there are actually nine tumours in one breast. Cancer is also found in most of her lymph nodes on the same side. She is diagnosed with stage III breast cancer. She is never informed of her Category D density. She has a radical mastectomy of the left breast, a full nodal dissection on the left side, and chemotherapy. In addition to the scar tissue, irreversible tightness in the chest muscles, hair loss, nausea, and fatigue associated with chemotherapy, her treatment pushes her into the menopause, accelerating the effects of aging, reducing her peak cardio fitness, and increasing her risk of osteoporosis. She is required to take an aromatase inhibitor daily.
2.4. Limited Awareness of Breast Density Risks and Screening Options
Story 5.A 36-year-old woman finds a lump on her right breast. After a mammogram, it is deemed to be benign and disappears over time. She is informed that she has dense breasts, but given no information about what this might mean. She assumes it is positive and related to her healthy and fit physique. Eighteen years later, at fifty-four, she finds another lump in the same breast. She had a clear mammogram six months earlier as part of the biennial screening program in Ontario, but has not been informed of her breast density or any associated risks through either the screening mammogram results letter she received or at any screening appointments or follow-ups. Upon the examination of her lump, her family doctor refers her for a mammogram and ultrasound, followed by a biopsy. She has a lumpectomy and sentinel node biopsy, revealing Triple Negative stage III aggressive grade 3 breast cancer. Her diagnosing physician tells her that the cancer has probably been developing for quite a time, but was likely missed on the previous mammogram because of her heterogeneously dense breasts. She receives chemotherapy, the removal of 17 more lymph nodes, a prophylactic bilateral mastectomy, and 25 rounds of radiation. An aggressive treatment plan is designed to target the late-stage breast cancer, which may have been detected sooner if breast density had been considered and supplemental screening performed.
2.5. Dismissal of Women
Story 6.A 42-year-old woman in Alberta starts experiencing back pain whilst walking. It does not improve. She has an X-ray, which comes back clear, and is referred to a physiotherapist and chiropractor. The pain persists and worsens over the next year to the extent that she has to stop work. During physiotherapy exercises, she hears a popping noise and experiences excruciating pain. She is referred for another X-ray, which shows arthritic changes, but with no explanation as to the cause. She does not think it could be breast cancer as she was dismissed by her family doctor as “too young” when she requested a mammogram. Serendipitously, she reads an article about a woman with metastatic breast cancer with no obvious symptoms apart from back pain. She does a self-exam and finds a lump. In quick succession, she has a mammogram, ultrasound, biopsy, and MRI (privately paid). She learns that the breast cancer has metastasized throughout her bones, liver, and lymph nodes. She is diagnosed with stage IV Invasive Ductal Carcinoma, hormone negative, and Her2-positive cancer. She has surgery to insert rods in both of her femurs, spends six weeks in the hospital, and has radiation targeting her pelvis and femurs as well as six rounds of chemotherapy. She has ongoing targeted therapy every three weeks. She uses a wheelchair and a walker. She is 46. She has three teenage children.
3. Discussion
Story 7.A 41-year-old woman living in Prince Edward Island self-refers for a mammogram, which leads to the detection of stage I Invasive Ductal Carcinoma. It is confirmed by the general practitioner and surgeon that the tumour could not have been identified by a physical examination. She has surgery to remove the tumour and sample the lymph nodes, 21 rounds of radiation, and hormone therapy scheduled for the next 5–10 years. She knows that access to self-referral for screening from the age of 40 in her province allowed her breast cancer to be found early.
Story 8.A 40-year-old woman from British Columbia is encouraged by her family doctor to have a screening mammogram to obtain a “baseline” and understanding of her breast density. Her breasts are identified as dense, and an abnormality is detected. She has a diagnostic mammogram, ultrasound, and then biopsy and is diagnosed with stage I breast cancer 17 days after her initial screening mammogram. She has a lumpectomy, completes 20 rounds of radiation, and receives hormone therapy, which is scheduled for the following 5 years. She is grateful to have been able to self-refer for screening at the age of 40, and that her proactive family doctor recommended her to go.
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Stage | Relative Survival (%) |
---|---|
Stage I | 100 |
Stage II | 93 |
Stage III | 72 |
Stage IV | 22 |
Breast Screening Recommendations: Canadian Task Force on Preventive Health Care | Recommendations: Canadian Society of Breast Imaging and Canadian Association of Radiologists |
---|---|
Screening for women aged 40–49 is not recommended | Women aged 40–49 should screen annually with mammography |
Women aged 50–74 should screen every 2–3 years with mammography | Women aged 50–74 should screen every 1–2 years with mammography |
There are no recommendations for screening women over age 74 | Women over aged 74 should screen every 1–2 years with mammography as long as they are in good health with life expectancy of ~7+ years |
Supplemental screening is not recommended for women with dense breasts | Women with dense breasts can benefit from a supplemental screening |
Risk assessment is not recommended | Risk should be assessed by age 25–30 to determine if early screening is appropriate |
Clinical breast exam is not recommended | Mammography may miss breast cancers and a clinical breast exam is complementary to mammography |
Breast self-exam is not recommended | Breast self-awareness is recommended |
Province/Territory | Can Self-Refer at Age of 40 | Can Self-Refer Annually in their 40s | Need a Requisition from Ages 40–49 |
---|---|---|---|
British Columbia | Yes | ||
Nova Scotia | Yes | Yes | |
Prince Edward Island | Yes | Yes | |
Yukon Territory | Yes | Yes | |
Alberta | 1st screen only | ||
Manitoba | Yes | ||
New Brunswick | Yes | ||
Saskatchewan | Yes | ||
Ontario | Yes | ||
Newfoundland | Yes | ||
Quebec | Yes | ||
North West Territories | 1st screen only | ||
Nunavut (no program) |
Province/Territory | All Women Having a Screening Mammogram Are Mailed Their Breast Density in Results Letter | Only Women in Category D Are Told Their Density | Women in Category D Are Offered Annual Mammograms |
---|---|---|---|
British Columbia | Yes | ||
Nova Scotia | Yes | ||
Prince Edward Island | Yes | Yes | |
Yukon Territory | Yes | Yes | |
Alberta | Yes | ||
Manitoba | Yes | ||
New Brunswick | Yes | ||
Saskatchewan | Yes | Yes | |
Ontario | Yes | Yes | |
Newfoundland | Yes | Yes | |
Quebec | |||
North West Territories | Yes | Yes | |
Nunavut (No program) |
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Dale, J.; Di Tomaso, M.; Gay, V. Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada. Curr. Oncol. 2022, 29, 3540-3551. https://doi.org/10.3390/curroncol29050286
Dale J, Di Tomaso M, Gay V. Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada. Current Oncology. 2022; 29(5):3540-3551. https://doi.org/10.3390/curroncol29050286
Chicago/Turabian StyleDale, Jennie, Michelle Di Tomaso, and Victoria Gay. 2022. "Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada" Current Oncology 29, no. 5: 3540-3551. https://doi.org/10.3390/curroncol29050286