Day: October 21, 2013

When in the Future Should An Adolescent Be Screened for Breast Cancer?

Patient Presentation
A 16-year-old female came to clinic for her health supervision visit. She had no concerns. Her mother who had recently finished treatment for breast cancer was wondering when her daughter should start screening mammograms. The past medical history was negative. The family history was positive for her mother and maternal grandmother both with BRCA gene negative breast cancer. The pertinent physical exam showed normal vital signs and growth parameters in the 75-90%. Her examination was negative. The diagnosis of a healthy adolescent with a strong family history of breast cancer was made. The pediatrician reviewed breast self-examination techniques with the young woman. She also said that she was not sure about when screening mammograms should be started so she would research the question and contact the family.

Discussion
Breast cancer is the most common cancer in women and is estimated to occur in 12% of women during their lifetimes. Although primary breast cancer is uncommon in children and adolescents it does occur. Most breast masses are benign in children and adolescents, and primary breast cancer is very uncommon. For a review of the differential diagnoses of breast masses see What is the Differential Diagnosis of a Breast Mass?.

In the general population annual screening using mammography is recommended starting at age 40 years. All women should be taught to do breast self-examination.

Learning Point
According to the American College of Radiology, high risk women (which includes those with a BRCA gene mutation, those first degree relatives who are untested for the BRCA gene mutation, women who had chest wall radiation between ages 10-30 years and women with a 20% or greater lifetime risk of breast cancer) should begin having screening mammograms at age 25-30 years, or 10 years before the age the first degree relative was diagnosed with their breast cancer, whichever is later. Women who had radiation should begin at 8 years after therapy but not before age 25. Magnetic resonance imaging is considered a complimentary examination to mammography and is also recommended for these high risk patients as the combination of mammography and MRI has the highest sensitivity for screening. Clinical breast examinations should be done every 6-12 months depending on the patient’s specific risk factors.

Questions for Further Discussion
1. When should children and adolescents who have first degree relatives with other cancers begin screening themselves such as colon cancer?
2. What is the risk of a secondary malignancy after treatment for a primary malignancy?
3. How common is breast cancer in males?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Breast Cancer and Mammography.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Alberta Provincial Breast Tumour Team. Risk reduction and surveillance strategies for individuals at high genetic risk for breast and ovarian cancer. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2011 Apr. 14 p.

Mainiero MB, Lourenco A, Mahoney MC, et. al. Expert Panel on Breast Imaging. ACR Appropriateness Criteria® breast cancer screening. Reston (VA): American College of Radiology (ACR); 2012. 5 p.
Available from the Internet at http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf (cited 9/7/13).

MD Anderson Cancer Center. Breast Cancer Screening: Increased Risk. Available from the Internet at http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-topics/prevention-and-screening/cancer-screening-guidelines/breast-cancer-screening-exams-increased-risk.html (rev. 2013, cited 9/6/13).

Children’s Hospital of Philadelphia. Breast Self-Examination. Available from the Internet at: http://www.chop.edu/healthinfo/breast-self-examination.html (cited 9/5/13)

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital