Early diagnosis of breast cancer. experience in a consultant breast clinic LEO J. MAHONEY,* BA, MD, MS, FRCS[C] BRUCE L. BIRD,t MD, FRCP[CJ; GABRIEL M. COOKE,* MB, B CH, FRCP[C]; DANIEL G. BALL,f B SC, MD, FRCP[C]
Of 2839 women referred to a consultant breast clinic for clinical, mammographic and thermographic examination, 480 underwent biopsy and 126 were found to have cancer. Ten percent of the tumours were occult and were classified as very early biologic disease; they were identified by routine mammography in women whose breasts were clinically normal. Biopsy of solid mass lesions nonsuspicious on mammography identified 200/0 of the cancers; half these lesions, classified as early biologic disease, were discovered by doctors at routine annual clinical breast examination, though the earliest cancers were detected by women who were confident and competent in monthly selfexamination of the breasts. Biopsy of solid mass lesions suspicious on mammography identified 70Gb of the cancers; these were classified as late biologic disease. Skin or nipple dimpling or retraction was evident in two thirds of the patients; their lesions seemed to be later biologically than the lesions of the patients without clinical signs, and 750/o had discovered the lesions themselves accidentally. Sur 2839 femmes dirigees vers une clinique de consultation specialisee dans l'examen du sein, pour evaluation clinique, mammographique et thermographique, 480 ont subi une biopsie, et un cancer a ete d6cele chez 126. Dix pourcent des tumeurs etalent occultes et ont ete classif lees comme pathologies tres precoces; elles ont 6te identifiees par mammographie systematique chez des femmes dont les seins etaient normaux selon lexamen clinique. La biopsie des lesions tumorales non suspectes a Ia mammographie a permis d'identifier
From the departments of general surgery and radiology, St. Michael's Hospital, University of Toronto *Senior surgeon and director, thermographic diagnostic services, St. Michael's Hospital; assistant professor of surgery, University of Toronto tMedical director, department of radiology, St. Michael's Hospital .Staff radiologist, department of radiology, St. Michael's Hospital Reprint requests to: Dr. U. Mahoney, 55 Queen St. E, Ste. 403, Toronto, Ont. M5C 1R5
200/o des cancers; Ia moitie de ces lesions, classifiees comme pathologies precoces, a ete decouverte par les medecins a lexamen clinique annuel des seins, bien que les cancers les plus precoces aient ete deceles par des femmes qui etaient capables de realiser avec confiance sur elles-m.mes un examen mensuel des seins. La biopsie des lesions tumorales suspectes a Ia mammographie a identifie 700/u des cancers; ceux-ci ont ete classifies comme pathologies tardives. Un repli ou une retraction de Ia peau ou du mamelon etait evident chez deux tiers des patientes; leurs lesions semblaient biologiquement plus tardives que les lesions des patientes sans signe clinique, et 750/o avaient decouvert elles-m.mes accidentellement les lesions. It has been estimated that breast cancer will develop in 1 of every 15 American women.' In any given closed population a substantial number of women - perhaps 10 per 10002 have undetected carcinoma of the breast. The only available diagnostic tools that possibly can be used in all women at risk are clinical examination, mammography and thermography. In an attempt to assess the effectiveness of these tools in diagnosing breast cancer earlier, a consultant breast clinic was opened at St. Michael's Hospital, Toronto in July 1972. The experience at the clinic is presented in this paper. Patients Up to January 1976, 2839 women of all ages had been examined at the clinic. All had been referred by their physician because of fear of breast cancer, pain, suspicious clinical findings or high-risk factors - previous breast cancer, a family history of the disease, first term pregnancy after age 30 or nulliparity, or previous breast operation for benign disorder. Many just wanted to make sure that they did not have breast cancer. Diagnostic procedures All patients were examined clinically and thermographically by one of us (L.J.M.). Their mammograms or xeromammograms were interpreted by one of three radiologists experienced in the
technique, and the findings of the three modalities were correlated while the patient waited (approximately 3 hours). If necessary in order to make a decision further examinations were conducted. Of the 480 biopsies performed, cancer was identified in 126. Clinical examination For years clinicians have taught students the importance, when examining a woman with a lump in the breast, of demonstrating very early signs of malignant diseases - namely, the slightest dimpling or retraction of the skin or nipple. Until relatively recently we were unaware that by the time such "very early signs" had become demonstrable the malignant cells that constituted the primary tumour in the breast had been growing slowly for years and the disease was biologically well advanced.34 Unintentionally we also were implying that if such "very early signs" were absent the lesion was probably benign and biopsy was not urgent. This has led to unnecessary delay in the identification of women with early breast cancer. We have dealt with the problem by adhering rigidly to the following guidelines: Clinical indications for biopsy: 1. Any discrete nodule. 2. Nipple discharge, whether bloody or not, localized to one quadrant. 3. Eczema or ulcer of the nipple. A mass lesion in a woman's breast (a discrete lump or nodule) should be considered cancerous until proven otherwise. If, by means of fine-needle aspiration, the lesion is found to be solid, it requires biopsy excision; such lesions include all "typically benign fibroadenomas". Many women have normally "lumpy" breasts. Identifying a mass lesion in such a patient is a great problem. Sometimes a decision can be made only after repeated clinical examination at 6-week or 3-month intervals. Radiography Film mammography and xeromammography are two techniques for producing soft-tissue images of the breast with x-rays. Competent radiologists can use either technique to demonstrate lesions in the breast that are impalpable yet prove to be cancerous when the
CMA JOURNAL/MAY 21, 1977/VOL. 116
1129
area is excised and examined histopathologically; 10% of the cancers we treated were identified this way. Radiation required for breast examination is relatively high compared with that required for other diagnostic radiology examinations. Currently it is too high to recommend annual radiographic examination for all women.6'7 With so little information available about the carcinogenic effect of radiation at low doses, we decided that every woman could safely have a routine radiographic breast examination once every 5 years. In high-risk and older patients it could be repeated more frequently. Currently at our clinic women with previous carcinoma of the breast - those at highest risk - have mammography repeated every 2 years. Thermography Thermography is as innocuous as clinical photography but it is not a precise anatomic indicator of disease comparable to clinical examination or mammography.8 Increased emission of heat from one breast or one area of a breast may stimulate the physician or radiologist to recommend a biopsy when the clinical or radiologic findings are equivocal. Thermography is of value only when complemented by clinical examination or mammography. Of our patients with proven cancer of the breast 35% had normal thermograms. Of the women whose breasts were normal clinically and mammographically, 30% had abnormal thermograms. However, abnormal thermographic findings stimulated early biopsy in 3 of the 126 cancers. Serial annual thermograms may identify changes in pattern that signal the probable development of cancer in the future. Time alone will tell. Results
Clinical staging Of the 114 patients with palpable mass lesions 51 (45%) had clinical stage I, 55 (48%) stage II and 8 (7%) stage III disease by the 1968 tumournodes-metastases staging system of Union internationale contre le cancer.9 Axillary dissection or biopsy was performed in 86 of these patients as part of their surgical treatment, and histopathologic examination showed the lymph nodes to be affected in 34. In 28 patients with palpable mass lesions and 10 of the 12 with occult lesions partial mastectomies were performed without axillary dissection or biopsy. Consequently we assessed how long the cancer had been present in each patient from the size of the primary tumour since there is good evidence of
a correlation between tumour size and
survival.10'1' Grouping by diagnostic findings The 126 patients with cancer were divided readily into four groups according to the diagnostic findings that indicated a biopsy should be performed; (a) those with a suspicious mammogram alone, (b) those with a solid mass lesion alone, (c) those with a solid mass lesion and a suspicious mammogram and (d) those with a solid mass lesion, a suspicious mammogram and a so-called very early sign of cancer (skin or nipple dimpling or retraction). Classification by biologic stage With the size of the primary tumour as the criterion, each group was classified as to whether they had mainly very early, early or late biologic disease. Of the 126 patients 19 with noninvasive cancer (15, intraductal and 4, lobular carcinoma in situ) were classified as having very early or early disease. Very early biologic disease: Fortyeight women with clinically normal breasts had routine mammograms or xeromammograms considered to be suspicious of cancer. In all 48 the suspicious area was excised and the specimen immediately radiographed for control. Histopathologic examination showed cancer in 12 specimens (25%). Half of these cancers were noninvasive (intraductal or lobular carcinoma in situ) and all but one of the invasive cancers were less than 2 cm in diameter. Of the 12 patients with cancer 2 were under 45 years of age but 9 were at high risk. We have no information as to how long these lesions can be present before they become clinically palpable. The prognosis in this group was excellent.'2 Early biologic disease: Twentynine patients had a solid mass lesion with no skin or nipple retraction and no mammographic suspicion of malignant disease; * 50% of these lesions were unsuspected by the patient and discovered on routine clinical examination by a doctor. In only eight (28%) was the diameter of the lesion more than 2 cm. Of the 29 patients 18 were under 45 years of age. Six of the lesions developed within 1 year of a trimodal (clinical, mammographic and thermographic) examination in our clinic that yielded completely normal results. These lesions were termed interval cancer. Two de8Prior to the writing of this paper 22 of the 29 mammograms were available for review by the radiologists. In retrospect four that had been considered normal at the time of the original examination had, in fact, subtle changes suggestive of malignant disease.
1130 CMA JOURNAL/MAY 21, 19771 VOL. 116
veloped within a few weeks or months of the trimodal examination and were discovered by the women during selfexamination. The remaining four were discovered at an intervening routine clinical examination by a doctor. None of the patients had skin or nipple retraction and in no instance did repeat mammography or thermography reveal any suspicion of malignant disease. Four of the cancers were noninvasive; both the invasive cancers were less than 2 cm in diameter. All six patients were at high risk. The prognosis in the whole group was good.'3 Late biologic disease: Twenty-eight patients had a solid mass lesion with no skin or nipple retraction but a mainmogram suggestive of malignant disease. The diameter of 15 (54%) of the lesions was more than 2 cm. Two thirds of the lesions had been present long enough for the patient to become aware of them. The relnainder were discovered during routine clinical examination by a doctor. Of the 28 patients 7 were under 45 years of age. Fifty-seven women had a mass lesion in the breast associated with some skin or nipple retraction (a so-called very early sign of cancer). All but one of the lesions were considered malignant from study of the mammogram or xeromammogram. Forty-one (72%) of the lesions were greater than 2 cm in diameter and 75% of these had been present long enough for the patient to become aware of them accidentally. Only 25% were discovered by doctors during routine clinical examination. Of the 57 women 3 were under 45 years of age. Discussion
At present, early breast cancer is being identified in one of two distinct ways: (a) routine mammography in women with clinically normal breasts and (b) routine clinical breast examination in women with normal or nonsuspicious mammograms. The methods cannot be substituted for each other. With our present facilities it is feasible for every woman to have a clinical examination annually by her doctor (family physician, gynecologist or other) and routine mammography every 5 years. The frequency of these examinations should be increased in women at high risk. Some of the earliest breast cancers are being discovered by women practising competent monthly self-examination of the breasts, but only 10% of the women who were referred to our clinic were doing so. More disturbing is the fact that 70% had tried selfexamination once or twice and stopped, usually because of confusion and frus-
tration over what they were feeling in their breasts. We recommend that women be advised not to start selfexamination until they have been examined by their doctor and reassured their breasts are normal. They should then examine their breasts and learn what normal for them feels like. At their monthly examination they ascertain whether there has been any change from normal. At best, 20% of women will find breast self-examination impossible for one reason or another and will have to rely on an annual clinical examination for early diagnosis. In women with solid mass lesions a mammogram suspicious of cancer suggests later biologic disease than in those in whom the mammogram is normal. Women with solid mass lesions, abnormal mammograms and skin or nipple dimpling or retraction (the socalled very early signs of cancer) probably have late biologic disease. Our group of 57 was typical of the women in our communities with undiscovered late biologic lesions. All could have been identified earlier by clinical examination or routine mammography. The
simplest and surest method would have been routine clinical examination by a doctor. Recommendations 1. Any solid mass lesion in a woman's breast should be considered cancerous until proven otherwise by biopsy excision. 2. All women should have a clinical examination of the breasts. When assured their breasts are normal - and not before - they should immediately start regular monthly self-examination. The clinical breast examination should be repeated annually. 3. All women should have one routine mammographic or xeromammographic examination. It should be repeated every 5 years in women 35 years of age or older. 4. In women at high risk the frequency of these routine examinations should be increased. 5. If thermography is available it should be performed at the same time as either clinical examination or mammography, to be of any help. Sincerest appreciation is expressed to Miss
Morag M. Simpson for her patient help in all phases of preparation of this article. References 1. SEIDMAN H: Cancer of the Breast: Statistical and Epidenijological Data, New York, American Cancer Society, 1972, p 3 2. STRAX P: New techniques in mass screening for breast cancer. Cancer 28: 1563, 1971 3. DELARUE NC: Clinical studies in the realm of tumor biology. Ann R Coil Physicians Surg Can 5: 179, 1972 4. CLARK RM: An approach to the detection and management of early breast cancer Can
Med Assoc J 108: 599, 1973
5. SKIPPER HL: Kinetics of mammary tumor cell growth and implications for therapy. Cancer 28: 1479. 1971 6. DELARUE NC, GALE G, RONALD A: Multiple fluoroscopy of the chest: carcinogenicity for the female breast and implications for breast cancer screening programs. Can Med Assoc J 112: 1405, 1975 7. LfGER J-L, NAIMARK AP, B.IQUE RA, et al: Report of the "ad hoc" committee on
mammography. J Can A ssoc Radiol 25: 3, 1974
8. LAWSON R: Implications of surface temperatures in the diagnosis of breast cancer. Can
Med Assoc J 75: 309, 1956 Classification of Malignant Twnours, Geneva,
9. Union internationale contre le cancer: TNM 1968 10. ADAIR F, BERG J, JOUBERT L, et al: Longterm followup of breast cancer patients: the 30-year report. Cancer 33: 1145, 1974 11. SAY CC, DONEGAN WL: Invasive carcinoma of the breast: prognostic significance of tumor size and involved axillary lymph nodes. Cancer 34: 468, 1974 12. WANEBO JH, Huvos AG, URBAN JA: Treatment of minimal breast cancer. Cancer 33: 349, 1974 13. STRAX P: Results of mass screening for breast cancer in 50,000 examinations Cancer 37:
30, 1976
Breast cancer in northern Alberta: pilot study in computerized registration PATRICIA E. BURNS,* MB, CH B, DMRT; JEREMY KREDENTSER,t BA; MICHAEL GRACE4 PH D, P ENG; JOHN HANSON,§ M SC
Analysis of data from 643 breast cancer patients seen between 1971 and 1973 in northern Alberta was undertaken as a preliminary study leading towards a comprehensive breast registry. Age at first treatment and menopausal status were found to be related significantly to the clinical stage of the disease. Other data reported included age at menarche, lymph node involvement and methods of primary treatment. A decline in use of the radical mastectomy was noted. The comprehensive breast registry, which will be used to identify high-risk groups, assess treatment modalities, test hypotheses and generate ideas, has a high probability of success because of compulsory registration of new cases of breast cancer in Alberta and collection of data by the same four individuals. *.j.j.y radiotherapist, Dr. W.W. Cross Cancer Institute, Edmonton and assistant professor of radiology, University of Alberta tSummer research student .Director, research and development, Provincial Cancer Hospitals Board and associate professor, faculty of medicine, University of Alberta §Statistical analyst, department of research and development, Provincial Cancer Hospitals Board, Dr. W.W. Cross Cancer Institute Reprint requests to: Dr. Michael Grace, Director, Department of research and development, Provincial Cancer Hospitals Board 11560 University Ave., Edmonton, Alta. ..6G 1ZZ
the world show remarkable extremes, Comme etude pr6liminaire a Ia mise ranging from 12.4 per 100 000 in en place d'un registre complet des maladies du sein on a entrepris l'analyse Japan to 62.3 per 100 000 in Connecticut.1 In the United States the incides donnees recuelllies chez 643 patientes souffrant de cancer du dence is increasing and mortality rates are declining slightly.2 However, stable sein denombr6es dans le nord de l'Alberta entre 1971 et 1973. On a incidence rates have also been retrouve que l'ige au moment du premier ported.3 Data collected from the protraitement et le stade de Ia m6nopause vincial cancer registry confirm increaspresentalent une association ing incidence rates in Alberta; the significative avec le stade de Ia maladie. crude and age-adjusted incidence of Les autres donnees enregistrees breast carcinoma in women in northern comprennent l'ige a Ia menarche, Alberta from 1953 to 1974 are illusl'atteinte des ganglions lymphatiques trated in Fig. 1. et les methodes de traitement primaire. Carcinoma of the breast accounts for On a constate une baisse du recours 350 a Ia mastectomie radicale. crud. N' Le registre des maladies du sein, 300 qui servira a identifier les groupes a risque eleve, a evaluer les modes de 025 traitement, a tester certaines hypotheses 8 *. .6 :0 et a susciter de nouvelles idees, a ...200 o ..**0** de fortes chances de succes puisque z l'enregistrement des nouveaux cas ISO A p. E de cancer du sein est obligatoire en 100 1953 Alberta Rpulaflan Alberta, et que Ia collecte des donnees est realisee par les quatre mimes *u*5I.uuEI5I3I!5'u.' I Sc personnes. 1953
Figures available on the incidence of breast cancer in women throughout
1958 1963 1968 Year at Diagnasis
1974
FIG. 1-Crude and age-adjusted incidence of breast carcinoma in women in northern Alberta, 1953 to 1974.
CMA JOURNAL/MAY 21, 1977/VOL. 116 1131
Of 2839 women referred to a consultant breast clinic for clinical, mammographic and thermographic examination, 480 underwent biopsy and 126 were found to have cancer. Ten percent of the tumours were occult and were classified as very early biologic disease; they were identified by routine mammography in women whose breasts were clinically normal. Biopsy of solid mass lesions nonsuspicious on mammography identified 200/0 of the cancers; half these lesions, classified as early biologic disease, were discovered by doctors at routine annual clinical breast examination, though the earliest cancers were detected by women who were confident and competent in monthly selfexamination of the breasts. Biopsy of solid mass lesions suspicious on mammography identified 70Gb of the cancers; these were classified as late biologic disease. Skin or nipple dimpling or retraction was evident in two thirds of the patients; their lesions seemed to be later biologically than the lesions of the patients without clinical signs, and 750/o had discovered the lesions themselves accidentally. Sur 2839 femmes dirigees vers une clinique de consultation specialisee dans l'examen du sein, pour evaluation clinique, mammographique et thermographique, 480 ont subi une biopsie, et un cancer a ete d6cele chez 126. Dix pourcent des tumeurs etalent occultes et ont ete classif lees comme pathologies tres precoces; elles ont 6te identifiees par mammographie systematique chez des femmes dont les seins etaient normaux selon lexamen clinique. La biopsie des lesions tumorales non suspectes a Ia mammographie a permis d'identifier
From the departments of general surgery and radiology, St. Michael's Hospital, University of Toronto *Senior surgeon and director, thermographic diagnostic services, St. Michael's Hospital; assistant professor of surgery, University of Toronto tMedical director, department of radiology, St. Michael's Hospital .Staff radiologist, department of radiology, St. Michael's Hospital Reprint requests to: Dr. U. Mahoney, 55 Queen St. E, Ste. 403, Toronto, Ont. M5C 1R5
200/o des cancers; Ia moitie de ces lesions, classifiees comme pathologies precoces, a ete decouverte par les medecins a lexamen clinique annuel des seins, bien que les cancers les plus precoces aient ete deceles par des femmes qui etaient capables de realiser avec confiance sur elles-m.mes un examen mensuel des seins. La biopsie des lesions tumorales suspectes a Ia mammographie a identifie 700/u des cancers; ceux-ci ont ete classifies comme pathologies tardives. Un repli ou une retraction de Ia peau ou du mamelon etait evident chez deux tiers des patientes; leurs lesions semblaient biologiquement plus tardives que les lesions des patientes sans signe clinique, et 750/o avaient decouvert elles-m.mes accidentellement les lesions. It has been estimated that breast cancer will develop in 1 of every 15 American women.' In any given closed population a substantial number of women - perhaps 10 per 10002 have undetected carcinoma of the breast. The only available diagnostic tools that possibly can be used in all women at risk are clinical examination, mammography and thermography. In an attempt to assess the effectiveness of these tools in diagnosing breast cancer earlier, a consultant breast clinic was opened at St. Michael's Hospital, Toronto in July 1972. The experience at the clinic is presented in this paper. Patients Up to January 1976, 2839 women of all ages had been examined at the clinic. All had been referred by their physician because of fear of breast cancer, pain, suspicious clinical findings or high-risk factors - previous breast cancer, a family history of the disease, first term pregnancy after age 30 or nulliparity, or previous breast operation for benign disorder. Many just wanted to make sure that they did not have breast cancer. Diagnostic procedures All patients were examined clinically and thermographically by one of us (L.J.M.). Their mammograms or xeromammograms were interpreted by one of three radiologists experienced in the
technique, and the findings of the three modalities were correlated while the patient waited (approximately 3 hours). If necessary in order to make a decision further examinations were conducted. Of the 480 biopsies performed, cancer was identified in 126. Clinical examination For years clinicians have taught students the importance, when examining a woman with a lump in the breast, of demonstrating very early signs of malignant diseases - namely, the slightest dimpling or retraction of the skin or nipple. Until relatively recently we were unaware that by the time such "very early signs" had become demonstrable the malignant cells that constituted the primary tumour in the breast had been growing slowly for years and the disease was biologically well advanced.34 Unintentionally we also were implying that if such "very early signs" were absent the lesion was probably benign and biopsy was not urgent. This has led to unnecessary delay in the identification of women with early breast cancer. We have dealt with the problem by adhering rigidly to the following guidelines: Clinical indications for biopsy: 1. Any discrete nodule. 2. Nipple discharge, whether bloody or not, localized to one quadrant. 3. Eczema or ulcer of the nipple. A mass lesion in a woman's breast (a discrete lump or nodule) should be considered cancerous until proven otherwise. If, by means of fine-needle aspiration, the lesion is found to be solid, it requires biopsy excision; such lesions include all "typically benign fibroadenomas". Many women have normally "lumpy" breasts. Identifying a mass lesion in such a patient is a great problem. Sometimes a decision can be made only after repeated clinical examination at 6-week or 3-month intervals. Radiography Film mammography and xeromammography are two techniques for producing soft-tissue images of the breast with x-rays. Competent radiologists can use either technique to demonstrate lesions in the breast that are impalpable yet prove to be cancerous when the
CMA JOURNAL/MAY 21, 1977/VOL. 116
1129
area is excised and examined histopathologically; 10% of the cancers we treated were identified this way. Radiation required for breast examination is relatively high compared with that required for other diagnostic radiology examinations. Currently it is too high to recommend annual radiographic examination for all women.6'7 With so little information available about the carcinogenic effect of radiation at low doses, we decided that every woman could safely have a routine radiographic breast examination once every 5 years. In high-risk and older patients it could be repeated more frequently. Currently at our clinic women with previous carcinoma of the breast - those at highest risk - have mammography repeated every 2 years. Thermography Thermography is as innocuous as clinical photography but it is not a precise anatomic indicator of disease comparable to clinical examination or mammography.8 Increased emission of heat from one breast or one area of a breast may stimulate the physician or radiologist to recommend a biopsy when the clinical or radiologic findings are equivocal. Thermography is of value only when complemented by clinical examination or mammography. Of our patients with proven cancer of the breast 35% had normal thermograms. Of the women whose breasts were normal clinically and mammographically, 30% had abnormal thermograms. However, abnormal thermographic findings stimulated early biopsy in 3 of the 126 cancers. Serial annual thermograms may identify changes in pattern that signal the probable development of cancer in the future. Time alone will tell. Results
Clinical staging Of the 114 patients with palpable mass lesions 51 (45%) had clinical stage I, 55 (48%) stage II and 8 (7%) stage III disease by the 1968 tumournodes-metastases staging system of Union internationale contre le cancer.9 Axillary dissection or biopsy was performed in 86 of these patients as part of their surgical treatment, and histopathologic examination showed the lymph nodes to be affected in 34. In 28 patients with palpable mass lesions and 10 of the 12 with occult lesions partial mastectomies were performed without axillary dissection or biopsy. Consequently we assessed how long the cancer had been present in each patient from the size of the primary tumour since there is good evidence of
a correlation between tumour size and
survival.10'1' Grouping by diagnostic findings The 126 patients with cancer were divided readily into four groups according to the diagnostic findings that indicated a biopsy should be performed; (a) those with a suspicious mammogram alone, (b) those with a solid mass lesion alone, (c) those with a solid mass lesion and a suspicious mammogram and (d) those with a solid mass lesion, a suspicious mammogram and a so-called very early sign of cancer (skin or nipple dimpling or retraction). Classification by biologic stage With the size of the primary tumour as the criterion, each group was classified as to whether they had mainly very early, early or late biologic disease. Of the 126 patients 19 with noninvasive cancer (15, intraductal and 4, lobular carcinoma in situ) were classified as having very early or early disease. Very early biologic disease: Fortyeight women with clinically normal breasts had routine mammograms or xeromammograms considered to be suspicious of cancer. In all 48 the suspicious area was excised and the specimen immediately radiographed for control. Histopathologic examination showed cancer in 12 specimens (25%). Half of these cancers were noninvasive (intraductal or lobular carcinoma in situ) and all but one of the invasive cancers were less than 2 cm in diameter. Of the 12 patients with cancer 2 were under 45 years of age but 9 were at high risk. We have no information as to how long these lesions can be present before they become clinically palpable. The prognosis in this group was excellent.'2 Early biologic disease: Twentynine patients had a solid mass lesion with no skin or nipple retraction and no mammographic suspicion of malignant disease; * 50% of these lesions were unsuspected by the patient and discovered on routine clinical examination by a doctor. In only eight (28%) was the diameter of the lesion more than 2 cm. Of the 29 patients 18 were under 45 years of age. Six of the lesions developed within 1 year of a trimodal (clinical, mammographic and thermographic) examination in our clinic that yielded completely normal results. These lesions were termed interval cancer. Two de8Prior to the writing of this paper 22 of the 29 mammograms were available for review by the radiologists. In retrospect four that had been considered normal at the time of the original examination had, in fact, subtle changes suggestive of malignant disease.
1130 CMA JOURNAL/MAY 21, 19771 VOL. 116
veloped within a few weeks or months of the trimodal examination and were discovered by the women during selfexamination. The remaining four were discovered at an intervening routine clinical examination by a doctor. None of the patients had skin or nipple retraction and in no instance did repeat mammography or thermography reveal any suspicion of malignant disease. Four of the cancers were noninvasive; both the invasive cancers were less than 2 cm in diameter. All six patients were at high risk. The prognosis in the whole group was good.'3 Late biologic disease: Twenty-eight patients had a solid mass lesion with no skin or nipple retraction but a mainmogram suggestive of malignant disease. The diameter of 15 (54%) of the lesions was more than 2 cm. Two thirds of the lesions had been present long enough for the patient to become aware of them. The relnainder were discovered during routine clinical examination by a doctor. Of the 28 patients 7 were under 45 years of age. Fifty-seven women had a mass lesion in the breast associated with some skin or nipple retraction (a so-called very early sign of cancer). All but one of the lesions were considered malignant from study of the mammogram or xeromammogram. Forty-one (72%) of the lesions were greater than 2 cm in diameter and 75% of these had been present long enough for the patient to become aware of them accidentally. Only 25% were discovered by doctors during routine clinical examination. Of the 57 women 3 were under 45 years of age. Discussion
At present, early breast cancer is being identified in one of two distinct ways: (a) routine mammography in women with clinically normal breasts and (b) routine clinical breast examination in women with normal or nonsuspicious mammograms. The methods cannot be substituted for each other. With our present facilities it is feasible for every woman to have a clinical examination annually by her doctor (family physician, gynecologist or other) and routine mammography every 5 years. The frequency of these examinations should be increased in women at high risk. Some of the earliest breast cancers are being discovered by women practising competent monthly self-examination of the breasts, but only 10% of the women who were referred to our clinic were doing so. More disturbing is the fact that 70% had tried selfexamination once or twice and stopped, usually because of confusion and frus-
tration over what they were feeling in their breasts. We recommend that women be advised not to start selfexamination until they have been examined by their doctor and reassured their breasts are normal. They should then examine their breasts and learn what normal for them feels like. At their monthly examination they ascertain whether there has been any change from normal. At best, 20% of women will find breast self-examination impossible for one reason or another and will have to rely on an annual clinical examination for early diagnosis. In women with solid mass lesions a mammogram suspicious of cancer suggests later biologic disease than in those in whom the mammogram is normal. Women with solid mass lesions, abnormal mammograms and skin or nipple dimpling or retraction (the socalled very early signs of cancer) probably have late biologic disease. Our group of 57 was typical of the women in our communities with undiscovered late biologic lesions. All could have been identified earlier by clinical examination or routine mammography. The
simplest and surest method would have been routine clinical examination by a doctor. Recommendations 1. Any solid mass lesion in a woman's breast should be considered cancerous until proven otherwise by biopsy excision. 2. All women should have a clinical examination of the breasts. When assured their breasts are normal - and not before - they should immediately start regular monthly self-examination. The clinical breast examination should be repeated annually. 3. All women should have one routine mammographic or xeromammographic examination. It should be repeated every 5 years in women 35 years of age or older. 4. In women at high risk the frequency of these routine examinations should be increased. 5. If thermography is available it should be performed at the same time as either clinical examination or mammography, to be of any help. Sincerest appreciation is expressed to Miss
Morag M. Simpson for her patient help in all phases of preparation of this article. References 1. SEIDMAN H: Cancer of the Breast: Statistical and Epidenijological Data, New York, American Cancer Society, 1972, p 3 2. STRAX P: New techniques in mass screening for breast cancer. Cancer 28: 1563, 1971 3. DELARUE NC: Clinical studies in the realm of tumor biology. Ann R Coil Physicians Surg Can 5: 179, 1972 4. CLARK RM: An approach to the detection and management of early breast cancer Can
Med Assoc J 108: 599, 1973
5. SKIPPER HL: Kinetics of mammary tumor cell growth and implications for therapy. Cancer 28: 1479. 1971 6. DELARUE NC, GALE G, RONALD A: Multiple fluoroscopy of the chest: carcinogenicity for the female breast and implications for breast cancer screening programs. Can Med Assoc J 112: 1405, 1975 7. LfGER J-L, NAIMARK AP, B.IQUE RA, et al: Report of the "ad hoc" committee on
mammography. J Can A ssoc Radiol 25: 3, 1974
8. LAWSON R: Implications of surface temperatures in the diagnosis of breast cancer. Can
Med Assoc J 75: 309, 1956 Classification of Malignant Twnours, Geneva,
9. Union internationale contre le cancer: TNM 1968 10. ADAIR F, BERG J, JOUBERT L, et al: Longterm followup of breast cancer patients: the 30-year report. Cancer 33: 1145, 1974 11. SAY CC, DONEGAN WL: Invasive carcinoma of the breast: prognostic significance of tumor size and involved axillary lymph nodes. Cancer 34: 468, 1974 12. WANEBO JH, Huvos AG, URBAN JA: Treatment of minimal breast cancer. Cancer 33: 349, 1974 13. STRAX P: Results of mass screening for breast cancer in 50,000 examinations Cancer 37:
30, 1976
Breast cancer in northern Alberta: pilot study in computerized registration PATRICIA E. BURNS,* MB, CH B, DMRT; JEREMY KREDENTSER,t BA; MICHAEL GRACE4 PH D, P ENG; JOHN HANSON,§ M SC
Analysis of data from 643 breast cancer patients seen between 1971 and 1973 in northern Alberta was undertaken as a preliminary study leading towards a comprehensive breast registry. Age at first treatment and menopausal status were found to be related significantly to the clinical stage of the disease. Other data reported included age at menarche, lymph node involvement and methods of primary treatment. A decline in use of the radical mastectomy was noted. The comprehensive breast registry, which will be used to identify high-risk groups, assess treatment modalities, test hypotheses and generate ideas, has a high probability of success because of compulsory registration of new cases of breast cancer in Alberta and collection of data by the same four individuals. *.j.j.y radiotherapist, Dr. W.W. Cross Cancer Institute, Edmonton and assistant professor of radiology, University of Alberta tSummer research student .Director, research and development, Provincial Cancer Hospitals Board and associate professor, faculty of medicine, University of Alberta §Statistical analyst, department of research and development, Provincial Cancer Hospitals Board, Dr. W.W. Cross Cancer Institute Reprint requests to: Dr. Michael Grace, Director, Department of research and development, Provincial Cancer Hospitals Board 11560 University Ave., Edmonton, Alta. ..6G 1ZZ
the world show remarkable extremes, Comme etude pr6liminaire a Ia mise ranging from 12.4 per 100 000 in en place d'un registre complet des maladies du sein on a entrepris l'analyse Japan to 62.3 per 100 000 in Connecticut.1 In the United States the incides donnees recuelllies chez 643 patientes souffrant de cancer du dence is increasing and mortality rates are declining slightly.2 However, stable sein denombr6es dans le nord de l'Alberta entre 1971 et 1973. On a incidence rates have also been retrouve que l'ige au moment du premier ported.3 Data collected from the protraitement et le stade de Ia m6nopause vincial cancer registry confirm increaspresentalent une association ing incidence rates in Alberta; the significative avec le stade de Ia maladie. crude and age-adjusted incidence of Les autres donnees enregistrees breast carcinoma in women in northern comprennent l'ige a Ia menarche, Alberta from 1953 to 1974 are illusl'atteinte des ganglions lymphatiques trated in Fig. 1. et les methodes de traitement primaire. Carcinoma of the breast accounts for On a constate une baisse du recours 350 a Ia mastectomie radicale. crud. N' Le registre des maladies du sein, 300 qui servira a identifier les groupes a risque eleve, a evaluer les modes de 025 traitement, a tester certaines hypotheses 8 *. .6 :0 et a susciter de nouvelles idees, a ...200 o ..**0** de fortes chances de succes puisque z l'enregistrement des nouveaux cas ISO A p. E de cancer du sein est obligatoire en 100 1953 Alberta Rpulaflan Alberta, et que Ia collecte des donnees est realisee par les quatre mimes *u*5I.uuEI5I3I!5'u.' I Sc personnes. 1953
Figures available on the incidence of breast cancer in women throughout
1958 1963 1968 Year at Diagnasis
1974
FIG. 1-Crude and age-adjusted incidence of breast carcinoma in women in northern Alberta, 1953 to 1974.
CMA JOURNAL/MAY 21, 1977/VOL. 116 1131
