Authors' objectives:

This review was commissioned by the Royal New Zealand College of General Practitioners and was primarily intended to update a previous report undertaken by Drs Pullon and MacLeod in 1996.

Authors' results and conclusions: The literature search identified 1273 articles. After a series of exclusion criteria were applied to the abstracts of the articles located by the search, 232 studies were formally appraised and included in this review in the following four sections: the symptoms of breast cancer, risk factors, diagnostic tests and mammography and breast cancer screening.

Authors' recommendations: Most of the findings in this review were either consistent with those presented in the Pullon and MacLeod (1996) report or were additional new material published since 1996 that were related to the issues presented in the previous report. The findings are as follows: Symptoms of breast cancer: - Among patients with breast cancer, mastalgia is an uncommon finding - The probability of cancer among women with nipple discharge is generally less than 10%, the probability is highest among older women and when the discharge is blood stained - Guidelines have been developed to assist with the investigation and referral of patients presenting with a palpable breast lump or other new breast symptom Risk factors: - A significantly increased risk of breast cancer has been found in association with the following: family history of breast cancer, increasing age, nulliparity, younger age of menarche, increased age at first birth. - There are indications of increased risk under certain conditions for oral contraceptive users - Inconclusive evidence exists for: hormone replacement therapy, diet, BMI, height and alcohol - Inconclusive evidence also exists for the following additional risk factors: abortion, perinatal and postnatal experience, miscellaneous medications, environmental toxins, electromagnetic fields, stress, occupation, smoking, lactation, and breast implants Diagnostic tests: - Mammography is more sensitive than clinical examination for women of all ages - The sensitivity and specificity of FNA varies in relation to where it is conducted, generally the sensitivity of FNA is high and the specificity is more variable - The triple test exceeds the accuracy of any of its component tests (mammography, FNA and clinical examination), when the results are concordant there is a high sensitivity and treatment can be planned, when all three tests are negative breast cancer is unlikely - Core biopsy is a valid alternative to FNA when the lesion is larger than 1cm - Ultrasound is very sensitive in the investigation of breast lesions among younger women (under 35 years) and is recommended as the first radiological investigation for these women - The clinical role of scintimammography, colour doppler and magnetic resonance mammography in the investigation of new breast lesions is still being determined Mammography and breast cancer screening: - There is currently no definite evidence that breast self examination is effective at improving survival - Among women aged 50-65 (and probably 65-75) evidence exists that population based, mammography screening improves survival, there may also be a benefit for younger women under 50 years of age but it appears to be smaller and less certain - GPs have an important role in increasing the uptake of screening. In particular, tailored letters from a GP accompanied with a specific appointment for a mammogram are very effective at increasing the uptake of screening - Variation exists between radiologists in test reporting - Clinical history should not be included with a request for a screening mammogram - Referral to a specialist breast cancer unit may be associated with a more favourable outcome than referral to a general surgical facility

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://nzhta.chmeds.ac.nz/publications.htm

Year Published: 1999

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: New Zealand

Organisation Name: New Zealand Health Technology Assessment

Contact Address: Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, P.O. Box 4345, Christchurch, New Zealand. Tel: +64 3 364 1145; Fax: +64 3 364 1152;

Contact Name: nzhta@chmeds.ac.nz

Contact Email: nzhta@chmeds.ac.nz

Copyright: New Zealand Health Technology Assessment