Breast Cancer: Policy Statement by the Health Division

Breast Cancer: Policy Statement by the Health Division

1.0. introduction

The Health Division would like to clarify its policy on female breast cancer and its position and opinion on the breast cancer screening programmes. It is important to emphasise that thorough knowledge of the complex issues around female breast cancer and not just the impact of screening programmes is the most essential element of the whole debate.

2.0. screening programmes
The success of any screening programme depends on :

2.1 the availability of a valid and relatively inexpensive test that is highly sensitive and specific;

1. the possibility of detecting a disease very early on its process and prior to its detection/diagnosis on clinical grounds;
2. the presence of effective treatment for the disease itself; and
3. the organizational framework within which the programme is offered.

3.0. breast cancer screening programmes

1. It is noted that breast cancer screening programmes abroad have moved from a single-view mammogram test interpreted by one radiologist every three years for women aged 50-64 years to a two view mammogram test interpreted by two different radiologists every 18 months to 2 years with some programmes doing this annually for the same age group.

3.2. The mammography test as a screening test gives rise to a number of false positives that is suspicious lumps on mammography that are found to be entirely normal on biopsy. There is also a problem with false negatives and there will be women with negative mammograms who actually turn out to have breast cancer. In order to minimize false results, appropriately trained and accredited radiologists have to be available. Accreditation of radiologists in mammogram interpretation requires viewing in excess of 6000 mammograms annually.

4.0. breast cancer risk factors and primary prevention

4.1. Turning to the disease itself, it must be stated that the causes of breast cancer are not fully understood but a number of risk factors have been identified. Risk factors for breast cancer include: late age at first birth, late age at menopause, a positive family history in first degree relatives (mother and sisters); use of oral contraceptives for prolonged periods at young ages, hormone replacement therapy using oestrogens only; a diet high in fat and protein of animal origin, alcohol consumption over 30g/day and obesity in post-menopausal women.

4.2. At the same time, the following have been suggested as possibly reducing the risk of developing the disease: breast feeding at early ages and for long periods; and a diet high in green vegetables.

1. Various awareness campaigns not strictly related to breast cancer can therefore impinge in the longer term on breast cancer. It is evident that diet and weight control, alcohol control, breast feeding and appropriate utilization of hormone therapy will have beneficial effect in the long-term.

5.1. In 1995 the, Health Division laid out its objective and key targets for control of female breast cancer in Health Vision 2000. The principal objective remains to reduce the level of ill health and mortality caused by female breast cancer.

5.2. The key targets are:

5.2.1. To gain further knowledge about the high incidence of breast cancer in Malta.

5.2.2. By 2005 the mortality rate for breast cancer in the population should be reduced by at least 5%.

5.2.3. To improve the quality of life, emotional and psychological well being of women suffering from breast cancer.

1. The activities identified to achieve such targets are:

5.3.1. Promoting research into the causes of the high incidence of female breast cancer in Malta.

5.3.2. To consolidate the existing mammography service and introduce selective mammography screening as appropriate.

5.3.3. Educational measures should be implemented to ensure that women are aware of the risk factors for breast cancer. A "breast awareness" programme should be mounted to ensure that women are sensitised to the symptoms and signs of breast cancer, and that they are encouraged to seek timely help on noting any breast changes.

5.3.4. General practitioners should be encouraged to carry out an annual clinical breast examination on all women aged 50 to 69 and on women aged 35 to 49 with a family history of pre-menopausal cancer in first degree relatives.

5.3.5. Well Women’s Clinics should provide staff who can teach techniques of self examination, advice and information. The practice of breast self examination should not however be portrayed as being a satisfactory cancer screening technique on its own.

5.3.6. Educating all pregnant women about the benefits of the practice of breast feeding as one of the risk reducing factors.

5.3.7. Facilitating access to self-help groups for both women who have undergone mastectomy and their spouses, palliative support services, counsellors, cosmetic surgeons, and prostheses.

6.0 progress to date

The above activities are at various stages of implementation. The following are some of the key achievements and main constraints identified to date:

6.1. The National Cancer Registry was established in 1992. It is only since then that we have solid data which has been verified and validated. Since 1992 there have been no significant increases in the number of new cases of breast cancer in Malta. Concerning deaths from breast cancer the data reveals that the figures have remained relatively constant. In the coming years more information on survival will become available and this will facilitate the evaluation of current diagnosis and treatment methods and likely effectiveness of screening programmes

6.2. Self-examination programmes, earlier referral for medical advice and more recently mammography, together with accelerated investigation and prompt treatment of suspicious cases have all contributed to a better knowledge of the true size of the problem.

1. Expansion of existing mammography services requires investment in training of an adequate number of radiologists to cover the service requirements not for mammography alone but for the entire Radiology Services. This cannot be done in a situation where we only have 3 consultant radiologists. We have a number of young doctors specializing in radiology and it will take 3-4 years before these can start to offer their services to Maltese patients. The organization of a screening service requires: effective call and recall systems to invite women to attend for screening and detect non-attenders ; and prompt biopsy facilities which means surgeons available to perform biopsies and pathologists to interpret biopsies. When these resources become available, first priority will be given to selective screening of first degree relatives of women who have developed breast cancer, since this is the risk factor which is the most predictive of the likelihood of developing breast cancer. In this way we can achieve a sustainable programme which can be expanded further eventually.

6.4. The Health Promotion Department has addressed several of the primary prevention issues which will impinge in the longer terms on cancer incidence. The efforts to promote healthy eating, to control weight , to encourage breast feeding, and to control alcohol abuse are well known to our local community.

6.5. Our Surgeons are constantly upgrading their techniques and this will lead to better outcomes in surgical interventions. We have all the treatment modalities for those who require chemotherapy and radiotherapy.

6.6. There are plans to extend further counselling services and palliative care and the enhancing of the role of NGO’s and self-help groups in this field is another policy objective.

7.0. conclusion

The Health Division affirms that the breast cancer screening programme debate is only part of the breast cancer problem. Breast Cancer is a disease which must be tackled by addressing the risk factors, by improving the processes of disease identification and by refining the treatment modalities available. It is only in this manner that a sustainable long term impact can be achieved which will lead to the attainment of the stated objective of reducing the level of ill health and mortality caused by female breast cancer.

05.12.98