Recomendaciones de tamizaje para cáncer de mama / Screening recommendations for breast cancer

El cáncer de mama no es una enfermedad transmisible ni infecciosa. A diferencia de algunos tipos de cáncer que tienen causas relacionadas con infecciones, como la infección por el virus del papiloma humano (VPH) y el cáncer de cuello uterino, no se conocen infecciones virales o bacterianas relacionadas con el desarrollo del cáncer de mama. Aproximadamente la mitad de los cánceres de mama se desarrollan en mujeres que no tienen un factor de riesgo de cáncer de mama identificable aparte del sexo (mujeres) y la edad (mayores de 40 años). Ciertos factores aumentan el riesgo de cáncer de mama, incluidos el aumento de la edad, la obesidad, el consumo nocivo de alcohol, los antecedentes familiares de cáncer de mama, los antecedentes de exposición a la radiación, los antecedentes reproductivos (como la edad en que comenzaron los períodos menstruales y la edad del primer embarazo), el consumo de tabaco y terapia hormonal posmenopáusica. Las pruebas recomendadas como tamizaje del cáncer de mama deben individualizarse según las siguientes características encontradas en cada paciente: edad, presencia o ausencia de factores de riesgo y densidad mamaria

Breast cancer is not a communicable or infectious disease. Unlike some cancers that have infection-related causes, such as human papillomavirus (HPV) infection and cervical cancer, there are no known viral or bacterial infections associated with the development of breast cancer. About half of breast cancers develop in women who do not have an identifiable risk factor for breast cancer other than gender (female) and age (over 40). Certain factors increase the risk of breast cancer, including increasing age, obesity, harmful use of alcohol, family history of breast cancer, history of radiation exposure, reproductive history (such as age at menstrual periods began and age at first pregnancy), tobacco use, and postmenopausal hormone therapy. The tests recommended for breast cancer screening must be individualized according to the following characteristics found in each patient: age, presence or absence of risk factors, and breast density.

Información y densidad mamaria, un biomarcador personal de cáncer de mama / Information and breast density, a personal biomarker of breast cancer

La evaluación de la densidad mamaria (DM) es un componente importante del informe de mamografía de detección y transmite información a los médicos remitentes sobre la sensibilidad mamográfica y el riesgo relativo de desarrollar cáncer de mama. La densidad mamaria se refiere a la cantidad de tejido fibroglandular en relación con el tejido adiposo. Entendiendo el tema y conociendo las categorías de densidad, se puede, potencialmente, salvar vidas. Mi interés sobre este tópico cobró personalidad al conocer a Nancy M. Cappello, Ph.D., quién podría ser llamada la fundadora del movimiento de educación sobre la densidad mamaria en los Estados Unidos. Cappello, una sobreviviente de cáncer de mama, falleció el 15 de noviembre de 2018 a causa de un síndrome mielodispástico secundario (MDS), un cáncer de médula ósea que fue una complicación de sus agresivos tratamientos anteriores contra el cáncer de mama avanzado al momento del diagnóstico.

Prevalência de tejido mamario denso en una población de Bucaramanga, Colombia / Prevalence of breast dense in a population in Bucaramanga, Colombia

Resumen Objetivo: Establecer la prevalencia de mujeres mayores de 50 años con mamas densas estudiadas por mamografía en el área de Bucaramanga. Métodos: Se realizó un estudio descriptivo retrospectivo durante el periodo comprendido entre enero de 2014 y agosto de 2015, en el que se revisaron 10.110 mamografías de pacientes mayores de 50 años. Posteriormente, se hizo una revisión de la literatura en las principales bases de datos. Resultados: De las 10.110 mamografías realizadas, 4.448 fueron encontradas como positivas para mama densa. De estas, el 39,69% correspondió a tejido mamario heterogéneamente denso y el 4,29%, a tejido mamario extremadamente denso, para un total de 43,9% de los casos estudiados. Conclusión: La densidad mamaria es un factor de riesgo independiente de cáncer de mama, considerado de mediana importancia frente a otros factores. A medida que incrementa la densidad mamaria, se genera la superposición del tejido mamario radio-opaco que puede ocultar y llegar a retardar el diagnóstico de un cáncer subyacente. Dada la alta prevalencia de tejido mamario denso encontrado en la población estudiada, se sugiere complementar el tamizaje con otros métodos de imágenes.

Abstract Objective: To establish the prevalence of dense breast tissue in a group of women aged over 50 years, who were studied with mammography in the city of Bucaramanga (Colombia). Methods: A retrospective descriptive study was conducted from January 2014 to August 2015; 10.110 mammograms of patients aged over 50 years were reviewed. Subsequently, a review of the literature in the main databases was made. Results: From 10.110 mammograms that were performed, 4.448 were found to be positive for dense breast tissue. 39,69% had heterogeneously dense breast tissue, and 4,29% extremely dense breast tissue, for a total result of 43,9% patients with positive dense breast tissue. Conclusion: Breast density is an independent risk factor for breast cancer, being of medium importance compared with other factors. As the breast density increases, the overlap of the radiopaque breast tissue that can hide and delay the diagnosis of an underlying cancer is generated. The high prevalence of dense breast tissue that we found in this population suggests the need of complementing screening with other imaging methods.

Cambios mamográficos en pacientes diabéticas tipo II / Mamographic changes in type II diabetic patients

La diabetes tipo 2 es un trastorno metabólico, caracterizado por resistencia y producción insuficiente de insulina cuyo resultado es la hiperglucemia, la que es causante de complicaciones que se pueden clasificar en microvasculares y macrovasculares, ademas de cambios de etiología mixta, como los cambios inflamatorios del tejido mamario, que aumenta el riesgo de cáncer de mama. Específicamente estos factores se encuentran vinculados a cambios en la densidad mamaria a causa de la proliferación, apoptosis y diferenciación del tejido mamario, este último asociado con paridad, menopausia, índice de masa corporal, e hipoglicemiantes. Al momento, pocos son los estudios que han evaluado la asociación del desarrollo de cáncer de mama en pacientes diabéticas, a nivel mundial sobresalen estudios Daneses, que ha encontrado asociación entre la diabetes con cambios en la densidad mamaria, lamentablemente en Latinoamérica, no se han encontrado estudios similares y es aquí donde el presente estudio toma importancia, pues su impacto a la largo plazo nos ayudará a comprender mejor esta relación con en el desarrollo de cáncer, para de esta manera buscar medidas preventivas. Metodología: Se realizó un estudio observacional, donde se incluyó 115 pacientes diagnosticadas de diabéticas tipo II, que acudieron a la consulta externa general. La recopilación de datos se efectuó por medio de fichas de recolección, cuyas fuentes de información las constituyeron las historias clínicas, se diseñó una base de datos en Excel, la misma que se importa a SPSS y Epi7, las variables cualitativas se presentan en tablas de frecuencia y las cuantitativas se analizan con medidas de tendencia central y dispersión, para el análisis multivarial se recurre a tablas 2x2 en el caso de variables cualitativas y a medias tabuladas en el caso de variables cuantitativas. Resultados: Se realizó un análisis cualitativo observándose que el valor promedio es mayor en el grupo de BIRADS IV-V, pese a que el análisis cuantitativo revela una relación directa proporcional débil pero significativa se pudo apreciar además al realizar el análisis cualitativo, que la probabilidad de presentar BIRADAS más severos es 4,6 veces mayor en las pacientes con malos controles OR 4.6 (1.2-16.8); p0.009. Se pudo apreciar en el análisis estratificado que el uso de terapia combinada es un factor protector para que las pacientes con mal control de la diabetes desarrollen BIRADS IV/V (OR 0,3846 / 0,0778-1,9005/ p 0,38); por el contrario, en el grupo de pacientes con adecuado control esta relación se invierte (OR 3,857 / 0,3211-46,3260/ p0.6). Las demás asociaciones no presentaron relevancia estadística. Conclusión: No se estableció relación entre alteraciones microvasculares, el uso de uno u otro esquema terapéutico con cambios mamográficos, sin embargo, el valor de hemoglobina glicosilada fuera del rango adecuado si presentó asociación con cambios mamográficos, sobre todo con BIRADS III y IV. La correlación hallada entre el mal control glicémico con hallazgos mamarios más sugestivos (BIRADS IV-V) de cáncer adquiere importancia, al sugerirnos que el inadecuado control glicémico sigue siendo aún un problema frecuente en esta población pese a las amplias posibilidades de manejo terapéutico. Revista Médica Vozandes Volumen 31, Número 1, 2020 * Corresponding author:: Zurita Alvarado Fabián E-mail: fzurita@hospitalvozandes.com Palabras clave: diabetes, mama, BIRADS, mamograf

Type 2 diabetes is a metabolic disorder, specified by resistance and insufficient production of insulin, the result of which is hyperglycemia, which is the cause of complications that can be classified into microvascular and macrovascular, in addition to changes of mixed etiology, such as changes inflammatory tissues of the breast, which increases the risk of breast cancer. Specifically, these factors are linked to changes in breast density due to proliferation, apoptosis, and differentiation of breast tissue, the latter associated with parity, menopause, body mass index, and hypoglycemic agents. At the moment, few studies have evaluated the association of the development of breast cancer in diabetic patients, a world level Danish studies stand out, which has found an association between diabetes with changes in breast density, unfortunately in Latin America, no similar studies have been found and it is here that the present study becomes important, since its long-term impact will help us to better understand this relationship with cancer development, in order to seek preventive measures. Methodology: An observational study was carried out, which included 115 patients diagnosed with type II diabetes, who attended the general outpatient consultation. The data collection was carried out by means of collection cards, whose sources of information were the medical records, an Excel database was designed, which is imported into SPSS and Epi7, the qualitative variables are presented in tables of Frequency and quantitative variables are analyzed with measures of central tendency and dispersion. For multivariate analysis, 2x2 tables are used in the case of qualitative variables and tabulated averages in the case of quantitative variables. Results: A qualitative analysis was carried out, observing that the average value is higher in the BIRADS IV-V group, despite the fact that the quantitative analysis reveals a weak but significant direct proportional relationship, it was also possible to appreciate when performing the qualitative analysis, that the probability to present more severe BIRADES is 4.6 times greater in patients with poor controls OR 4.6 (1.2-16.8); p0.009. It could be seen in the stratified analysis that the use of combined therapy is a protective factor for patients with poor control of diabetes to develop BIRADS IV / V (OR 0.3846 / 0.0778-1.9005 / p 0.38 ); on the contrary, in the group of patients with adequate control this relationship is reversed (OR 3,857 / 0.3211-46.3260 / p0.6). The other associations did not present statistical relevance. Conclusion: No relationship was established between microvascular alterations, the use of one or another therapeutic scheme with mammographic changes, however, the value of glycated hemoglobin was outside the appropriate range if it was associated with mammographic changes, especially with BIRADS III and IV. The correlation found between poor glycemic control with more suggestive breast findings (BIRADS IV-V) of cancer becomes important, suggesting that inadequate glycemic control is still a frequent problem in this population despite the wide possibilities of therapeutic management.

Estudio de Casos y Controles: Cáncer de Mama y su Asociación con la Densidad Mamaria Incrementada Visualizada por Mamografía en el Instituto del Cáncer SOLCA Cuenca ­ Ecuador, 2013 ­ 2015 / Case-Control Study: Breast Cancer and the Association with Increased Breast Density Visualized by Mammography at the Cancer Institute SOLCA Cuenca - Ecuador, 2013 - 2015

INTRODUCCIÓN: En la actualidad el cáncer de mama es el segundo tipo más frecuente de cáncer en el mundo, representando una de las principales causas de mortalidad femenina. El objetivo de este estudio fue determinar la asociación entre cáncer de mama y densidad mamaria incrementada visualizada por mamografía en mujeres de 45 a 70 años del Instituto del Cáncer SOLCA ­ Cuenca. MATERIALES Y MÉTODOS: Se realizó un estudio de casos y controles; el universo incluyó a pacientes que se realizaron un control mamográfico en el Instituto del Cáncer SOLCA ­ Cuenca, durante el período 2013 ­ 2015. La definición de caso o control estuvo dada por el diagnóstico de cáncer de mama confirmado por estudio histopatológico; se investigó la relación entre densidad mamaria de alto riesgo (C y D) y cáncer de mama. Se utilizó estadística descriptiva, análisis de asociación y riesgo; los datos fueron procesados mediante el programa estadístico SPSS versión 22.0. RESULTADOS: El promedio de edad fue 55.3 años (±7,62). La densidad mamaria C y D estuvo asociada a un incremento del riesgo de desarrollar cáncer de mama OR 8.58 (IC 3.5 ­ 20.60, p=0.001). Los principales hallazgos mamográficos presentes en pacientes con patología maligna fueron: calcificaciones amorfas p= 0.014, calcificaciones finas pleomorfas p= ≤0.001, presencia de nódulos irregulares, hiperdensos y espiculados p= ≤0.001, asimetría focal p= ≤0.001, distorsión de la arquitectura del tejido fibroglandular p= ≤0.001, retracción cutánea p= 0.029, engrosamiento cutáneo p= ≤0.001, y la presencia de ganglios linfáticos de morfología sospechosa p= 0.032. CONCLUSIÓN: El patrón de densidad mamaria C y D se asocia a un incremento del riesgo de presentar cáncer de mama. Se requiere implementar políticas de prevención que faciliten la notificación, diagnóstico y manejo específico de estas pacientes.(AU)

BACKGROUND: Breast cancer is the second most frequent type of cancer worldwide, representing one of the main causes of female mortality. The aim of this study was to determine the association between breast cancer and increased breast density visualized by mammography in women from 45 to 70 years old of the Cancer Institute SOLCA ­ Cuenca. METHODS: A case-control study was performed; the universe included patients who underwent a mammographic study at the Cancer Institute SOLCA Cuenca ­ Ecuador during the period 2013 ­ 2015. The definition of case of control was given by the diagnosis of breast cancer confirmed by histopathological study; the relationship between high-risk breast density (C and D) and breast cancer was evaluated. Descriptive statistics, risk and association analysis were used; data were processed using statistical program SPSS version 22.0. RESULTS: The average age was 55.3 years (± 7.62). Mammary density C and D was associated with an increased risk of developing breast cancer OR 8.58 (IC 3.5 - 20.60, p= 0.001). The main mammographic findings present in patients with malignant pathology were: amorphous calcifications p= 0.014, pleomorphic fine calcifications p= ≤0.001, presence of irregular, hyperdense and speculated nodules p= ≤0.001, focal asymmetry p= ≤0.001, distortion of the architecture of fibroglandular tissue p= ≤0.001, cutaneous retraction p= 0.029, cutaneous thickening p= ≤0.001, and the presence of lymph nodes of suspicious morphology p= 0.032. CONCLUSION: Type C and D breast density is associated with an increased risk of breast cancer. It is necessary to implement prevention policies that facilitate timely notification, diagnosis and specific management of these patients.(AU)

Measuring breast density: Comparing computer-automated breast density quantification with an observer-based method in a South African academic context

Background: Dense breast tissue may not only 'mask' small, non-calcified cancers but also represents an independent risk factor for the development of breast cancer. Computer-automated breast density quantification (CABD) software tools have been developed for the calculation of volumetric breast density. Objectives: This study sought: (1) to compare observer-based breast density scores, using the fifth edition of the Breast Imaging Reporting and Data System (BI-RADS), with the breast density scores calculated using CABD quantification software tools, (2) to determine inter-reader variability in breast density scoring between qualified radiologists, between radiologists in training (registrars) and between these two groups and (3) to determine intra-reader reliability in breast density scoring. Methods: A cross-sectional study was performed using the data of 100 patients (200 breasts). Three qualified radiologists and three registrars were asked to review the mammograms in question and to assign a breast density score according to the fifth edition of the Breast Imaging Reporting and Data System (BI-RADS) reporting system. Two readings took place at a minimum of 30 days apart. The percentage agreement between the automated and observer-based scores was calculated and intra-reader and inter-reader reliability values were determined. Results: The study found that there was poor agreement between the breast densities calculated by CABD and the more subjective observer-based BI-RADS density scores. These results further reflect a statistically significant degree of inter-reader and intra-reader variability in the evaluation of breast density. Conclusion: We conclude that the use of automated breast density quantification (i.e. CABD) is a valuable tool for the reduction of variability in breast density ratings

Mammographic density among indigenous women in forested areas in the state of Amapá, Brazil: a cross-sectional study / Densidade mamográfica em mulheres indígenas de áreas da floresta do estado do Amapá, Brasil: estudo transversal

ABSTRACT CONTEXT AND OBJECTIVE: There is no register of breast cancer cases among indigenous populations in Brazil. The objective here was to evaluate the association of clinical and demographic characteristics with mammographic density among indigenous women. DESIGN AND SETTING: Cross-sectional analytical study conducted in indigenous territories in the state of Amapá, Brazil. METHODS: Women were recruited from three indigenous territories and underwent bilateral mammography and blood collection for hormonal analysis. They were interviewed with the aid of an interpreter. Mammographic density was calculated using computer assistance, and was expressed as dense or non-dense. RESULTS: A total of 137 indigenous women were included in this study, with an average age of 50.4 years, and an average age at the menarche of 12.8 years. Half (50.3%) of the 137 participants had not reached the menopause at the time of this study. The women had had an average of 8.7 children, and only two had never breastfed. The average body mass index of the population as a whole was 25.1 kg/m2. The mammographic evaluation showed that 82% of women had non-dense breasts. The clinical characteristics associated with mammographic density were age (P = 0.0001), follicle-stimulating hormone (FSH) (P < 0.001) and estrogen levels (P < 0.01). CONCLUSIONS: The majority of the indigenous women had non-dense breasts. Age, menopausal status and FSH and estrogen levels were associated with mammographic density.

RESUMO CONTEXTO E OBJETIVO: Não há registro de casos de câncer de mama em populações indígenas no Brasil. O objetivo foi avaliar a associação de características clínicas e demográficas com a densidade mamográfica em mulheres indígenas. TIPO DE ESTUDO E LOCAL: Estudo transversal, analítico, realizado em territórios indígenas no estado do Amapá, Brasil. MÉTODOS: Mulheres foram recrutadas de três territórios indígenas e submetidas a mamografia bilateral e a coleta de sangue para análise hormonal. As participantes foram entrevistadas com a ajuda de um intérprete. A densidade mamográfica foi calculada com assistência de computador, e expressa como densa ou não densa. RESULTADOS: 137 mulheres foram incluídas no estudo, com média de 50,4 anos e média de idade à menarca de 12,8 anos. Metade (50,3%) das 137 participantes não havia entrado na menopausa no momento do estudo. As mulheres tinham em média 8,7 filhos, e duas nunca haviam amamentado. O índice de massa corpórea médio da população como um todo foi de 25,1 kg/m2. A análise mamográfica mostrou que 82% das mulheres tinham mamas não densas. As características clínicas associadas com a densidade mamográfica foram idade (P = 0.0001), hormônio folículo-estimulante (FSH, P < 0,001) e níveis de estrogênio (P < 0,01). CONCLUSÕES: A maioria das indígenas tinha mamas não densas. Idade, status menopausal e níveis de estrógeno e FSH foram associados com a densidade mamográfica.