Optimal Early Diagnosis

Every woman coming in for early diagnosis wants to be sure, first and foremost, that any tumor will be detected at an early stage with minimal consequences in case treatment is necessary.

How can we address this issue?

In Germany, there is a breast cancer screening program for women aged 50 to 69, every 2 years, consisting of mammography of both breasts in two projections. At first glance, this may seem sufficient, and there are data indicating a 25% reduction in breast cancer mortality in women in this age group (German Cancer Society data, 2017). Do you think this is enough? I believe your response is similar to mine. You likely have many questions. For example, what should you do if you are under 50 or over 69? The problem with screening also exists: the likelihood of missing breast cancer during screening can be up to 50% (dense breast, interval cancers, interpretation errors).

So, should we rely solely on luck and hope that we will be fortunate?

No, that's not our approach. Let's investigate further! What does "early diagnosis" actually mean, and why is it so important? Early diagnosis means detecting non-invasive in situ carcinoma (located within the milk ducts) or when the tumor has become invasive (with a tendency to metastasize) but is no larger than 10 mm. And now I will tell you that the average tumor size found through palpation (self-examination) is 2-3 (!) cm. Tumors less than 1 cm are almost impossible to palpate and do not cause pain! They are still growing, often slowly, doubling in size on average every 20 months (about 2 years). Here's a typical scenario: a woman comes for a screening mammogram, receives a report stating that everything is fine, but six months later, she feels a "lump," and ultrasound confirms it as a 2 cm cancer with lymph node involvement. How is that possible? (See above).

So, is it practically impossible to find cancer at an early stage?

Cancer originates from a single cell, grows slowly (with rare exceptions), and doubles in size every 20 months. A 3-4 mm cancer can already be seen on mammography for breast density 1 or on MRI for any density. After 2 years, it will be 8 mm, and that is still considered early diagnosis. Only 50-60% of women have breast density 1-2; at a young age (under 40), breast density 3-4 is more common (when mammography is ineffective). You may argue that microcalcifications are visible on mammograms. Yes, but only 30% of tumors are associated with microcalcifications; 70% are without them. That's it, I surrender my passwords and credentials – as you may have already guessed, breast MRI is our savior.

I recommend the following scheme for early breast cancer diagnosis:

• 25-30 years old – annual ultrasound
• 30-40 years old – MRI with contrast every 2 years
• 40-50 years old – MRI with contrast plus mammography of both breasts at oblique projections (Göttinger Optipack)
• 50 and older – If breast density is 1, mammography and ultrasound every 2 years. For densities 2, 3, 4 – the same scheme as for 30-40 years.