French college of gynecologists and obstetricians (CNGOF) recommendations for clinical practice: Place of breast self-examination in screening strategies

Breast cancer is the most common female cancer in the world. Numerous studies have shown that the risk of metastatic disease increases with tumor volume. In this context, it is useful to assess whether the regular practice of formal breast self-examination (BSE) as opposed to breast awareness has an impact on the number of cancers diagnosed, their stage, the treatments used and mortality.

DESIGN

The Commission of Senology (CS) of the Collège National de Gynécologie et Obstétrique Français (CNGOF) respected and followed the Grading of Recommendations Assessment, Development and Evaluation method to assess the quality of the evidence on which the recommendations were based.

METHODS

The CS studied 16 questions individualizing four groups of women (general population, women aged over 75, high-risk women, and women previously treated for breast cancer). For each situation, it was determined whether the practice of BSE versus abstention from this examination led to detection of more breast cancers and/or recurrences and/or reduced treatment and/or increased survival.

RESULTS

BSE should not be recommended for women in the general population, who otherwise benefit from clinical breast examination by practitioners from the age of 25, and from organized screening from 50 to 74 (strong recommendation). In the absence of data on the benefits of BSE in patients aged over 75, for those at high risk and those previously treated for breast cancer, the CS was unable to issue recommendations. Thus, if women in these categories wish to undergo BSE, information on the benefits and risks observed in the general population must be given, notably that BSE is associated with a higher number of referrals, biopsies, and a reduced quality of life.

[Place of breast self-examination in screening strategies. French College of Gynecologists and Obstetricians (CNGOF) recommendations for clinical practice]

OBJECTIVES

Breast cancer is the most common female cancer in the world. In France, over 60,000 new cases are currently diagnosed, and 12,000 deaths are attributed to it annually. Numerous studies have shown that the risk of metastatic disease increases with tumor volume. In this context, it is useful to assess whether the regular practice of breast self-examination (BSE) has an impact on the number of cancers diagnosed, their stage, the treatments used and mortality.

DESIGN

the CNGOF's Commission de Sénologie (CS), composed by 17 experts and 3 invited members, drew up these recommendations. No funding was provided for the development of these recommendations. The CS respected and followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the quality of the evidence on which the recommendations were based.

METHODS

The CS studied 16 questions concerning BSE, individualizing four groups of women (general population, women aged over 75, high-risk women, and women previously treated for breast cancer). For each situation, it was determined whether the practice of BSE compared with abstention from this examination led to the detection of more breast cancers and/or recurrences and/or reduced treatment and/or increased survival.

RESULTS

BSE should not be recommended for women in the general population, who otherwise benefit from a clinical breast examination (by the attending physician or gynecologist) from the age of 25, and from organized screening from 50 to 74 (strong recommendation). However, in the absence of data on the role of BSE in patients aged over 75, those at high risk of breast cancer and those previously treated for breast cancer, the CS was unable to issue recommendations. Thus, if women in these latter categories wish to undergo BSE, they must be given rigorous training in the technique, and information on the benefits and risks observed in the general population. Finally, the CS invites all women who detect a change or abnormality in their breasts to consult a healthcare professional without delay.

CONCLUSION

BSE is not recommended for women in the general population. No recommendation can be established for women aged over 75, those at high risk of breast cancer and those previously treated for breast cancer.

[Non-genetic indications for risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To determine the value of performing a risk-reducting mastectomy (RRM) in the absence of a deleterious variant of a breast cancer susceptibility gene, in 4 clinical situations at risk of breast cancer.

DESIGN

The CNGOF Commission of Senology, composed of 26 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The Commission of Senology adhered to the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted.

METHODS

The Commission of Senology considered 8 questions on 4 topics, focusing on histological, familial (no identified genetic abnormality), radiological (of unrecognized cancer), and radiation (history of Hodgkin's disease) risk. For each situation, it was determined whether performing RRM compared with surveillance would decrease the risk of developing breast cancer and/or increase survival.

RESULTS

The Commission of Senology synthesis and application of the GRADE method resulted in 11 recommendations, 6 with a high level of evidence (GRADE 1±) and 5 with a low level of evidence (GRADE 2±).

CONCLUSION

There was significant agreement among the Commission of Senology members on recommendations to improve practice for performing or not performing RRM in the clinical setting.

Management of lactating breast abscesses by ultrasound-guided needle aspiration and continuation of breastfeeding: A pilot study

INTRODUCTION

Needle aspiration of breast abscesses during lactation are currently recommended as an alternative to surgery only for moderate forms. In case of breast abscess, many patients stop breastfeeding on the advice of a health professional. We reviewed our experience of treatment of lactating breast abscesses by ultrasound-guided aspiration and suggest an algorithm of their management. We also analyzed the continuation of breastfeeding of these patients after advices from trained teams.

MATERIEL AND METHODS

We conducted a retrospective study from April 2016 to April 2017, including 28 patients referred for a breast abscess during lactation at the Duroc Breast Imaging Center. A management by ultrasound-guided aspiration was proposed to each patient. We collected data about the breastfeeding between October 2018 and January 2019.

RESULTS

A single aspiration was sufficient in 64.3% of cases. The delay between the occurrence of the abscess and the indication for drainage was significantly higher for patients who have needed finally surgical drainage (p = 0,0031). There were no difference of size of abscesses between patients receiving needle aspiration alone and those who have undergone surgery (p = 0,97). All patients who had been managed by needle aspiration continued breastfeeding after the treatment and 40% of the patients were still breastfeeding at 6 months.

CONCLUSION

The management of lactating breast abscess by ultrasound-guided needle aspiration is an effective alternative to surgery. It appears to be effective regardless of the size of the abscess and is compatible with the continuation of breastfeeding. Our study has indeed shown that if they are well advised, the majority of patients continue breastfeeding so that it is essential that health professionals be better trained regarding the management of breastfeeding complications.

[Use of stereotaxic aspiration macrobiopsies in managing breast microcalcifications: first series of 115 prospective cases]

The objective of this prospective study of a 115-case series cases was to delineate the specific usefulness of this technique for the diagnosis and management of patients with microcalcifications.

MATERIALS AND METHODS

Patients with probably benign ACRII and III (n = 87) or suspicious ACRIV (n = 14) and high suspicious lesion ACRV (n = 7) lesions. The microcalcification sites were blopsied with a dedicated table and a vacuum assisted aspiration system (Mammotome). The results were correlated either with the results of any surgery or, for the lesions with benign histology findings, with the results of the six-month follow-up mammography.

RESULTS

These results concern a series with a follow-up longer than one year. The patients' mean age was 53 years. The procedure was possible in 108 of 115 cases (feasibility). There were two failures. We studied 87 patients with ACRII or III findings; the mean size of the microcalcification cluster was 8.3 +/- 6 mm. For 67, it was less than or equal to 10 mm. The mean size for the 21 patients initially staged as ACRIV or V was 18 +/- 9 mm, and for 15 of them, it was less than or equal to 10 mm. Microcalcifications were found on the radiographs of 96% of the biopsies specimens. Excision was complete in 59 of 73 cases for the clusters less than or equal to 10 mm and in only 12 of 35 cases for the larger clusters. The correlation between the ACR staging and the histology results was excellent.

CONCLUSION

Vacuum-aspirated biopsies are indicated especially among patients with an ACRIII finding and a cluster smaller than 10 mm. Surgery was avoided in more than 60% of these cases. When surgery was performed, it most often resulted in the discovery of malignant lesions. This procedure was also useful for the very small ACRIV clusters, which were totally benign and completely excised. Finally it can be useful for obtaining a preoperative diagnosis in the case of extensive ACRIV or ACRV lesions (strategic biopsies).

[Stereotactic core biopsy of breast microcalcifications. Aid to diagnosis?]

We assessed the accuracy with which stereotactic core biopsy of breast microcalcifications helps to justify follow-up or indicate required surgical planning. Eighty-nine patients underwent stereotactic breast biopsy performed with large core needles. Histopathologic findings of microbiopsies were correlated with radiological findings, with follow up and with surgical findings. Agreement between radiological and histopathologic findings on biopsies was obtained in 86% for benign results. Even in the case of benign radiological findings, the histological results of microbiopsies required a surgical biopsy justified in 10% of cases. Radiologically suspicious or malignant microcalcifications were correlated with 35% benign and 65% malignant histologies on biopsies. The positive predictive value, negative predictive value and accuracy were respectively 93%, 86% and 95%. Invasive lesions were found on microbiopsies in 39% of excised malignant lesions. Multifocal lesions were proved on microbiopsies in 50% of all excised carcinomas. Microbiopsies help to disclose malignant lesions undetected on radiological analysis, and may obviate diagnostic surgical biopsy in many cases.

[Role of microbiopsies in the therapeutic and diagnostic approach in cases of mammary microcalcification: preliminary results]

The increase of mammographies has lead to the discovery of more frequent mammary microcalcifications. Presently, about 30% of breast tumors are discovered from infraclinics lesions. Instead of the different classifications, the microcalcifications are the omnious sign with bad specificity. It is in the aim to improve the diagnostic etiology and the choice of therapy, that the directed microbiopsies on microcalcifications had been realized. After an orthogonal location and under local anesthesia, we performed at least six biopsies with a 2.1 mm (14 gauge) needle. This allowed recovery of malignant lesions during the control of microcalcifications and permitted considerable early operative treatment. In fact, a diagnostic and therapeutic advancement of 12 months as compared to a clinical diagnosis, permitting a 30% reduction of metastasis.