Early Detection: Breast Awareness, Self-examination, And .
KNOWLEDGE SUMMARYEARLY DETECTION:BREAST AWARENESS, SELF-EXAMINATION,AND CLINICAL BREAST EXAM(DIAgNOSTIC AND SCREENINg)What this Knowledge Summary (KS) covers:This module covers the major breast cancer early detection strategies including breast cancer awareness (patient,community and health professional education), breast self-exams (BSE), and clinical breast exams (CBE). A descriptionof how to perform a CBE is included in the Early Diagnosis: Signs and Symptoms module. A discussion of breast cancermammographic screening is provided in the Early Detection: Imaging Modalities module.
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMKey Policy Summary: In addition to using CBE to evaluate breast complaints, CBEcan be used to screen for breast cancers as part of a breastawareness education program targeting women aroundage 30. CBE screening is a lower cost, less resource intensivescreening approach than is mammographic screening and isappropriate for previously unscreened populations. Mammographic screening has been shown to reducebreast cancer mortality in high-resource settings (SeeEarly Detection: Imaging Modalities module), but CBE isan acceptable screening method when mammographicscreening is unavailable, unaffordable or unrealistic. Ultrasound imaging is not recommended as a screeningmodality but is important as a diagnostic tool for evaluatingbreast findings like masses or thickenings.Early detection programs Detecting breast cancer early in its natural history improvessurvival, lowers morbidity, and reduces the cost of care.Effective early detection programs should focus on:-- Early diagnosis – through increased breast awarenessand reducing barriers to accessing care;-- Screening by clinical breast exam (CBE) or CBE inconjunction with mammography performed in a costeffective, resource-sustainable and culturally-appropriatemanner;-- Timely diagnosis for all women found to have abnormalfindings and prompt stage-appropriate treatment for allwomen proven by tissue diagnosis to have breast cancer.Breast awareness educationInterventions across the continuum of careaccording to resource level Breast awareness includes public health and professionalmedical education on the symptoms of breast cancer andthe importance of seeking medical evaluation for breastsymptoms such as lumps or thickenings that a womanappreciates in her breast. Awareness education can have a significant impact onreducing breast cancer morbidity and/or mortality and is anintegral part of all early detection programs. Breast health messages should emphasize that a womanshould promptly seek and receive care when she notices abreast mass, thickening or other new, persistent finding. Breast self-examination (BSE) contributes to a woman’ssense of empowerment and awareness about her breasthealth, although formal training in BSE technique hasnot been shown to improve breast cancer early detectionbeyond basic breast awareness education. Collaboration with advocacy and community groups iscrucial for the effective creation and dissemination of breastawareness messages.Clinical breast examination Clinical breast exam (CBE) performed by a trained healthcareprovider involves a physical examination of the breasts andunderarm. CBE is a basic element of breast health care andshould be offered to any woman with a breast finding thatshe identifies as abnormal for her. CBE should be incorporated into standard medical schoolcurricula and training programs. Quality assurance measures should be in place to ensurethat health professionals are proficient in CBE and knowhow women with an abnormal CBE can access diagnosisservices. CBE can be performed by trained non-physician providers inlow resource settings.2Breast cancer programs in low-and middle-income countries(LMICs) should follow a defined care pathway in line withavailable resources and capacities to allow for coordinatedincremental program improvement across the continuum ofcare (see Table 1).
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMINTRODUCTION& THE CHALLENGEBreast cancer early detection requires early diagnosis of womenwith breast cancer symptoms, and in addition can include moreintensive breast cancer screening in which women withoutrecognized cancer symptoms are tested for disease. Both earlydiagnosis efforts and early detection screening programs cancontribute to data collection on breast cancer incidence andmortality in a community or region. When well collected andproperly documented in hospital-based, regional or nationalcancer registries, these data regarding tumor size and stageat diagnosis inform breast cancer control programs aboutthe current effectiveness of early detection efforts. Both earlydiagnosis and screening programs should consider the culturalcontext of the community served, the resources available forprogram support and the sustainability of such efforts over time(see Table 2).Policy ImpactPreplanningEstablish goalsEarly diagnosis of symptomatic women relies on breast cancerawareness by patients, their community, and frontline healthprofessionals. It requires women to have timely access to breastevaluations, follow-up diagnostic services (imaging, biopsyand pathology) and breast cancer treatment as appropriate forthe stage of disease. Health systems require trained frontlinepersonnel competent in CBE and breast health counseling tocoordinate care through a referral network for timely breastcancer diagnosis and treatment. Centralized diagnosis andtreatment facilities are resource-efficient if patients can reliablybe triaged for care (see Early Detection: Breast Cancer Signs andSymptoms and Policy and Advocacy: Access to Breast CancerCare modules.) The goal of breast cancer early detection is todiagnose cancer at earlier tumor stages, whichallows for simpler and more cost-effectivetreatment to reduce both morbidity and mortality. Breast awareness education and clinical breastexams (CBEs) should be a standard part of breastcancer awareness efforts. When women find lumps or thickenings in thebreast, they need access to facilities where theycan undergo a diagnostic work-up to determine ifit is a benign or malignant process.The challenge is to provide health services using sustainableresources to optimize finding breast cancers early in their courseand then provide appropriate treatment that minimizes thechances of cancer spread (metastasis). Early detection programs should include anearly diagnosis component (e.g., programsto increase awareness, reduce access barriersto diagnostic and treatment facilities), and ascreening component (i.e., CBE or mammography;opportunistic or organized). Programs should be designed to be culturallysensitive and appropriate.The World Health Organization (WHO) emphasizes the value ofa strategy called “stage-shifting” or “down-staging”, meaningthe establishment of early detection programs to reduce theproportion of patients presenting with advanced (“late stage”)breast cancer. When linked to effective treatment, stageshifting improves breast cancer survival rates. Although the goldstandard for early detection programs in high-income settingsis mammographic screening, clinical breast exams (CBE) inlower income settings have been used successfully and are anecessary tool in any breast health system for frontline evaluationof patients with breast symptoms. Early detection screeningprograms can be opportunistic, i.e., initiated during routinepatient visits or organized, i.e., initiated by invitation sent to atargeted at-risk patient population (see Table 3).Establish prioritiesEstablish a resource-stratified pathway approach Early detection programs can be developed in lowresource settings and be incrementally improved asmore resources are allocated to the program usinga resource-stratified pathway (see Table 1).3
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMWHAT DO WE KNOWBreast awareness programsBreast cancer early detection: In many LMICs, and sometimesin high income countries, women delay seeking medicalevaluation of breast changes for months or even years, especiallywhen they do not hurt or cause lifestyle problems. Early cancersare generally painless lumps, while advanced cancers progressto become large, painful and/or ulcerated tumors. The goal ofbreast awareness is to educate women about the importance ofdiagnosing cancer at early stages when treatment is easier andoutcome is better. Advanced cancers demand more extensivetherapies and are more likely to spread (“metastasize”) to otherorgans at which point they no longer can be cured.Educational targets: Breast awareness efforts include teachingabout breast cancer symptoms, e.g., palpable lumps orasymmetric thickening, skin and/or nipple changes, especiallythose that worsen over time (see Early Detection: Signs andSymptoms module). The importance of timely medical evaluationis emphasized. Because most women in LMICs (and 1 in 6 inhigh income countries) have advanced cancers at diagnosis,programmatic goals include 1) heightened cancer awarenessin the community, 2) increased breast evaluation training forfrontline clinical staff, and 3) improved access for breast cancertesting and treatment, which together can reduce mortality.Even before the introduction of screening programs in the UK,over 50% of the decreased mortality in women younger than65 years of age was associated with an increase in breast cancerawareness and earlier staged cancer diagnosis.Cultural context: Breast cancer awareness messages are moreeffective if they are culturally appropriate and developed withcommunity input. Messages should emphasize that breast cancercan be treated best if treated early, and the majority of womentreated for early breast cancer will recover after treatment tolive healthy and productive lives. While effective treatment andcare options can still help those with advanced disease, earlydiagnosis allows for less morbid treatments, including breastconservation surgery rather than mastectomy (if radiationtreatment is also available). Community input can help identifygeneral misconceptions about breast cancer detection, diagnosis,treatment and/or outcomes. For example, if in a communitythere is reported fear of breast disfiguration during diagnosis, itmight be important to stress that breast cancer is diagnosed bya small biopsy not by breast removal. If in another community,breast cancer is reported to be considered an incurable disease,it might be important to provide examples of women who haverecovered from breast cancer after treatment (breast cancersurvivors). Breast cancer advocates, including but not limitedto breast cancer survivors, can play an important role in breastcancer awareness programs. Efforts to increase general publicawareness and openness, and reduce stigma about breast cancercan result in more women who have breast cancer symptoms orbreast concerns seeking expeditious and reliable care (see Policyand Advocacy: Cultural Context module).4Breast self-exam (BSE) as part ofbreast awarenessMost breast tumors are discovered by women themselves,whether through formal or informal breast self-exams (BSEs).Teaching breast self-exams can be part of breast awarenessteaching, although no specific BSE technique is consideredsuperior to another. The critical components are visualexamination of the breast and palpation of the entire breast,preferably with the finger pads of the three middle fingers in aneffective search pattern. Health professionals should be preparedas part of breast health education to instruct a woman using aculturally sensitive approach on how to examine her breasts. BSEcan improve a woman’s breast knowledge and her willingnessto present for evaluation and care for a breast concern. TeachingBSE may be part of breast awareness and early diagnosisstrategies but is not recommend by itself as an early detectionscreening method. Studies suggest that the BSE may decreaselate-staged cancer presentation, increase early cancer detection,and improve utilization of health system resources. However,studies that focused heavily on formal BSE training as a screeningmethod showed that BSE led to increased breast biopsieswithout improving mortality.CBE as a diagnostic toolClinical breast exams (CBEs) are a necessary component ofearly detection efforts. CBE should be part of routine breasthealth care, and part of any evaluation for a woman whopresents with a breast concern (e.g., breast mass, skin or nipplechange). A CBE should include an axillary (underarm) lymphnode examination. Adequate time is required for a CBE (6 to 10minutes), especially when imaging is not routinely employed.There is no clear superiority of any one CBE technique. Criticalcomponents of a CBE include a visual inspection of the breasts,proper positioning of the patient for breast palpitation inboth the upright-seated and lying-on-the-back positions, andthoroughness (use of a vertical-strip or concentric circle searchpattern) with proper position and movement of the fingers. Withproper training, health professionals, including non-physicians,can achieve proficiency in CBE. Quality assurance protocols arerequired to ensure continued health professional competency inCBE (see Early Detection: Signs and Symptoms module for detailson CBE techniques, training, and quality assurance).Cultural context: A culturally sensitive approach to breastexams and breast health counseling can reduce a woman’sdiscomfort and anxiety during a breast health visit, and allow herto make informed decisions about her preferred breast healthcare.Effectiveness of CBE: Studies on the effectiveness of CBEreport a wide range of data and suggest that CBE can findmasses not reported by women (asymptomatic cancers), but mayalso miss small tumors detectable by imaging modalities (seeEarly Detection: Imaging Modalities module). Certain groups ofwomen, such as obese women or younger women with morenodular breast tissue, may receive less benefit from CBE.
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMCBE as a screening toolAs a screening modality, CBE requires fewer resources comparedto mammography and can be implemented in settings wheremammography is not feasible. When used for screening, CBEis often started among women at age 30 as a breast healthawareness education tool to help familiarize women with theirown breasts. CBE can be used as a transitional screening methodduring the introduction of a mammography screening program;CBE pilot screening projects can help inform larger screeningprojects about the patient population and effective recruitmentstrategies. Successful implementation of CBE screening isdependent on resource allocations for trained staff and accessto follow-up services or facilities for pathology, diagnosis andtreatment, as well as cultural considerations. Studies haveshown CBE screening to be associated with lower stage tumorat diagnosis and improved age-standardized incidence rates foradvanced-stage breast cancer, which in turn is associated withimproved breast cancer mortality rates. However, CBE screeningdoes not find as many of the very earliest stage cancers as doesscreening mammography.Low cost early detection interventions would appear to meetconventional criteria for cost-effectiveness based on marginalcosts per year of life saved, or quality adjusted year of life saved.While there is some debate about how many lives are savedby CBE screening, there is no debate that CBE is a necessarycomponent of a breast health program and strategy.Community support: Community support for participationin early detection screening programs must be matched bycommunity support for follow-up diagnosis and treatment.Studies have shown that barriers to early treatment includehealth system obstacles such as lack of access to care, highcost of care, and patient issues such as fear of diagnosis andtreatment (see Policy and Advocacy: Access to Care and Policyand Advocacy: Cultural Context and Psychosocial Impact ofBreast Cancer modules).Opportunistic versus organized screening: CBE can bean effective opportunistic or organized screening method.Opportunistic screening can occur during any health carevisit if the health system has prepared providers (throughreimbursement and protocols) to perform breast health examsand refer patients for further screening tests (ie. imaging), ifappropriate. In opportunistic screening, additional diagnosticservices and care is coordinated by the woman and her healthcare team. Opportunistic screening differs from organizedscreening in that organized screening invites a specific at-riskpopulation to participate outside of routine health care visits,and has preset screening intervals (e.g. every two years). Bothopportunistic and organized screening programs require qualitycontrol measures, including data on false-positive, false-negativeand recall rates (see Early Detection: Imaging Modalities chapterfor a detailed discussion of quality measures).Cost and effectiveness: CBE is a less expensive screeningmodality than mammography. However, the exact cost of earlydetection programs will vary by region and depends on thebreast cancer incidence rate, available resources and providerexpertise. Cost-effectiveness studies of CBE early detectionprograms continue to be reported from LMICs. Studies in Ghana,Peru, Central America (Costa Rica and Mexico), sub-SaharanAfrica and East Asia, India, and the Ukraine suggest screeningwith CBE may reduce breast cancer deaths with estimatedmortality reductions of 12-55%.5
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMPolicy ImpactPlanning Step 1:Where are we now?Assess the burden of breast cancer Information on the stage of disease at diagnosis isrequired to determine the focus of early detectionprograms. Cancer registries provide the best regionspecific data. If no registry is available, hospital datacan be used, with the limitation that institution-specificdata suffers from patient selection bias.Assess existing early diagnosis and early detectionprograms Determine what breast cancer awareness efforts areongoing at a national, regional or local level by thehealth system as well as advocacy and communitygroups. Determine what early detection efforts are currentlybeing implemented at a national, regional or hospitalbased level. Assess the size of the population to serve in the earlydetection program and confirm services are in placeto meet the diagnostic and treatment requirements aswell as screening needs.Assess barriers to early detection6 Identify potential health system, patient andcommunity barriers to early diagnosis and screeningprograms. Consider using focus group discussion or interviewswith key stakeholders (e.g., patients, patient advocates,health professionals, community leaders).Assess cost and potential effectiveness of CBEscreening programs The costs of CBE screening include cost of trainingpersonnel, delivery of the services and evaluations. The potential effectiveness will depend on breastcancer incidence rate and target population, healthprofessional expertise and availability, and availablehealth system, patient, and community resources tosupport programs.Assess health system capacity Early detection programs require the additional supportof diagnostic and treatment facilities. Development or expansion of early detection programsshould be coordinated with the development orexpansion of diagnostic and treatment programs usingcoordinated resource-stratified pathways.Assess evaluation capacity Early detection programs should be evaluated routinelyto ensure high-quality, reliable screening tests are beingperformed safely. A program self-assessment tool kit is available fromthe WHO at http://www.who.int/cancer/publications/nccp tool2011/en/index.html.
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMWhat Works and WhatDoes Not WorkBreast cancer awarenessFrom a patient and community perspective: Breast cancerawareness efforts targeted to women and their communities canaugment early diagnosis efforts and increase participation in earlydetection screening programs. Involving breast cancer survivorsor women undergoing breast cancer treatment in breast cancerawareness planning efforts can provide insight into effectivemessages and help identify barriers to breast cancer earlydetection; including breast cancer survivor stories in awarenessmessages can provide hope to women who suspected they havebreast cancer, and encourage women to participate in earlydiagnosis or early detection screening programs (see “Policy andAdvocacy: Cultural Context and Psychosocial Impact of BreastCancer Diagnosis for a full discussion on community outreach).From a health professional perspective: Breast cancer awarenessefforts targeted to health professionals, especially those whowill be the point of contact for women who seek breast healthcare, should include training in CBE (including the signs andsymptoms of breast cancer), and breast health counseling (seeEarly Detection: Signs and Symptoms module).CBE screening programsFor any early detection program to be successful, it must bewell-organized and sustainable, target a well-defined at-riskpopulation, and establish coordination and quality acrossthe continuum of care. Because CBE screening programs aregenerally linked to breast awareness education and possiblycervical cancer screening, the age of initial CBE screeningis younger than what is recommended for mammographicscreening. While mammographic screening programs are notinitiated until ages 40, 45 or 50, CBE screening can be providedto women in their 30s.CBE screening programs should collect and contribute data onbreast cancer tumor stage, breast cancer incidence rates, andother pre-identified program metrics. Participants in screeningprograms, including pilot programs, should be fully informedabout potential benefits and harms of tests, including possibleincreased anxiety, the possible need for additional tests and, ifcancer is detected, the available treatment options (also see EarlyDetection: Imaging Modalities module). To see a group effect ofscreening, effective programs should attempt to screen at least70% of the target population. With CBE screening, between10 and 20% of women will have findings warranting diagnosticwork-up, most of which will be benign findings like cysts,fibroadenomas, or palpably asymmetric but normal breast tissueresponding to hormonal cycling. Even in high-risk populations,less than 1-2% of screened asymptomatic women will be foundto have cancer. For these reasons, screening programs of anytype must provide access to women for diagnostic work-up ofabnormalities identified during screening.Opportunistic versus organized screening (Table 3): Opportunisticprograms provide screening to women who are accessing thehealthcare system for some other purpose and find themselvesavailable for screening, while organized programs provideoutreach to all women in the targeted subgroup at heightenedrisk in the population. From a public health perspective,organized screening is superior to opportunistic screening,because 1) it has greater potential to reduce cancer mortalityrates (by reaching more people); 2) it provides more equitableaccess to care (since participation is usually not dependent onpatient payment or transportation); 3) it provides populationlevel approach to protecting patients from the potential harms ofscreening (since quality control may be easier); and 4) it decreasesoverall cost of individual screening (economy of scale). However,significant challenges exist to organized screening, particularlyin LMICs or regions with decentralized care and limited availableresources. Organized CBE screening programs require 1) datato identify at-risk target populations, 2) resources and processesto guarantee high coverage and participation of the targetpopulation, 3) available health professionals with expertise inCBE, 4) an effective referral system for diagnosis and treatment,and 5) a process to monitor and evaluate the program.Long-term planning requires quality control and data collection:All early detection programs should be monitored for qualityof screening techniques, false-negative, false-positive andrecall rates, timeliness and quality of follow-up diagnostic andtreatment procedures. Data should be systematically collected,validated, reviewed, and reported, and used to identifydeficiencies and improve program performance.Coordination of care across the continuum: Early detectiononly works when diagnostic and treatment resources are alsoavailable. Thus, investing in higher level resources for screening(e.g., population-wide, organized mammography screening)requires parallel investment in quality control efforts, follow-uptissue sampling and pathology for suspicious findings, and timelytreatment for confirmed diagnosis subjects women to a potentialdiagnosis without available care, and places a financial burden onthe health system. When resources are limited, CBE screening isthe best initial approach for starting an early detection program.7
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMHow Do We Get There?Policy ImpactPlanning Step 2:Where do we want to be?Choose your target service population andapproach The at-risk population should be defined bythe local breast cancer incidence rate anddemographics. While certain demographics (age, reproductivehistory, family history) help define groups atheightened risk, early detection and screeningprogram selection criteria are primarily basedon gender and age (e.g., women startingmammographic screening beginning at a certainage (40, 45 or 50) and at defined intervals (every1-2 years) as determined by local factors, resourcesand programmatic choices by local decisionmakers. Criteria for the target population may vary bythe type of program (opportunistic or organized),screening tool used (CBE witth or withoutmammography), and the program scope (pilotprogram or large scale coverage).Anticipate health system, community and patientbarriers to program activities Health system barriers can include location ofprogram activities and transportation issues, timelyreferral system, equipment and human resourcecapacity issues, quality of care of the healthservices, sex of the provider. Community barriers can include local social,cultural and political norms. Patient barriers can include language barriers, lackof financial support, lack of access to care (e.g.transportation), cultural beliefs (e.g., fatalism),social fears (e.g., fear of being ostracized), orpreference for traditional healers.Set achievable objectives8 Objectives could include increasing breastawareness, effective training of relevant staffin breast awareness counseling and CBE, andincreasing availability of appropriate diagnosticand treatment modalities. Consider assessing feasibility of program objectivesthrough demonstration or pilot projects. Follow a resource-stratified pathway for programdevelopment that identifies available resourcesacross the continuum of care.Public awareness: Public awareness education supports earlydiagnosis goals and prepares a community to support earlydetection efforts. At an individual level, advocacy can impact awoman’s decisions about whether to take part in screening andhelp shape her understanding about the risks and benefits ofscreening. National breast cancer public awareness campaignscan be customized for a local community (see Policy andAdvocacy modules).Collaborative efforts: Determining the most appropriate earlydetection method requires joint efforts by hospital systems,regional centers, and Ministries of Health. Considerationsshould include how to optimize existing early detectionefforts by reducing patient and system barriers to accessingcare, improving the quality and cultural sensitivity of existingprograms, and augmenting diagnostic and treatment servicesto support new early detection efforts. Pilot projects canbe used to identify sustainable practices and inform policydecisions. Deciding between optimizing existing programs andinvesting in new resource initiatives should consider local needs,regional expertise, current program effectiveness, and resourceavailability.Optimizing primary care visits: Studies from LMICs suggestthat women without regular primary care providers have lowercancer awareness and are less likely to participate in cancerscreening activities. Programs that improve access to primarycare providers and expand referral networks can improve earlybreast cancer detection, assuming that primary care providers areeducated in early detection techniques such as CBE and also areable to provide access to breast diagnostic services for patientswith abnormal breast findings.Optimizing referral services: Efficient referrals are a keycomponent of the WHO Framework for Health SystemsPerformance Assessment. If not optimized by a health system,they can be expensive for individuals and health systems. Studiesin LMICs have observed protracted referral times to specialtycare resulting in long delays and multiple visits (7.9 clinic visitson average) before existing cancers are diagnosed and treatmentis initiated. Such delays and unnecessary clinic visits resultin increased tumor size, worsened outcomes, and increasedpatient and health system costs. Improving referral networks,communication between providers, and timely access to care isone important method to optimize early detection efforts.
KNOWLEDGE SUMMARYEARLY DETECTION MODULE (1 OF 3): BREAST AWARENESS & CLINICAL BREAST EXAMMixed methods for early detection: In some countries, mixedscreening strategies may be appropriate based on differencesin local availability of resources and expertise
Breast cancer early detection requires early diagnosis of women with breast cancer symptoms, and in addition can include more intensive breast cancer screening in which women without recognized cancer symptoms are tested for disease. Both early diagnosis efforts and early detection screening programs can
4 Breast cancer Breast cancer: A summary of key information Introduction to breast cancer Breast cancer arises from cells in the breast that have grown abnormally and multiplied to form a lump or tumour. The earliest stage of breast cancer is non-invasive disease (Stage 0), which is contained within the ducts or lobules of the breast and has not spread into the healthy breast tissue .
Breast cancer develops in 50% of these women by age 50 ("Early onset" breast cancer gene). Lifetime risk of breast cancer is 85%. . "Breast awareness," beginning at age 18, which involves paying attention to changes in breasts and may include regular breast self-exams. GENETIC TESTS : History of test development
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A recent large-scale study conducted by The University of Hong Kong found that positive family history of breast cancer among first-degree relatives, prior benign breast disease diagnosis, . Breast Awareness and Primary Prevention of Breast Cancer Page 2 Non-Communicable Diseases Watch March 2021 Every woman should be breast aware at all
5 yrs of anti-hormone therapy reduces the risk of: – breast cancer coming back somewhere else in the body (metastases / secondaries) – breast cancer returning in the same breast – a new breast cancer in the opposite breast – death from breast cancer The benefits of anti-hormone therapy last well
Breast cancer development In the United States, breast cancer is the most common cancer diagnosed in women (excluding skin cancer). Men may also develop breast cancer, but less than 1% of all people with breast cancer are men. Breast cancer begins when healthy cells in the breast change and grow uncontrollably, forming a mass called a tumor.
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orientations/briefings before any 3-day weekend. The training must include a review of local driving laws/regulations, motor vehicle safety inspections, the effects of fatigue or alcohol on a driver’s capabilities, and review of any local driving hazards. Commanders will ensure POVs of all military personnel are given a safety inspection prior to holidays as required by AR 385-10, at a .
