Mode of detection matters: Differences in screen-detected versus symptomatic breast cancers


      • Screening mammography diagnoses cancers when they are smaller and less aggressive.
      • Waiting for breast cancer to become symptomatic leads to more extensive treatment.
      • Relying on breast cancer symptoms for diagnosis could lead to increased deaths.



      Although extensive analyses evaluating screening mammography for breast cancer have been published, some utilized databases do not distinguish between modes of detection, which confounds the conclusions made about the impact of screening mammography.


      A retrospective cohort study of women at our institution with pathologically-proven breast cancer from January 2015 to April 2018 was conducted. Subjects were categorized by their mode of diagnosis: screening or non-screening. Patient demographics, tumor characteristics, and treatments were compared between detection methods using Wilcoxon rank-sum test for continuous variables and chi-squared or Fisher's exact test.


      1026 breast cancers were analyzed. 80.8% of screen-detected breast cancers were invasive. Compared to symptomatically detected cancers, screen-detected were smaller (median size 8 mm vs. 15 mm, p < 0.001), less invasive (80.8% vs. 94.3), had a lower pathologic grade (29% grade 3 vs. 45.7%, p < 0.001), a lower clinical stage, and less aggressive histology (51.9% low Ki67 vs. 30.5%, and 88.2% HER2 negative vs. 76.6%, p < 0.001). Screen-detected cancers were less likely to have extramammary disease (13.2% positive lymph nodes vs. 34.0% and 0.4% distant metastases vs. 6.9%, p < 0.001). Women with screen-detected cancers were more likely to undergo conservative treatment (74.8% underwent lumpectomy vs. 59.9%, and 80.0% received no chemotherapy vs. 51.3%, p < 0.001).


      In this study, while the vast majority of screen-detected cancers were invasive, they were more likely to be smaller, less aggressive, and a lower pathologic grade and clinical stage. Furthermore, women with screen-detected cancers were less likely to have extramammary disease and more likely to undergo conservative treatment.
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        • Harding C.
        • Pompei F.
        • Burmistrov D.
        • Welch H.G.
        • Abebe R.
        • Wilson R.
        Breast cancer screening, incidence, and mortality across US counties.
        JAMA Intern Med. 2015; 175 (Sep): 1483-1489
        • Soojin A.
        • Wooster M.
        • Valente C.
        • et al.
        Impact of screening mammography on treatment in women diagnosed with breast cancer.
        Ann Surg Oncol. 2018; 25: 2979-2986
        • Sanders M.E.
        • Schuyler P.A.
        • Simpson J.F.
        • Page D.L.
        • Dupont W.D.
        Continued observation of the natural history of low-grade ductal carcinoma in situ reaffirms proclivity for local recurrence even after more than 30 years of follow-up.
        Mod Pathol. 2015; 28 (May): 662-669
        • Chootipongchaivat S.
        • van Ravesteyn N.T.
        • Li X.
        • et al.
        Modeling the natural history of ductal carcinoma in situ based on population data.
        Breast Cancer Res. May 27, 2020; 22: 53
      1. Surveillance, Epidemiology, and End Results (SEER) Program Populations (1969–2018), December 2019 (, National Cancer Institute, DCCPS, Surveillance Research Program.

        • Kopans D.B.
        More misinformation on breast cancer screening.
        Gland Surg. 2017; 6: 125-129
        • Malmgren J.A.
        • Parikh J.
        • Atwood M.K.
        • Kaplan H.G.
        Impact of mammography detection on the course of breast cancer in women aged 40-49 years.
        Radiology. 2012; 262 (Mar): 797-806
        • Harvey J.A.
        • Bovbjerg V.E.
        Quantitative assessment of mammographic breast density: relationship with breast cancer risk.
        Radiology. 2004; 230 (Jan): 29-41
        • Phi X.A.
        • Tagliafico A.
        • Houssami N.
        • Greuter M.J.W.
        • de Bock G.H.
        Digital breast tomosynthesis for breast cancer screening and diagnosis in women with dense breasts - a systematic review and meta-analysis.
        BMC Cancer. Apr 3, 2018; 18: 380
        • Wolff A.C.
        • Hammond M.E.H.
        • Allison K.H.
        • et al.
        Human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists Clinical Practice Guideline Focused Update.
        J Clin Oncol. 2018; 36 (Jul 10): 2105-2122
        • Hammond M.E.
        • Hayes D.F.
        • Dowsett M.
        • et al.
        American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer (unabridged version).
        Arch Pathol Lab Med. 2010; 134 (Jul): e48-e72
        • American Joint Committee on Cancer
        in: AJCC cancer staging manual. 8th ed. Springer, New York, NY2017: 589
        • Inwald E.C.
        • Klinkhammer-Schalke M.
        • Hofstädter F.
        • et al.
        Ki-67 is a prognostic parameter in breast cancer patients: results of a large population-based cohort of a cancer registry.
        Breast Cancer Res Treat. 2013; 139 (Jun): 539-552
        • Committee on Practice Bulletins—Gynecology
        Practice bulletin number 179: breast cancer risk assessment and screening in average-risk women.
        Obstet Gynecol. 2017; 130 (Jul): e1-e16
        • Burstein H.J.
        The distinctive nature of HER2-positive breast cancers.
        N Engl J Med. 2005; 353 (Oct 20): 1652-1654
        • Arteaga C.L.
        • Sliwkowski M.X.
        • Osborne C.K.
        • Perez E.A.
        • Puglisi F.
        • Gianni L.
        Treatment of HER2-positive breast cancer: current status and future perspectives.
        Nat Rev Clin Oncol. 2011; 9 (Nov 29): 16-32
        • Yoshimura A.
        • Ito H.
        • Nishino Y.
        • et al.
        Recent improvement in the long-term survival of breast cancer patients by age and stage in Japan.
        J Epidemiol. 2018; 28: 420-427
        • Caswell-Jin J.L.
        • Plevritis S.K.
        • Tian L.
        • et al.
        Change in survival in metastatic breast cancer with treatment advances: meta-analysis and systematic review.
        JNCI Cancer Spectr. 2018 Oct; 2pky062
        • Saadatmand S.
        • Bretveld R.
        • Siesling S.
        • et al.
        Influence of tumor stage at breast cancer detection on survival in modern times: population based study in 173797 patients.
        BMJ. 2015; 351h4901
        • de Boer M.
        • van Dijck J.A.
        • Bult P.
        • Borm G.F.
        • Tjan-Heijnen V.C.
        Breast cancer prognosis and occult lymph node metastases, isolated tumor cells, and micrometastases.
        J Natl Cancer Inst. 2010; 102 (Mar 17): 410-425
        • Wang M.
        • Chen H.
        • Wu K.
        • Ding A.
        • Zhang M.
        • Zhang P.
        Evaluation of the prognostic stage in the 8th edition of the American Joint Committee on Cancer in locally advanced breast cancer: an analysis based on SEER 18 database.
        Breast. 2018; 37 (Feb): 56-63
        • Petrelli F.
        • Viale G.
        • Cabiddu M.
        • Barni S.
        Prognostic value of different cut-off levels of Ki-67 in breast cancer: a systematic review and meta-analysis of 64,196 patients.
        Breast Cancer Res Treat. 2015; 153 (Oct): 477-491
        • Yang C.
        • Zhang J.
        • Ding M.
        • et al.
        Ki67 targeted strategies for cancer therapy.
        Clin Transl Oncol. 2018; 20 (May): 570-575
        • Beusterien K.
        • Grinspan J.
        • Kuchuk I.
        • et al.
        Use of conjoint analysis to assess breast cancer patient preferences for chemotherapy side effects.
        Oncologist. 2014; 19 (Feb): 127-134
        • Chow R.
        • Pulenzas N.
        • Zhang L.
        • et al.
        Quality of life and symptom burden in patients with breast cancer treated with mastectomy and lumpectomy.
        Support Care Cancer. 2016; 24 (May): 2191-2199
        • Independent UK Panel on Breast Cancer Screening
        The benefits and harms of breast cancer screening: an independent review.
        Lancet. 2012; 380 (Nov 17): 1778-1786
        • Nazari S.S.
        • Mukherjee P.
        An overview of mammographic density and its association with breast cancer.
        Breast Cancer. 2018; 25: 259-267