Screening Mammography: The Controversy, Risk Assessment and - PowerPoint PPT Presentation

Screening Mammography: The Controversy, Risk Assessment and Individualized Screening recommendations. Jonathan T. Sims MD, MBA

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Agenda • Discuss the recent studies calling into question the benefits of mammography. • What are the facts and statistics we track • Screening recommendations in the general public, special populations, and the importance of breast density

RECENT STUDIES CALLING INTO QUESTION THE BENEFITS OF MAMMOGRAPHY

• UK Independent Review • Nordic Cochrane Institute Review • US Preventive Services Task Force Review • EUROSCREEN Review – All of the studies attempted to answer the question “how many women need to undergo breast cancer screening, in order to save 1 woman’s life, from dying from breast cancer (during the observation time period) ?” – Results varied from 80-2,000

Why the large variance? • Definition of undergo breast cancer screening – Nordic Cochrane Institute Review considered a women being notified and instructed to undergo mammography as “being screened.” • 23% of women didn’t show up. • During the observational time period – Studies ranged from 10 years to 20 years • The longer the observational time period, the more efficaous screening mammography became. • Which ages were included – 40-74 – 50-74

Nordic Cochrane Institute Review • 2,000 women need to get “screened” to save 1 life. – Screening means- getting a reminder – Time period- over 10 years – Age- 40-74. • Change the variables, changes the numbers: – 600:1- Screening=mammogram, time frame is 20 years, ages included 40-74 – 300:1 – restrict ages to 50-74

The controversy’s take home points • Screening mammography works- • Are the benefits immediate- • The benefits can be concentrated- • But they shouldn't be

FACTS

FACT #1 Age is the number one risk factor

FACT #2 Must catch it early • Prognosis most influenced by axillary node status – No nodes- 5 year survival 82.8% – 1-3 nodes- 5 year survival 73% – 4-12 nodes- 5 year survival 46% – >13 nodes- 5 year survival 28.4% • Tumor size matters immediate and long term – size correlates with axillary node status And is an independent prognostic indicator – <1cm- 99% five year survival (88% 20 year recurrence free survival) – 1-3 cm – 89% (72% 20 year recurrence free survival) – >3 cm – 86% (59% 20 year recurrence-free survival

FACT #3 Screening mammography works • Technological improvements have led to better detection

FACT #4 Detecting small tumors decreases mortality

Take home facts: • Screening mammography is the only modality that is proven to save lives • Best chances of surviving breast cancer is catching it early • 1/8 women will have breast cancer sometime during their lifetime • Of women that undergo screening mammography, about 6-8% will need additional evaluation, and 6-8% of those women will be diagnosised with breast cancer • Of all the baseline screening exams, almost 1% will have breast cancer • Non baseline screening exams, about 0.5% will have breast cancer • Over the last 4 months OIC has diagnosised 13 breast cancers in asymptomatic women between 40-50 years of age. • All of our mammographers see every cancer that is diagnosised at OIC

ACR target statistics

RECOMMENDATIONS: THEN, NOW, AND TOMORROW

THEN: Screening recommendations Normal Risk Yearly Mammograms- starting at 40 years of age and continuing for as long as the patient is in good health Clinical breast exams, every three years from 20-40, yearly for patients >40 Monthly self breast exams

NOW: Screening recommendations Normal Risk Moderate Risk High Risk Yearly Mammograms- starting at 40 years of age and continuing for as long as the patient is in good health Clinical breast exams, every three years from 20-40, yearly for patients >40 Monthly self breast exams NOW: recommendations are influenced by breast density, and personal/familial risk factors.

Family history • Family history risk: – Strong family history – First degree w/ premenopausal – Male relatives – Known family history of BRCA genes – Intermediate family history – First degree w/ postmenopausal – Weak family history – Second degree relatives – No family history

Family history of proven genetic cancer syndromes • Li-fraumeni syndrome (p53 gene mutation) – Sarcoma, breast, leukemia and adrenal gland (SBLA) syndrome • Bannayan-Riley-Ruvalcaba syndrome (PTEN mutation) • Cowden syndrome – breast carcinoma, follicular carcinoma of the thyroid, and endometrial carcinoma (hamartomas everywhere)

Personal medical history • History of XRT of chest for lymphoma • History of Breast Cancer (IDC or ILC) • Previous breast biopsies – Atypical anything – LCIS (50% multi ipse, 30% bilateral) • 5-20% will be diagnosised with breast cancer within the next 5 years.

Mammographic breast density • Not perceived density on breast exam. • Proportion of breast composed of glandular elements and stoma seen at mammography

Mammographic breast density • Senate bill 420 – Effective January 1, 2014 Oregon became the 11 th state to pass breast density legislation requiring providers to inform women with dense breast tissue that they have dense breasts. • This increases their risk of developing breast cancer • Decreases the sensitivity of screening mammography • The patient may need additional screening – Failed to require the additional screening be covered by insurances – “intended to start a conversation between patients and their providers concerning if and what they need.”

Required notification

Required notification

Case report • Patient presents with confusion- – “I got a letter saying “no breast cancer.” But on the same letter, it says I have “dense breasts” so I might have cancer. And I was instructed to talk to you.”

Reassure and risk stratify • Risk stratify – Risk model (like the Gail model) – Take a detailed history

Personal breast cancer risk assessment • Gail model, the Claus model, and the Tyrer- Cuzick model – Give approximate estimates of breast cancer risk based on different combination of risk factors and different data sets • May give different risk estimates for the same women • Take home- Gail model is the best one currently- used for determining adjuvant hormonal therapy

Gail model • The tool calculates a woman's risk of developing breast cancer within the next five years and within her lifetime (up to age 90). It takes into account seven key risk factors for breast cancer. – Age – Age at first period – Age at the time of the birth of her first child (or has not given birth) – Family history of breast cancer (mother, sister or daughter) – Number of past breast biopsies – Number of breast biopsies showing atypical hyperplasia – Race/ethnicity • Women with a five-year risk of 1.67 percent or higher are classified as "high-risk." This score (a five-year risk of 1.67 percent or higher) is the cut-off for the FDA guidelines for taking tamoxifen or raloxifene to reduce breast cancer risk. • Limitations- based on white women, no paternal history), doesn’t take into account personal history of DCIS, IDC, LCIS, or ILC

NOW: Screening recommendations Normal Risk (10- Moderate Risk (15- High Risk (>20%) High Risk and 15%) 20%) dense Yearly Mammograms- starting at 40 years of age and continuing for as long as the patient is in good health Clinical breast exams, every three years from 20-40, yearly for patients >40 Monthly self breast exams NOW: recommendations are influenced by breast density, and personal/familial risk factors.

When is additional screening recommended? • People at normal risk (10-15% lifetime risk)- No change – CBE q3 years between ages 20-40 – CBE q1 year beginning at age 40 – Screening digital mammography starting at age 40 • Yearly, for as long as the patient is in moderately good health.

Patients at moderate risk 15-20% lifetime risk. Would additionally screen with bilateral whole breast US with elastography • Dense breasts • Previous biopsy results of LCIS, atypical anything • Intermediate family history and heterogeneously dense breasts

Additional Screening with Whole breast US • Is elastography important- yes • What screening interval? • Is this covered by insurance? • Is this done else where in the world?

Patients at high risk >20% lifetime risk. Strongly consider additional breast MRI • Personal or family history of genetically proven cancer syndrome (BRCA/p53/PTEN) • Strong family history (1 st degree w/ pre- menpasual disease, or male relatives) • Previous mediastinal XRT (starting 10 years after cessation of mediastinal XRT) • Previous breast cancer (IDC or ILC)

Additional screening with Breast MRI • Best done at a facility that also does breast biopsies. Or the patient may ultimately get billed for an additional breast MRI.