breast cancer screening where do we stand? rakhshanda layeequr rahman md director, ttuhsc amarillo...

Breast Cancer ScreeningWhere do we stand?

Rakhshanda Layeequr Rahman MDDirector, TTUHSC Amarillo Breast Center

of ExcellenceDivision of Surgical Oncology

How Big a Deal Is It?

• US New Breast Cancer 200,000/year• US Deaths 50,000/year

• Panhandle New Breast Cancers 900/year• Panhandle Deaths 212/year

• No. 1 Cancer in Women• No. 1 Cause of Death in Women 45 – 60 yrs

The elephant in the roomUSPSTF !!!

USPSTF Level of Certainty

USPSTF Recommendation Grades

USPSTFScreening Guidelines

USPSTFScreening Guidelines

USPSTFReactions

• Detailed ACR statement on Ill advised and dangerous USPSTF mammography recommendations

• ACR , SBI statement on Annals of Internal Medicine Poll regarding flawed USPSTF mammography recommendations

• Why the critics of screening mammography are wrong

The Real Issue• Federal healthcare legislation mandates

preventive coverage without co-pays• To have this protection category A or B

recommendation is a must form USPSTF• The only screening service that qualifies

is “ biennial screening mammography b/w 50 and 74 yrs of age”

The Aftermath• Avon Foundation survey of grant recipients in

48 states✓BCCED / BCCS program changes 25%

states✓Elimination of mammograms < 50 yrs✓Fewer mammograms for older women

Result

Higher rate on interval cancers and larger cancers in indigent population

…so what do we do?...

• Since widespread use of screening mammography, breast cancer mortality has dropped 30%• Majority of breast cancer deaths are in women who never had a mammogram or had one >2 years ago

Consider Basic FactsI

• USPSTF focused on mortality outcome

studies, therefore

Ignore improved detection technology

Pre MQSA Act

Many contain 1 view mammogram

Consider Basic FactsII

Consider Basic FactsIII Digital versus Analogue Mammography

Pisano 2005

• In USA, as of August 1, 2009:

# of mammography sites

8711

Digital units

54%

New analogue unit purchases

<5%

Consider Basic FactsIV

• USPSTF considered anxiety related to false

positive mammograms in younger women

• Anxiety related to interval / advanced

cancers in unscreened population is not

discussed

Consider Basic FactsV

• USPSTF studies have 15% mortality

reduction in favor of screening in women

aged 39-49 years

• The comparisons are made between

“invited to screen vs. not invited” and NOT

between “screened and un-screened”

Consider Basic FactsVI

• Women 40 years or older yearly mammogram

• Women younger than 40 yearly mammogram

starting 10 years younger than the youngest first

degree relative with breast cancer

The Answer - AMA

Cancers caught early with screening…… 9 out of 10 are curable (like it never happened)

Death

Stage IV

Stage III

Stage II

Stage ILife

Cancer

Situation Analysis• Cancer picked up by screening

mammogram prolongs life

• Less than 1 in 4 women > 40 years old had

mammograms in 2009

• Less than 1 in 3 doctors recommended

appropriate breast screening

Who’s Job Is It?

• Primary Care Physician or Gynecologist orders the

mammograms (no physician order needed in Texas)

• If they miss you should request