screening for breast cancer jane e. méndez, md, facs associate professor of surgery boston...

Screening for Breast CancerScreening for Breast Cancer

Jane E. Méndez, MD, FACSAssociate Professor of Surgery

Boston University School of MedicineDecember 6, 2011

Breast Cancer

• Most common cancer in women• Breast cancer is the leading cause of death

among American women 40-55 years of age• 12% American women will be diagnosed with

breast cancer during their lifetime (1/8)• 3.5% will die of the disease• Incidence of breast cancer increases with age

2010 ACS Estimated Incidence and Cancer Deaths US *

ONS=Other nervous system.Source: American Cancer Society, 2010.

Women270,290 • 26% Lung & bronchus

• 15% Breast

• 9% Colon & rectum

• 7% Pancreas

• 5% Ovary

• 4% Non-Hodgkin lymphoma

• 3% Leukemia

• 3% Uterine corpus

• 2% Liver and bile duct

• 2% Brain/ONS

• 22% All other sites

• 28% Breast• 14% Lung & bronchus

• 10% Colon & rectum

• 6% Uterine corpus

• 4% Non-Hodgkinlymphoma

• 4% Melanoma of skin• 3% Kidney and renal pelvis • 3% Pancreas• 3% Ovary• 21% All Other Sites

Women739,940

When should mammography be used to screen for breast cancer?

1. After age 20

2. After age 30

3. After age 40

4. After age 50

5. After age 60

6. Never.

Current age Probability of Breast Ca in % the next 10 years is 1 in:

20 2, 044 0.05

30 249 0.40

40 67 1.49

50 36 2.77

60 29 3.45

70 24 4.16

American Cancer Society, Surveillance Research, 2001

Age specific probabilities of developing breast cancer

BreastCancer

Sporadic85%

Familial10%

Hereditary

5%

Breast Cancer

• Breast cancer mortality has been decreasing since 1990 by 2.3% per year overall and by 3.3% for women aged 40 to 50 years.

• This decrease is largely attributed to the combination of mammography screening with improved treatment

Copyright ©2010 American Cancer Society

From Jemal, A. et al. CA Cancer J Clin 2010;60:277-300.

FIGURE 5 Annual Age-Adjusted Cancer Death Rates* Among Females for Selected Cancers, United States, 1930 to 2006

Is Breast Cancer an Appropriate

Disease for Screening??

Is Breast Cancer an Appropriate Disease for Screening?

Long preclinical phase (2-4 years)

Screening techniques tolerable, relatively inexpensive (CBE, BSE, mammography)

Effective therapies exist for early stage disease

YES!

Screening Tools for Breast Cancer

• Self breast exam

• Clinical breast exam

• Mammography

American Cancer Society Guidelines • age 20-39 monthly breast self-exam

clinical breast exam every 3 years

• age 40+ monthly breast self-exam

annual clinical breast exam

annual mammogram

Breast Cancer

Breast Self exam

Breast familiarity

Changes

BREAST

For BSE, sensitivity ranges from 12% to 41%, lower than that of CBE and mammography, and is age-dependent

Clinical Breast Examination

Clinical breast examination has a sensitivity of 40% to 69% and a specificity in the range of 88% to 99%.

Mammography is the gold standard for breast cancer screening.

Are there any potential harms associated with these screening methods?

1. Yes

2. No

3. I don’t know; I wasn’t paying attention.

Benefits of Screening by Mammography

• Numerous randomized clinical trials demonstrate benefit of screening women older than age 49

• Reduction in breast cancer mortality

• Detection of cancers smaller than on CBE, more likely to respond to more conservative treatments (decreased morbidity)

Risks of Screening with Mammography

• Exposure to unnecessary radiation, risk greater in younger women and those with genetic predisposition

• Costs

• Unnecessary additional testing

• Psychological risk of screening, false assurance vs. false positive result

Breast Screening

• Anxiety • Distress• Other psychosocial effects

How good is mammography as a screening tool?

1. Perfect

2. Excellent

3. Good

4. Fair

5. Poor

Mammography as a Screening Tool

• 85% Sensitivity • 90% Specificity• Sensitivity lowered by increased breast density,

younger age, lower body mass index, second half of menstrual cycle, equipment, skill of interpreting radiologist

• False positive rate 6.5% (lower if comparison films)• Validity of mammography standardized per ACR

accreditation program

The BigSQUEEZE

Risks and Benefits

Case #1

Mrs. Jane Jones is a 28 year old woman who comes in today for her yearly routine examination. She has no history of medical problems, has two children and no physical complaints. She reports to you that an aunt on her mother’s side just died of breast cancer at the age of 59. Mrs. Jones is very worried and wants a mammogram immediately.

Is Mrs. Jones at Risk for Developing Breast Cancer?

How do you assess the How do you assess the Breast Cancer risk?Breast Cancer risk?How do you assess the How do you assess the Breast Cancer risk?Breast Cancer risk?

Exercise

Breast Cancer

Lifestyle ModificationsLifestyle Modifications

Recommended for ALL women Recommended for ALL women – Weight control– No cigarette smoking– Decreased alcohol consumption– Exercise– Avoid non-diagnostic, ionizing – radiation

Breast Cancer Risk Factors

• NonmodifiableNonmodifiable– Age>60 – Personal h/o Breast

CA– LCIS/ DCIS– Family History

(BRCA1,BRCA2)– Atypical hyperplasia– Radiation exposure

– Early menarche– Late menopause– Nulliparity– First live birth after age

30– Previous breast biopsy– High level of education/

socioeconomic status

Modifiable vs. NonmodifiableModifiable vs. Nonmodifiable

Breast Cancer Risk Factors

• ModifiableModifiableDiet

Sedentary lifestyle

Alcohol consumption

Environmental exposure

Estrogen replacement therapy

Risks of Screening with Mammography

• Exposure to unnecessary radiation, risk greater in younger women and those with genetic predisposition

• Costs• Psychological risk of screening, false assurance

vs. false positive result

Summary - Mrs. Jones

• 28 year old asymptomatic woman requesting a screening test for a serious disease.

• Her only risk factor is first degree relative with the disease, but prevalence of the disease is low in her age group.

• Test is valid, but sensitivity of test markedly decreased in her age group, and not recommended based upon current screening guidelines.

What to Offer?

• Reassurance that her risk of having or developing breast cancer in next ten years is very low

• Knowledge that screening test is not as effective in her age group and could lead to false sense of security and /or false positive result necessitating biopsy

• Possibility for genetic screening, given concern about family history

• Education on proper use of self breast exam and reminder for annual breast exams

www.superlaugh.com/fun/mammogram.jpg

Ms. Annie Hunter is a 43 year old woman with no significant past medical history who comes in to discuss the results of her mammogram, ordered by you as part of routine health care maintenance. The report notes a finding of an increased density in her left breast, category 3. There is no previous film for comparison and physical exam is normal. The recommendation, based upon the radiological criteria of this density, is that she should have a repeat mammogram in 6 months. She is extremely anxious, has been unable to sleep since receiving the original phone call from you, and wants a repeat mammogram monthly for next 6 months ‘just to be sure” its not cancer.

CASE #2

Was It Appropriate to Order a Mammogram for Ms. Hunter?

• No family history of breast cancer• No other risk factors• No significant past medical history

How to explain the findings? Could this be a cancer?

• Lead time bias

• DCIS (ductal carcinoma in situ) more frequently diagnosed by mammography

• Detection of this noninvasive lesion may not affect survival

Would you obtain a repeat mammogram in one month?

Would you obtain a repeat mammogram in one month?

• False positive rate of one mammogram 6.5%

• Cumulative probability of having a false positive mammogram is 56.2% after 10 mammograms

Summary- Case #2

• 43 year old premenopausal woman with a mammographic abnormality picked up on routine screening that has lead to significant degree of anxiety and unreasonable demands for further testing.

• She has no significant risk factors other than age (1:25 risk).

• Routine screen was appropriate given the current guidelines and prior informed discussion with the patient.

• Mrs. Eleanora Snow is a highly functional, 79 year old woman with a history of diabetes and hypertension who you have been following for a number of years. One year ago you discovered the presence of suspicious “microcalcifications” on her mammogram, but the patient refused to go for biopsy, as was recommended by the radiographic findings. She visits you today and now refuses to have a repeat mammogram, stating she does not wish to have any sort of invasive procedure on her body as she is about to turn 80.

CASE #3

Was it appropriate to perform screening mammography on Mrs. Snow last year?

Mammography in the Elderly

• Mammography in women 65-75 resulted in avoiding 2.2 breast cancer deaths per 1000 women screened vs. 1.9 deaths per women screened ages 50-64

• Importance of tailoring decision to screen based upon individual, functional status, co-morbid conditions

November 16, 2009

Breast Screening CONTROVERSY

Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force

Background: This systematic review is an update of evidence since the 2002 U.S. Preventive Services Task Force recommendation on breast cancer screening.

Purpose: To determine the effectiveness of mammography screening in decreasing breast cancer mortality among average-risk women aged 40 to 49 years and 70 years or older, the effectiveness of clinical breast examination and breast self-examination, and the harms of screening.

Nelson, Tyne et al, Annals Internal Medicine Nov 2009;151:727-37.

Controversy

• Women aged 40-49

• Women aged 70 and older

• Frequency of screening mammography in women aged 50-69

• American Cancer Society• American College of Radiology• American College of Surgeons• American Society of Breast

Surgeons• Susan G. Komen Breast

Cancer Foundation

Great opposition

Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society

Yearly mammograms are recommended starting at age 40. A clinical breast exam should be part of a periodic health exam, about

every three years for women in their 20s and 30s, and every year for women 40 and older.

Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.

Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

Copyright ©2010 American Cancer Society

From Jemal, A. et al. CA Cancer J Clin 2010;60:277-300.

FIGURE 5 Annual Age-Adjusted Cancer Death Rates* Among Females for Selected Cancers, United States, 1930 to 2006

Female Breast Cancer SEER Incidence Rates* by Race and Ethnicity, U.S., 1975–2005

Incidence source: Surveillance, Epidemiology, and End Results (SEER) Program, National Cancer Institute (NCI) 1975–1991 = SEER 9; 1992–2005 = SEER 13.

Female Breast Cancer U.S. Death Rates* by Race and Ethnicity, 1975–2005

Mortality source: U.S. Mortality Files, National Center for Health Statistics, CDC.

Percentage of U.S. Women Aged 40 Years and Older Who Have Had a Mammogram in the Last

2 Years by Race and Ethnicity

www.cancer.gov

Ward et al, CA Cancer J Clin 2004;54:78-93.

Breast Cancer Disparities by Race / Ethnicity and Socioeconomic Status

Best defense is to find breast cancer early

Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2004

*A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States.Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005.

0

10

20

30

40

50

60

70

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004

Year

Pre

va

len

ce

(%

) Women with less than a high school education

Women with no health insurance

All women 40 and older

Stage at Diagnosis by Race and Ethnicity, SEER 1996-2000

White 66 29 5

African American 55 36 9

Hispanic 57 35 7

Asian/ Pacific Is 63 30 5

Localized (%) Regional (%) Distant (%)

Ward et al, CA Cancer J Clin 2004;54:78-93.

Mammograms save lives – spread the word

Women who engage in regular mammogram tests has proven to be beneficial for many reasons. Here are just a few: The early detection of breast cancers by

mammograms can exponentially improve chances for successful treatment.

Mammograms are able to detect a lump up to 2 years before it can be discovered by a self examination.

Mammograms are able to detect 85 to 90 percent of breast cancers in women who are over 50 years old