breast cancer screening what’s new to know? the issue of breast density
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Breast Cancer Screening What’s New to Know? The Issue of Breast Density. Catherine Babcook MD Partner, Mountain Medical Physician Specialists Medical Director of Breast Imaging McKay Dee Hospital Center. Disclosure. - PowerPoint PPT PresentationTRANSCRIPT
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Breast Cancer ScreeningWhat’s New to Know?
The Issue of Breast Density
Catherine Babcook MDPartner, Mountain Medical Physician Specialists
Medical Director of Breast Imaging McKay Dee Hospital Center
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DisclosureThis presentation has no commercial content,
promotes no commercial vendor and is not supported financially by any commercial vendor.
I receive no financial remuneration from any commercial vendor related to this presentation.
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Screening Recommendations• ACS, ACR, ACOBGYN, Intermountain
HC– Annual mammographic screening
beginning at age 40
– Continue screening if a woman is in good health and has a life expectancy of 5 years or more
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Mammography Facts• < Screening 1980’s, the death rate for breast cancer in
the U.S. was unchanged for 50 years• Since 1990 the death rate from breast cancer has
decreased by 30%• In women ages 50-74, 15- 20% more lives saved by
screening every year instead of every two years When analyze appropriately performed RCTs and service
screening data - 30 to 40% decrease in mortality in the 40-49 year-old group.
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More Facts• Update of the Swedish Trials by Lazlo Tabar, when
“no shows” were placed in the control group, there was a 63% decrease in the death rate of the screened group.
• Anxiety of a false positive mammogram or invasive procedure - Recent study of 1171 women, 97% indicated a false positive result would not deter them from screening.
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Many Components of Cancer detection
• Woman has to get a screening mammogram
• Radiologist factors: Interpretation variability
• Woman factors: Breast density, implants
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Radiologist Factors
Recall Rate PPV1 PPV2 Cancer Detection Rate
ACR Guidelines
< 12% 5-10% 25-40% 2-10/1000
Interpretive Ability:
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Woman Factors
Clinically “dense” = Mammographically Dense
Breast Tissue – Pattern and Density:
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Breast Density on Mammography
• Density = How much White tissue
White tissue - glandularDark tissue – fat
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Breast DensityFatty Breast Extremely Dense Breast
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4 Categories of Density• Mammography Report
– Parenchymal Density:• Almost Entirely Fatty (< 25% Glandular )• Scattered Fibroglandular Densities (25-50%
Glandular)• Heterogeneously Dense (51-75% Glandular)• Extremely Dense (> 75% Glandular)
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Almost Entirely Fat (< 25% Glandular
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Scattered Fibroglandular Densities (25-50% Glandular)
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Heterogeneously Dense (51-75% Glandular
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Extremely Dense (>75% Glandular
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Why Does it Matter?• Cancer is WHITE on
mammograms• Amount of WHITE glandular
tissue impacts visibility of WHITE cancer
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Mass visibility on Mammo
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Dense Tissue – White Cancer
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Dense Tissue – White Cancer
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Cancer Can be Hidden by Glandular Tissue on Mammo
• ‘Snowflakes in a snowball’, ‘polar bear in a snowstorm’
• What do we do:– Wait until it’s big enough to feel– Add a test that improves cancer
detection in white glandular tissue
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White on White Mammo Cancer Problem
• Mammographic Sensitivity Varies with Breast Density– Fatty – 85%– Dense – 70% with Digital Mammo
• NOT USELESS BY A LONG WAY
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Density Issue Not New• Awareness of Density Issue Is New
– Nancy Cappello PhD– Dx with advanced stage breast cancer after years
of normal annual screening mammography from age 40
– 34 yrs as an educator, administrator and state dept. consultant in Connecticut
– “Nancy’s Law” 2009; Areyoudense.org
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Magnitude of Density Issue
• 40% of Women have dense breasts– 65% of premenopausal women– 25% of postmenopausal women
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Adjunctive Screening Tests
• Tomosynthesis – Oslo,N=13000,27% CA,15% FP• Longer compression, increased dose, exp. capital, no reimbursement, doubled
interpretation time
• Whole Breast Ultrasound: handheld, automated
• MRI – not indicated for density alone, cost, annual gadolinium risk, FP
• BSGI – expensive capital, space, sig additional dose, no reimburse
• PEM – expensive capital, space, sig additional dose, no reimburse
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Breast Ultrasound
• Glandular Tissue is WHITE on ultrasound just like mammography
• Cancer is DARK on ultrasound
Contrast advantage
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Cancer on UltrasoundNot visible in dense tissue on mammo Visible dark cancer on
ultrasound
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Cancer on UltrasoundNot visible in dense tissue on mammo Visible dark cancer on
ultrasound
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Screening Breast Ultrasound
– Kolb et al Radiol 2002;225(1):165-175– Crystal et al AJR 2003;1818(1):177-182– Gordon et al Cancer 1995:76(4):626-630– Kaplan Radiology 2001;221 (3):641-649– All criticized:
• Single center studies• Retrospective studies• Not blinded to mammo findings etc.
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Screening Breast US Studies
• ACRIN 6666: N= 2600, Berg et al 2008 JAMA, Vol 299(18)2151-2163
– 60 % increase in cancer detection over mammo alone– Low PPV for biopsy: 11%, mammo 25-40%, – radiologist handheld scanning, too much time to be practical– No documentation to allow for future comparison
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Automated Whole Breast US
• Efficient – rad not scanning, tech not interpreting
• Large Volume of patients• Standardized, reproducible• Comparison capability
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AWBU Studies• Kelly et al 2010 Eur Radiology 20:734-742
• N= 4500• 23 additional Cancers found on US• 100% Increase in cancer detection• 22/23 invasive cancers, ave size 0.9
cm
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AWBU Studies: Kelly et al 2010 Eur Radiology 20:734-742
• Mammography alone found 23 • AWBU found 38 • 23 mammographically occult• Recall Rate: ACR < 10% for Mammo
– Mammo 4.2%– AWBU 6.5%
• Positive Predictive Value Bx (PPV) ACR 25-40%– Mammo 39%– AWBU 38.4%– AWBU + Mammo 62.5%
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AWBU Studies
• USys FDA study submission:– 30% increase in cancer detection over
mammography alone– RSNA presentation: 25% increase in CA
detection
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AWBU: Our Experience
• 15,000 Screening Mammograms/yr– 5 cancers/1000 women screened
• 600 AWBU/yr– 4/600 ~ 6/1000 additional cancers
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Cases – 51 year old
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Cases – 51 year old
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Cases – 53 year oldMammo AWBU
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Dense Breast Tissue 40% of Women
40% x 15,000 scr mammos = 6000 eligible women seen at McKay Dee Breast Center
600 AWBU exams/yr.
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Breast Density and AWBU
• Women don’t have to get it• Not covered by insurance – $275, $200
– Flex spending acct etc.
• Women do need to be informed – our job• Women need the opportunity to make
the choice