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