Female Breast Cancer Death Rates/100,000 Women, Age Adjusted, by State, 2011†

†Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2011 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2014. Available at: http://www.cdc.gov/uscs. (full site)

20 30 40 50 60 70 Lifetime0

2

4

6

8

10

12

14

0.06 0.441.44

2.393.4 3.73

12.08

Age specific probability of developing invasive breast cancer (%)

The Probability of Developing Breast Cancer in the Next 10 Years

Breast Cancer Screening

Tumors detected at an early stage that are small and confined to the breast are more likely to be successfully treated◦ 98% 5-year survival for localized disease

89% of tumors measuring 1 cm or less cured by primary surgery (mastectomy and axillary dissection)

90% of patients 10+year disease free survival periods after tumors measuring 1 cm or less were detected by mammography

Rationale for Mammogram Screening

Twenty five year follow-up for breast cancer incidenceand mortality of the Canadian National BreastScreening Study: randomized screening trialOPEN ACCESS

Anthony B Miller professor emeritus 1, Claus Wall data manager 1, Cornelia J Baines professoremerita 1, Ping Sun statistician 2, Teresa To senior scientist 3, Steven A Narod professor 1 21Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada; 2Women’s College Research Institute, Women’sCollege Hospital, Toronto, Ontario M5G 1N8, Canada; 3Child Health Evaluative Services, The Hospital for Sick Children, Toronto, Ontario, Canada

BMJ 2014;348:g366 doi: 10.1136/bmj.g366

Conclusion : Annual mammography in women aged 40-59 does notreduce mortality from breast cancer beyond that of physical examinationor usual care when adjuvant therapy for breast cancer is freely available.Overall, 22% (106/484) of screen detected invasive breast cancers wereover-diagnosed, representing one over-diagnosed breast cancer forevery 424 women who received mammography screening in the trial.

Other studies have shown decreased mortality

Did not look at differences in treatment morbidity

Other Studies

Mammogram CBE SBE

Best Recommendations for Breast Cancer Screening

National Breast and Cervical Cancer Early Detection Program◦ 752,081 clinical breast examinations in women

age 40 and older◦ CBE alone

Sensitivity 58.8% Specificity 93.4%

◦ 5 cases of cancer/1000 CBE◦ If mammogram normal 7.4 cancers/1000 CBE◦ Modest improvement in detection

Clinical Breast Examination

When to Start Mammograms 40

◦ Risk of cancer in next 10 years comparable to 50 (1.4 v 2.4/1000)

◦ Mortality reduction similar to 50 (16% v. 15%)

◦ 50,000 new breast cancers annually in US in women under 50

50◦ USPSTF◦ Screening younger than

50 should be individualized based on “patient values regarding specific benefits and harms”

Breast Cancer Screening Recommendations 

MammographyClinical Breast Examination

Breast Self-Examination Instruction

Breast Self-Awareness

American College of Obstetricians and Gynecologists

Age 40 years and older annually

Age 20-39 years every 1-3 years

Consider for high-risk patients

Recommended

Age 40 years and older annually

American Cancer Society

Age 40 years and older annually

Age 20-39 years every 1-3 years

Optional for age 20 years and older

Recommended

Age 40 years and older annually

National Comprehensive Cancer Network

Age 40 years and older annually

Age 20-39 years every 1-3 years

Recommended Recommended

Age 40 years and older annually

National Cancer Institute

Age 40 years and older every 1-2 years

Recommended Not Recommended

—

U.S. Preventative Services Task Force

Age 50-74 years biennially

Insufficient evidence

Not Recommended

—

False Positive◦ Up to 20-30% of mammograms will require more

evaluation to reach diagnosis Diagnostic mammograms with supplementary views Ultrasound Biopsy

Radiation Risks False Negative

◦ Up to 10% of breast cancers will not be found on mammogram

Potential Harms of Mammography

Ultrasound◦ Can be adjunct to mammogram

MRI◦ High risk women

BRCA gene mutation First degree relative with BRCA mutation and has not had

testing Lifetime breast cancer risk >20% Radiation therapy to the chest between ages of 10-30 Other specific genetic syndromes

PET, Thermography, etc.◦ Selected clinical situations or adjunct to mammogram◦ Not for screening

Other Imaging

Ovarian Cancer Screening Ovarian cancer has a

low prevalence 1 case per 2,500

women per year

If a screening test had 100% sensitivity and 99% specificity◦ Positive predictive value

would be 4.8% ◦ 20 of 21 women

undergoing surgery would not have primary ovarian cancer

Potential Screening Tools in Low-Risk Women Transvaginal

Ultrasound Tumor markers

◦ CA 125◦ OVA 1

78,216 women randomly assigned to either annual screening with CA-125 and transvaginal ultrasound (n=39,105)or usual care (n-39,111)

From: Effect of Screening on Ovarian Cancer Mortality:  The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled TrialJAMA. 2011;305(22):2295-2303. doi:10.1001/jama.2011.766

From: Effect of Screening on Ovarian Cancer Mortality:  The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled TrialJAMA. 2011;305(22):2295-2303. doi:10.1001/jama.2011.766

Conclusion Obstetrics

◦ Don’t induce labor unless it is warranted Gynecology

◦ Screen appropriate women at the appropriate age with the appropriate screening test

Breast cancer specific mortality, by assignment to

mammography or control arms (all participants)

Breast cancer specific mortality from cancers diagnosed in screening period, by

assignment to mammography orcontrol arms

q3y q2y Annual0

500

1000

1500

2000

2500

760

1080

2000

Colposcopies/1000 women

Lifetime risk of colposcopy

Mammogram/Palpable

Palpable Mammogram/ only50

55

60

65

70

75

80

85

66.3

62.8

79.6

%

25 year survival (%)