1. Screening for Breast Cancer Jane E. Méndez, MD, FACS Associate Professor of Surgery Boston University School of Medicine December 6, 2011

2. 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

3. 2010 ACS Estimated Incidence and Cancer Deaths US * ONS=Other nervous system. Source: American Cancer Society, 2010. Women 270,290 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-Hodgkin lymphoma 4%Melanoma of skin 3% Kidney and renal pelvis 3%Pancreas 3% Ovary 21%All Other Sites Women 739,940

4. 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.

5. Current age Probability of Breast Ca in %the next 10 years is 1 in: 20 2, 0440.05 30 2490.40 40 671.49 50 362.77 60 293.45 70 244.16 American Cancer Society, Surveillance Research, 2001 Age specific probabilities of developing breast cancer

6. Breast Cancer Sporadic 85% Familial 10% Hereditary 5%

7. 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

8. 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

9. Is Breast Cancer an Appropriate Disease for Screening? ?

10. 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!

11. Screening Tools for Breast Cancer Self breast exam Clinical breast exam Mammography

12. 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

13. Breast Self exam Breast familiarity Changes

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

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

16. Mammography is the gold standard for breast cancer screening.

18. Are there any potential harms associated with these screening methods? 1.Yes 2.No 3.I don’t know; I wasn’t paying attention.

19. 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)

20. 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

21. Breast Screening Anxiety Distress Other psychosocial effects

22. How good is mammography as a screening tool? 1.Perfect 2.Excellent 3.Good 4.Fair 5.Poor

23. 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

24. The Big S Q UEEZE

25. Risks and Benefits

26. 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.

27. Is Mrs. Jones at Risk for Developing Breast Cancer?

28. How do you assess the Breast Cancer risk?

31. Exercise

35. Breast Cancer Lifestyle Modifications Recommended for ALL women –Weight control –No cigarette smoking –Decreased alcohol consumption –Exercise –Avoid non-diagnostic, ionizing –radiation

36. 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. Nonmodifiable

37. Breast Cancer Risk Factors ModifiableModifiable Diet Sedentary lifestyle Alcohol consumption Environmental exposure Estrogen replacement therapy

38. 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

39. 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.

40. 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

41. www.superlaugh.com/fun/mammogram.jpg

42. 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

43. 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

44. 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

45. Would you obtain a repeat mammogram in one month?

46. False positive rate of one mammogram 6.5% Cumulative probability of having a false positive mammogram is 56.2% after 10 mammograms

47. 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.

48. 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

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

50. 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

51. November 16, 2009 Breast Screening CONTROVERSY

52. 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.

53. Controversy Women aged 40-49 Women aged 70 and older Frequency of screening mammography in women aged 50-69

54. American Cancer Society American College of Radiology American College of Surgeons American Society of Breast Surgeons Susan G. Komen Breast Cancer Foundation Great opposition

55. 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.

56. 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

57. 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.

58. 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.

60. 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

61. Ward et al, CA Cancer J Clin 2004;54:78-93. Breast Cancer Disparities by Race / Ethnicity and Socioeconomic Status

62. Best defense is to find breast cancer early

63. 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. Women with less than a high school education Women with no health insurance All women 40 and older

64. Stage at Diagnosis by Race and Ethnicity, SEER 1996-2000 White66295 African American55369 Hispanic57357 Asian/ Pacific Is63305 Localized (%) Regional (%) Distant (%) Ward et al, CA Cancer J Clin 2004;54:78-93.

65. 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