BREAST CANCER UPDATE DETECTION TO DIAGNOSIS Vincent M. Scarpinato, M.D., F.A.C.S. Senior Medical Director Department of Surgery Southern Ohio Medical Center October 2009

BREAST CANCER Most commonly diagnosed cancer in women (excluding skin cancer) Second most common cause of cancer related deaths (second to lung cancer) Early Detection = Improved Survival

Breast Cancer Statistics 1960: 1/20 2008: 1/8 (12%) Breastcancer.org

Breast Cancer Statistics 2006 212,920 cases of Invasive Breast Cancer 61,980 cases of Noninvasive (“In Situ”) Breast Cancer 40,970 Deaths Breast Cancer Facts & Figures 2005-2006 (ACS)

Breast Cancer Statistics 2009 192,370 cases of Invasive Breast Cancer (212,920 in 2006) 62,280 cases of In Situ Breast Cancer (61,980 in 2006) 40,170 Deaths (40,970 in 2006) Breast Cancer Facts & Figures 2008-2009 (ACS)

Breast Cancer Deaths Steady decrease in death-rate since 1990 Earlier detection Increased awareness Improved screening/diagnostics Improved treatment modalities

Breast Cancer Therapy Evolution Halsted: “If some is good, more is better” Radical Mastectomy Fisher: “Less is more” Lumpectomy/Complete Axillary Node Dissection Plus Whole Breast Irradiation = Mastectomy Today: “Less and less is more” Lumpectomy/Sentinel Lymph Node Biopsy Plus Partial Breast Irradiation (PBR) = Mastectomy

DETECTION SCREENING MAMMOGRAPHY Baseline Study 35-40 Earlier Family History (1st Degree) Yearly after age 40 ACS/Am Col Surg

DETECTION “BI-RADS” Classification Breast-Imaging Reporting and Data System (BI-RADS) American College of Radiology (ACR) Risk Assessment Categories (7)

BI-RADS CLASSIFICATION CATEGORY DIAGNOSIS CRITERIA Incomplete More imaging required Rec: Additional Studies 1 Negative No abnormal findings Rec: Routine Screening 2 Benign Clearly Benign findings Rec: Routine Screening 3 Probably Findings have a High Prob of being Benign (>90) Rec: 6 month F/U

BI-RADS CLASSIFICATION CATEGORY DIAGNOSIS CRITERIA 4 Suspicious Abnormality Suspicious but not fully characteristic of malignancy Rec: Consider Biopsy 5 Highly Suspicious Abnormality High Prob of being malignant (>95%) Rec: Biopsy 6 Biopsy Proven Malignancy Known Malignancy being imaged prior to treatment

Breast Biopsy Options “Open”/Surgical Biopsy “Closed”/Percutaneous Incisional Excisional “Closed”/Percutaneous Fine needle aspiration (FNA) Core Biopsy/”Tru-cut” Vacuum Assisted/Rotational Biopsy

Palpable Breast Biopsy Options

Non-Palpable Breast Biopsy Options Image Guided: “Radiologically Assisted” Ultrasound Mammographic/Stereotactic CT MRI

Fine Needle Aspiration “FNA”

Ultrasound Guided FNA Cyst Aspiration “FNA”

Core Biopsy Devices

Ultrasound Guided Breast Biopsy Solid Lesions

Ultrasound Guided Breast Biopsy Malignant Lesion

Ultrasound Guided Breast Biopsy

Ultrasound Guided Breast Biopsy Core Biopsy of Solid Lesion

Mammographic/Stereotactic Bx Microcalcifications

Mammographic/Stereotactic Bx Microcalcifications/Magnification View

Mammographic/Stereotactic Bx

Stereotactic Bx Specimen Xray

Mammographic/Stereotactic Bx Clip Application/Postprocedure

Post procedure Mammogram

Mammographic Wire Localizing Breast Lumpectomy

Mammographic Wire Localizing Breast Biopsy

Mammographic Wire Localizing Breast Biopsy

INTRAOPERATIVE ULTRASOUND Guided Wire Localizing Lumpectomy For nonpalpable lesion Seen sonographically Intraoperative Wire Placement under Ultrasound guidance Partial Mastectomy/ “Lumpectomy”

CT GUIDED LOCALIZATION

CT GUIDED LOCALIZATION

CT GUIDED LOCALIZATION

MRI Breast

MRI GUIDED LOCALIZATION or BIOPSY

MRI of the Breast CONS PROS More Expensive (much more!) Claustrophobia False Positives Leads to many more biopsies Leads to more mastectomies J Am Col Surg Oct 2009 PROS More sensitive than ultrasound More sensitive than mammogram More sensitive than physical exam Better in younger pts (dense tissue)

MRI of the Breast May be helpful… Assessing extent of disease Additional foci Axillary metastasis Contralateral disease Response to chemotx (neoadjuvant) Residual disease postop Breast augmentation

MRI of the Breast ?Screening Lifetime Breast Cancer Risk (predictive models) 20 – 25%. BRCA1 or BRCA2 mutations Chest Wall Radiation ages 10-30 Congenital Syndromes: Li-Fraumeni, Cowden, etc. ACS Guideleines for Breast Cancer Screening CA Cancer J Clin 2007;57:75-89

USA 2009 1,000,000 BREAST BIOPSIES ANUALLY 80% BENIGN 35% OF MALIGNANCIES ARE (STILL) DIAGNOSED WITH OPEN BX 30% “unnecessary” mastectomies The Breast Journal, Volume 15 Number 1, 2009 93–10041% receive “unnecessary” mastecto~41% receive “unnecessary” mastectomy

Percutaneous Histology (vs Open/Surgical Biopsy) Represents “Best Practice” and should be…. “Gold Standard” over open biopsy Should be <5-10% open biopsies Consensus Conference III Jo Am Co Surg Oct 2009

Recommendations after Percutaneous Needle Biopsy Benign/Concordant Benign/Discordant Observation (Routine Screening) Surgery High Risk Histology (ADH,Radial Scars, Papillary) Malignant Surgery Surgery

Clinical Quality Dashboards (Detection to Diagnosis) Time from reporting abnormal screening to diagnostic mammogram (average: 20 days) Time from reporting diagnostic mammogram to biopsy (average: 20 days) Time from reporting of biopsy results to surgery (8.1-16.9 days) Oncology Roundtable

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