1. Breast Cancer Screening Where do we stand? Rakhshanda Layeequr Rahman MD Director, TTUHSC Amarillo Breast Center of Excellence Division of Surgical Oncology

2. How Big a Deal Is It? US New Breast Cancer200,000/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

3. The elephant in the room USPSTF !!!

4. USPSTF Level of Certainty

5. USPSTF Recommendation Grades

6. USPSTF Screening Guidelines

7. USPSTF Screening Guidelines

8. USPSTF Reactions 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

9. 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”

10. The Aftermath Avon Foundation survey of grant recipients in 48 states ✓ BCCED / BCCS program changes25% states ✓ Elimination of mammograms < 50 yrs ✓ Fewer mammograms for older women Higher rate on interval cancers and larger cancers in indigent population

11. …so what do we do?...

12. 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 Facts I

13. USPSTF focused on mortality outcome studies, therefore Ignore improved detection technology Pre MQSA Act Many contain 1 view mammogram Consider Basic Facts II

14. Consider Basic Facts III Digital versus Analogue Mammography Pisano 2005

15. In USA, as of August 1, 2009: # of mammography sites8711 Digital units54% New analogue unit purchases<5% Consider Basic Facts IV

16. 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 Facts V

17. 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 Facts VI

18. Women 40 years or olderyearly mammogram Women younger than 40yearly mammogram starting 10 years younger than the youngest first degree relative with breast cancer The Answer - AMA

19. Cancers caught early with screening… … 9 out of 10 are curable (like it never happened) Death Stage IV Stage III Stage II Stage I Life

20. 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

21. 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