1. What’s Next After an Abnormal Screening Mammogram? James A. Stewart, M.D. Beth Burnside, M.D. May 19, 2004

2. Goals for Today Review selected issues in breast screening Describe the current and planned services at UW Breast Center Discuss communication flow

3. Rate per 100,000 Female Population Year Adapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:26. 0 10 20 30 40 Uterus † Breast Pancreas Ovary Stomach Lung & bronchus Colon & rectum 193019401950196019701980 1990 Evolution of cancer death rates, females

4. Why Reduction in BC Mortality ? Time of diagnosis (screening) Optimal “loco-regional” treatment –Surgery and Radiation Adjuvant chemo and endocrine Rx Treatment of overt systemic disease Swiss show same curves but <1/2 the mammography use Goldhirsch et al Annals of Oncology 14:1212, 2003

5. Case Scenarios 1.First impression? 2.Barriers? 3.Research question?

6. 28yo woman with a family history of breast cancer wants to start routine mammography: ( 1 ST impression, barrier?, research?) 1.Just what is the family history? Is it suggestive of a BRCA family? 2.Will the radiologist do it? Is that the best test 3.I wish the researchers would identify people who won’t get breast cancer.

7. 84yo woman who asks about continuing her regular mammography ( 1 ST impression, barrier?, research?) 1.How long is she likely to live? 2.What if the radiologist finds a very small cluster of calcifications? 3.I need a better way of “summing” her co-morbidities to plan her care.

9. Wisconsin Comorbidity Assessment Scale (WCAS) Comorbid Conditions Cognition / Mood Physical Function Assessment Instrument Validation Medication and Polypharmacy Falls/ Mobility

10. The Future of Residents’ Education in Internal Medicine ….evidence-based medicine, and judicious use of technology will be essential skills of the future ….management of large volumes of data with an ever-changing scientific knowledge base. LG Smith, et al AJM, May 1, 2004

11. Test and technology oriented culture Who puts things in context and gives advice?

12. The best communicators?

15. Computerized Health Enhancement Support System (CHESS) Breast

16. Breast Imaging Training: Who Will Sign Up? Promotion and increase compliance If > 40 mammo rate 29  67% (‘87-’98) Reimbursement, wait times, litigation Survey of 211 programs Majority of residents had Negative Attitude Malpractice exposure a leading reason Bassett, et al Radiology, June 2003

17. 132 residents who would not choose breast imaging fellowship if offered

18. Breast Spectroscopy: PreChemo TE 144msTE 35ms Location of ROI Diffusion - Axial Maximal Slope of Increase

19. BSE in Shanghai Will intensive BSE instruction reduce breast cancer mortality? n = 266,064 women in 519 factories Accrual from 1989-91 (no mammograms) Randomize by factory Low back pain prevention BSE education with reinforcement Thomas et al, JNCI 2002;94

20. BSE Shanghai: Final Results (12/2000) BSE Control Breast Cancer Deaths 135 131 Number of Cancers 857 890 % Cancers Tis or T1 48.8% 44.8% Total biopsy specimens 3,620 2,395 Thomas et al, JNCI 2002; 94

21. Enthusiasm for Cancer Screening in the US National telephone survey n = 500 Finding cancer early saves lives (74%) 66% want testing even if nothing to do 73% would choose body CT over $1,000 in cash Schwartz LM et al, JAMA Jan 7, 2004

22. Screening as an Obligation Schwartz LM et al, JAMA Jan 7, 2004 41% for mammography In 80yo woman

23. Challenges Where to put our resources for reducing breast cancer burden The population is aging Application and communication of technology Screening strategies in general

24. UW Breast Center 1 st Quarter 2004 Screening Mammogram2619 Ultrasound 556 Stereotactic core biopsy 110