1. BREAST CANCER: Half a million women later… Amy Miglani M.D September 3, 2004

2. PERCEPTION VS. REALITY 46% women think they will get Breast Cancer 4% women will die from Breast Cancer 36% women will die from Heart Disease 4% women think they will get Heart Disease

3. STATISTICS In 2002: 205,000 women were diagnosed with Breast Cancer & 40,000 women died from Breast Cancer Breast Cancer is the leading cause of death in women 40-55 years 30 million mammograms done yearly; 66 million screens should be done

4. MAJOR RISK FACTORS Age Family History – especially premenopausal …think BRCA1/BRCA2 Personal History of Breast Cancer History of atypical hyperplasia on biopsy

5. MINOR RISK FACTORS Early menarche Late menopause Nulliparous >35yrs at first pregnancy ??HRT…

6. USPSTF- SCREENING MAMMOGRAPHY Screening mammogram with or without clinical breast exam, every one to two years for women aged 40 and older.

7. CLINICAL CONSIDERATIONS Evidence is strongest for women 50-69 Between 40-49, absolute benefit is less Older than 70, screening has an unclear effect on mortality When to stop screening becomes a judgement call.

8. USPSTF- CLINICAL BREAST EXAM Evidence is insufficient to recommend for or against clinical breast exam alone to screen for breast cancer

9. CLINICAL CONSIDERATIONS Most studies included both mammography and CBE, unclear what incremental benefit CBE adds National Breast and Cervical Cancer Early Detection Program- CBE detects 5% of cancers not visible on mammography

10. USPSTF- SELF BREAST EXAM Evidence is insufficient to recommend for or against teaching or performing routine breast self-examination

11. AN ABNORMAL MAMMOGRAM… WHAT NEXT? BI-RADS Categories 1: Negative 2: Benign 3: Probably Benign 4: Suspicious 5: Highly suggestive of malignancy 0: Incomplete

12. AN ABNORMAL MAMMOGRAM Negative/Benign- Routine screening, no intervention Probably Benign (3)- 6mo follow up diagnostic mammogram Suspicious/Highly Suggestive- Clinical exam. → PALPABLE- FNA or Core Biopsy NON-PALPABLE- U/S or stereotactic guided FNA or Core Biopsy

13. DOCTOR, I FEEL A LUMP… WOMEN WITH PALPABLE MASSES Breast Cancer was found in 11% of women complaining of a lump History: Location, How long, Nipple discharge, Size change, relation to menstrual cycle Physical: Single, Hard, Immovable, Irregular borders, >2cm

14. PALPABLE MASS When the woman is <35 yrs… 1) Without evidence of malignancy, have patient return in 3-10d after next menses to see if it regresses 2) If feels cystic → FNA Clear/Green Fluid- Reassurance and f/u in 4 weeks Bloody Fluid- Cytology 3) If doesn’t feel cystic → Ultrasound Solid mass- FNA, Core Needle Biopsy, or Excisional Biopsy

15. PALPABLE MASS When the woman is >35… 1) Diagnostic Mammography Negative/Benign- Repeat clinical exam Probably Benign- Ultrasound Suspicous/Suggestive-F/U with surgeon for tissue sample

16. ULTRASONOGRAPHY Determines whether breast mass is a simple or complex cyst or a solid tumor. It is most useful for… -Women <35 -If a mass on screening mammo can’t be felt -Pt declines FNA of mass -Mass is too small or too deep for FNA

17. FINE NEEDLE ASPIRATION Used to determine if a palpable lump is a simple cyst -22-24 gauge needle -+/- local anesthesia -Can be therapeutic if all fluid is removed -Clear/Green Fluid- reassure patient -Bloody Fluid- Cytology, 7% cases are cancer

18. CORE NEEDLE BIOPSY Since surrounding tissue is obtained, it is useful for distinguishing atypical hyperplasia and ductal carcinoma in situ from invasive disease. -14-18 gauge needle -Most often for evaluating non-palpable lumps with stereotactic or ultrasound guidance

19. GENETICS Inherited alterations in genes BRCA1 and BRCA2 are involved in many cases of hereditary breast cancer. Women with these mutations are 3-7 times more likely to develop premenopausal breast cancer than those without the mutations

20. WHO SHOULD BE TESTED? In 2003, the American Society of Clinical Oncology recommended testing when 1) There is family history suggesting genetic cancer susceptibility 2) The test can be adequately interpreted 3) The results will aid in the diagnosis and management of patient/family at hereditary risk of cancer

21. OPTIONS IF POSITIVE Prophylactic Mastectomy Intensive Surveillance Chemoprevention with Tamoxifen

22. BREAST CANCER AND HRT Women’s Health Initiative The risk of invasive breast cancer was significantly increased with combined hormone replacement. HRT and a positive family history appear to be synergistic risk factors. Women with both have a RR=3.4