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What’s new in Breast Disease
M. Whitney Parnell MD FACS
Surgical Associates of Myrtle Beach
Breast and General Surgery
Hot topics
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Dense Breasts
ABUS
3-D Mammography
BRCA1 BRCA2 and beyond
Prophylactic Surgery
Cancer Sub-typing (oncotype
DX/Mammoprint)
Dense Breasts
What does it mean to say dense breasts?
Who has dense breasts?
Are women with dense breasts at increased risk
of developing cancer?
What should we do differently?
Legislation
Breast Anatomy
 Fat and glandular tissue
 More glandular
tissue=denser breast
 Denser the breasts the
whiter the mammogram
 Mammogram may miss
up to 40% of cancers in
dense breasts
Dense Breasts
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Age
Hormone levels
Genetics
Age at first pregnancy
#of pregnancies
HRT
Mammograpy’s dirty little secret
 Up to 40% of cancer
can be missed on
standard
mammography in
dense breasts !
Dense breast Classifications
 Type 1—mostly fatty replaced
 Type 2 Average breast tissue 25-50%
 Type 3 Heterogenously dense 50-75%
 Type 4 Extremely dense >75% dense tissue
Dense Breast Classifications
Why Mammography?
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Inexpensive
Safe (low radiation)
Accessible
Sensitive and Specific
Effective in reducing
mortality from Breast
Cancer
 Since 1990’s there has
been a decrease in
mortality from breast
cancer 2.2%/year due
to screening
mammography
Breast Cancer Stats
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Most frequent dx non-skin cancer in Women
226,870 new cases/yr in US
63,000 new cases of DCIS
40,000 women die annually of breast cancer
Second leading cause of cancer death in
women
Breast Cancer Risk Factors
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Early menarche
Late Menopause
Nulliparous
HRT
Post-menopausal obesity
ETOH
Breast Density
Dense breasts=more Cancer?
 Dense breast are an independent risk cancer
for cancer development
 Mult retrospective studies show the odds ratios
for developing breast cancer in the least
dense compared with the densest breast
ranges from 1.9-6.0 (ave 4.0)
 Harvey et al. Radiology 2004
Early Detection
 Breast cancer is a progressive disease and
early detection offers women an opportunity
to halt the natural evolution of the cancer,
increases her treatment options, and ultimately
saves lives.
Why get a mammogram if I have
dense breasts?
 Mammogram is still the gold standard for
screening and it is an invaluable tool—
 Assessing interval change
 Architectural distortions
 Calcifications (i.e. DCIS—stage 0)
Other Imaging Modalities
 Breast Ultrasound
 MRI
 Digital breast tomosynthesis
Ultrasound
 Safe—no radiation
 Technologic advancements have improved
resolution
 Breast density is a non-issue
 Easy to perform
 Well tolerated by patient
 Invaluable asset to mammography
Improved Cancer Detection
 High risk women with dense breasts
 Improved cancer detection 13-28%
 Most cancers were early stage invasive node
negative cancer
 Kolbe et al Radiology 2002
 ACRIN 6666; JAMA 2008
Legislation
 Connecticut was first 2009—Public Act 09-41
 "If your mammogram demonstrates that you have dense
breast tissue, which could hide small abnormalities, you might
benefit from supplementary screening tests, which can
include a breast ultrasound screening or a breast MRI
examination, or both, depending on your individual risk
factors. A report of your mammography results, which contains
information about your breast density, has been sent to your
physician's office and you should contact your physician if you
have any questions or concerns about this report.
South Carolina
 Introduce bill Feb 2013
 Currently in the House Committee on Labor
Commerce and Industry
 Sponsored by Senator Joel Lourie
Breast Ultrasound
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Staffing/Time intensive with low reimbursement
Technician dependent
ACR/ACS lack guidelines
Adding u/s to mammography increases the
false positive rate 4X—ACRIN 6666: Jama 2008
ABUS
Automated Breast Ultrasound Screening
3mins per breast (19mins with u/s tech)
Full exam time 15 mins
Gives complete 3-D volumetric imaging of the
breast
 Approved in Sept 2012 “explicitly for breast
cancer screening for asymptomatic women
with dense breast tissue.”
 97% sensitive when used with mammograpy
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Breast MRI
 ACS guidelines Recommended for high risk
individuals annually with mammography
 Known BRCA 1 or 2 mutations
 First degree family member with genetic
mutation
 >20% lifetime risk based on Risk analysis models
 Chest wall radiation ages 10-30
 Li-Fraumeni, Cowden and Bannayan-Riely
Ruvalcaba syndromes and first degree relatives
Breast MRI
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Expensive
Requires contrast agent (baseline creatinine)
Uncomfortable (prone position)
Lacks insurance mandate
Lacks specificity
Time in the magnet
3-D Mammography
 Originally approved as add-on only
 FDA 2013-approved for use without standard
2-D mammography
 Provides images of the breast in “slices” from
many different angles
 Not always covered by insurance
 Machines cost 2x as much
3-D Mammography
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Higher cancer detection rate 4.1 vs 2.9/1000
Less call backs 91 vs 107/1000
Higher bx rate 19.3 vs 18.1
Higher radiation dose (both within safe limits)
Overseas use since 2008—restrict it to patients
with breast problems
 JAMA. 2014;311(24):2499-2507
Genetics
 BRCA1 and BRCA 2 are human genes that
produce tumor suppressor proteins
 Help repair damaged DNA
 With mutations of these genes—damaged
DNA is not repaired properly
 Responsible for 25% of genetic breast cancer
 5-10% of all breast cancer
 15% of ovarian cancer
Genetics
BRCA1
 55-65% will develop breast
cancer in their lifetime
 40% lifetime risk of ovarian
cancer
 Fallopian tube and
peritoneal cancer
 Prostate cancer
 Pancreatic cancer
BRCA2
 45% will develop breast
cancer in their lifetime
 12% lifetime risk of ovarian
caner
 Linked with male breast
cancer
 Prostate cancer
 Pancreatic cancer
Who should get tested?
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Breast cancer before 50
Cancer in both breasts
Breast and ovarian cancer
Personal or family hx of
Male breast cancer
 Triple negative breast
cancer before age 60
 Ashkenazi Jewish heritage
and family hx of breast or
ovarian cancer
 Ovarian cancer before 50
3 rules
 Multiple –combination of cancers in the same
side of the family
 Young--<50
 Rare—male breast; triple neg; colorectal or
endometrial cancer with abnormal MSI/IHC;
Expanded panel testing
 Identifies elevated risk of 8 cancers by
analyzing multiple clincally actionable genes
 Retrospective analysis of patients (2006-2013)
 6.9% of patients appropriate for HBOC testing
also meet Lynch criteria
 30% of patients appropriate for Lynch testing
also meet HBOC
Previvor
 Previvor - "Cancer previvors" are individuals
who are survivors of a predisposition to cancer
but who haven’t had the disease. This group
includes people who carry a hereditary
mutation, a family history of cancer, or some
other predisposing factor.
 Unaffected carrier
Angelina Jolie Effect
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Increased awareness
Increased inquiries into testing
Better lay understanding of genetic testing
Prophylactic Mastectomy
Prophylactic Mastectomy
 Risk reduction of 90+ %
 Still need to consider prophylactic
oophorectomy
 Nipple sparing techniques (1% less risk
reduction)
Molecular profiling
 Oncotype Dx
 Mammoprint
OncotypeDX
 Genomic test of the activity of a group of
genes
 How cancer may respond to treatment
 Early stage ER+ breast cancer recurrence and
?benefit from chemo
 DCIS—recurrence and or risk of new invasive
cancer developing and ?benefit from XRT
Summary
 Dense breasts Birads 3 and 4 benefit from
annnual screening ultrasound
 Consider genetic testing for multiple/
young/rare
 Nipple sparing prophylatic mastectomy option
 Cancer molecular profiling or subtyping
expanding—targeted therapy
Questions