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• Disclosure
– I am human and I have biases.
– I am a breast cancer survivor.
– I make my living in breast imaging and diagnosis.
– I have met and come to know a few of the experts
embroiled in the CNBSS controversy in my former
university capacity in Texas.
– I am a radiologist. I am not an epidemiologist, an
oncologist, or a surgeon.
• The practice of medicine is a
human endeavor that uses science
as a tool.
SCIENCE………….DOCTOR……………PATIENT
• Breast cancer mortality is DOWN ~ 30%
• Mammography is not perfect, but it is the
BEST tool we have for screening to detect
early clinically occult breast cancer.
• YET----BREAST CANCER SCREENING IS ABOUT
TO BE CUT BACK
• Why all the fuss?
• USPSTF is about to finalize their new
guidelines for breast cancer screening
– (2014: Now “finalized” and incorporated into
ObamaCare)
• Major influences include:
– Canadian National Breast Screening Study 25
years later
– Economic factors
A Sampling of Controversy…
• Reduction in breast cancer mortality
– Screening Mammography?
– Better Treatment?
– (Evolving Knowledge….?)
•
•
•
•
•
Overdiagnosis?
Overtreatment?
Stage Shift?
Does mammography help in women <50yrs?
Does screening mammography cause harm?
Costs of Breast Cancer Diagnosis
• Median Cost of Screening a Woman for Breast
Cancer:
$94
• Median Cost Per Breast Cancer Detected:
• $10,566
Ekwueme DU, Gardner JG, et al: Cost analysis of the National Breast and
Cervical Cancer Early Detection Project: selected states, 2003 – 2004. Cancer
2008 Feb 1,112(3):626-35.
A Sampling of the Economic Factors
• Screening Costs
• Workup Costs
– Approx 10 in 100
• Followup Costs
– Approx 5 in 100
• Biopsy Costs
– Approx 2 in 100
• Breast Cancer - approx 4/1000
Costs of Breast Cancer Diagnosis
• Median Cost of Screening a Woman for Breast
Cancer:
$94
• Median Cost Per Breast Cancer Detected:
• $10,566
Ekwueme DU, Gardner JG, et al: Cost analysis of the National Breast and
Cervical Cancer Early Detection Project: selected states, 2003 – 2004. Cancer
2008 Feb 1,112(3):626-35.
Breast Cancer Screening
(until now)
• Annual Clinical Breast Exam (CBE) by physician
or provider
• Monthly Breast Self Exam (BSE) by patient
beginning at age 20
• Annual Screening Mammography beginning at
age 40 on
USPSTF New Guidelines
• Biennial screening mammography for women
50-74 years
• Screening mammography under age 50
individual decision, considering patient
context and patient values regarding specific
benefits and harms
• Inconclusive evidence concerning benefits and
harms of screening mammography in women
age 75+
USPSTF New Guidelines, cont’d
• Recommend against teaching BSE
• Insufficient evidence to assess benefits or
harms of CBE beyond screening
mammography in women over age 40
• Insufficient evidence to assess benefits or
harms of screening with either digital
mammography or MRI
Clinical Breast Exam
• Consider
– Skin changes
• Puckering/retraction
• Focal redness…mastitis?....early inflammatory BC?
– Nipple changes
• Nipple erosion
• Nipple adenoma
• Nipple retraction
– Lymph nodes
Breast Self Exam
• At least 5% of breast cancers are ECCENTRIC
in location; ie, NOT visible within the tissue
seen on the standard mammogram images!
Accessory Breast Tissue
Breast Self Exam
• At least 5% of breast cancers are ECCENTRIC
in location; ie, NOT visible within the tissue
seen on the standard mammogram images!
• Aggressive cancers (30% of all cancers in
young women and 10% of all cancers in older
women) often arise BETWEEN SCREENING
EXAMS and will be detected on BSE!
Esserman L, Shieh Y, Thompson I: Rethinking Screening for Breast Cancer and Prostate
Cancer. JAMA 2009;302(15):1685-1692.
Tub
4%
Muc
2%
Med
2%
ILC
12%
Other Pap/ Apoc
2%
2%
IDC,NOS
36%
DCIS
16%
IDC HG 50+
6%
IDC HG <50
18%
Breast Cancer Subtypes
Appendix Table 3. USPSTF
Ave # Screening Exams & % Reduction in BC Mortality by Screening Strategy
Strategy
Ave Screens
Per1000 Wom
Efficient Strategies
Biennial 60-69
Biennial 55-69
Biennial 50-69
Biennial 50-74
Biennial 50-79
Biennial 50-84
Biennial 40-84
Annual 50-84
Reduction in Breast Cancer Mortality
D
E
G
M
S
W
4263
6890
8947
11066
12366
13837
18708
36550
11
15
16
22
25
29
31
38
13
18
23
27
29
31
37
49
11
15
17
21
24
25
28
32
10
14
16
21
24
27
29
29
9
13
15
20
25
26
27
35
12
19
23
28
30
33
39
54
17241
24419
29905
34078
27
32
35
34
35
39
41
46
26
27
28
30
26
26
28
27
25
30
33
33
36
42
45
51
Borderline Strategies
Biennial 40-79
Annual 50-79
Annual 50-84
Annual 40-79
Appendix Table 3. USPSTF
Ave # Screening Exams & % Reduction in BC Mortality by Screening Strategy
Strategy
Ave Screens
Per1000 Wom
Efficient Strategies
Reduction in Breast Cancer Mortality
D
E
G
M
S
W
Biennial 50-74
11066
22
27
21
21
20
28
Biennial 40-84
18708
31
37
28
29
27
39
Annual 40-84
36550
38
49
32
29
35
54
17241
27
35
26
26
25
36
Borderline strategies
Biennial 40-79
USPSTF Says
• Screening mammography under age 50:
individual decision, considering patient context
and patient values regarding specific benefits and
harms
• PROBLEMS:
– Breast cancer is a DEADLIER DISEASE in a younger
woman
– Breast cancer deaths affecting women ages 40-49 will
have a GREATER IMPACT on families, communities,
and society
– Approximately 70% of breast cancers occur in patients
with NO known risk factors
Percent of Deaths by Age Group:
Breast Cancer
SEER.cancer.gov/statfacts
USPSTF Says
• Inconclusive evidence concerning benefits and
harms of screening mammography in women
age 75+
• PROBLEMS:
– The whole point of breast cancer screening, in
older women (age 75+) is to MAINTAIN QUALITY
OF LIFE, not necessarily to “cure” her cancer
– Neglected breast cancer causes significant PAIN
• Concept of Overdiagnosis
– Based on expectation that increased diagnosis and
treatment of early stage breast cancers should
lead to fewer advanced breast cancers in later
years. This has NOT been observed.
• Remember--– Breast cancer is a biological process
Biological processes EVOLVE
--”Stage Shift” occurs due to technological advance
in detection of early mets in lymph nodes
apparent increase in “advanced” cancers
Overdiagnosis/Overtreatment?
• DCIS Controversy
– Low Nuclear Grade 1
– Intermediate Nuclear Grade 2
• Mixed cell types and grades
• Slow evolution----faster-----islands of INVASION
– 25% DCIS is High Nuclear Grade 3
– ALWAYS goes on to invasive ductal carcinoma
CNBSS: Overdiagnosis/Overtreatment
Miller AB, Wall c, Baines CJ, et al: Twenty five year follow-up for breast cancer incidence and
mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ
2014;348:g366.
Final Words on USPSTF
• Clearly oriented toward decreasing consumption
of resources now used in breast cancer screening
– Embraced (troubled) Mammography Results from
CNBSS
– IGNORED Breast Self Exam (BSE) and Clinical Breast
Exam (CBE) from same CNBSS study (!)
• Too involved in “Safe” Science; too little
consideration of the needs of the population they
serve
Our meta-analysis of mammography screening trials
indicates breast cancer mortality benefit for all age
groups from 39–69 years, with insufficient data for
older women. False-positive results are common in
all age groups and lead to additional imaging and
biopsies. Women age 40–49 years experience the
highest rate of additional imaging whereas their
biopsy rate is lower than older women.
Mammography screening at any age is a tradeoff of
a continuum of benefits and harms. The ages at
which this tradeoff becomes acceptable to
individuals and to society are not clearly resolved
by available evidence.
US Preventative Services Task Force: Screening for Breast Cancer:
Systematic Evidence Review Update for the US Preventive Services
Task Force [Internet]. Nelson HD, Tyne K, et al. Nov, 2009.
• The practice of medicine is a
human endeavor that uses science
as a tool.
Canadian National Breast Screening
Study (CNBSS)
GOLDEN OPPORTUNITY LOST
CNBSS: All Cause Mortality
Miller AB, Wall c, Baines CJ, et al: Twenty five year follow-up for breast cancer incidence
and mortality of the Canadian National Breast Screening Study: randomized screening
trial. BMJ 2014;348:g366.
CNBSS--Problems
• NOT PREPARED for demands of screening
– Images – technologists – radiologists – surgeons
• Randomization –
– Clinical breast exam BEFORE randomization
– 4x locally advanced cancers in 40-49 screening
group compared to controls
• Only 2 mm difference between mean tumor size in
control vs screening groups
Diagnostic “Chain” of Breast Cancer
• Image quality – Machine – Anode – Filter – Grid – Developer –
Positioning - - -
• Interpretation –
– Detection – Workup – Diagnosis – Biopsy
Guidance ?
• Surgical Assessment –
– Accuracy of Excision of Nonpalpable Tumors?