Download document

Screening for Breast Cancer
Jane E. Méndez, MD, FACS
Associate Professor of Surgery
Boston University School of Medicine
December 6, 2011
Breast Cancer
• Most common cancer in women
• Breast cancer is the leading cause of death
among American women 40-55 years of age
• 12% American women will be diagnosed with
breast cancer during their lifetime (1/8)
• 3.5% will die of the disease
• Incidence of breast cancer increases with age
2010 ACS Estimated Incidence and
Cancer Deaths US *
Women
739,940
• 28%
• 14%
Breast
Lung & bronchus
• 10%
Colon & rectum
Women
270,290
• 26% Lung & bronchus
• 15% Breast
• 9% Colon & rectum
• 7% Pancreas
• 6%
Uterine corpus
• 5% Ovary
• 4%
Non-Hodgkin
lymphoma
• 4% Non-Hodgkin
lymphoma
• 3% Leukemia
• 4%
• 3%
• 3%
• 3%
• 21%
Melanoma of skin
Kidney and renal pelvis
Pancreas
Ovary
All Other Sites
ONS=Other nervous system.
Source: American Cancer Society, 2010.
• 3% Uterine corpus
• 2% Liver and bile duct
• 2% Brain/ONS
• 22% All other sites
When should
mammography be used to
screen for breast cancer?
1.
2.
3.
4.
5.
6.
After age 20
After age 30
After age 40
After age 50
After age 60
Never.
Age specific probabilities
of developing breast cancer
Current age
%
20
30
40
50
60
70
Probability of Breast Ca in
the next 10 years is 1 in:
2, 044
249
67
36
29
24
American Cancer Society, Surveillance Research, 2001
0.05
0.40
1.49
2.77
3.45
4.16
Breast
Cancer
Sporadic
85%
Familial
10%
Hereditary
5%
Breast Cancer
• Breast cancer mortality has been decreasing
since 1990 by 2.3% per year overall and by
3.3% for women aged 40 to 50 years.
• This decrease is largely attributed to the
combination of mammography screening with
improved treatment
FIGURE 5 Annual Age-Adjusted Cancer Death Rates* Among Females
for Selected Cancers, United States, 1930 to 2006
From Jemal, A. et al.
CA Cancer J Clin 2010;60:277-300.
Is Breast Cancer
an Appropriate
Disease for
Screening?
Is Breast Cancer an Appropriate Disease
for Screening?
 YES!
 Long preclinical phase (2-4 years)
 Screening techniques tolerable, relatively
inexpensive (CBE, BSE, mammography)
 Effective therapies exist for early stage disease
Screening Tools for Breast Cancer
• Self breast exam
• Clinical breast exam
• Mammography
Breast Cancer
American Cancer Society Guidelines
• age 20-39
monthly breast self-exam
clinical breast exam every 3 years
• age 40+
monthly breast self-exam
annual clinical breast exam
annual mammogram
Breast Self exam
Breast familiarity
Changes
For BSE, sensitivity ranges from
12% to 41%, lower than that of
CBE and mammography,
and is age-dependent
BREAST
Clinical Breast Examination
Clinical breast examination has a sensitivity of 40% to 69%
and a specificity in the range of 88% to 99%.
Mammography is the gold standard
for breast cancer screening.
Are there any potential harms
associated with these
screening methods?
1.
2.
3.
Yes
No
I don’t know; I wasn’t paying attention.
Benefits of Screening by Mammography
• Numerous randomized clinical trials demonstrate
benefit of screening women older than age 49
• Reduction in breast cancer mortality
• Detection of cancers smaller than on CBE, more
likely to respond to more conservative treatments
(decreased morbidity)
Risks of Screening with Mammography
• Exposure to unnecessary radiation, risk greater
in younger women and those with genetic
predisposition
• Costs
• Unnecessary additional testing
• Psychological risk of screening, false
assurance vs. false positive result
Breast Screening
• Anxiety
• Distress
• Other psychosocial effects
How good is mammography
as a screening tool?
1.
2.
3.
4.
5.
Perfect
Excellent
Good
Fair
Poor
Mammography as a Screening Tool
• 85% Sensitivity
• 90% Specificity
• Sensitivity lowered by increased breast density,
younger age, lower body mass index, second half
of menstrual cycle, equipment, skill of interpreting
radiologist
• False positive rate 6.5% (lower if comparison
films)
• Validity of mammography standardized per ACR
accreditation program
The Big SQUEEZE
Risks and Benefits
Case #1
Mrs. Jane Jones is a 28 year old woman
who comes in today for her yearly routine
examination.
She has no history of
medical problems, has two children and
no physical complaints. She reports to
you that an aunt on her mother’s side just
died of breast cancer at the age of 59.
Mrs. Jones is very worried and wants a
mammogram immediately.
Is Mrs. Jones at Risk for
Developing Breast Cancer?
How do you assess the
Breast Cancer risk?
Exercise
Breast Cancer
Lifestyle Modifications
Recommended for ALL women
–
–
–
–
–
–
Weight control
No cigarette smoking
Decreased alcohol consumption
Exercise
Avoid non-diagnostic, ionizing
radiation
Breast Cancer Risk Factors
Modifiable vs. Nonmodifiable
• Nonmodifiable
– Age>60
– Personal h/o Breast
CA
– LCIS/ DCIS
– Family History
(BRCA1,BRCA2)
– Atypical hyperplasia
– Radiation exposure
–
–
–
–
Early menarche
Late menopause
Nulliparity
First live birth after age
30
– Previous breast biopsy
– High level of education/
socioeconomic status
Breast Cancer Risk Factors
• Modifiable
Diet
Sedentary lifestyle
Alcohol consumption
Environmental exposure
Estrogen replacement therapy
Risks of Screening with Mammography
• Exposure to unnecessary radiation, risk greater
in younger women and those with genetic
predisposition
• Costs
• Psychological risk of screening, false assurance
vs. false positive result
Summary - Mrs. Jones
• 28 year old asymptomatic woman requesting
a screening test for a serious disease.
• Her only risk factor is first degree relative with
the disease, but prevalence of the disease is
low in her age group.
• Test is valid, but sensitivity of test markedly
decreased in her age group, and not
recommended based upon current screening
guidelines.
What to Offer?
• Reassurance that her risk of having or developing
breast cancer in next ten years is very low
• Knowledge that screening test is not as effective in her
age group and could lead to false sense of security
and /or false positive result necessitating biopsy
• Possibility for genetic screening, given concern about
family history
• Education on proper use of self breast exam and
reminder for annual breast exams
www.superlaugh.com/fun/mammogram.jpg
CASE #2
Ms. Annie Hunter is a 43 year old woman with no
significant past medical history who comes in to discuss
the results of her mammogram, ordered by you as part
of routine health care maintenance. The report notes a
finding of an increased density in her left breast,
category 3. There is no previous film for comparison
and physical exam is normal. The recommendation,
based upon the radiological criteria of this density, is
that she should have a repeat mammogram in 6
months. She is extremely anxious, has been unable to
sleep since receiving the original phone call from you,
and wants a repeat mammogram monthly for next 6
months ‘just to be sure” its not cancer.
Was It Appropriate to Order a
Mammogram for Ms. Hunter?
• No family history of breast cancer
• No other risk factors
• No significant past medical history
How to explain the findings?
Could this be a cancer?
• Lead time bias
• DCIS (ductal carcinoma in situ) more
frequently diagnosed by mammography
• Detection of this noninvasive lesion may
not affect survival
Would you obtain a repeat
mammogram in one month?
Would you obtain a repeat mammogram in one
month?
• False positive rate of one mammogram
6.5%
• Cumulative probability of having a false
positive mammogram is 56.2% after 10
mammograms
Summary- Case #2
• 43 year old premenopausal woman with a
mammographic abnormality picked up on
routine screening that has lead to significant
degree of anxiety and unreasonable demands
for further testing.
• She has no significant risk factors other than
age (1:25 risk).
• Routine screen was appropriate given the
current guidelines and prior informed
discussion with the patient.
CASE #3
• Mrs. Eleanora Snow is a highly functional, 79 year
old woman with a history of diabetes and
hypertension who you have been following for a
number of years. One year ago you discovered the
presence of suspicious “microcalcifications” on her
mammogram, but the patient refused to go for
biopsy, as was recommended by the radiographic
findings. She visits you today and now refuses to
have a repeat mammogram, stating she does not
wish to have any sort of invasive procedure on her
body as she is about to turn 80.
Was it appropriate to perform
screening mammography
on Mrs. Snow last year?
Mammography in the Elderly
• Mammography in women 65-75 resulted in
avoiding 2.2 breast cancer deaths per
1000 women screened vs. 1.9 deaths per
women screened ages 50-64
• Importance of tailoring decision to screen
based upon individual, functional status,
co-morbid conditions
Breast Screening
CONTROVERSY
November 16, 2009
Screening for Breast Cancer: An Update for the
U.S. Preventive Services Task Force
Background: This systematic review is an update of
evidence since the 2002 U.S. Preventive Services Task
Force recommendation on breast cancer screening.
Purpose: To determine the effectiveness of
mammography screening in decreasing breast cancer
mortality among average-risk women aged 40 to 49
years and 70 years or older, the effectiveness of clinical
breast examination and breast self-examination, and
the harms of screening.
Nelson, Tyne et al, Annals Internal Medicine Nov 2009;151:727-37.
Controversy
• Women aged 40-49
• Women aged 70 and older
• Frequency of screening mammography
in women aged 50-69
Great opposition
•
•
•
•
American Cancer Society
American College of Radiology
American College of Surgeons
American Society of Breast
Surgeons
• Susan G. Komen Breast
Cancer Foundation
Screening Guidelines for the Early Detection of
Breast Cancer, American Cancer Society
 Yearly mammograms are recommended starting at age 40.
 A clinical breast exam should be part of a periodic health exam,
about every three years for women in their 20s and 30s, and every
year for women 40 and older.
 Women should know how their breasts normally feel and report any
breast changes promptly to their health care providers. Breast selfexam is an option for women starting in their 20s.
 Women at increased risk (e.g., family history, genetic tendency, past
breast cancer) should talk with their doctors about the benefits and
limitations of starting mammography screening earlier, having
additional tests (i.e., breast ultrasound and MRI), or having more
frequent exams.
FIGURE 5 Annual Age-Adjusted Cancer Death Rates* Among Females
for Selected Cancers, United States, 1930 to 2006
From Jemal, A. et al.
CA Cancer J Clin 2010;60:277-300.
Female Breast Cancer SEER Incidence Rates* by
Race and Ethnicity, U.S., 1975–2005
Incidence source: Surveillance, Epidemiology, and End Results (SEER) Program,
National Cancer Institute (NCI) 1975–1991 = SEER 9; 1992–2005 = SEER 13.
Female Breast Cancer U.S. Death Rates* by
Race and Ethnicity, 1975–2005
Mortality source: U.S. Mortality Files, National Center for Health Statistics, CDC.
Percentage of U.S. Women Aged 40 Years and
Older Who Have Had a Mammogram in the Last
2 Years by Race and Ethnicity
www.cancer.gov
Breast Cancer Disparities by Race /
Ethnicity and Socioeconomic Status
Ward et al, CA Cancer J Clin 2004;54:78-93.
Best defense is to find breast cancer early
Mammogram Prevalence (%), by Educational Attainment and
Health Insurance Status, Women 40 and Older, US, 1991-2004
All women 40 and older
70
Prevalence (%)
60
50
Women with less than a high school education
40
30
Women with no health insurance
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2002
2004
Year
*A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated
to represent the United States.
Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data
Tape (2000, 2002, 2004), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005.
Stage at Diagnosis by Race and Ethnicity, SEER 1996-2000
Localized (%)
White
African American
Hispanic
Asian/ Pacific Is
66
55
57
63
Ward et al, CA Cancer J Clin 2004;54:78-93.
Regional (%)
29
36
35
30
Distant (%)
5
9
7
5
Mammograms save lives –
spread the word
Women who engage in regular mammogram tests has
proven to be beneficial for many reasons. Here are just a
few:
 The early detection of breast cancers by
mammograms can exponentially improve chances for
successful treatment.
 Mammograms are able to detect a lump up to 2 years
before it can be discovered
by a self examination.
 Mammograms are able to detect 85 to 90 percent of
breast cancers in women who are over 50 years old