Breast Cancer Breast Cancer ScreeningScreening

The Search for ConsensusThe Search for Consensus

Presented for Paint it PinkSeptember 19, 2011

Nathaniel W. Cuthbert, MD.

Breast CancerBreast Cancer

Excluding skin cancer, breast cancer is the most Excluding skin cancer, breast cancer is the most commonly diagnosed cancer in U.S. womencommonly diagnosed cancer in U.S. women

Second only to lung cancer in cancer deaths in Second only to lung cancer in cancer deaths in womenwomen

200,000 new cases of invasive breast cancer in 200,000 new cases of invasive breast cancer in 20102010

54,000 news cases of non-invasive breast 54,000 news cases of non-invasive breast cancer in 2010cancer in 2010

2,000 new cases in men (<1%)2,000 new cases in men (<1%)

U.S. Preventive Services Task U.S. Preventive Services Task Force (USPSTF) Force (USPSTF) November 2009November 2009

Biennial (every 2 years) mammograms, Biennial (every 2 years) mammograms, age 50-74age 50-74

No screening mammogram for age 75+ No screening mammogram for age 75+ BSE discouraged, harm outweighs BSE discouraged, harm outweighs

benefitsbenefits

USPSTF RationaleUSPSTF Rationale

Psychological harmPsychological harm Unnecessary tests and biopsies, Unnecessary tests and biopsies,

inconvenience associated with false +’sinconvenience associated with false +’s OverdiagnosisOverdiagnosis

To be or not to be, that To be or not to be, that is the question:is the question:

Whether ‘tis nobler in Whether ‘tis nobler in the mind to sufferthe mind to suffer

The slings and arrows The slings and arrows of outrageous of outrageous fortunefortune

Or to take arms against Or to take arms against a sea of troublesa sea of troubles

And by opposing end And by opposing end them?them?

To screen or not to screen, that is the question:Whether ‘tis wiser to avoid the anxietiesAnd costs of screening mammography, and hopeBy good fortune to avoid the ravages of breast cancerOr be proactive through screening and improve one’s odds of early detection and treatment?

BREAST CANCER BREAST CANCER DETECTIONDETECTION

Breast self-exams (BSE)Breast self-exams (BSE) Clinical breast exams (CBE)Clinical breast exams (CBE) MammographyMammography Breast MRI (newest recommendation for Breast MRI (newest recommendation for

some high risk women)some high risk women)

RISK FACTORS FOR BREAST RISK FACTORS FOR BREAST CANCER CANCER

Personal hx of prior breast cancerPersonal hx of prior breast cancer BRCA-1 and BRCA-2 carriersBRCA-1 and BRCA-2 carriers Family hx of breast cancer (esp. if young)Family hx of breast cancer (esp. if young) Menopause after age 55Menopause after age 55 First period before age 12First period before age 12 Never having children, or having children after Never having children, or having children after

3030 Race Race

If < 40 African American women higher riskIf < 40 African American women higher risk If > 40 White women have higher riskIf > 40 White women have higher risk

BREAST CANCER RISKBREAST CANCER RISK

Birth to age 39– 1 in 229Birth to age 39– 1 in 229 From age 40 to 59– 1 in 24From age 40 to 59– 1 in 24 From age 60 to 79—1 in 13From age 60 to 79—1 in 13

RISK OVER LIFETIME IS 1 IN 7RISK OVER LIFETIME IS 1 IN 7

MYTHS OF BREAST CANCERMYTHS OF BREAST CANCER

MYTH # 1MYTH # 1 Breast cancer only affects older womenBreast cancer only affects older women

• Can occur in younger women tooCan occur in younger women too

MYTHS MYTHS OFOF

BREAST CANCER BREAST CANCER

MYTH # 1MYTH # 1

Breast cancer only affects older womenBreast cancer only affects older women NOT TRUENOT TRUE

• Can occur in younger women tooCan occur in younger women too

MYTH # 2MYTH # 2

If you have a risk factor for breast cancer, If you have a risk factor for breast cancer, you are likely to get the diseaseyou are likely to get the disease NONO

• You are not destined to get the disease just You are not destined to get the disease just because you have a risk factorbecause you have a risk factor

• Be diligent about your care and follow upBe diligent about your care and follow up

MYTH # 3MYTH # 3

If breast cancer doesn’t run in your family, If breast cancer doesn’t run in your family, you won’t get ityou won’t get it NONO

• 80% of women with breast cancer have NO family 80% of women with breast cancer have NO family historyhistory

MYTH # 4MYTH # 4

Only mother’s family history can affect Only mother’s family history can affect your riskyour risk NONO

• Mother’s or father’s history is importantMother’s or father’s history is important

MYTH # 5MYTH # 5

Using antiperspirants causes breast Using antiperspirants causes breast cancercancer NONO

• No evidence that there is a linkNo evidence that there is a link

MYTH # 6MYTH # 6

Birth control pills cause breast cancerBirth control pills cause breast cancer NONO

• Today’s pills are very low doseToday’s pills are very low dose

MYTH # 7MYTH # 7

I am at high risk and I can do nothing I am at high risk and I can do nothing about itabout it NOT TRUENOT TRUE

• Regular breast care and diligenceRegular breast care and diligence• Medication (Tamoxifen)Medication (Tamoxifen)• Lifestyle changes (Heart healthy plan)Lifestyle changes (Heart healthy plan)• Genetic counseling to discuss optionsGenetic counseling to discuss options

MYTH # 8MYTH # 8

If I am diagnosed with breast cancer, I will If I am diagnosed with breast cancer, I will diedie NOT TRUENOT TRUE

• 80% have no cancer outside of the breast80% have no cancer outside of the breast• Survival today is improving all the time even in Survival today is improving all the time even in

patients with cancer which has spreadpatients with cancer which has spread• 87% of breast cancer patients are alive at 5 years87% of breast cancer patients are alive at 5 years

MYTH # 9MYTH # 9

Most breast lumps are cancerousMost breast lumps are cancerous NOT TRUENOT TRUE

• Most breast lumps are not cancerous, but are Most breast lumps are not cancerous, but are benign (cysts or fibrous tissue or fibroadenomas)benign (cysts or fibrous tissue or fibroadenomas)

MYTH # 10MYTH # 10

If I have to have a biopsy, it is most If I have to have a biopsy, it is most certainly cancercertainly cancer NOT TRUENOT TRUE

• Over 80% of all breast biopsies are not cancer!!Over 80% of all breast biopsies are not cancer!!• Over 1.6 million breast biopsies are performed Over 1.6 million breast biopsies are performed

every year in the U.S.every year in the U.S.

MYTH # 11MYTH # 11

I am a man, therefore I can not get breast I am a man, therefore I can not get breast cancercancer NONO

• 1 % of all breast cancers occur in men1 % of all breast cancers occur in men

Why is the definitive assessment of Why is the definitive assessment of screening mammography so screening mammography so

difficult?difficult? Relatively slow progression in many cases Relatively slow progression in many cases

requires patients to be followed for 10-30 requires patients to be followed for 10-30 yearsyears

Changing treatmentsChanging treatments Changing incidence of cancerChanging incidence of cancer Improving technology, i.e. Digital Improving technology, i.e. Digital

mammographymammography StatisticsStatistics BiasesBiases

BiasesBiases

Radiologists:Radiologists:MonetaryMonetary Fulfillment from detecting cancersFulfillment from detecting cancers AcademiciansAcademicians Pressure to publishPressure to publish Government affiliated agenciesGovernment affiliated agencies High cost of paying for what has been High cost of paying for what has been

promisedpromised

Radiology- September 2011Radiology- September 2011

Mammographic Screening and Mammographic Screening and “Overdiagnosis” (Kopans, et al.)“Overdiagnosis” (Kopans, et al.)

Swedish Two County Trial: Impact of Swedish Two County Trial: Impact of Screening on Breast Cancer Mortality Screening on Breast Cancer Mortality during 3 Decades (Tabár, et al.)during 3 Decades (Tabár, et al.)

Is Mammographic Screening Justifiable Is Mammographic Screening Justifiable Considering Its substantial Overdiagnosis Considering Its substantial Overdiagnosis Rate and Minor Effect on Mortality? Rate and Minor Effect on Mortality? (Jorgensen, et al.)(Jorgensen, et al.)

Mammographic Screening and Mammographic Screening and “Overdiagnosis”“Overdiagnosis”

31% reduction in breast cancer mortality 31% reduction in breast cancer mortality rate, 1990-2007rate, 1990-2007

75,000 fewer women died than if mortality 75,000 fewer women died than if mortality rates had been stablerates had been stable

Computer models estimate 28%-65% of Computer models estimate 28%-65% of this reduction due to mammographythis reduction due to mammography

Swedish Two County TrialSwedish Two County Trial

The number of breast cancer deaths The number of breast cancer deaths prevented increases with timeprevented increases with time

20 years or more needed to see full 20 years or more needed to see full benefitbenefit

1 breast cancer prevented for every 414 1 breast cancer prevented for every 414 women screened for 7 yearswomen screened for 7 years

Is Mammographic Screening Is Mammographic Screening Justifiable…?Justifiable…?

Screening increases mastectomyScreening increases mastectomy Screening increases biopsiesScreening increases biopsies Screening increases psychological Screening increases psychological

distressdistress Overdiagnosis- detection of cancers which Overdiagnosis- detection of cancers which

would not be clinically evident before a would not be clinically evident before a patient dies of something elsepatient dies of something else

American Cancer Society American Cancer Society

Annual mammograms beginning at age 40 Annual mammograms beginning at age 40 for as long as in good healthfor as long as in good health

Clinical breast exam, every 3 years in 20’s Clinical breast exam, every 3 years in 20’s or 30’s, annually for 40+or 30’s, annually for 40+

Self-awareness, BSE optional beginning in Self-awareness, BSE optional beginning in 20’s 20’s

American College of Gynecology American College of Gynecology (July 2011)(July 2011)

Annual mammograms beginning age 40 Annual mammograms beginning age 40 (previous recommendation every 1-2 years (previous recommendation every 1-2 years starting at age 40)starting at age 40)

Sojourn time- time between when cancer first Sojourn time- time between when cancer first discoverable mammographically until clinically discoverable mammographically until clinically evidentevident

Sojourn time 2-2.4 years for ages 40-49, 4-4.1 Sojourn time 2-2.4 years for ages 40-49, 4-4.1 years for 74+years for 74+

Clinical breast exam every 1-3 years for ages Clinical breast exam every 1-3 years for ages 20-39, annually for 40+20-39, annually for 40+

Self-awareness beginning at age 20Self-awareness beginning at age 20

American College of RadiologyAmerican College of Radiology

Annual mammogram beginning at age 40 Annual mammogram beginning at age 40 for average risk patientfor average risk patient

Annual mammogram beginning at age 30, Annual mammogram beginning at age 30, but no sooner than 25, for higher but no sooner than 25, for higher

High risk (BRCA gene or 20% lifetime risk) High risk (BRCA gene or 20% lifetime risk) should have annual breast MRI beginning should have annual breast MRI beginning at age 30, in addition to mammographyat age 30, in addition to mammography

Breast Cancer SurvivalAge at Diagnosis:

The 5-year relative survival rates for breast cancer increase with age at diagnosis until the age of 75.82% for women age under 4586% for women ages 45–5487% for women ages 55–6488% for women ages 65–7484% for women ages 74 and over

American Cancer SocietyBreast CancerFacts & Figures 2001–2002

CONCLUSIONCONCLUSION

Breast cancer can be detected in the early Breast cancer can be detected in the early stagesstages

Breast cancer can be treated effectivelyBreast cancer can be treated effectively Breast cancer when it is most treatable, Breast cancer when it is most treatable,

does not produce any symptoms, does not produce any symptoms, therefore be diligent with breast healththerefore be diligent with breast health