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Breast cancer screening dr.ayman jafar
1.
2. Objectives
Demonstrate the incidence of breast cancer, facts and statistics
Review the risk factors of breast cancer and the tools of risk estimation
Outline the various current screening guidelines and related controversy
Discuss the available modalities for breast cancer screening
( indication, benefits, harms…)
3. Introduction
Worldwide, breast cancer is the most frequently diagnosed life-
threatening cancer in women and the leading cause of cancer
death in women.
In the United States, breast cancer accounts for 29% of all
cancers in women and is second only to lung cancer as a cause
of cancer deaths
1 in 8 U.S. women (about 12%) will develop breast cancer over
the course of her lifetime.
Because of early detection, intervention, and postoperative
treatment, breast cancer mortality has been decreasing.
Mammography for screening has largely contributed to early
detection
37. Risk Factors
Risk Factors Estimated Relative
Risk
Advanced age >4
Family history
• Family history of ovarian cancer in women < 50y >5
• One first-degree relative >2
•Two or more relatives (mother, sister) >2
Personal history
•Breast cancer history 3-4
•Positive BRCA1/BRCA2 mutation >4
•Breast biopsy with atypical hyperplasia 4-5
•Breast biopsy with LCIS or DCIS 8-10
38. Risk Factors
Con. Risk Factors Estimated Relative Risk
Reproductive history
•Early age at menarche (< 12 y) 2
•Late age of menopause 1.5-2
•Late age of first pregnancy (>30 y)/Nulliparity 2
•Use of combined estrogen/progesterone HRT 1.5-2
•Current or recent use of oral contraceptives 1.25
Lifestyle factors
•Adult weight gain 1.5-2
•Sedentary lifestyle 1.3-1.5
•Alcohol consumption 1.5
39. Risk Factors
BRCA1, BRCA2: genes produce tumor suppressor proteins that help
repair damaged DNA and stabilize the cell’s genetic material.
When mutated, or altered, DNA damage may not be repaired properly.
As a result, cells are more likely to develop additional genetic alterations
that can lead to cancer.
Specific inherited mutations in BRCA1 and BRCA2 increase the risk of
breast and ovarian cancers
Together, BRCA1 and BRCA2 mutations account for 20 to 25% of
hereditary breast cancers and 5 to 10% of all breast cancers.
Breast and ovarian cancers associated tend to develop at younger ages
A harmful BRCA1 or BRCA2 mutation can be inherited from a person’s
mother or father.
40. Risk Factors
BRCA1 mutation increases the risk 55 to 65%, and BRCA2 45%
Genetic testing considered
Breast cancer diagnosed before age 50 years
Bilateral breast cancer
Both breast and ovarian cancers in either the same woman or the
same family
Multiple breast cancers
Male breast cancer
Ashkenazi Jewish ethnicity
Management of positive genetic test:
1. Enhanced Screening; at younger ages, CBE, mammogram and MRI
2. Chemoprevention: Tamoxifen, Raloxifene
3. Prophylactic (Risk-reducing) Surgery.
41. Risk Factors
Risk estimation models
Gail model
Claus model
BRCAPRO model
Cuzick–Tyrer model
BOADICEA model
44. What is screening?
Test and exam used to find a disease like cancer in people who do
not have any symptoms. i.e. early detection
Aiming at reduction of reduction of morbidity and mortality
46. What benefit to screening?
Early detection remains the primary defense available to patients in
preventing the development of life-threatening breast cancer
For 50-74 year group, there is an intimated 30% reduction in mortality
For 40-49 year group, there is an intimated 17% reduction in mortality
50. Guidelines
Age 20+ Self-breast examination(optional) monthly
Breast clinical examination every 3 yrs
Age 40+ Mammography annually
High Risk mammography annually
+ 30 +
MRI
51. Guidelines
(controversy)
No requirement for clinicians to teach women how to perform BSE.
Insufficient current evidence to assess the additional benefits and
harms of CBE beyond mammography in women 40 years or older
No requirement for routine screening mammography in women aged
40 to 49 years. the decision to start regular screening before 50 should
be an individual one and take into account patient context, including the
patient's values regarding specific benefits and harms
Biennial screening mammography for women between 50 -74 years
Stopping screening at age 74 as there is insufficient data to assess the
benefits and harms in women > 75
November, 2009
57. Breast Self-Examination (BSE)
Potential Benefits
Simple and non-invasive test
Women gain a sense of control over their health
Become comfortable with their own breasts
Some breast cancer has been detected with BSE
Increased awareness of breast changes
Lumps can be palpated with a BSE
58. Breast Self-Examination (BSE)
Potential Harms
Increased number of healthcare visits
Twice the number of benign breast biopsies
Increased healthcare costs
Increased levels of cancer-related anxiety
No change in mortality from breast
cancer with detection from BSE
60. Breast Self-Examination (BSE)
Organizations that recommend BSE
ACOG Recommends monthly BSE
AMA Recommends BSE, no age specified
Susan G. Komen Foundation Recommends monthly BSE
Organization that recommends against BSE
Canadian Task Force for Preventive Healthcare
Organizations that recommend further discussion or indicate insufficient evidence
ACS Starting at age 20, pros and cons of BSE should be
reviewed; it is the individual's choice
US PSTF Insufficient evidence to recommend for or against
BSE
NCI No specific recommendation
62. Clinical Breast Examination (CBE)
Benefits
Not tested independently
Clinical trial support combining CBE with mammography to
enhance screening sensitivity, particularly in younger women in
whom mammography may be less effective and in women who
receive mammograms every other year as opposed to annually.
Harms
False-Positives additional testing and anxiety.
False-Negatives potential false reassurance and delay in
cancer diagnosis. Of women with cancer, 17% to 43% have a
negative CBE. Sensitivity is higher with longer duration and
higher quality of the examination by trained personnel.
63. Mammography
48 million mammograms are performed each year in US
Special type of low-dose x-ray imaging used to create detailed
images of the breast.
Currently it is the best available population-based method to
detect breast cancer at an early stage, when treatment is most
effective
Can demonstrate microcalcifications smaller than 100 µm.
Often reveals a lesion before it is palpable by clinical examination
and, on average, 1-2 years before noted by self-examination
69. False-positive
Recalled examinations that does not lead to diagnosis of cancer.
Estimated average false-positive rate in US is 11%
Factors
previous breast biopsies
family history of breast cancer
estrogen use
Lack of a comparison mammogram(s).
70. False-negative
Sensitivity range from 70-90% false-negative 20%
Factors:
Mammographically occult cancer.
Overlapping dense breast tissue
Poor technique
Reader variability
72. Overdiagnosis
A cancer never become clinically apparent without screening
before a patient’s death.
The median prevalence: an overview of 7 autopsy studies,
occult invasive breast cancer 1.3% and of DCIS 8.9%
A “perfect” screening would identify 10% of women as having
breast cancer, even though most of those cancers would
probably not result in illness or death. Treatment would constitute
overtreatment.
Currently, cancers that will cause illness and/or death cannot be
confidently distinguished from those that will remain occult, so all
cancers are treated.
73. Ultrasonography
Useful adjunct to mammography
Assist in suspicious lesion detected on
mammography or physical examination
Useful in the guidance of biopsies and
therapeutic procedures.
Originally, used as method of
differentiating cystic from solid breast
masses
Limitations as screening test:
Failure to detect microcalcifications
Poor specificity (34%)
75. Ultrasonography
somo-v Automated Breast Ultrasound System (ABUS)
FDA approved, Sep. 2012
Breast cancer screening specifically in
women with dense breast tissue
Indicated as an adjunct to mammo for
women with a negative mammogram, no
breast cancer symptoms and no
previous breast intervention
76. Magnetic Resonance Imaging (MRI)
Explored in women at high risk and in younger women
MRI found to be highly sensitive (99% when combined with
mammography and CBE)
An important adjunct screening tool for women
BRCA1 or BRCA2 mutations, identifying cancers at earlier stages.
MRI has limited use as a screening tool:
Cost. 10-fold higher cost than mammography
Poor specificity (26%) false-positive reads
78. Magnetic Resonance Imaging (MRI)
American Cancer Society MRI screening criteria
Annual breast MRI screening in patients with the following risk
factors:
BRCA mutation
First-degree relative of BRCA carrier but untested
Lifetime risk approximately 20-25% or greater, as defined by
BRCAPRO or other risk models
Radiation to chest when aged 10-30 years
79. Magnetic Resonance Imaging (MRI)
American Cancer Society MRI screening criteria
The ACS found insufficient evidence to recommend for or
against MRI screening in patients with the following risk factors:
Lifetime risk 15-20%
LCIS or atypical lobular hyperplasia (ALH)
Atypical ductal hyperplasia (ADH)
Heterogeneously or extremely dense breast on mammography
Personal history of breast cancer, including DCIS
The ACS does not recommend MRI in women <15% lifetime
risk
For those with average risk, a combination of clinical breast
examinations and yearly mammograms is recommended.
80. Conclusion
Breast cancer is the most commonly diagnosed cancer in women and
the second leading cause of cancer death in women
Screening breast cancer has proven benefits in reducing mortality and
this is independent of the benefits of improved therapy.
Various screening guidelines are currently being validated and followed
by different medical organizations
Mammography remains the mainstay of screening, and in women at
high risk, annual MRI is recommended
Understanding of the risks a benefits of a particular screening tool helps
clinicians to make informed decision
81. • References
• National Cancer Institute. Surveillance, Epidemiology, and End Results Program. SEER stat fact sheets:
breast cancer. http://seer.cancer.gov/statfacts/html/breast.html.
• American Cancer Society. What are the key statistics about breast cancer?
http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics.
• National Cancer Institute. Breast cancer treatment (PDQ). General information about breast cancer.
http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient.
• American Cancer Society. What are the risk factors for breast cancer?
• http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/Page8#_483
• http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors.
• National Cancer Institute. Breast cancer screening (PDQ).
http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional.
• American Cancer Society. Breast cancer survival rates by stage.
• http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-survival-by-stage.
• http://www.medscape.org/viewarticle/583982
• US Preventive Services Task Force. About the USPSTF.
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-can
.
• The American Congress of Obstetricians and Gynecologists.
http://www.acog.org/About-ACOG/News-Room/News-Releases/2011/Annual-Mammograms
• http://emedicine.medscape.com/article/1945498-overview
• http://www.ncbi.nlm.nih.gov/books/NBK22311
• http://www.haad.ae/simplycheck/tabid/131/Default.aspx
• http://www.cancer.gov/bcrisktool/
• http://www.slideshare.net/rajud521/breast-self-examination
Editor's Notes
Good evening,
I will be presenting breast cancer screening. I am going to speak on incidence, risk factors, discuss the screening guidelines and available modalities of screening
As you all know that breast cancer of great concern for women all over the world
Incidence rates breast cancer vary greatly worldwide
This map shows the incidence of breast cancer in the world.
The highest incidence is in western Europe, northern America and Australia.
and the lowest incidence in Africa and Asia
Belgium had the highest rate of breast cancer, followed by Denmark and France.
screening is looking for cancer before a person has any symptoms. This can help find cancer at an early stage. When abnormal tissue or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread.
Early detection remains the primary defense available to patients in preventing the development of life-threatening breast cancer, although advances in imaging technology and disagreements over recommended schedules have complicated the issue of screening.
For women younger than 40 years, monthly breast self-examination (BSE) and clinical breast exams every 3 years have been recommended, beginning at age 20 years. The most widely recommended screening approach in the United States has been annual mammography beginning at age 40 years
We can conclude the recommendations of ACS
In November 2009, however, the US Preventive Services Task Force (USPSTF) issued updated breast cancer screening guidelines that recommend against routine mammography before age 50 years. The specific USPSTF guidelines can be summarized as follows:
No requirement for clinicians to teach women how to perform BSE (grade D recommendation); this recommendation is based on studies that found that teaching BSE did not reduce breast cancer mortality but instead resulted in additional imaging procedures and biopsies[2]
No requirement for routine screening mammography in women aged 40-49 years (grade C recommendation); the decision to start regular, biennial screening mammography before age 50 years should be an individual one and should take into account patient context, including the patient&apos;s values regarding specific benefits and harms
Biennial screening mammography for women between age 50 and 74 years (grade B recommendation)
Insufficient current evidence to assess the additional benefits and harms of screening mammography in women aged 75 years or older
Insufficient current evidence to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women aged 40 years or older
Despite the USPSTF recommendations, the American College of Obstetricians and Gynecologists (ACOG) continues to recommend counseling patients that BSE has the potential to detect palpable breast cancer and can be performed.[3]
ACOG also continues to recommend adherence to its current guidelines, which include the following[3] :
Screening mammography every 1-2 years for women aged 40-49 years
Screening mammography every year for women aged 50 years or older
At the end of recommendations it valuable to mention that Abu Dhabi Health Authority recommends mammography every 2 years for women 40 and above
Moving to discuss the modalities of screening. In fact there are 5 screening modalities
There are 2 types of mammography examinations: screening and diagnostic. Screening mammography is done in asymptomatic women. Diagnostic mammography is performed in symptomatic women (eg, when a breast lump or nipple discharge is found during self-examination or an abnormality is found during screening mammography). This examination is more involved, time-consuming, and expensive than screening mammography and is used to determine the exact size and location of breast abnormalities and to image the surrounding tissue and lymph nodes. Women with breast implants or a personal history of breast cancer will usually require the additional views used in diagnostic mammography.
Each breast is imaged separately, typically in both
the cranial-caudal (CC)
Medio-lateral-oblique (MLO) views.
Breast compression to flatten the breast
maximum amount of tissue can be imaged and examined.
allows for a lower X-ray dose
immobilization of the breast to reduce motion blur.
reduces X-ray scatter, which may degrade the image.
may cause some discomfort,
Each breast is imaged separately, typically in both
the cranial-caudal (CC)
Medio-lateral-oblique (MLO) views.
Breast compression to flatten the breast
maximum amount of tissue can be imaged and examined.
allows for a lower X-ray dose
immobilization of the breast to reduce motion blur.
reduces X-ray scatter, which may degrade the image.
may cause some discomfort,
Regarding the interpretation of mammography. The American College of Radiology (ACR) has established the Breast Imaging Reporting and Data System (BI-RADS) to guide the breast cancer diagnostic routine.
The BI-RADS system includes categories or levels that are used to standardize interpretation of mammograms among radiologists. For referring physicians, the BI-RADS categories indicate the patient’s risk of malignancy and recommend a specific course of action.
Of all of the screening mammograms performed annually, approximately 90% show no evidence of cancer. On necessary further diagnostic testing, approximately 2% of all screening mammograms are shown to be abnormal and require biopsy. Among cases referred for biopsy, approximately 80% of the abnormalities are shown to be benign, and 20% are shown to be cancerous.
Although mammography remains the most cost-effective approach for breast cancer screening, the sensitivity (67.8%) and specificity (75%) are not ideal. Mammography combined with clinical breast examination (CBE) slightly improves sensitivity (77.4%), with a modest reduction in specificity (72%).
One of the problems that we have is with false positives.
False positive is defined as a recall examination that does not lead to a diagnosis of cancer. And in the United States, false positives are estimated to be approximately 10% to 11%.
Factors that are responsible for false-positive rates include previous breast cancers, a prior family history of breast cancer, estrogen use, and a very important one, lack of a comparison mammogram.
The sensitivity of mammography ranges from 70% to 90%, depending on a woman’s age and the density of her breasts,. Assuming an average sensitivity of 80%, mammograms will miss approximately 20% of the breast cancers that are present at the time of screening (false-negatives). Many of these missed cancers are high risk, with adverse biologic characteristics .
False negatives are perhaps more important and some of these cancers are mammographically occult. We cannot see these because of limitations with the technology itself. Overlapping dense breast tissue is particularly difficult for us. Poor technique, such as underpenetrated films and poor positioning, makes cancers difficult to see. There may be oversight by the radiologist and there is always reader variability.
Sensitivity declines significantly with increasing breast density, and the risk of breast cancer is higher in women with dense breasts
Overdiagnosed disease is a neoplasm that would never become clinically apparent without screening before a patient’s death. The prevalence of cancer in women who died of noncancer causes is surprisingly high. In an overview of seven autopsy studies, the median prevalence of occult invasive breast cancer was 1.3% and of ductal carcinoma in situ was 8.9% (range, 0%–14.7%).[16,17] A “perfect” screening test would identify approximately 10% of “normal” women as having breast cancer, even though most of those cancers would probably not result in illness or death. Treatment of these cancers would constitute overtreatment.
Currently, cancers that will cause illness and/or death cannot be confidently distinguished from those that will remain occult, so all cancers are treated.
To determine the number of screen-detected cancers that are overdiagnosed, one can compare breast cancer incidence over time in a screened population with that of an unscreened population.
Population-based studies could demonstrate the extent of overdiagnosis if the screened and nonscreened populations were the same except for screening. Unfortunately, the populations may differ in time, geography, culture, and the use of postmenopausal hormone therapy. Investigators also differ in their calculation of overdiagnosis as they adjust for characteristics such as lead-time bias.[18,19] As a consequence, the magnitude of overdiagnosis due to mammographic screening is controversial, with estimates ranging from 0% to 54%.[8,18-20]
Several observational population-based comparisons consider breast cancer incidence before and after adoption of screening.[21-25] If there were no overdiagnosis—and other aspects of screening were unchanged—there would be a rise in incidence followed by a decrease to below the prescreening level, and the cumulative incidence would be similar. Such results have not been observed. Breast cancer incidence rates increase at the initiation of screening without a compensatory drop in later years. One study in 11 rural Swedish counties showed a persistent increase in breast cancer incidence following the advent of screening.[22] A population-based study showed increases in invasive breast cancer incidence of 54% in Norway and 45% in Sweden in women aged 50 to 69 years, following the introduction of nationwide screening programs. No corresponding decline in incidence in women older than 69 years was ever seen.[26] Similar findings suggestive of overdiagnosis have been reported from the United Kingdom [23] and the United States.[24,25]
Estimates of the extent of overdiagnosis noted in the Canadian National Breast Screening Study, a randomized clinical trial, have been reported. At the end of the five screening rounds, an excess of 142 invasive breast cancer cases was diagnosed in the mammography arm, compared with the control arm.[27] At 15 years, the excess number of cancer cases in the mammography arm versus the control arm was 106; this represents an overdiagnosis rate of 22% for the 484 screen-detected invasive cancers.[27]
Table 3 shows the estimated number of women with breast cancers or ductal carcinoma in situdiagnosed during a 10-year period of screening 10,000 women that would never become clinically important (overdiagnosis). There was no overdiagnosis in the Health Insurance Plan study, which used old-technology mammography and clinical breast examination. Overdiagnosis has become more prominent in the era of improved-technology mammography. However, the benefits of newer-technology mammography over older-technology mammography in regard to reduced mortality have not been demonstrated.[1]
MRI explored as a modality for detecting breast cancer in women at high risk and in younger women
MRI found to be highly sensitive (99% when combined with mammography and CBE) to malignant changes in the breast.
Demonstrated to be an important adjunct screening tool for women with BRCA1 or BRCA2 mutations, identifying cancers at earlier stages.
MRI has limited use as a general screening tool, with a 10-fold higher cost than mammography and poor specificity (26%), resulting in significantly more false-positive reads that generate significant additional diagnostic costs and procedures.