1. Screening Mammography in Israel
Issues and Future
Tal Arazi-Kleinman MD
Wolfson Medical Center, Holon, Israel

2. Israel
! A small country
! About the size of New Jersey
! Approx. 27,800 km2 (10,700
mi2) / 22, 000 km2

3. France (632760 km²) is
22.76/28.67 times as big as
Israel
(27,800 km²/22,000 km2)

4. ! Small size is an advantage regarding breast
cancer screening
! Enables accurate monitoring
! Breast cancer is a reportable disease to the
ministry of health (national cancer registry)
! Mammography screening is monitored by a
national breast cancer screening program since
1992

5. Israel - population
! 8.132 million population (= to Switzerland)
! Constitutes 1/900(0.11%) of the world population
! Diverse population
§ 75.2% Jewish
§ 20.6% Arab
§ 4.2% other
! Distinct minorities – immigrants, ultra-orthodox
jews, bedouins and more

6. BC Incidence
Female breast cancer
incidence rates, 2008
• Israel ranks 4th in the OECD in
breast cancer cases with
96.8/100,000 after Belgium, France
(99.7) and the Netherlads
• Average OECD – 71.6/ 100,000

8. INBCSP

9. BC – Origin of birth
! In 2012 Jewish population:
73%- “Sabras” – born in Israel
§ 38.2% - Israeli-born to at least one parent who was
also Israeli-born
§ 36% - European and American ancestry
§ 14.5% - Africans ancestry
§ 11.2% - Asians ancestry

11. BC incidence & Age

12. BC incidence & Age

13. MECC
! Middle east cancer
consortium
! 4 neighboring countries
with cancer registries
compared with US SEER
(recently Turkey joined as
well)
! 2006 NCI published a
mongram with data from
1996-2001

14. MECC

15. MECC
Among Israeli
Jewish women,
as in American
women, a larger
proportion of
breast cancer was
diagnosed at an
earlier age

16. ! Breast cancer in Israeli Jewish women is
more prevalent and appears at a younger
age than Israeli Arab women or women in
the neighboring countries
! Likely due to high prevalence of BRCA
mutations

17. Breast Cancer Mortality
29.5
11.1

18. Breast Cancer Mortality
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
per100,000(ASR)
1998199920002001200220032004200520062007
Year
Jewish Arab
29.5
11.1

19. National Screening Program
! Established in 1992 by the Israeli Government
along with the health maintenance organizations
and the Israel cancer association
! In Israel, by law, every resident has health
insurance coverage by one of 4 health
maintenance organizations (HMO)
! Mammography screening is initiated and funded
by these organizations, established by law

20. National Screening Program
! Average population: bi-annual mammogram
between 50-75 yrs (est. 760,000 women)
! High risk population: annual mammography
between 40-75 yrs
! 56/62 mammography centers in the country
participate (including 2 mobile unit) – under go
quality assurance
! >80% of mammograms performed in the country

21. Screening US
! Performed very commonly in Israel
! All high risk women with dense breasts
! Most average risk women with dense breasts
! No clear guidelines, left to the decision of the
mammographer or referring physician
! Data not yet routinely gathered on a national
basis

22. National Screening Program
Since the program began
! 4 million mammograms
! In over 1 million women
! 72% compliance
! 85.6% having repeat studies

23. National Screening Program
In 2009
! Screening compliance among Arab Israeli
women almost equal to Jewish Israeli
! 4,147 newly diagnosed breast cancer – 1,216 of
them screen diagnosed (30%)
! >70% of screen diagnosed cancers early stage
(18.1%DCIS, 52.2% stage 1)

24. 2008 world health statistics WHO

25. OECD - Mammography
screening, percentage of
women aged 50- 69
screened, 2000 to 2009 (or
nearest year)
France (76.7%) & Israel
(69.5%) are above the OECD
average (62.2%)

26. ! 2001 NCR issued a
geographic report on
breast cancer
prevalence in different
parts of the country
! The peripheral regions
(north and south)
showed a lower
prevalence

27. # of mammography
units in the region

28. Mobile Unit – Reaching out
! 2002: The Israel Cancer Association
purchases a mobile mammography unit
reaching out to more remote areas of
the country
! Over 15,000 women a year
! Education programs are established in
these remote areas
! Recent analysis shows the gap in breast
cancer prevalence is closing between
peripheral and central areas

29. Screening in Ultra-Orthodox
! A minority group
compromising less than
10% of the population
(mostly Ashkenazi)
! Special cultural issues
make screening for
breast cancer or the
BRCA gene problematic

30. Screening in Ultra-Orthodox
! Jewish Religious Practice
§ Family and childbearing
§ Modesty and humility
§ Marriage prospect for oneself or children
§ Belief in fate and God’s will
! Close knit community – privacy issues important

31. Screening in Ultra-Orthodox
! Special programs for breast cancer awareness
within the community
! Consultation with the Rabbi (who often directs
medical attention and approves procedures).
! Ever growing awareness – in 2009 screening
compliance was only 10% lower than the general
population and recently similar to secular
population (88%)

32. Screening in Ultra-Orthodox
! Recent study revealed that the rate of haredi
women diagnosed with BC was 70% lower than
secular women
! Detected at a later stage -> lower survival rates,
more aggressive tumors and higher chance of
cancer recurrence
! Different life style

33. BRCA screening
! BRCA mutations found in 0.3% of general
population (USA and Europe) – about 1 in
350-500
! In Ashkenazi Jews found in 2.5% - 1 in 40
! Estimated 30,000 Ashkenazi BRCA gene carriers
in Israel
! Not clear how many non-Ashkenazi carriers exist

34. BRCA screening
! Between 30-80% lifetime risk of breast cancer
! Tend to be more aggressive and at younger
ages

35. BRCA screening protocol
! Age 20-25: bi-annual clinical breast examination
! Age 25-30: annual screening US, annual MRI
rotating at 6 month intervals (MRI funded by the
HMOs for BRCA carriers)
! Age 40 or 10 years younger than first relative
diagnosed: add annual mammography at time of
screening US
! Age 35: Bi-annual US of ovaries.

36. Routine Screening 32 yr old BRCA
Mutation Carrier
On MR
guided
biopsy a 6
mm triple
negative IDC

37. Summary
! Breast cancer screening in Israel is well established
and supported by the government
! Jewish Israeli women have a high incidence of
breast cancer at a relatively early age compared to
the Arab population
! Results of screening are analyzed and reported and
adjustments are made to the program to specifically
target less compliant groups

38. Thank your for your attention
Acknowledgments
! Miri Ziv – CEO of the Israel
Cancer Association
! Dr Gad Rennert – Former director
of the National mammography
Screening Program
! Dr Lital Keinan-Boker–Deputy
director of the National Cancer
Registry
Radiology Selfie