About this webinar: Breast radiologist Dr. Paula Gordon will discuss the optimal strategy for achieving early detection of breast cancer. She will also describe the flawed process used in making Canadian breast screening guidelines, impacting millions of women. Patient advocate Jennie Dale from Dense Breasts Canada will look at the inequities in breast cancer screening and surveillance practices in Canada. She will also explore ways to advocate for better screening and surveillance. About the presenters: Dr. Paula Gordon is a Clinical Professor in the Department of Radiology at the University of British Columbia, and has been practicing for over 35 years. She is Founding Medical Director of the Sadie Diamond Breast Program at BC Women’s Hospital, and a founding member of the Canadian Society of Breast Imaging. She’s given hundreds of lectures at meetings around the globe. She received a Queen Elizabeth Diamond Jubilee Medal, and was invested in the Order of British Columbia. She was named one of Canada’s 100 Most Powerful Women by the Women’s Executive Network. Jennie Dale is the Co-founder and Executive Director of Dense Breasts Canada (DBC). She was diagnosed with breast cancer in October 2014. Inspired by the successful advocacy and education efforts of similar American organizations, Jennie co-founded DBC with Michelle Di Tomaso in 2016. They teamed up with breast cancer survivors, dedicated individuals, and health care professionals nationwide to raise awareness of the risks of dense breasts and advocate for patient notification of breast density and access to supplemental screening. She is fighting for necessary revisions to the current Canadian Task Force breast cancer screening guidelines, which put women's lives at risk. In 2021, Jennie was named a top 5 finalist in Charity Village's awards in the category of Most Outstanding Impact by a Volunteer.

1. Paula B Gordon, OBC, MD, FRCPC, FSBI
Clinical Professor, UBC
@DrPaulaGordon
z
Breast Cancer Screening and Surveillance:
Where We Are and The Way Forward
CCSN April 2022

2. Disclosures
• Volunteer Advisor:
• densebreast-info.org
• densebreastscanada.ca
• Medical Advisory Board: Besins Healthcare
• Stockholder: Volpara
• Mitigating Potential Bias: All statements
referenced from peer-reviewed literature

3. Objectives
• Explain the importance of early detection of breast
cancer
• Describe the optimal strategy for achieving early
detection in as many women as possible.
• Discuss the flawed process used in making
guidelines that affect millions of Canadian women.
• Demonstrate the value of supplemental screening
for women with dense breasts.
• Discuss recommended surveillance for women with
breast cancer

4. https://www.breastcancer.org/symptoms/understand_bc/statistics
https://familysecurityplan.com/reduce-your-risk-of-breast-cancer/
• A woman’s risk of breast cancer nearly doubles if
she has a first-degree relative (mother, sister,
daughter) who has been diagnosed with breast
cancer. Less than 15% of women who get breast
cancer have a family member diagnosed with it.
The most significant risk factors for breast cancer are
being a woman and growing older

5. Why Do We Screen For Cancer?
• To save lives (reduce mortality) by finding and
treating the disease earlier
• To allow less aggressive treatment required for
more advanced disease.

6. Why Do We Screen For Cancer?
• The overall 5 year survival is 88%
• If cancer is found early, when confined to the
breast, the 5 year survival is 100%
• ~ 65% of cases are found at stage 1
cancer.ca

7. Breast Cancer Survival by Stage at Diagnosis
cancer.ca

8. How Do We Screen For Cancer?
Breast Self Examination
Clinical Breast Examination
Mammography – 2D, 3D
Ultrasound – HH or ABUS
MRI
Breast Specific Gamma Imaging/MBI
Dual-Energy Contrast-Enhanced Mammography
Dedicated Breast CT
Blood test?
Not Thermography!

9. Annual Mammography Starting At Age 40
Saves The Most Lives
This is recognized even by organizations that
recommend starting later,
or screening less often
Mandelblatt JS et al. Ann Intern Med 2016; 164:215-225
Yaffe MJ et al. J Med Screen. 2018; 25:197-204

10. Courtesy Dr. Jean Seely

11. Mortality from Breast Cancer 1996 vs 2020
Breast cancer mortality has
decreased by 48% since 1989
Screening mammography began in
1988.
Courtesy Dr. Jean Seely

12. Breast Cancer Deaths Avoided in Canada
32,000 Breast Cancer Deaths
Avoided
Courtesy Dr. Jean Seely

13. • Data were obtained on 2,796,472 screening
participants from 7/12 screening programs in
Canada, representing 85% of the population
• 40% mortality reduction overall
• 44% mortality reduction for women 40-49

14. The Canadian Task Force on
Preventive Health Care
• Recommends against routine screening
mammography in women aged 40 to 49 years
• Recommends screening mammography every 2-3
years for women aged 50 to 74 years
• Recommends against performing breast self-
examination (BSE)
• Recommends against performing clinical breast
examination (CBE)
• Recommend against supplemental screening for
women with dense breasts

15. Benefits of Early Detection
• Option for Breast-conserving Surgery
• Option for Avoiding Axillary Dissection
• Option to Avoid Chemotherapy

16. Early Detection Can Mean The Difference
Between Needing A Mastectomy Or
Being a Candidate For A Lumpectomy
Courtesy of Dr. Urve Kuusk

17. Lymphedema
http://lymphademainfo.blogspot.com/2007/08/what-is-
lymphadema.html
Giuliano AE et al. JAMA 2011;305:569–575

18. Node Staging
• Sentinel node biopsy now the standard of
care for cancers smaller than 2cm, and if
there are no suspicious nodes on imaging or
physical examination
• Less invasive
• Much lower risk of lymphedema (1.4,5%)
than axillary dissection (16, 33%)
McLaughlin. SA et al. J Clin Oncol 2008; 26:5213–5219
Terada M et al. Breast Cancer Res Treat 2020; 179:91-100
Belmonte R et al. Support Care Cancer 2018; 26:3277-3287

19. Chemotherapy
Many women with early breast cancer and showing low
risk of recurrence on 21-Gene Expression Assay can avoid
chemotherapy
Sparano JA et al. NEJM 2018; 379:111-121

20. Courtesy of Dr. Wendie Berg
Stapleton SM et al JAMA Surg 2018;153:594-595

21. Breast Cancer is not a Trivial
Problem for Women in Their 40s
cancer.ca

22. Women in Their 40’s

23. False Alarms
• For every 1000 women screened, 93% (930) will get
a normal result
• 7% (70) will need additional tests
• The majority of these will need only one or more
additional mammographic views
• Some will need ultrasound
• 16% (11 of the 70) will need a needle biopsy. These
are done with local freezing and should be not
significantly more painful than a blood test
• 4 will be diagnosed with breast cancer

24. Screening Mammography: Do Women Prefer
A Higher Recall Rate Given The Possibility Of
Earlier Detection Of Cancer?
Ganott MA et al. Radiology 2006; 238:793-800
• 1570 women responded
• 97% believed that a false-positive result would
not deter them from continuing with regular
screening
• 82% would have been willing to have an invasive
procedure if it might increase the chance of
detecting a cancer (if present) earlier

25. Over-Diagnosis
• The theoretical possibility that some cancers would never
surface on their own and are only found when screening
was done, so there is really no need to know about them.
• Some cancers grow so slowly, they may never become
life-threatening (we don’t know yet, how to recognize
these)
• Or a woman might die of something else, before her
cancer becomes life-threatening
• Heart disease
• A different cancer
• A car accident

26. Helvie MA. JBI 2019; 1:278–282
Many women are willing to accept
screening risks in order to reduce the
likelihood of breast cancer death.”

27. Anxiety?

28. When to Stop
RCTs included women up to age 74
87 84
76

30. Who Needs Additional Screening?
• Women at higher-than-average risk
(regardless of breast density),
including women with breast cancer
• Women at higher risk of interval
cancer (those with dense breasts)

31. What’s the Issue with Breast Density?

32. Fatty Scattered
Fibroglandular
Densities
Heterogeneously
Dense
Extremely
Dense
A B C D
BIRADS Density Categories

39. Courtesy DBI

40. Interval Cancers
• Diagnosed in screen-negative breasts outside of the
screening program in the interval between two
screening rounds.
• Larger at diagnosis & more often node-positive
• Higher nuclear grades, more aggressive subtypes
• a greater predominance of HER2 and triple negative
molecular subtypes
• Have a poorer prognosis compared to screen-detected
Boyd NF et al. Breast Cancer Res 2011; 13:223
Pisano ED et al. NEJM 2005; 353:1773–1783
Boyd NF et al. NEJM 2007; 356:227–236
Yaghjyan L et al. JNCI 2011; 103:1179–1189
Niraula S et al. JAMA Network Open. 2020;3(9):e2018179.

41. How is Breast Density Determined?
• Only by the radiologist when viewing a mammogram.
• Not by breast size or touch.
• Not by a physical exam.
• Lumpy breasts are not the same
as dense breasts
• Both fatty and dense breasts can feel soft, firm or lumpy.
• Some provinces such as Nova Scotia, PEI and Alberta are
beginning to use software to measure the level of density.
• Only 60% of women have mammograms, so the rest
cannot find out their density

42. 42
Dense Breasts Increase the Risk of Cancer
• Dense breasts are an independent risk factor for
cancer.
• Cancer is 4-6 X more likely in women with the
highest level of density, than in fatty breasts
• More prevalent risk than having a mother/sister
with breast cancer
• Increase the risk of interval cancer
• Increase the likelihood of a recall from screening
Boyd N et al. NEJM 356:227-236.
Engmann N et al. JAMA Oncol 2017;3(9):1228-1236

43. Quantitative Classification of Mammographic Densities
and Breast Cancer Risk: Results From the CNBSS
Boyd NF et al. JNCI 1995; 87:670-675
Courtesy Dr. J. Harvey via Dr. W. Berg

44. Quantitative Classification of Mammographic Densities
and Breast Cancer Risk: Results From the CNBSS
Boyd NF et al. JNCI 1995; 87:670-675
Courtesy Dr. J. Harvey via Dr. W. Berg

45. Breast Cancer Screening Effect Across
Breast Density Strata: A Case-Control Study
van der Waal et al. Int J Cancer 2017;140:41-4
• Sensitivity better in the fatty than in the dense group
(75.7% vs 57.8%).
• Estimated mortality reduction of 13% in women with
dense breasts compared to 41% in women with fatty
breasts.
• Reduced benefit from mammographic screening is
attributed to the masking effect of dense tissue with
tumors detected later, when they were larger, in women
with dense breasts

46. Dense Breasts Are Normal And Common
• In Canada, there are 3.4 million women over
age 40 with dense breasts.
• Over 800,000 women in Canada are in the
highest density Category D

47. Role of Ultrasound

48. Cancer 1995; 76: 626-630

49. Supplemental Yield Of US: ACRIN 6666
• 5.3 cancers/1000 in the first year (p<.001)
• 3.7/1000 in the 2nd and 3rd years (p<.001)
• Average 4.3/1000 all 3 years
• 94% were invasive
• median size: 10 mm (range 2-40 mm)
• 96% of those staged were node negative
• MRI 14.7/1000 after negative M & US
• But 42% eligible women declined MR
Berg WA, et al. JAMA 2012; 307:1394-1404

50. Automated
Ultrasound
Hand-Held
Ultrasound

51. • Hand-held, technologist-performed
• Biopsy rate 1.3%, PPV3 42%
• Incremental cancer detection rate 7/1000
• Average age 55 +/- 10 years
• Average size was 9.0 +/- 1.4 mm, all node –ve
• 40% no family hx, 60% Category C density

52. Ultrasound
PROS:
• Widely available, relatively inexpensive
• Uses no IV injection or ionizing radiation
• Uses minimal pressure so it’s not uncomfortable
• Easy to guide biopsy
• Finds mostly invasive cancers: 2-7/1000*
• Reduced interval cancer rate
CONS:
• 2-5% rate of biopsy for benign masses
Courtesy Dr. Wendie Berg

53. BSE

54. Role of Tomosynthesis
• sometimes called 3D
mammography or
digital breast
tomosynthesis (DBT)
• done in combination
with 2D or with
synthetic 2D
mammograms
• Reduces recalls
• Increases cancer
detection
• Not widely available in
Canada

55. Tomosynthesis:
Is Screening US Necessary?

56. Tagliafico AS et al. Lancet 2016;387:341-8
• 3,231 participants (median age, 51)
• 24 additional BCs were detected (23 invasive)
• 13 DBT-detected (incremental CDR, 4.0/1,000 screens;
versus 23 US-detected (incremental CDR, 7.1/1,000
screens; P = .006.
• FP recall (any testing) & FP recall (biopsy) also did not
differ between tomosynthesis (FP = 22) and ultrasound
(FP = 24), P = .86

57. PROS:
• Highest cancer detection
10-16 per 1000 first round
• No ionizing radiation
• Reduced interval cancers
• Reduced late-stage disease
• Includes axillary nodes
Contrast-Enhanced Breast MRI
CONS:
• Requires IV contrast
• Gd accumulates in the brain (Unknown effects)
• Claustrophobia, pacemaker
• Cost, availability Courtesy Dr. Wendie Berg

58. Abbreviated/Fast/Mini MRI
• One pre- and one post-contrast series
• Optional T2 series
• ~10 minutes in scanner, reduced interpretation
time and cost
• Still requires IV contrast

59. Who Should Have Screening MRI?
• Women with calculated lifetime risk of ≥ 20%
(www.densebreast-info.org)
• BRCA +ve and untested 1st ˚ relatives
• Mantle radiation for Hodgkins disease
• Women who’ve had cancer younger than 50
• Women with cancer who have dense breasts

60. • EUSOBI now recommends offering screening breast
MRI every 2 to 4 years and urges radiological
societies and policymakers to act on this now
• Acknowledges that it may currently not be possible
to offer breast MRI immediately and everywhere
• Since the wishes and values of individual women
differ, the principles of shared decision-making
should be embraced

61. MBI: Dual Head CZT Detectors
• 8 mCi 99mTc-Sestamibi
• 10 min per view with
gentle stabilization
• Opaque paddles as they
are also detectors
20 x 16 cm FOV 24 x 16 cm FOV
1.6 mm resolution 2.5 mm resolution
PRO: better cancer detection than US: 7-8/1000
CON: Whole body radiation; 40 minute exam;
Not available anywhere in Canada
Courtesy Dr. Wendie Berg

62. Dual-Energy Contrast-Enhanced
Mammography
• Uses mammography equipment
• IV injection of iodinated contrast (same as CT)
• 2 exposures made simultaneously: one low-
energy, one high-energy (radiation 2X mammo)
• Subtraction shows areas of contrast uptake
• Similar CDR as MRI, biopsy capability in devmt
• Proposed as excellent alternative for women who
can’t tolerate MRI

63. Blood Tests

64. Optimal Breast Screening
• Annual mammograms starting at 40 for average-
risk women. Younger for high-risk women.
• Continue at 1-2 years after menopause,
depending on individual risk, as long as life-
expectancy ≥ 10 years
• All women should be told their breast density.
• Women with dense breasts should be encouraged
to do BSE and offered supplemental screening
• US/MRI/ contrast mammo

65. Optimal Breast Surveillance
• Women who’ve had breast cancer should all have
annual mammograms, starting at whatever age
they’re diagnosed.
• If diagnosed younger than age 50, or have dense
breasts, they should also have MRI/US