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Breast cancer screening dr.ayman jafar
- 2. Objectives Demonstrate the incidenceof 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 canceris 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
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- 33. Mortality Percent of Deathsby Age Group The percent of breast cancer deaths is highest among women aged 55-64. Median Age at death 68
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- 37. Risk Factors Risk FactorsEstimated 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. RiskFactors 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 mutationincreases 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 estimationmodels Gail model Claus model BRCAPRO model Cuzick–Tyrer model BOADICEA model
- 42. Risk Factors Risk AssessmentModel (Gail)
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- 44. What is screening? Testand 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
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- 46. What benefit toscreening? 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
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- 50. Guidelines Age 20+ Self-breastexamination(optional) monthly Breast clinical examination every 3 yrs Age 40+ Mammography annually High Risk mammography annually + 30 + MRI
- 51. Guidelines (controversy) No requirement forclinicians 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
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- 54. Guidelines (controversy) 20-30% do notundergo screening
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- 57. Breast Self-Examination (BSE) PotentialBenefits 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) PotentialHarms 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
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- 60. Breast Self-Examination (BSE) Organizationsthat 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
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- 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 mammogramsare 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
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- 69. False-positive Recalled examinations thatdoes 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 from70-90% false-negative 20% Factors: Mammographically occult cancer. Overlapping dense breast tissue Poor technique Reader variability
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- 72. Overdiagnosis A cancer neverbecome 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 tomammography 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%)
- 74. Ultrasonography Useful in detectingoccult breast cancer in dense breasts. Highly operator-dependent
- 75. Ultrasonography somo-v Automated BreastUltrasound 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
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- 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 isthe 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 • NationalCancer 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
- #2 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
- #8 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.
- #45 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.
- #49 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
- #51 We can conclude the recommendations of ACS
- #52 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
- #55 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
- #56 At the end of recommendations it valuable to mention that Abu Dhabi Health Authority recommends mammography every 2 years for women 40 and above
- #57 Moving to discuss the modalities of screening. In fact there are 5 screening modalities
- #65 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.
- #66 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,
- #68 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,
- #69 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.
- #70 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.
- #71 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.
- #72 Sensitivity declines significantly with increasing breast density, and the risk of breast cancer is higher in women with dense breasts
- #73 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]
- #77 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.