The document discusses breast cancer screening guidelines and recommendations. It notes that various medical organizations have different guidelines for mammography screening, with some recommending annual screening beginning at age 40 while others recommend biennial screening between ages 50-74. The document also discusses debates around overdiagnosis from mammography screening and challenges in assessing its effectiveness due to the slow progression of breast cancer.

1. Breast Cancer Screening The Search for Consensus Presented for Paint it Pink September 19, 2011 Nathaniel W. Cuthbert, MD .

2. Breast Cancer Excluding skin cancer, breast cancer is the most commonly diagnosed cancer in U.S. women Second only to lung cancer in cancer deaths in women 200,000 new cases of invasive breast cancer in 2010 54,000 news cases of non-invasive breast cancer in 2010 2,000 new cases in men (<1%)

3. U.S. Preventive Services Task Force (USPSTF) November 2009 Biennial (every 2 years) mammograms, age 50-74 No screening mammogram for age 75+ BSE discouraged, harm outweighs benefits

4. USPSTF Rationale Psychological harm Unnecessary tests and biopsies, inconvenience associated with false +’s Overdiagnosis

5. To be or not to be, that is the question: Whether ‘tis nobler in the mind to suffer The slings and arrows of outrageous fortune Or to take arms against a sea of troubles And by opposing end them? To screen or not to screen, that is the question: Whether ‘tis wiser to avoid the anxieties And costs of screening mammography, and hope By good fortune to avoid the ravages of breast cancer Or be proactive through screening and improve one’s odds of early detection and treatment?

6. BREAST CANCER DETECTION Breast self-exams (BSE) Clinical breast exams (CBE) Mammography Breast MRI (newest recommendation for some high risk women)

7. RISK FACTORS FOR BREAST CANCER Personal hx of prior breast cancer BRCA-1 and BRCA-2 carriers Family hx of breast cancer (esp. if young) Menopause after age 55 First period before age 12 Never having children, or having children after 30 Race If < 40 African American women higher risk If > 40 White women have higher risk

8. BREAST CANCER RISK Birth to age 39– 1 in 229 From age 40 to 59– 1 in 24 From age 60 to 79—1 in 13 RISK OVER LIFETIME IS 1 IN 7

9. MYTHS OF BREAST CANCER MYTH # 1 Breast cancer only affects older women Can occur in younger women too

10. MYTHS OF BREAST CANCER

11. MYTH # 1 Breast cancer only affects older women NOT TRUE Can occur in younger women too

12. MYTH # 2 If you have a risk factor for breast cancer, you are likely to get the disease NO You are not destined to get the disease just because you have a risk factor Be diligent about your care and follow up

13. MYTH # 3 If breast cancer doesn’t run in your family, you won’t get it NO 80% of women with breast cancer have NO family history

14. MYTH # 4 Only mother’s family history can affect your risk NO Mother’s or father’s history is important

15. MYTH # 5 Using antiperspirants causes breast cancer NO No evidence that there is a link

16. MYTH # 6 Birth control pills cause breast cancer NO Today’s pills are very low dose

17. MYTH # 7 I am at high risk and I can do nothing about it NOT TRUE Regular breast care and diligence Medication (Tamoxifen) Lifestyle changes (Heart healthy plan) Genetic counseling to discuss options

18. MYTH # 8 If I am diagnosed with breast cancer, I will die NOT TRUE 80% have no cancer outside of the breast Survival today is improving all the time even in patients with cancer which has spread 87% of breast cancer patients are alive at 5 years

19. MYTH # 9 Most breast lumps are cancerous NOT TRUE Most breast lumps are not cancerous, but are benign (cysts or fibrous tissue or fibroadenomas)

20. MYTH # 10 If I have to have a biopsy, it is most certainly cancer NOT TRUE Over 80% of all breast biopsies are not cancer!! Over 1.6 million breast biopsies are performed every year in the U.S.

21. MYTH # 11 I am a man, therefore I can not get breast cancer NO 1 % of all breast cancers occur in men

22. Why is the definitive assessment of screening mammography so difficult? Relatively slow progression in many cases requires patients to be followed for 10-30 years Changing treatments Changing incidence of cancer Improving technology, i.e. Digital mammography Statistics Biases

23. Biases Radiologists: Monetary Fulfillment from detecting cancers Academicians  Pressure to publish Government affiliated agencies  High cost of paying for what has been promised

24. Radiology- September 2011 Mammographic Screening and “Overdiagnosis” (Kopans, et al.) Swedish Two County Trial: Impact of Screening on Breast Cancer Mortality during 3 Decades (Tabár, et al.) Is Mammographic Screening Justifiable Considering Its substantial Overdiagnosis Rate and Minor Effect on Mortality? (Jorgensen, et al.)

25. Mammographic Screening and “Overdiagnosis” 31% reduction in breast cancer mortality rate, 1990-2007 75,000 fewer women died than if mortality rates had been stable Computer models estimate 28%-65% of this reduction due to mammography

26. Swedish Two County Trial The number of breast cancer deaths prevented increases with time 20 years or more needed to see full benefit 1 breast cancer prevented for every 414 women screened for 7 years

27. Is Mammographic Screening Justifiable…? Screening increases mastectomy Screening increases biopsies Screening increases psychological distress Overdiagnosis- detection of cancers which would not be clinically evident before a patient dies of something else

28. American Cancer Society Annual mammograms beginning at age 40 for as long as in good health Clinical breast exam, every 3 years in 20’s or 30’s, annually for 40+ Self-awareness, BSE optional beginning in 20’s

29. American College of Gynecology (July 2011) Annual mammograms beginning age 40 (previous recommendation every 1-2 years starting at age 40) Sojourn time- time between when cancer first discoverable mammographically until clinically evident Sojourn time 2-2.4 years for ages 40-49, 4-4.1 years for 74+ Clinical breast exam every 1-3 years for ages 20-39, annually for 40+ Self-awareness beginning at age 20

30. American College of Radiology Annual mammogram beginning at age 40 for average risk patient Annual mammogram beginning at age 30, but no sooner than 25, for higher High risk (BRCA gene or 20% lifetime risk) should have annual breast MRI beginning at age 30, in addition to mammography

31. Breast Cancer Survival Age 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 45 86% for women ages 45–54 87% for women ages 55–64 88% for women ages 65–74 84% for women ages 74 and over American Cancer Society Breast Cancer Facts & Figures 2001–2002

32. CONCLUSION Breast cancer can be detected in the early stages Breast cancer can be treated effectively Breast cancer when it is most treatable, does not produce any symptoms, therefore be diligent with breast health