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In this webinar:
Dr. Paula Gordon will share information on when individuals should start screening for breast cancer, and how often to screen - in order for cancer to be found as early as possible, and to allow the least aggressive options for treatment. Dr. Gordon will also discuss how to screen for recurrence in women who’ve had cancer, explain why these methods are not always offered, and suggest what you can do to improve access to optimal screening.
View the video: https://youtu.be/7uFksz6_4Zk
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Wendy Noe, education coordinator for the Central Indiana Affiliate of Susan G. Komen for the Cure® presents an overview of breast cancer information, facts and advances in treatment.
Wendy Noe, education coordinator for the Central Indiana Affiliate of Susan G. Komen for the Cure® presents an overview of breast cancer information, facts and advances in treatment.
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Here in these slides we have explain about the Breast cancer Screening with the help of which one can get the x-ray image to identify the breast cancer and it is a mammogram which is used when one have no symptoms.
Opportunities for Immune Therapy and Preventionbkling
Dr. Margaret Gatti-Mays of the National Cancer Institute, a Staff Clinician of Laboratory of Tumor Immunology and Biology and the Co-Director of the Clinical Trial Group, explores the future of immunotherapy in breast cancer treatment.
About this Webinar: This talk will explore breast screening for women 40-49. The benefits and harms for screening will be discussed, as well as what is unique about breast cancer in women in their 40s. In order to understand the controversy around current guidelines recommending against screening women 40-49, we will review the evidence upon which these guidelines are based, and their impact on breast cancer outcomes for these women.
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.
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Here in these slides we have explain about the Breast cancer Screening with the help of which one can get the x-ray image to identify the breast cancer and it is a mammogram which is used when one have no symptoms.
Opportunities for Immune Therapy and Preventionbkling
Dr. Margaret Gatti-Mays of the National Cancer Institute, a Staff Clinician of Laboratory of Tumor Immunology and Biology and the Co-Director of the Clinical Trial Group, explores the future of immunotherapy in breast cancer treatment.
About this Webinar: This talk will explore breast screening for women 40-49. The benefits and harms for screening will be discussed, as well as what is unique about breast cancer in women in their 40s. In order to understand the controversy around current guidelines recommending against screening women 40-49, we will review the evidence upon which these guidelines are based, and their impact on breast cancer outcomes for these women.
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.
A presentation looking at breast health and BreastScreen Victoria. The presentation covers breast cancer, risks of breast cancer, breast awareness and the BreastScreen Victoria pathway.
Triple Negative Breast Cancer and Women of Color (Slide 1)bkling
In this webinar, Dr. Onyinye D. Balogun and Dr. Lisa Newman of Weill Cornell Medicine-New York Presbyterian Hospital Network discuss all aspects of triple negative breast cancer and its impact on women of color in recognition of Black History Month.
About the Webinar: Michelle Colero, Executive Director of Bladder Cancer Canada, will cover the essentials of bladder cancer facts and symptoms while also outlining the support and educational resources provided by Bladder Cancer Canada for those dealing with a diagnosis. Additionally, she’ll share ways individuals can contribute to raising awareness and supporting our community.
About the Webinar: Alcohol is classified as a Group one carcinogen and is estimated to be one of the top three causes of cancer deaths worldwide. Yet, over 40 per cent of people in Canada remain unaware that alcohol consumption increases the risk of developing at least nine cancers. In this presentation, we’ll look at what is and isn’t known about the relationship between alcohol and cancer. We’ll explore what the Canadian Cancer Society is doing to raise awareness of alcohol as a modifiable cancer risk factor, its commitment to funding world-leading research on this subject, and its advocacy for stronger policies that reduce, and increase awareness about the risk of cancer related to, alcohol consumption. Attendees will be invited to seek more information and/or take action on this important topic. We hope you’ll join us in learning more about cancer risk and alcohol — the most commonly used psychoactive substance in Canada.
Dr. Rob Rutledge returns for his first webinar of 2024 to discuss the basics behind emotional intelligence. Learn how to develop greater emotional awareness, and learn how to settle fear and frustration. Dr. Rutledge will also share tips on how to live in a more peaceful and connected way as you navigate through your cancer journey.
About the Webinar: Health technology assessment (HTA), the approval process for drugs and healthcare technology, the processes and organizations that support them, such as Canadian Agency for Drugs and Technologies in Health (CADTH), have evolved over the years in response to changing healthcare system priorities and the need to establish their legitimacy. Don Husereau will provide an overview of current processes in Canada, and highlight their perceived (and real) shortcomings and what can be done to overcome these. He will highlight that some perceived weaknesses (such as review times) are not as bad as they appear while perceived strengths (such as stakeholder involvement) need considerable improvement. He will also discuss other opportunities for HTA to innovate and whether there are current plans to address these.
About this Webinar: The time between regulatory approval for new drugs and when drugs became publicly available to patients averaged 736 days (25 months) in 2022. This is double the average time reported in comparable Organisation for Economic Development (OECD) countries. This webinar will highlight variations in drug listing time for new drugs across time, provinces, and type of drugs (oncology vs. non-oncology). It will also present the specific phases involved in moving a drug from approval stage to listing, and the time spent in each. This Conference Board of Canada analysis uses IQVIA’s Market Access Metrics Database (2012 to 2023), which tracks all new products and their indications through the Canadian access journey.
About the Webinar: Learn about pancreatic cancer symptoms, diagnosis, treatment options, statistics, supports and barriers. The presentation will also include some helpful tools that can improve quality of life for those with pancreatic cancer, including the Craig's Cause's PERT (Pancreatic Enzyme Replacement Therapy) calculator and available patient support programs.
As referenced by John Adams in his 2024 CCSN Webinar on the US importing drugs from Canada, this is a slide deck from Health Canada which outlines the timetable and actions taken by the government on this particular issue.
About this Webinar: John Adams takes a dive behind the headlines, news stories and media releases to better understand any real threats to Canadian patients getting the prescription drugs they need.
About this Webinar: We know that methods of eating and diet are a large part of cancer care, but how can you make your diet work for you in your cancer journey? Dr. Rob Rutelege is back to present the latest science around healthy eating and cancer care. In addition, Dr. Rutledge will share the benefits of time-restricted eating, and how you can incorporate it into your daily routine.
Colorectal cancer is the second leading cause of cancer death in Canada, with approximately 24,100 Canadians diagnosed with the disease in 2023. The incidence of colorectal cancer has been declining in Canadians over 50 years of age, largely due to population-based screening programs. Recent evidence has shown, however, that rates have been increasing in adults younger than 50 years. Given that younger adults are typically classified as at low risk for colorectal cancer, this epidemiologic shift is cause for concern.
Individuals under the age of 50 now represent a significant number of colorectal cancer cases. The disease is often being diagnosed at a later stage, and tumour characteristics tend to be more lethal. As for what is accounting for the increasing trend, ongoing research efforts focus on environmental toxicities, lifestyle patterns, and the gut microbiome.
In this webinar, we will present an overview of the current evidence surrounding the rising rates of colorectal cancer in young adults and discuss the unique needs of this patient population, through screening, diagnosis, treatment, and survivorship. A young colorectal cancer patient will share his lived experience in managing this disease and the impact that cancer has had on himself and his family.
About this Talk: This talk will provide a nutritional perspective on the role of diet in cancer focusing on healthy fats known as omega-3 fatty acids. Sources, amounts and types of omega-3 fatty acids will be highlighted. Clinical and experimental evidence in support of a role for omega-3 fatty acids in the prevention and treatment of breast cancer will be presented. Lastly, some practical strategies to support a healthy diet will be shared.
About the Webinar: Genomic testing has already become commonplace in oncology, but exponential growth in more comprehensive genomic tests, other innovative tests and testing approaches in oncology, as well as a number of other therapeutic areas is expected in the coming years. With the emergence of more complex, more expensive, and more promising tests, policymakers and healthcare providers may be challenged to provide these to patients at the pace of innovation. Don Husereau will describe what conditions are necessary for equitable access to advanced innovative testing, how major Canadian provinces are doing, and what more needs to be done in the coming years to benefit all patients.
About this Webinar: This presentation will discuss the pathway to pharmaceutical treatments in Canada that involve health technology assessment reviews and decision making. Observations on the current challenges and the importance of patient input to inform decision making will also be discussed. Finally, the key elements that can be critical to successful outcomes will be presented.
About this Webinar: When Canadians turn on the tap for a drink of water or a shower, we take for granted that the water is safe. Few are aware that old asbestos cement water pipes still deliver water to millions of people. As these pipes age and deteriorate, asbestos erodes into the water and poses health concerns, including cancer.
Dr. Meg Sears, Chair of the Board of Prevent Cancer Now, and board member Julian Branch will talk about the history of asbestos in water, the science behind ingested asbestos, and recent developments.
André Deschamps will show the results of the Europa UOMO Euproms studies. These are the first studies ever from patients for patients, measuring the burden of treatment. More than 5000 patients have shared with us their experiences after treatment. The data has been analyzed by the university of Rotterdam in the Netherlands and has been published in peer reviewed scientific papers.
This webinar will serve as an introduction to Cancer and Work, a website that “was designed to address the unique needs of cancer survivors with returning, remaining, changing work or looking for work after a diagnosis of cancer. The website provides newly created information, resources, and interactive tools for cancer survivors, healthcare providers, employers, and highlights helpful information from across the globe.” The talk will include 10 steps to return to work, and job search ideas for cancer survivors
This webinar will have two perspectives.
Jasveen will be presenting about the impact of cancer and treatment on a person’s physical, cognitive & mental health and how an Occupational therapist can work with the person to gradually overcome these challenges to return to work with or without modifications. The presentation will cover some case studies of past success with the opportunity to answer questions at the end.
Then we will hear from Jen who has experienced her own journey with breast cancer and how she advocated for herself and occupational therapy to help her return to full time employment.
About this Webinar: we’ll summarize the findings of a 10-minute online study conducted by Leger among cancer patients who experienced Long-COVID. We identified 119 cancer patients, diagnosed within the past 10 years, who developed symptoms or were diagnosed with Long-COVID. We primarily wanted to understand how Long-COVID impacted cancer patients and their ability to receive treatment. We also asked about the effect on their overall wellbeing, their ability to access Long-COVID treatments and assistance, and the ongoing impact to this day.
About this Presenter: Colette Faust is a Research Director at Leger (largest Canadian-owned market research company) and has 10 years of market research experience, spending the last 3 years in the healthcare industry. As a member of Leger’s North American Healthcare team, Colette has worked on both quantitative and qualitative healthcare research among healthcare professionals, patients, and the general population across a variety of topics including oncology. Colette received her B.A. in Psychology and Media & Communications from Muhlenberg College in Allentown, PA.
Various cancer treatments can impact one’s gut health and digestive system. This presentation will discuss why a healthy gut is important to overall health. We will talk about the roles the gut is involved in beyond just digestion. We will also discuss nutrition strategies that will support our gut health and promote a healthy microbiome.
In this Webinar, participants will learn about:
– Balancing rising costs and a limited budget
– Eating healthily, food banks, other resources in your community
– Budget formats that work for cancer patients
– Money management
– Debit and credit management
– Credit counselling
– Consumer protection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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WEBINAR: Breast Screening and Breast Density
1. Breast Cancer: Optimal Screening,
Why We Don’t Get it
& The Importance of Breast Density
Paula B. Gordon, OBC, MD, FRCPC, FSBI
Clinical Professor, University of British Columbia
@DrPaulaGordon
3. Objectives
• Describe the best time to start screening for cancer
• How and how often to screen for breast cancer so it can
be found as early as possible, to allow the least aggressive
options for treatment
• How to screen for recurrence in women who’ve had
cancer
• Explain why these methods are not always offered
• Suggest what you can do about it
4. • A disease where a group of cells loses normal control
• These abnormal cells grow, usually into a lump, and
invade and damage the adjacent normal tissue
• They can spread to other parts of the body
• Nearby or distant lymph nodes
• Lung/bone/brain, etc
• Many cancers can be found before this happens, and
when they can be more easily treated
What is Breast Cancer?
5. “1 In 8” Statistic is if we all live till Age 90
Probability of developing invasive breast cancer
in the next 10 years
• age 20: the probability is .06%, or 1 in 1,732
• age 30: the probability is .44%, or 1 in 228
• age 40: the probability is 1.45%, or 1 in 69
• age 50: the probability is 2.31%, or 1 in 43
• age 60: the probability is 3.49%, or 1 in 29
• age 70: the probability is 3.84%, or 1 in 26
6. Breast Cancer in the 40s
1 in 6 breast cancers are diagnosed in women
in their forties
41% of the years of life lost to breast cancer,
are in women diagnosed in their forties
https://www.sbi-
online.org/endtheconfusion/PatientResources
/WhyScreenat40.aspx
7. Factors that Increase Risk
• Estrogen use
• Dietary: fat, alcohol
• Lack of exercise
• Smoking
• Body Weight
• Genetic Mutation
• Chest Wall Radiation
• Dense Breast Tissue*
• Family History
• Previous Atypia or
Atypia
• Early Menarche
• Late Menopause
• Nulliparity
Factors you cannot control Factors you can control
* Dense Breast tissue is now known
to be a more important risk factor
than Family History
Engmann NJ et al. JAMA Oncol 2017
8.
9. 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.
• When cancer is found earlier, women can often:
• Avoid mastectomy
• Avoid axillary dissection
• Avoid chemotherapy
10. 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
Not Thermography!
11. Women are 20-49% less likely to die of breast
cancer if they are invited to have, or actually
have, screening mammography, than women
who do not.
Arleo et al. SBI Screening Leadership Group 2016
Tabar et al. Breast J 2015; 21:13-20
Independent UK Panel on Breast Cancer Screening. Lancet 2012; 380:1778-1786
Broeders et al.J Med Screen 2012; 19 Suppl;14-25
Coldman et al. JNCI 2014; 106
Nickson et al. Cancer Epidemiol Biomarkers Prev 2012; 21:1479-1488
12. Annual Screening 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
13. Current Guidelines: When To Begin Screening
American College of Radiology: age 40
Society of Breast Imaging: age 40
National Comprehensive Cancer Network: age 40
American Society of Breast Surgeons: age 40
American College Obstetricians and Gynecologists: age 40-50,
after discussion with PCP
American Cancer Society: age 45 or 40 if women prefer
US Task Force: age 50
Canadian Task Force: age 50
Canadian Cancer Society: age 50
Conflicting guidelines did not arise because of alternative facts.
They arose because of different value judgments applied to the same
facts.
14. Evidence that Screening Saves Lives
11 Randomized Trials
• NYHIP 1963
• Malmö 1 1976
• Malmö 2 1978
• Kopparberg 1976
• Östergötland 1978
• Edinburgh 1978
• CNBSS 1 1980
• CNBSS 2 1980
• Stockholm 1981
• Göteberg 1982
• Finland 1987
And dozens of systematic reviews and meta-analyses
Courtesy Dr. Jean Seely
23. MYTH: In the Era of Modern Therapy, it’s Not as
Important to Find Cancers Early
Conclusion:
Tumour stage at diagnosis of breast cancer still
influences overall survival significantly in the current
era of effective systemic therapy. Diagnosis of breast
cancer at an early tumour stage remains vital.
Saadatmand S et al. BMJ 2015;351:h4901 doi: 10.1136/bmj.h4901
24. The Incidence of Fatal Breast Cancer Measures the
Increased Effectiveness of Therapy in Women
Participating in Mammography Screening
Tabar et al. Cancer 2019; 125:515-523
• 52,438 women aged 40‐69 screened 1977-2015 in
Dalarna County, Sweden with 85% participation rate
• Compared to non-screened women during the same
period, and non-screened women in the prior 19 yrs
• 58 years total
• Women who chose to be screened were 60% less
likely to die in the 10 yrs after diagnosis, and 47%
less likely to die within 20 yrs of diagnosis
25. The Incidence of Fatal Breast Cancer Measures the
Increased Effectiveness of Therapy in Women
Participating in Mammography Screening
Tabar et al. Cancer 2019; 125:515-523
• 52,438 women aged 40‐69 screened 1977-2015 in
Dalarna County, Sweden with 85% participation rate
• Compared to non-screened women during the same
period, and non-screened women in the prior 19 yrs
• 58 years total
• Women who chose to be screened were 60% less
likely to die in the 10 yrs after diagnosis, and 47%
less likely to die within 20 yrs of diagnosis
“These results demonstrate that women who have
participated in mammography screening obtain a
significantly greater benefit from the therapy
available at the time of diagnosis than do those who
have not participated.”
26. In 2014, the Canadian National Breast Screening Study
released of their 25 year follow.
To understand their conclusions, you have to know that the study was
poorly designed and poorly executed.
Bear in mind, it was done in the 1980’s using obsolete technology.
27. Many experts internationally are painfully familiar with the details
of the trial and have to stay on guard to respond.
29. • 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
30. A Failure Analysis of Invasive Breast Cancer:
Most Deaths From Disease Occur in Women NOT
Regularly Screened
Webb ML et al. Cancer Sept 9, 2013
• 7301 women diagnosed with breast cancer
1990-1999 at 2 hospitals in the Harvard system
in Boston
• 609 breast cancer deaths, 905 non-breast cancer
deaths
31. Webb ML et al. Cancer Sept 9, 2013
• 71% of deaths occurred in the 20% of women who
did not undergo regular mammographic screening
and 29% occurred in regularly screened women
(19% screen-detected, 10% interval)
• Of all breast cancer deaths, only 13% occurred in
women 70 years or older but 50% occurred in
women under age 50; 31% occurred in women
initially diagnosed between ages 40 and 49 years
32. Mortality Reduction is the
Only Benefit that can be Seen in an RCT
But there are other benefits of early detection
• Option for Breast-conserving Surgery
• Option for Avoiding Axillary Dissection
• Option to Avoid Chemotherapy
33. Finding Cancer Early Can Mean The Difference
Between Needing A Mastectomy (Left) Or
Being Able To Have A Lumpectomy (Right)
34. Impact of Screening Mammography on Treatment in
Women Diagnosed with Breast Cancer
Ahn S et al. Ann Surg Oncol https://doi.org/10.1245/s10434-018-6646-8
• 2 groups: mammo 1-24 months prior to diagnosis, or
25+ months prior
• Women having screening mammography less often
more likely to receive chemotherapy, undergo
mastectomy, and require axillary dissection
• Patients aged 40–49 years with no prior mammography
were more likely to have larger tumors and positive
nodes, undergo mastectomy, undergo axillary
dissection and require chemotherapy than women who
had mammo in the 2 years prior
35. http://lymphademainfo.blogspot.com/20
07/08/what-is-lymphadema.html
• Swelling in the arm and
hand from blockage of the
lymphatic vessels in the
armpit: a side effect of
traditional armpit surgery
done as part of breast
cancer lymph node staging.
• This surgery can be avoided
when cancer is detected
early
Lymphedema
Giuliano AE et al. JAMA 2011;305:569–575
36. 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 than
traditional armpit surgery
37. 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
38. Randomized Controlled
Trials
using death as the endpoint
They did not measure reduced morbidity
Suffering
Harsh Treatment
Medical Problems Created By Treatment
Proof of Benefit of Screening
39. Does Screening Save Lives?
• Randomized Controlled Trials (RCTs) of Mammography
have shown a 15-20% mortality reduction in women
invited to be screened
• Observational studies show 40-49% fewer deaths in
women who attend screening
40. “Harms” Of Mammography Screening
According to US and CA Task Forces
• Pain from compression 1-4%
• Radiation Oncogenesis < 1%
• False Alarms: recall, biopsy 5-15%
• Anxiety
• Inconvenience
• Discomfort
• False Negatives (false reassurance) < 1%
• Overdiagnosis 1-
10%
Sickles
41. Radiation Risk From Mammography
• Radiation risk of breast cancer from mammogram is
primarily in women less than 20 years old
• Mammogram (4 pictures) 0.4 mSv
• Transcontinental flight 0.08 mSv
• The higher you are in altitude, the higher the dose
of radiation. This is a result of less shielding of
cosmic radiation by the atmosphere at higher altitudes.
• The dose from a mammogram is similar to 7 weeks of
average natural background radiation (or 3-4 weeks living in
Colorado)
42. Risk vs Benefit: Radiation
• For 1000 women aged 50-69 having a
mammogram every 2 years, radiation would
hypothetically cause 0.27 cancers and 0.04
deaths
• The mammograms would prevent 5 deaths (125
times more than lives lost) and save 105 years of
life
• So avoiding mammograms for fear of radiation is
not a winning bet
Yaffe MJ, Mainprize JG. Radiology 2011; 258:98-105
43.
44. 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
45. 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
• 86% would have been willing to be recalled more
often for a noninvasive or 82% for an invasive
procedure if it might increase the chance of
detecting a cancer (if present) earlier
46. 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
47. Helvie MA. JBI 2019; 1:278–282
“Assessing the importance of overdiagnosis is a
subjective judgment that contrasts the value of
unnecessary treatment of an overdiagnosed cancer,
with the value of saving a life from breast cancer:
that is, overdiagnosis from screening versus
increased mortality by not screening (“over dying”).
Many women are willing to accept screening risks in
order to reduce the likelihood of breast cancer
death.”
48. 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)
50. US and Canadian Task Forces’ Rationale
Exaggerated the harms of mammographic screening
Underestimated the benefits
Then say that the harms outweigh the benefits
BUT THE HARMS DON’T EQUATE TO POSSIBLE
DEATH IF NO SCREENING
51. USPSTF
Screening Mammography Recommendations:
Science Ignored
Hendrick and Helvie. AJR 2011; 196:112-6
If women who were age 30-39 (entering their
forties over the next 10 years), follow the
USPSTF guidelines, 100,000 more would die
from breast cancer that could have been saved
by annual screening beginning at the age of 40
52. Women in Their 40’s
• Women 40-49 are not
offered breast cancer
screening in all
provinces.
• They often are caring
for young children and
aging parents
• They are working and
contributing to the
economy
They are not expendable!
53. Screening in Canada
• Seven provinces: women may self-refer every
2 years, starting at 50
• Three provinces start at 40
• In BC, women with a mother or sister with
breast cancer may attend annually
• In some provinces, women are recalled
annually if they have dense breast tissue
54. When to Stop
• RCTs included women up to age 74
• Over 6/10 years
• Women ≥ 75 years comprised 6/10% of the
screening mammograms
• 5.8 cancers per 1000 overall
• 5.9/8.4 cancers per 1000.
• 85/82% invasive
• 98% had surgery
Hartman M et al. AJR 2015; 204:1132-6
Destounis S et al. JBI 2019; 1:182-185
56. Radiologists are pretty good at recognizing cancer on a mammogram, when
it’s visible. Here is a cancer in a 55 year old woman and it’s jaggedy edges
are typical of cancer
57. And it is relatively easy to see cancer when the breast is mainly fatty
like in this woman. Fat is dark gray on a mammogram.
58. But as the amount of normal dense tissue (the white stuff)
increases relative to fat….
59. It becomes harder to see cancers (which are white).
It is like trying to see a snowball in a snowstorm.
60. And some women have virtually no fat, and are all dense.
Even a large cancer can be masked in these breasts.
61. A B C D
Today, radiologists grade density into 4 categories. Some provinces still use a
quartile system, where the radiologist subjectively decides what percentage of
the area is dense tissue: < 25%, 25-50, 50-75, and >75%.
BC and NS use the new system introduced in 2014: A – D, based on the
possibility of masking a cancer, so even in a breast with less dense tissue, if it’s
concentrated in a small area, can be a category D.
B
63. 8 Months later: She had a palpable mass
Repeat Mammogram was Still Negative – even with
Tomosynthesis (3D)
63
64. Her 3.2 cm cancer was not visible on her
mammogram in her dense breast tissue
But was easily seen on Ultrasound
64
• A cancer that is found as
a lump, after a negative
mammogram is called an
interval cancer.
• Interval cancers are 18X
more common in women
with dense breasts
WE SEE CASES LIKE THIS
EVERY SINGLE WEEK
65. Dense Breasts Are Normal And Common
• Every woman has fat, glands and fibrous tissue in her
breasts, but the proportions vary from woman to
woman.
• Breasts that have more than 50% glands and fibrous
tissue are called dense breasts.
• > 40% of women, aged 40-74 have dense breasts, and
the only way to tell is on a mammogram
• Breasts may, (but not always) become less dense and
more fatty with age.
66. Dense Breasts Are Normal And Common
While it is normal to have dense breasts, women
need to know if they have dense breasts so that
they can understand the implications.
• 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 ( >75% dense breast
tissue)
• Only 60% of women have mammograms, so the
rest cannot find out their density
67. Why It’s Important To Know
If You Have Dense Breasts
• Women in the D category have 4-6 X higher risk of
developing breast cancer than women with fatty breasts
• Masking effect: dense tissue and cancer both appear
white on a mammogram, so cancers can hide
• Cancers are larger and more often node positive
• 18X higher risk of an interval cancer (cancer discovered
between screenings); these cancers have a worse
prognosis than screen-detected cancer
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
68. How is Breast Density Determined?
• Only by the radiologist when viewing a mammogram.
• Not by breast size or touch.
• Your GP cannot tell 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.
70. For many years, it was believed that ultrasound could not find cancers
that were not visible on mammography, and too small to feel.
We published this paper 25 yrs ago, and it was followed by work from
multiple other institutions and then multicentre trials, that showed that
high resolution ultrasound can indeed find cancers that are too small to
be palpable, and missed on mammography, largely because of dense
breast tissue.
Cancer 1995; 76: 626-630
71. 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
73. • In spite of all the evidence on breast
density, it was still not being shared with
women, and in many cases, with their
doctors.
• Nancy Cappello is an American advocate.
In 2004, only weeks after a routine
annual screening mammogram that was
negative, she found a lump in her breast.
After an ultrasound showed a cancer, she
was diagnosed as stage 3C with 13
positive axillary nodes.
• She lobbied for legislation to require
patient notification of density and its
impact on mammogram sensitivity, and
potential for supplementary screening.
74. There are currently 38 states with some degree of density notification in
the USA. FDA has said all women must be notified.
75. The Connecticut Experiment;
The 3rd Installment: 4 Years of screening women with
Dense Breasts with bilateral Ultrasound
• Additional yield 3.2 cancers / 1000 in year 1
• Additional yield 3.8 cancers / 1000 in year 2
• Additional yield 3.2 cancers / 1000 in year 3
• Additional yield 3.5 cancers / 1000 in year 4
• Average size < 1cm
• PPV of 6.7% in year 1, 17.2% in year 4
• Only 30% of eligible women, even though insured
Weigert J. The Breast J 2016;1-6
76. Small, node negative cancers
Not seen on mammogram, but seen on ultrasound
Courtesy Dr. Regina Hooley
77. How Do We Screen For Cancer?
• “The only screening method that has been proven to
reduce mortality is mammography.”
• It’s the only modality that has been studied in
Randomized Control Trials (RCTs)
• An RCT of Ultrasound is being done now in Japan
• Other methods for screening, used in select populations,
like Ultrasound, MRI, and MBI have not been studied for
mortality reduction.
• Yet MRI is used for screening high risk women
84. How Can I Find Out My Breast Density
After a Screening Mammogram
• As of now: BC, NS, PEI notification for all women
• AB, NB committed to notifying all women
• SK, MB, ON tell only highest category
• PQ – tells physician, but not women
• NL – no notification so far
• For easy to follow instructions on how to find out your
density visit densebreastscanada.ca
85. Your Doctor May be Unaware!
• Of the greater risk of getting breast cancer, when
breasts are dense
– Having dense breasts is a stronger risk factor than a family history
– Women with dense breasts are 5X more at risk than those with
fatty breasts
• Of the greater likelihood of a cancer being missed on a
mammogram when breasts are dense
– 50% of cancers are missed in women with the highest density
• Of the ability of ultrasound to find the cancers missed
on a mammogram, when breasts are dense
86. What About 3D Mammography
(Digital Breast Tomosynthesis)?
• Finds 30% more cancers
• Has fewer false alarms
• But sees only half the cancers visible on
ultrasound, that were missed on
mammograms
87. DBT vs Screening Breast US
US detects more cancers than tomo
3 Small Invasive Cancers, not seen on 3D Mammography
Visible on Screening Ultrasound
Courtesy Dr. Regina Hooley
92. What Should I Do If I Have Dense Breasts?
• Continue having mammograms because they can
detect cancer not visible on ultrasound.
• Perform regular self-exams between screenings. Look
for any change that may be cancer, not seen on your
mammogram, and see your doctor.
• Consider modifying your lifestyle factors to decrease
the risk of cancer, or recurrence such as: getting to
and staying at a healthy weight, doing moderate
exercise, decreasing alcohol intake and decreasing
hormone use.
93. What Should I Do If I Have Dense Breasts?
• Speak with your doctor about: your level of density, the
associated risks, any additional risk factors you have
and the best screening options for you.
• To improve early cancer detection in dense breasts,
consider additional screening, such as ultrasound or
MRI,* especially if you’ve had cancer
• If you are diagnosed with breast cancer, consider MRI
to ensure no additional tumours are hidden, before
deciding on lumpectomy vs. mastectomy, and to check
the other breast for hidden cancer(s).
94. Mammographic breast density is associated with the
development of contralateral breast cancer
Raghavendra A et al. Cancer 2017; 123:1935-1940
• 229 stage I - III BC between Jan 1997 and Dec 2012
• 451 matched controls
• After adjustment for potential prognostic risk factors for
BC, the odds of developing CBC were found to be
significantly higher for patients with dense breasts (odds
ratio, 1.80; 95% confidence interval, 1.22-2.64 [P<.01])
than for those with non-dense breasts.
95. The Association of Mammographic Density
With Risk of Contralateral Breast Cancer
and Change in Density With Treatment
in the WECARE Study
Knight JA et al Breast Cancer Res. 2018;20
• In women < 55 the risk of CBC increased linearly with
increasing mammographic density.
• Breast density can decrease with Tamoxifen or Chemotherapy
(but not radiation)
• In women where it decreases > 10% with treatment, there
may be a lower risk of CBC (more studies needed)
96. Mammographic Density and the Risk
of Breast Cancer Recurrence After
Breast-Conserving Surgery
Cil T et al Breast Cancer Res. 2018;20
• Post lumpectomy and radiation, overall risk of local
recurrence is ~ 10-15% in 10 years
• Patients with high mammographic density experienced a
much greater risk of local recurrence (21%)compared with
women with the least dense breasts (5%)
• The risk of local recurrence at 10 years was higher for women
who did not receive radiotherapy (22%) than for women who
did (10%).
• Important if considering partial breast irradiation
97. Breast Cancer Screening in Women
at Higher-Than-Average Risk:
Recommendations From the ACR
Monticciolo DL et al. J Am Coll Radiol 2018;15:408-414.
• For women with genetics-based increased risk (and their
untested first-degree relatives), with a calculated lifetime risk
≥ 20% or a history of mantle radiation therapy at a young age,
supplemental screening with contrast-enhanced breast MRI is
Recommended
• Breast MRI is also recommended for women with personal
histories of breast cancer and dense tissue, or those
diagnosed by age 50.
• Others with histories of breast cancer and those with atypia
at biopsy should consider additional surveillance with MRI,
especially if other risk factors are present.
98. Take Away Points - Breast Cancer Screening
• Optimal screening: mammograms, ideally annually
starting at age 40, and should continue as long as in
good health, with a life expectancy of at least 10 years.
• Some cancers are not detectable on mammograms
• Most abnormalities on mammograms are NOT cancer
• Woman who have mammograms are 40% less likely to
die of breast cancer….
• 3D mammography finds more cancer than 2D, and has
fewer false alarms
The benefits outweigh the harms
99. Take Away Points
Breast Cancer Screening
• Ultrasound finds cancer missed on mammograms in dense
breasts, even if 3D mammo used
• Having dense breasts poses 2 risks:
• dense breasts increase the risk of getting breast cancer
• and reduce the accuracy of mammography
• It is important to know your breast density and understand
the implications. Please speak to your doctor about your risk
factors.
Please tell your friends, family and colleagues
what you learned about screening and density.