Breast Screening - Mercy Health Partners

9/29/2014
Presentation Objectives:
Attendees will:
Nancy L. Gantt, MD FACS
Co-Medical Director, JACBCC
2014 Primary Care Update
Humility of Mary Health Partners
Disclosures:
1) Become familiar with background of current
controversies in breast screening
2) Understand considerations involved in the
recommendation for breast screening and additional
diagnostic imaging.
3) Become aware of the COC indicators for quality care of
breast cancer patients.
Breast Cancer Screening Guidelines
 BSE starting in their 20’s
 Female
 CBE every 3 years for woman in their 20’s and 30’s, yearly
starting at age 40
 Breast cancer survivor
 Mammograms:
 Yearly starting at age 40, continuing as long as women
remain in good health
 Start 10 years prior to age of onset of any first degree
relative if premenopausal
 Women at high risk (greater than 20% lifetime risk) should
get an MRI and a mammogram every year.
Breast Cancer Screening USPTF
2002 vs. 2009
Mortality
 Does screening reduce the mortality from breast cancer?
 Overall mortality reduction of 30% since peak in 1980’s. Why?
 Past understanding (Scandinavian studies) mortality reduction
of 30-50% with screening
 Recent review:
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15% reduction mortality ages 40-49
32% mortality reduction 60’s
False + with 10 yrs. screening cumulative 61%
Possibly 19% “overdiagnosis”
Pace, et al. JAMA 2014 Apr 2;311(13):1327-35.
 2002 Recommendations:
 For all women >39, mammograms every 1-2 years
 2009 Recommendation Statement:
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
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For women ages 50-74, mammography every 2 years
For women < 50, “against routine screening”
No benefit for CBE
Recommended against teaching women BSE
Ann Intern Med 2002;137:344-6 and 2009;151:716-26
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Subsequent USPTF addendum
Breast screening “harms”
“the decision to begin regular biennial screening “
before age 50 “should be an individual one and should
take into account a woman’s own situation and her
values regarding specific benefits and harms”
 False positive results leading to biopsy
 Cost, discomfort, imaging challenges
Ann Intern Med 2009;151:716-26
 Patient anxiety
 Can lead to prolonged psychosocial distress
 Radiation exposure
 Minimized (Analog 2.4 mGy, Digital 1.9 mGy)
 Overdiagnosis
 Can only be inferred from long-term F/U of RCT
Screening (subsequent)
 Physician adherence to recommendations
 Majority: Mammo at age 40
 Annual imaging: 98% GYN, 77% IM, 74% FM
Womens Health Issues. 2014 May-Jun;24(3):e313-9.
 National guidelines:
 ACS, ASBS: Annual mammograms after age 40
 ASBD: Annual mammograms and CBE after 40
 AAFP (2007): Biennial mammograms after 40, yearly after
age 50
 NAPBC represents 20 organizations, supports ACS
Canadian National Study
Canadian National Study
Study Structure:
Study Conclusions:
 Patients who had mammograms between 1980-1985
 Two groups of volunteers, ages 40-59
 Group #1: CBE “only”

Ages 40-49 received single CBE followed by “usual care”
 Group #2: CBE and screening mammography
 Followed up to 25 years
 Outcomes sought:
 Detecting cancers
 Cancer-specific mortality
 “Annual mammography for ages 40-59 does NOT reduce
mortality from breast cancer above that of CBE and usual care
when access to adjuvant care is readily available.”
 “Overall, 22% (106/484) of screen-detected invasive breast
cancers were overdiagnosed, representing one overdiagnosed
cancer for every 464 women who received screening in the
trial
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Canadian National Study
Breast screening studies: Caveats
Criticisms of Study:
 Earlier discovery, stage QOL benefit
 More conservative local and systemic therapy
 ** If caught regionally, newer therapy can increase survival
 Not population based-”opportunistic”
 Lack of randomization-CBE prior to group assignment
placed 11 palpable cancers in mammogram arm
 Poor quality imaging
Hologic-Selenia Dimensions
 Earlier discovery, stage survival benefit
 Lead-time bias (earlier diagnosis W/O altered outcome)
 Length bias (preferential Dx. of slow-growing tumors)
 “Invite to screen” vs. “Usual care”
 Noncompliance (invited to screen but didn’t)
 Contamination (not invited to screen but did)
Digital vs Analog Mammography
3-D Digital Mammography
 Includes a 3-D tomosynthesis image in combination
with a 2-D image. Radiation exposure about 2.7 mGy.
 3-D scan results in a stack of thin, high resolution
image slices that show the inner structure of the
breast without distortion typically caused by tissue
shadowing or density.
 The thin layers of tissue are shown separately, which
helps to separate benign lesions from suspicious
lesions, and avoid biopsies.
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Why Breast Tomosynthesis
(3D mammography)?
 Tissue superimposition hides
pathologies in 2D
 Tissue superimposition mimics
pathologies in 2D
MRI of the Breast
MRI Indications-NCCN
 Evaluating extent of cancer including multifocality
 REQUIREMENTS:
 Dedicated breast MRI
 Specialized software, table, and coils to enhance imaging
and facilitate MRI guided breast biopsy
 Images interpreted by trained radiologists in conjunction
with all of the patient’s other imaging
 Evaluating contralateral breast in woman with breast
cancer
 Evaluate response to neoadjuvant therapy, potential for
conservative therapy.
 Detecting primary breast cancer in woman with axillary
nodal adenocarcinoma or Paget’s disease and otherwise
negative imaging
 Yearly screening for abnormal BRCA gene carriers and
women whose lifetime risk is >20%
Additional MRI Indications-ACR
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Evaluating the augmented breast (non-contrast)
Invasion of cancer deep to pectoralis fascia
Extent of residual cancer post-lumpectomy
Evaluation of possible breast cancer recurrence
 CAUTION:
 False-positive imaging-high sensitivity/low specificity
 Do not order in lieu of biopsy of suspicious lesions.
 Consider patient’s menstrual cycle
 $$$$$-obtain precertification
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Gamma Medica-Luma Gem
Molecular Breast Imaging
Analog Mammography/MBI
 Target population- women with dense breast tissue
and increased risk for breast cancer.
 High resolution functional study of the breast.
 Patient is injected IV with short lived radioactive
agent that is absorbed by breast tissue.
 Cancer cells absorb more of the radioactive agent,
 MBI is available in a limited number of Centers- only
2 in Ohio.
Breast Density-the new “hot topic”!
 Clinically:
 Dense breasts convey 4-5X increased cancer risk
 Increased difficulty in imaging-tumors hide.
 Grading: Bi-Rads 4 categories
Breast Density Legislation
 History:
 Nancy M. Cappello, Ph.D. of CT diagnosed with Stage III breast
cancer 2 months after a “normal” mammogram, attributed to
dense breast tissue
 Are You Dense Advocacy, Inc. is a 501(c)(4) tax–exempt
organization
 Ohio:
 SB 54 was originally introduced by John Eklund (R-Chardon) and
Eric Kearney (D-Cincinnati) on February 25, 2013. Substitute bill
adopted by the Senate MHHS committee expected to be passed.
 Places the requirement to notify a patient on the facility, not the
physician and contains a broad immunity clause.
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Breast Density Legislation
Breast density awareness
Legislative & grass-roots activities – January 2014
Illinois
2009 – Insurance Coverage Law
2013 - Density-Inform LawPOOR
Washington
Breast Density-”Minimal language”
Maine
Utah
Ohio
Indiana
Colorado
Missouri
Kentucky
8
Tennessee
Arizon
a
Massachusetts
1
Connecticut
2006 – Insurance Coverage
Law
2009 – Density-Inform Law
New Jersey
Delaware
Maryland
7
10
2
Virginia
No. Carolina
11
So. Carolina
Breast Density and Mammography
Reporting Act, October, 2011,
Rosa DeLauro (CT)
Steve Israel (NY)
Georgia
Alabama
9
Texas
Effective Dates:
Pennsylvania
Tennessee
Working on a Bill/ Organized
Activity
Has inform law but not
mandatory/poor
3
Michiga
4
n
Pennsylvania
13
Iowa
California
6
Introduced inform or notify bill
7
New York
Minnesota
Nevada
Hawaii
6
New Hampshire
12
Oregon
5
14 Mandatory Density-Inform
3
01-30-14
07-01-14
Has Insurance Coverage
Florida
Law
"Your mammogram demonstrates that you have dense
breast tissue, which could hide abnormalities. Dense breast
tissue, in and of itself, is a relatively common condition.
Therefore, this information is not provided to cause undue
concern; rather, it is to raise your awareness and promote
discussion with your health care provider regarding the
presence of dense breast tissue in addition to other risk
factors."
Over 1/3 of U.S. screening population live in states enacting density-inform legislation
Source data from Are You Dense, Advocacy, dated January, 2014
DOC1437277
GE Automated Breast Ultrasound (ABUS)
Imaging Architecture
Acquire images
• Automated image acquisition
• 15 cm field-of-view transducer
• Image acquisition time less than
3 minutes each breast
• Total exam time ~15 minutes
Interpret images
• Supports image interpretation
• Review 3D image sets on workstation
• Read entire case in ~3 minutes1
1. ARRS 2012 Breast Imaging: Screening/Emerging Technologies Oral Abstract; Radiologist
Interpretation Time for 3D Automated Breast Ultrasound Screening, R. Brem
Clinical Practice Recommendations
 Patient risk assessment
 Personal/family history
 Risk assessment tools


Gail model
Tyrer-Cuzick (IBIS)
 Referral to Genetic Counselor
 Baseline screening age based on risk, personal choice
 Subsequent screening based on results of baseline
 Biennial imaging effective at balancing benefits/risks
 Discuss ongoing CBE, BSE
 Stop screening based on performance status
Breast Cancer Screening Guidelines
 BSE starting in their 20’s
 CBE every 3 years for woman in their 20’s and 30’s, yearly
starting at age 40
 Mammograms:
 Yearly starting at age 40, continuing as long as women
remain in good health
 Start 10 years prior to age of onset of any first degree
relative if premenopausal
 Women at high risk (greater than 20% lifetime risk) should
get an MRI and a mammogram every year.
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Mission
The Commission on Cancer (CoC) is a consortium of professional organizations
dedicated to improving survival and quality of life for cancer patients through
standard-setting, prevention, research, education, and the monitoring of
comprehensive quality care.
NCDB
Cancer Program Practice Profile Reports
1.
Breast Conservation rate
2. Needle biopsy utilized for diagnosis of cancer
3. RT after mastectomy if >3 +LN
4. RT after lumpectomy age <70
5. Combination chemotherapy considered age <70
6. Tamoxifen or AI considered +ERA/PRA
Questions?
[email protected]
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