slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Each year in the U.S. alone: PowerPoint Presentation
Download Presentation
Each year in the U.S. alone:

Loading in 2 Seconds...

play fullscreen
1 / 42

Each year in the U.S. alone: - PowerPoint PPT Presentation


  • 196 Views
  • Uploaded on

Magnetic Resonance Imaging (MRI) Screening for High Risk Patients Ellen Warner M.D. Division of Medical Oncology Sunnybrook & Women’s College Health Sciences Center Toronto, Ontario, Canada. Each year in the U.S. alone:. 5.3 million affected 40,000 deaths. Motor Vehicle Injuries.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Each year in the U.S. alone:' - Sophia


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Magnetic Resonance Imaging (MRI) Screening for High Risk PatientsEllen Warner M.D. Division of Medical OncologySunnybrook & Women’s College Health Sciences CenterToronto, Ontario, Canada

each year in the u s alone
Each year in the U.S. alone:
  • 5.3 million affected
  • 40,000 deaths
slide3

Motor Vehicle

Injuries

Breast Cancer

  • Primary Prevention:
  • obey traffic laws • tamoxifen
  • don’t drink & drive • oophorectomy
  • Secondary Prevention:
  • seat belts  air bags • breast screening
slide4

Is MRI

Screening

of the Breast

an Effective

Seat Belt

For High Risk

Women?

definition of high risk
Definition of ‘High Risk’
  • Known BRCA mutation carrier

or

  • Close relative of mutation carrier

or

  • Family history suggestive of inherited predisposition
cumulative risk of breast cancer
Cumulative Risk of Breast Cancer

1. Antoniou et al. Am J Hum Genet, 2003

2.SEER Cancer Stats Review, 2004.

BRCA1

BRCA1 +

oophorectomy

no family

mutation

general

population

mammography screening for high risk women
The Ideal

100% sensitivity

DCIS

invasive  1cm,

node -ve

The Reality

50% sensitivity

DCIS rarely found

50% > 1 cm

40% node +ve

Brekelmans et al. JCO, 2001

Scheuer et al. JCO, 2002

Komenaka et al. Cancer, 2004

Mammography Screening for High Risk Women
mammographic visibility of palpable breast cancers
Mammographic Visibility of Palpable Breast Cancers

P=.03

P=.01

P=.01

Chang

Lancet, ‘99

Goffin

JNCI ‘01

Tilanus -Linthorst

Int J Cancer ‘02

limitations of mammography for hbc surveillance
Limitations of Mammographyfor HBC Surveillance
  • young age = dense breasts
  • tumour pathology (BRCA1)
    • less DCIS
    • fleshy, ‘pushing’ borders
advantages of breast mri
Advantages of Breast MRI
  • Contrast agent concentrates in areas of tumor angiogenesis
  • tomographic images (3-D)
  • less influenced by breast density
  • no ionizing radiation
disadvantages of mri
Disadvantages of MRI
  • $$$
  • lower specificity
  • biopsy more difficult
  • logistics
    • menstrual phase
    • weight
  • claustrophobia
breast mri screening studies for high risk women
Breast MRI Screening Studiesfor High Risk Women

Kriege et al. The Netherlands

Kuhl, et al. Bonn, Germany

Leach et al. U.K.

Podo et al. Italy

Schnall, Lehman et al. U.S.

Warner, Plewes, et al. Toronto, Canada

breast mri screening studies for high risk women16
Breast MRI Screening Studiesfor High Risk Women

Similarities

  • prospective, non-randomized
  • not restricted to mutation carriers
  • annual mammography + MRI
  • Differences
  • single / multiple centers
  • patient population
  • additional modalities
  • MRI technique
dutch national study kriege et al nejm 351 427 2004
Dutch National Study Kriege et al. NEJM 351: 427, 2004.
  • 6 centers
  • unaffected women
  • ages 25-70
  •  15% lifetime risk
  • MRI + mammography + CBE
dutch national study results
Dutch National Study: Results
  • 1909 women
    • 358 mutation carriers
    • mean age 40
    • mean # screens = 2
  • 45 evaluable cancers
    • 39 invasive, 6 DCIS
    • 50% in carriers
    • 50% 1st screen
  • 4 (9%) interval cancers!
false positives

Dutch Study: Results

False Positives

RecallsBiopsies

MRI 10% 5.8%

Mammography 5% 1.7%

invasive tumor stage

Dutch Study: Results

Invasive Tumor Stage

21% node +

52% node +

56% node +

n=45

n=1500

n=45

toronto study warner et al jama 292 1317 2004
Toronto StudyWarner et al. JAMA 292: 1317, 2004
  • single center
  • affected & unaffected women
  • ages 25 - 65
  • >25% lifetime risk
  • MRI + mammography + CBE + US
the toronto study
Medical Biophysics

Donald Plewes PhD.

Martin Yaffe PhD.

Elizabeth Ramsay MSc

Cameron Piron MSc

Medical Imaging

Petrina Causer M.D.

Roberta Jong M.D.

Belinda Curpen M.D.

Joan Glazier MRT

Garry Detzler MRT

Caron Murray MRT

Joanne Muldoon MRT

Genetics

Steven NarodM.D.

Sandra MessnerM.D.

Wendy MeschinoM.D.

Andrea Eisen M.D.

Pathology

John WongM.D.

Judit Zubovits M.D.

General Surgery

Glen Taylor M.D.

Claire HollowayM.D.

Frances Wright M.D.

Study Co-ordinator

Kimberley Hill, BSc

The Toronto Study

Nurse Examiner

MargCutraraR.N.

Biostatistics

Gerrit DeBoer PhD

Alice Chung BSc

Funding

CBCRA

NBCF

Amersham Health

Papoff Family

toronto study results
Toronto Study: Results
  • 437 women
    • 318 BRCA mutation carriers
    • mean age 43
    • mean # screens = 3
  • 37 cancers
  • – 32 in carriers
  • – mean age 48 (34-64)
  • – 28 invasive (2 lobular), 9 DCIS
  • Only 1 interval cancer!
toronto study results33
Toronto Study::Results

Sensitivity by Year of Screening

toronto study results37
Toronto Study:Results

Tumor Stage by Year

Yr.# cancersDCISMean Invasive SizeNode +

1 18 22% 1.1 (0.4 - 3.0) cm 3

2 9 11% 1.2 (0.4 - 2.0) cm 1

3-5 9 44% 0.8 (0.7 - 1.0) cm 0

No recurrences to date. Median f/u 3yrs. (range 1 to 7)

cost benefit estimate
$$$

62 million women

ages 30-60 in U.S.

1% high risk (620,000)

$1200 per screen

____________________

$744 million/year

620,000 high risk

1% (6,200) have cancer

mortality 30%  10%

1240 more cured

mean years saved = 25

________________________

31,000 life years saved

Cost-Benefit Estimate

$24,000 / year of life saved

summary
Summary

Breast MRI for high risk women:

  • most sensitive screening modality
  • finds cancers at an earlier stage
  • has acceptable specificity
  • saves lives?
other research questions
Other Research Questions
  • Optimal MRI screening schedule for subgroups?
    • age
    • mutation status
    • breast density
  • Role of other screening modalities?
  • Role of MRI for other high risk women?
    • Atypical hyperplasia, LCIS
    • Chest irradiation < age 30
    • Very dense breasts