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Breast Cancer Screening

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  1. Breast Cancer Screening Eve Espey, M.D. University of New Mexico

  2. Objectives • To explain the epidemiology of breast cancer among US women • To understand screening modalities and current breast cancer screening recommendations • To discuss strategies to reduce risk of developing breast cancer

  3. Epidemiology of Breast Cancer • 2003: 211,300 new cases of breast cancer and 39,800 deaths • 32% of all newly diagnosed cancers in women are cancers of the breast • Most common cancer diagnosed in women • Most feared health condition by women

  4. Leading Sites of Cancer Incidence and Death in Women (1997 Estimates) CANCER CANCER RANK INCIDENCE DEATHS 1 Breast Lung 192,200 66,000 2 Lung Breast 79,800 40,200 3 Colon/Rectum Colon/Rectum 64,800 27,900 4 Corpus Uteri Ovary 34,900 14,200

  5. Selected Cancer Statistics by Ethnicity

  6. New Mexico Breast Cancer Data

  7. Cancer Mortality Rate Ratio for Females, 1994-98, AI/AN Compared to U.S. All Races All Sites Lung Colon/Rect. Ill Def/Unk. Breast Stomach Liver Pancreas Kidney Ovary Esophagus Cervix Gallbladder .5 .75 1 1.5 2 *AI/AN rate statistically different from US All Races death rates

  8. Breast Cancer Mortality RatesFemales, 1994-98 All IHS (14.1) * All US (24.2) Rate per 100,000 per year, adjusted to 1970 U.S. population Figure 26 ** Denotes a rate significantly higher (* lower) than the U.S. rate.

  9. Risk Factors for Breast Cancer • Female gender • Age over 50

  10. Age

  11. Putting Breast Cancer Risk in Perspective • The “1 in 9” statistic • Cohort of 1000 women • By age 85: • 33 dead from breast cancer • 99 will have diagnosis of breast ca • 203 dead from CV disease

  12. Putting Breast Cancer Risk in Perspective • 1 woman in 9 develops breast cancer • That woman has a 50% chance of being diagnosed after age 65 • That woman has a 60% chance of surviving breast cancer and dying of another cause

  13. Fear of Breast Cancer • Survey of 1000 women age 45-64 • Condition they feared most: • Breast cancer: 61% • Cardiovascular disease: 9%

  14. Other Major Risk Factors • Family History • 1st degree relative • Premenopausal • Bilateral cancer • Personal History • Breast cancer • Carcinoma in situ • Atypical hyperplasia

  15. Minor Risk Factors • Late age at first pregnancy • Nulliparity • High socioeconomic status • Exposure to high dose radiation • Hyperplasia on breast biopsy

  16. Risk factors for BRCA 1 and BRCA 2 • Breast and ovarian cancer • 2 or more relatives < 50 with breast cancer • Male breast cancer • > or = 1 relative < 50 with breast cancer + Ashkenazi Jew • Ovarian cancer + Ashkenazi Jew

  17. Breast cancer and HRT • 5 years of ERT does not increase risk • 5 years of HRT increases risk by 26%

  18. Unproven Risk Factors • Oral contraceptives • Obesity • High fat diet

  19. Breast Cancer Screening • Breast self exam (BSE) • Clinical breast exam (CBE) • Mammography

  20. USPSTF and Canadian TFPHCRating of evaluations • A: Strong recommendation to include the service • B: Recommendation to include the service • C: No recommendation either for or against • D: Recommendation against routine provision of the service • I: Evidence insufficient

  21. Breast self exam:Canadian Task force on Prevention • Fair evidence of no benefit • Good evidence of harm • Overall fair evidence that routine teaching of BSE should be excluded from the annual exam • D recommendation June, 2001

  22. USPSTF: 2002Should we recommend BSE? BSE: insufficient evidence to recommend for or against • “I” recommendation

  23. Studies evaluating BSE • 2 RCTs, 1 quasi RCT, 3 case-control studies • No difference in breast cancer mortality • No difference in stage of cancer at diagnosis • More provider visits: 8% vs. 4% • More benign biopsies

  24. ACOG Practice Bulletin: Breast cancer screening April, 2003 • Despite a lack of definitive data for or against breast self-examination, breast self-examination has the potential to detect palpable breast cancer and can be recommended.

  25. Costs of BSE • $700 per competent frequent self-examiner • Opportunity cost: limited time for counseling • Anxiety, worry, depression

  26. Should we recommend mammography?

  27. Disadvantages of Screening Age 40-49 1/3 of women undergoing annual screening mammography between 40-49 will have an abnormal mammo requiring: • Further imaging studies • FNA or core biopsy • Excisional biopsy

  28. Does mammography work? • 2001: Cochrane review by Olsen and Gotzsche found no reduction in mortality • 5 of 8 trials seriously flawed • 3 “sound” trials showed no benefit • Methodological flaws negate findings of benefit

  29. Does mammography work? • 2002: USPSTF reviewed Cochrane findings • Only 1 trial seriously flawed • Flaws “problematic” but unlikely to negate findings of benefit • Downgraded recommendation (A to B) but included all women > 40

  30. Mortality is declining • 1990-1999: breast cancer mortality has decreased by 17%

  31. New screening technologies • Full-field digital mammography • Computer-assisted detection • MRI • Ultrasound

  32. Screening Mammogram ReportsBirads • Birads 0: Incomplete study • Birads 1: Normal, routine follow-up • Birads 2: Benign finding, routine follow-up • Birads 3: Probably benign finding, 6 month follow-up • Birads 4: Suspicious finding, consider biopsy • Birads 5: Highly suspicious, biopsy required

  33. Limitations of Mammography • Palpable masses must be evaluated despite NEGATIVE results

  34. Gail Model • http://bcra.nci.nih.gov/brc/ • Calculates 5 year risk of developing breast cancer • Age • Age at menarche • # of breast biopsies • Age at first live birth • Number of first degree relatives with breast cancer

  35. Reducing the risk of breast cancer • Chemoprevention • Tamoxifen and raloxifene: • 38% decrease in breast cancer incidence?? Reduction in mortality • Tamoxifen • Endometrial cancer, DVT • Raloxifene • DVT

  36. Chemoprevention • NSAIDs?? • 2 or more tabs/wk of ASA/ibuprofen led to a 21% decrease in breast cancer risk in the WHI trial

  37. Reducing the risk of breast cancer • Prophylactic surgery • Bilateral mastectomy • Reduces risk by 90% • Bilateral oophorectomy • Lifestyle • Reduction in fat intake, exercise, weight loss, reduction in alcohol

  38. Summary • Take down your shower card for BSE • Encourage mammography • Work up palpable masses • Don’t worry quite so much…