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Breast Cancer Screening What’s New to Know? The Issue of Breast Density. Catherine Babcook MD Partner, Mountain Medical Physician Specialists Medical Director of Breast Imaging McKay Dee Hospital Center. Disclosure.

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breast cancer screening what s new to know the issue of breast density

Breast Cancer ScreeningWhat’s New to Know?The Issue of Breast Density

Catherine Babcook MD

Partner, Mountain Medical Physician Specialists

Medical Director of Breast Imaging McKay Dee Hospital Center

disclosure

Disclosure

This presentation has no commercial content, promotes no commercial vendor and is not supported financially by any commercial vendor. I receive no financial remuneration from any commercial vendor related to this presentation.

screening recommendations
Screening Recommendations
  • ACS, ACR, ACOBGYN, Intermountain HC
    • Annual mammographic screening beginning at age 40
    • Continue screening if a woman is in good health and has a life expectancy of 5 years or more
mammography facts
Mammography Facts
  • < Screening 1980’s, the death rate for breast cancer in the U.S. was unchanged for 50 years
  • Since 1990 the death rate from breast cancer has decreased by 30%
  • In women ages 50-74, 15- 20% more livessavedby screening every year instead of every two years
  • When analyze appropriately performed RCTs and service screening data -30 to 40% decrease in mortality in the 40-49 year-old group.
more facts
More Facts
  • Update of the Swedish Trials by Lazlo Tabar, when “no shows” were placed in the control group, there was a 63% decrease in the death rate of the screened group.
  • Anxiety of a false positive mammogram or invasive procedure - Recent study of 1171 women, 97% indicated a false positive result would not deter them from screening.
many components of cancer detection
Many Components of Cancer detection
  • Woman has to get a screening mammogram
  • Radiologist factors: Interpretation variability
  • Woman factors: Breast density, implants
radiologist factors
Radiologist Factors

Interpretive Ability:

woman factors
Woman Factors

Clinically “dense” = Mammographically Dense

Breast Tissue – Pattern and Density:

breast density on mammography
Breast Density on Mammography
  • Density = How much White tissue

White tissue - glandular

Dark tissue –fat

breast density
Breast Density

Fatty Breast

Extremely Dense Breast

4 categories of density
4 Categories of Density
  • Mammography Report
    • Parenchymal Density:
      • Almost Entirely Fatty (< 25% Glandular )
      • Scattered Fibroglandular Densities (25-50% Glandular)
      • Heterogeneously Dense (51-75% Glandular)
      • Extremely Dense (> 75% Glandular)
why does it matter
Why Does it Matter?
  • Cancer is WHITE on mammograms
  • Amount of WHITE glandular tissue impacts visibility of WHITE cancer
cancer can be hidden by glandular tissue on m ammo
Cancer Can be Hidden by Glandular Tissue on Mammo
  • ‘Snowflakes in a snowball’, ‘polar bear in a snowstorm’
  • What do we do:
    • Wait until it’s big enough to feel
    • Add a test that improves cancer detection in white glandular tissue
white on white m ammo cancer problem
White on White Mammo Cancer Problem
  • Mammographic Sensitivity Varies with Breast Density
    • Fatty – 85%
    • Dense – 70% with Digital Mammo
      • NOT USELESS BY A LONG WAY
density issue not new
Density Issue Not New
  • Awareness of Density Issue Is New
    • Nancy Cappello PhD
    • Dx with advanced stage breast cancer after years of normal annual screening mammography from age 40
    • 34 yrs as an educator, administrator and state dept. consultant in Connecticut
    • “Nancy’s Law” 2009; Areyoudense.org
magnitude of density issue
Magnitude of Density Issue
  • 40% of Women have dense breasts
    • 65% of premenopausal women
    • 25% of postmenopausal women
adjunctive screening tests
Adjunctive Screening Tests
  • Tomosynthesis – Oslo,N=13000,27% CA,15% FP
      • Longer compression, increased dose, exp. capital, no reimbursement, doubled interpretation time
  • Whole Breast Ultrasound: handheld, automated
  • MRI – not indicated for density alone, cost, annual gadolinium risk, FP
  • BSGI – expensive capital, space, sig additional dose, no reimburse
  • PEM – expensive capital, space, sig additional dose, no reimburse
breast ultrasound
Breast Ultrasound
  • Glandular Tissue is WHITE on ultrasound just like mammography
  • Cancer is DARKon ultrasound

Contrast advantage

cancer on ultrasound
Cancer on Ultrasound

Not visible in dense tissue on mammo

Visible dark cancer on ultrasound

cancer on ultrasound1
Cancer on Ultrasound

Not visible in dense tissue on mammo

Visible dark cancer on ultrasound

screening breast ultrasound
Screening Breast Ultrasound
  • Kolb et al Radiol 2002;225(1):165-175
  • Crystal et al AJR 2003;1818(1):177-182
  • Gordon et al Cancer 1995:76(4):626-630
  • Kaplan Radiology 2001;221 (3):641-649
  • All criticized:
    • Single center studies
    • Retrospective studies
    • Not blinded to mammo findings etc.
screening breast us studies
Screening Breast US Studies
  • ACRIN 6666: N= 2600, Berg et al 2008 JAMA, Vol 299(18)2151-2163
    • 60 % increase in cancer detection over mammo alone
    • Low PPV for biopsy: 11%, mammo 25-40%,
    • radiologist handheld scanning, too much time to be practical
    • No documentation to allow for future comparison
automated whole breast us
Automated Whole Breast US
  • Efficient – rad not scanning, tech not interpreting
  • Large Volume of patients
  • Standardized, reproducible
  • Comparison capability
awbu studies
AWBU Studies
  • Kelly et al 2010 Eur Radiology 20:734-742
  • N= 4500
  • 23 additional Cancers found on US
  • 100% Increase in cancer detection
  • 22/23 invasive cancers, ave size 0.9 cm
awbu studies kelly et al 2010 eur radiology 20 734 742
AWBU Studies: Kelly et al 2010 Eur Radiology 20:734-742
  • Mammography alone found 23
  • AWBU found 38
  • 23 mammographically occult
  • Recall Rate: ACR < 10% for Mammo
    • Mammo 4.2%
    • AWBU 6.5%
  • Positive Predictive Value Bx (PPV) ACR 25-40%
    • Mammo 39%
    • AWBU 38.4%
    • AWBU + Mammo 62.5%
awbu studies1
AWBU Studies
  • USys FDA study submission:
    • 30% increase in cancer detection over mammography alone
    • RSNA presentation: 25% increase in CA detection
awbu our experience
AWBU: Our Experience
  • 15,000 Screening Mammograms/yr
    • 5 cancers/1000 women screened
  • 600 AWBU/yr
    • 4/600 ~6/1000 additional cancers
dense breast tissue 40 of women

Dense Breast Tissue 40% of Women

40% x 15,000 scrmammos= 6000 eligible women seen at McKay Dee Breast Center

600 AWBU exams/yr.

breast density and awbu
Breast Density and AWBU
  • Women don’t have to get it
  • Not covered by insurance – $275, $200
    • Flex spending acct etc.
  • Women do need to be informed – our job
  • Women need the opportunity to make the choice