Welcome to Welcome to BREAST CANCER SCREENING BREAST CANCER SCREENING Presented by: Marianne McKennett, Presented by: Marianne McKennett, M.D. M.D. The presentation will begin shortly This webinar will be recorded and used for future presentations. Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative. This webinar is being offered by the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and
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Welcome to Breast Cancer Screening Presented by: Marianne McKennett , M.D.
Welcome to Breast Cancer Screening Presented by: Marianne McKennett , M.D. The presentation will begin shortly This webinar will be recorded and used for future presentations . - PowerPoint PPT Presentation
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Welcome to Welcome to BREAST CANCER SCREENINGBREAST CANCER SCREENING
This webinar will be recorded and used for future presentations.
Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and
Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and
Evaluation Activities (REA) Initiative.This webinar is being offered by the California Statewide AHEC
program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the
California Primary Care Office (PCO).
Breast Cancer Screening
Marianne McKennett, M.D.Scripps FM Residency Program
San Diego Border Area Health Education Center
February 14, 2013
Workshop Goals
• Breast Cancer Epidemiology and Disparities• Risk Assessment• Evidence-Based Breast Cancer Screening
– SBE– CBE– Mammography
• CBE- Clinical Breast Exam Competencies
Evidence Based-Breast CA Screening
• Risk Assessment
• SBE - Self Breast Exam
• CBE - Clinical Breast Exam
• Mammography
• Ultrasound
• MRI - Magnetic Resonance Imaging
• A healthy, 42-year-old white woman wants to discuss breast-cancer screening.
• She has no breast symptoms, had menarche at the age of 14 years, gave birth to her first child at the age of 26 years, is moderately overweight, drinks two glasses of wine most evenings, and has no family history of breast or ovarian cancer.
• She has never undergone mammography.• She notes that a friend who maintained the “healthiest lifestyle
possible” is now being treated for metastatic breast cancer, and she wants to avoid the same fate.
• What would you advise?
Breast Cancer Epidemiology
• Most commonly diagnosed cancer in women• Second leading cause of cancer death in women• Breast cancer dx increasing 0.3% per year (1990)
– USA 1 in 8 chance of invasive breast CA in lifetime
population– 46% estimated due to screening– Rest due to treatment such as chemotherapy and
tamoxifen/femara
Ethnic Disparities
• Age adjusted breast cancer incidence is greater in White vs Black women
• Mortality rates are higher in Black women• 1995-2001: 64% white women and 53%
Black localized disease at diagnosis• SD County study in Hispanic women-later
stage at dx especially in younger than 50 yrs
Why Disparities?• Lower Socio-economic status (SES)• Lower Education Level• Less access to screening and treatment• MediCaid recipients and uninsured have
later stage at Dx and decreased survival from time of diagnosis
• Hispanic women have lower rates of screening at all income levels
Community Screening• Achieve high participation rate of screening• Cochrane review of 151 articles• 59 articles describing 70 community-based
trials were accepted for review• Five active strategies showed improved rates
– Letter of invitation– Mailed educational materials– Invitation and phone call– Phone call– Training activities and direct reminders
Risk Assessment
• Risk Calculation/Individual– Age– First degree relative with breast or ovarian
cancer– Previous breast biopsies – Age at menarche - early– Age at first delivery - late
Risk Factors for Breast Cancer.
Warner E. N Engl J Med 2011;365:1025-1032
Breast Cancer Risk Factors
Risk “Calculators”
• National Cancer Institute online tool
• Estimate five-year and lifetime risk
• http://www.cancer.gov/bcrisktool
• 5-year risk of 1.66 % or higher is high-risk
• More specific tools are available for BRCA1 or BRCA2 risks
• Detection of small breast masses by residents improved with standardized training in a silicone breast model
Mammography• Eight randomized trials have addressed
effectiveness of mammography• Cochrane Breast Cancer Group (7)• RR of all 7 trials combined was 0.81• Breast cancer mortality was unreliable• Numbers of lumpectomies and
mastectomies increased in screened• XRT also increased
Relative Risk of Death from Breast Cancer, Number Needed to Invite to Screening, and Rates of False Positive and False Negative Results, According to Age.
Warner E. N Engl J Med 2011;365:1025-1032
Cochrane Conclusions
• Screening is likely to reduce Breast CA mortality
• 15% reduction = ARR of 0.05%• Screening 30% overdiagnosis = ARI
0.5% (ie: DCIS)• 2000 women over 10 yrs, 1 will have life
prolonged 10 women treated unnecessarily, 200 psych distress false
Women 50-69 years
• Universal recommendation for screening
• Meta-analysis clear for women in 60’s• Subgroup in 50’s less clear• Meta-analysis
– 50’s 14% reduction in Breast CA deaths– 60’s 32% reduction in Breast CA deaths
Women 70 yrs and Older
• Data more limited- 70-74 yrs
• Agreement against screening with increased co-morbidities
• Swedish national screening program– Relative risk of death invited to screen 1.08– CISNET: 2 additional deaths/1000 women
Age 40 - 49 years
• No single randomized trial shows benefit
• Meta-analysis including 40’s showed 15-20% risk reduction
• Screening in 40’s but diagnosis in 50’s?• “Age” trial looked at only 39-48 years• Non-significant reduction in death at 10
yrs (RR 0.83 CI 0.66-1.04)
Controversy Women in 40’s
• Less effect of mammography
• Breast density (decrease sensitivity)
• Faster spread of cancer in younger women
• Begin screening in 40’s, Dx in 50’s?
• Meta: decrease 15 yr mortality by 20%
• Screening most effective after age 55
Mammography Technique
• Digital vs Film mammography
• Contrast between tumor and tissue
• DMIST study: equal sensitivity and specificity
• Under age 50 yrs: digital significantly more sensitive (78% vs 51%)
• Premenopausal or denser breasts
Recommendations
• ACS - women age 40 and older should have a mammogram yearly while in good health
• USPSTF - The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. B
• Screening before age 50 is individual
Guidelines for Breast-Cancer Screening.
Warner E. N Engl J Med 2011;365:1025-1032
Bias in Early Detection
• Lead time bias: Survival time includes time between detection and when would have been found clinically
• Length bias: preclinical detection• Over-diagnosis bias: may never be found or