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Breast Cancer Screening

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To explain the epidemiology of breast cancer among US women. To understand screening modalities and current breast cancer screening recommendations ... – PowerPoint PPT presentation

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Title: Breast Cancer Screening


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 Sto
mach 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
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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
  • Male breast cancer
  • or 1 relative 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 examCanadian 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 2002 Should 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
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35
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36
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

37
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

38
Chemoprevention
  • NSAIDs??
  • 2 or more tabs/wk of ASA/ibuprofen led to a 21
    decrease in breast cancer risk in the WHI trial

39
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

40
Summary
  • Take down your shower card for BSE
  • Encourage mammography
  • Work up palpable masses
  • Dont worry quite so much
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