Breast Cancer Screening

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Breast Cancer Screening

• Eve Espey, M.D.
• University of New Mexico

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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

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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

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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

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Selected Cancer Statistics by Ethnicity
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New Mexico Breast Cancer Data
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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
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Risk Factors for Breast Cancer

• Female gender
• Age over 50

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Age
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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

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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

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Fear of Breast Cancer

• Survey of 1000 women age 45-64
• Condition they feared most
• Breast cancer 61
• Cardiovascular disease 9

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Other Major Risk Factors

• Family History
• 1st degree relative
• Premenopausal
• Bilateral cancer
• Personal History
• Breast cancer
• Carcinoma in situ
• Atypical hyperplasia

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Minor Risk Factors

• Late age at first pregnancy
• Nulliparity
• High socioeconomic status
• Exposure to high dose radiation
• Hyperplasia on breast biopsy

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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

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Breast cancer and HRT

• 5 years of ERT does not increase risk
• 5 years of HRT increases risk by 26

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Unproven Risk Factors

• Oral contraceptives
• Obesity
• High fat diet

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Breast Cancer Screening

• Breast self exam (BSE)
• Clinical breast exam (CBE)
• Mammography

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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

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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
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USPSTF 2002 Should we recommend BSE?

• BSE insufficient evidence to
• recommend for or against
• I recommendation

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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

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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.

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Costs of BSE

• 700 per competent frequent self-examiner
• Opportunity cost limited time for counseling
• Anxiety, worry, depression

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Should we recommend mammography?
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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

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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

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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

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Mortality is declining

• 1990-1999 breast cancer mortality has decreased
  by 17

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New screening technologies

• Full-field digital mammography
• Computer-assisted detection
• MRI
• Ultrasound

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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

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Limitations of Mammography

• Palpable masses must be evaluated despite
  NEGATIVE results

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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

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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

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Chemoprevention

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

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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

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Summary

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