? Mai Elezaby, MD Big Picture Population Prospective Breast - - PowerPoint PPT Presentation

Mai Elezaby, MD

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“Big Picture”

Population Prospective

Breast Cancer

 Most common cancer in

women

 2nd leading cause of death  U.S. 2016 estimates ▪ 246,660 new cases ▪ 40,450 deaths from breast

cancer

https://seer.cancer.gov/statfacts/html/breast.html

https://www.dhs.wisconsin.gov/publications/p01573a.pdf

2016

• One in eight women will

be diagnosed with breast cancer

• ¾ of breast cancers occur

in women without family history of breast cancer

• One in six breast cancers
• ccur in women in their

forties

20 40 60 80 100 I IIA IIB IIIA IIIB IIIC IV

5-Year Survival (%) Stage

20 40 60 80 100 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5

5-Year Survival (%) Tumor size (cm)

Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

✓ Smaller size ✓ Earlier stage More likely to be curable

20 40 60 80 100 I IIA IIB IIIA IIIB IIIC IV

5-Year Survival (%) Stage

20 40 60 80 100 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5

5-Year Survival (%) Tumor size (cm)

Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

✓ Smaller size ✓ Earlier stage SCREENING

 Requirements: ▪ Readily available ▪ Low cost ▪ Can differentiate those that have the disease from

those who don’t (high sensitivity, acceptable specificity) Simple test to identify those who have disease, but do not yet have symptoms

20 40 60 80 100 I IIA IIB IIIA IIIB IIIC IV

5-Year Survival (%) Stage

20 40 60 80 100 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5

5-Year Survival (%) Tumor size (cm)

Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

http://seer.cancer.gov/statfacts/html/ld/breast.html

Surveillance, Epidemiology, and End Results Program (SEER), Cancer Statistics Review 1975-2013. Courtesy of Dr. Amy Fowler

• 37%

Screening Mammography Advancement in Treatments

 Can be scheduled without

physician referral

 20 min visit  Images read by radiologist  Patients receive summary

letter by mail

 Physician receives formal

report

Study Design % Reduction in Breast Cancer Mortality Randomized control trials 20-22% Service screening studies 38-40% Case-control studies 48-49% Computer modeling 46%

Fowler AM et al (2016) Society of Breast Imaging News 2:15-18

 Radiation (minimal)

▪

~ yearly background radiation if you live in Denver

 False negative results (does

not identify a cancer)

▪ 60% to 90% sensitivity for

cancer, depending on a woman’s age and the density

• f her breasts

“Individual Perspective”

 Anxiety ▪ Subjective ▪ Recalls increase baseline

anxiety…transient

▪ Patients with family

history of breast cancer have lower levels of anxiety

“Individual Perspective”

Gilbert FJ, Cordiner CM, Affleck IR, Hood DB, Mathieson D, Walker LG. Breast screening: the psychological sequelae of false- positive recall in women with and without a family history of breast cancer. European journal of cancer;34(13):2010-4.

 False Positives ▪ Additional imaging/or biopsy,

but do not have cancer (benign results)

 For every cancer averted,

180 women will be called back

 There is a 1 in 50 chance you

will be called back once if you get annual screening mammograms for 10 years

“Individual Perspective”

Screening Pool (n=1000) 90% (n=900) Negative

Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 90% (n=900) Negative

Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 90% (n=900) Negative 20% (n=20) Recommend biopsy

Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 90% (n=900) Negative 20% (n=20) 30% Cancer 5/1000

Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 90% (n=900) Negative 20% (n=20) Recommend biopsy 30% Cancer Benign biopsy (n=15) Back to imaging (n=80) False Positive (n=95)

Screening exam Call back Benign cyst

 Overdiagnosis- overtreatment

▪ Cancers that are detected/

treated as a result of screening test, will not kill the patient

▪ Unavoidable harm to any

screening test (prostate, lung, colon)

▪ Estimates (best guess) is 11% -

19%)

“Individual Perspective”

 Overdiagnosis-

Overtreatment

▪

In situ-DCIS

▪ Proposes low grade DCIS will

not progress

▪ There are currently no reliable

individual indicators to guarantee which DCIS will progress and which will not

“Individual Perspective”

Benefits Harms

Screening Algorithms for Average risk

Mammography

Screening Interval Society

Starting at 40 years Every year (Annual)

• American College of Radiology (ACR)
• Society of Breast Imaging (SBI)
• The American Congress of Obstetricians and

Gynecologists (ACOG)

• National Comprehensive Cancer Network

(NCCN)

Baseline mammogram 40-45 Every year 45-55 Once every two years (Biennial) >55

American Cancer Society (NEW)

Individual decision 40-49 Once every two years (Biennial) 50-74

• United States Preventative Services Task

Force (USPSTF) 2009-Draft 2015

• American College of Family Practice (AAFP)

 We do not have the accurate tools to

make individual decisions regarding best screening interval

 Data from prior studies suggest that

delaying screening till age 50 years will decrease lives saved by 6,500/year

 Changing screening recommendations

ratings will ultimately affect reimbursement

 High risk patients (≥ 20% risk) ▪ Annual Mammography +MRI  Moderate risk patients (> 12-<20%) ▪ Annual mammogram + (3D mammography

• r Ultrasound)

“Precision Medicine”

“Precision Medicine”

▪ Better screening tools ▪ TMIST: Tomosynthesis Mammography In

Screening Trial

Digital Breast Tomosynthesis- 3D mammography ↑ ↑ Cancer detection ↓False positives

“Precision Medicine”

▪ Tailored screening intervals based on individual

patient risks

▪ WISDOM: Women Informed to Screen Depending

On Measures of risk

“Precision Medicine”

▪ Tailored treatment options based on

individual cancer and patient biology

▪ COMET: Comparing surgery to Endocrine

Therapy for Low-risk DCIS

 Must guarantee women’s access to basic

mammography screening, protecting “OUR RIGHT to CHOOSE”

 Big national studies are on the way to reach

the goal of “Precision Medicine” , but… we are not there yet

 The driving factor in choices in screening

should be based on individual preferences on risk-benefit ratio

Emphasis on research to identify patient-specific factors to tailor treatment, rather than limit access to diagnosis