1 / 72

Breast Cancer Screening and Diagnosis

Breast Cancer Screening and Diagnosis. Dr. Ruth Heisey Family Physician/GP Oncologist Women’s College Hospital/Princess Margaret Cancer Centre Clinician Investigator/Associate Professor University of Toronto Sandy Fawcett RN(EC) NP-Adult Gattuso Rapid Diagnostic Centre

phill
Download Presentation

Breast Cancer Screening and Diagnosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Breast Cancer Screening and Diagnosis Dr. Ruth Heisey Family Physician/GP Oncologist Women’s College Hospital/Princess Margaret Cancer Centre Clinician Investigator/Associate Professor University of Toronto Sandy Fawcett RN(EC) NP-Adult Gattuso Rapid Diagnostic Centre Breast Disease Site University Health Network- Princess Margaret Cancer Centre Adjunct Lecturer University of Toronto May 2, 2014

  2. Canadian Breast Cancer Statistics In 2013: 23,800 women will be diagnosed 5,000 will die One in nine expected to develop breast cancer Mortality rates declining www.cancer.ca

  3. Objectives: • Review current breast screening guidelines • Introduce personalized risk assessment tools • Review strategies for timely breast cancer diagnosis

  4. Question Which is the gold standard tool used to screen for breast cancer? • Breast ultrasound • Breast MRI • Mammogram • Clinical breast exam

  5. Breast Cancer Screening Principles • Breast screening aims to detect cancer before palpable (pre-clinical phase) • Early detection leads to better outcome

  6. 1012 Number ofcancer cells Diagnosticthreshold(1cm) 109 time Undetectablecancer Detectablecancer Limit ofclinicaldetection Hostdeath ONCOLOGY - Cancer biology Tumor growth and detection

  7. 2011: Breast Cancer Screening Guidelines CMAJ 2012 Warner et al

  8. The Canadian Task Force screening recommendations are for average risk women with no breast symptoms

  9. Screening Mammography • Canadian Task Force Recommendations: • “For women aged 50-74, we recommend routinely screening for breast cancer every two to three years” www.ctfphc.org

  10. Screening Mammography • Canadian Task Force Recommendations: • “For women aged 40-49, we recommend not routinely screening for breast cancer with mammography” www.ctfphc.org

  11. Screening Mammography • Canadian Task Force Recommendations (40-49yo): • “this recommendation places a relatively low value on a very small absolute decrease in mortality… clinicians should discuss the benefits and harms with their patients and must help each woman to make a decision consistent with her values and preferences” www.ctfphc.org

  12. Effect of Mammographic Screening (1976-2008) • Early stage breast cancers-2 fold increase • Late stage breast cancers-small decrease • More than 30% of breast cancers detected were overdiagnosed (would never have resulted in clinical symptoms if left untreated) NEJM Bleyer and Welch

  13. Mammographic Screening-Polling Results NEJM 2013 Feb 368;9, Colbert,Adler

  14. Views on mammographic screening • Until we can determine which cancers will remain indolent we must “ treat all (cancers)as potential killers ” • Need to prioritize interventions that increase life expectancy and reduce disease burden • Agreement that women at greater risk need vigilant screening NEJM 2013 Feb 368;9, Colbert,Adler

  15. Clinical Breast Exam Canadian Task Force Guidelines: “We recommend not routinely performing clinical breast examinations alone or in conjunction with mammography to screen for breast cancer”

  16. Detection of breast cancer by physical examination versus mammogram for different age groups: Clinical Breast Cancer 2005;6(4):330-3

  17. CBE • Continue as part of periodic health exam or antenatal visit (opportunistic approach)

  18. What is average risk? • No family history of breast cancer • No previous breast biopsies showing atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) • No history of chest wall radiation

  19. What is higher than average? Moderate/High: • History of breast biopsy showing ADH(atypical ductal hyperplasia), LCIS (lobular carcinoma in situ) Previous history of breast cancer • Family history of breast cancer

  20. What is higher than average? Very High: • BRCA carrier or untested first degree relative of BRCA carrier • Previous chest wall radiation • History of LCIS, ADH and family history

  21. Role of Screening MRI • Definite role for very high risk patients such as BRCA mutation carriers in conjunction with mammography and CBE • MRI more sensitive for detecting breast cancers than mammography, ultrasound or CBE alone • MRI=77-100% • Mammography=16-40% JAMA 2004, 292 (11) 1317-25 J Clin Oncol 2006, 23:8469-8476

  22. Magnetic Resonance Imaging ( MRI ) Bilateral breast MRI

  23. American Cancer Society Recommendations for Screening MRI Gene mutation (BRCA 1 or 2; Li-Fraumeni syndrome; Cowden syndrome; Bannayan-Riley-Ruvalcaba syndrome) First-degree relative with one of these mutations (if the woman has not yet been tested) History of radiation therapy to the chest between ages 10 and 30 Lifetime risk >20-25% based largely on family history SaslowD, et al. CA Cancer J Clin 2007;57(2):75-89

  24. Warner et al

  25. OBSP High Risk Screening Program- 2011 MRI in addition to mammogram annually for women ages 30-69: • known BRCA carrier • untested first degree relative of BRCA carrier • chest irradiation before age 30 and at least 8 years previously • ≥ 25% lifetime risk of breast cancer (using IBIS or BODICEA risk calc) www.cancercare.on.ca

  26. Breast Screening in Clinical Practice • All women should be asked re: family history of breast, ovarian cancer or both • If concerns re: mutation carrier discuss implications and referral • Consider mammography screening in all women starting at age 40 (no woman should be denied!)

  27. Breast Screening in Clinical Practice The 50-74yo asymptomatic woman: • Mammogram q 2 years (annual if high risk) • Consider OBSP • Discuss breast awareness • Opportunistic CBE

  28. Breast Screening in Clinical Practice The 40yo asymptomatic woman: • Consider mammogram q1-2 years based on risk, density and patient preference • Discuss breast awareness • Opportunistic CBE

  29. Breast Screening in Clinical Practice The 75yo asymptomatic woman: • Continue to offer mammography until life expectancy is less than 10 years

  30. Breast Screening in Clinical Practice Moderate/High risk: • Annual mammography and CBE starting at age 40

  31. Breast Screening in Clinical Practice Very high risk: (e.g. BRCA carrier) • Annual mammography, MRI starting at age 30 • CBE every 6 months

  32. Personalized Risk Assessment To determine who should be offered: • Referral for consideration of genetic testing • Enhanced screening • Preventive Therapy • Surgery

  33. Figure 1: Management of Women at Risk for Breast Cancer Average/ Moderate risk R B-RST +ve EIBIS > 20-25% P GAIL > 3% SBRCA carrier High risk Very high risk

  34. Why determine candidates for genetic counseling? • 33yo strong family history breast cancer, start screening digital mammography age 40 At age 42 presents with bloating irregular periods- Stage 3c ovarian cancer • You now take a more thorough family history-BRCA1 carrier

  35. ref

  36. Why Calculate Risk? Risk calculators useful in primary care • B-RST Tool: determine candidates for referral for genetic counseling • IBIS: determine candidates for enhanced screening • Gail model: determine candidates for preventive therapy

  37. R: Referral (for genetic testing) • Two or more first degree relatives same side of family with breast cancer (maternal or paternal) • Family members with breast cancer diagnosed before the age of 50 (maternal or paternal) • Relative with bilateral breast cancer or breast and ovarian cancer • Multiple relatives with ovarian cancer • Male relative with breast cancer • Ashkenazic Jewish (Eastern European Jewish) ancestry • Relative known to be BRCA mutation carrier

  38. Breast –Referral Screening Tool (B-RST) • https://www.breastcancergenescreen.org

  39. B-RST

  40. E: Enhanced screening • Use IBIS tool to calculate lifetime risk www.ems-trials.org/riskevaluator • if lifetime risk ≥ 25% refer to OBSP high risk program for MRI screening in addition to mammographic screening www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=99484

  41. IBIS Risk Calculator:

  42. IBIS: Calculated Risk

  43. P: Preventive Therapy • Consider for women with strong family history, or history of atypical hyperplasia or LCIS. • Use Gail model to assess eligibility for chemoprevention http://www.cancer.gov/bcrisktool/ • If 5 year risk ≥3% offer preventive therapy

  44. Gail model: http://www.cancer.gov/bcrisktool/

  45. Age Numberof breastbiopsies Age atmenarche 5 year risk (>1.66 %) Age of firstlive birth (ornulliparity) Family Hxin first degreerelative Breast Cancer Risk Assessment Tool(GAIL MODEL) • http://www.cancer.gov.bcrisktool/.com CP1089285-9

  46. Canadian Task Force Recommendations • Fair evidence to recommend counseling about the potential benefits and risks of using tamoxifen to reduce the likelihood of breast cancer in higher risk women (B) • Who qualifies?: A woman with >1.7% 5-year risk using Gail model www.ctfphc.org

  47. S: Prophylactic Surgery • For highest risk women: known BRCA carriers, or history of LCIS (lobular carcinoma in situ) or AH (atypical hyperplasia) and a significant family history • Always offer reconstruction

More Related