Welcome to Breast Cancer Screening Presented by: Marianne McKennett , M.D.

1. Welcome to Breast Cancer ScreeningPresented by: Marianne McKennett, 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 Development (OSHPD), designated as the California Primary Care Office (PCO).

2. Breast Cancer Screening Marianne McKennett, M.D. Scripps FM Residency Program San Diego Border Area Health Education Center February 14, 2013

3. Workshop Goals • Breast Cancer Epidemiology and Disparities • Risk Assessment • Evidence-Based Breast Cancer Screening • SBE • CBE • Mammography • CBE- Clinical Breast Exam Competencies

4. Evidence Based-Breast CA Screening • Risk Assessment • SBE - Self Breast Exam • CBE - Clinical Breast Exam • Mammography • Ultrasound • MRI - Magnetic Resonance Imaging

5. 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?

6. 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 • Mortality decreasing 2.3% annually • 1999 age-adjusted mortality 27/100,000 population • 46% estimated due to screening • Rest due to treatment such as chemotherapy and tamoxifen/femara

7. 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

8. 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

9. 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

10. 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

11. Risk Factors for Breast Cancer. Breast Cancer Risk Factors Warner E. N Engl J Med 2011;365:1025-1032

12. 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

13. Age-Specific Incidence of Invasive Breast Cancer per 1000 Women per Year in the United States. Warner E. N Engl J Med 2011;365:1025-1032

14. Chances of the Development of and Death from Breast Cancer within the Next 10 Years. Fletcher SW, Elmore JG. N Engl J Med 2003;348:1672-1680.

15. Recommendations Regarding Breast-Cancer Screening in Women Age-related Screening Fletcher S and Elmore J. N Engl J Med 2003;348:1672-1680

16. Breast Self Exam BSE • Large trials show no reduction in breast cancer or all-cause mortality • (CI 0.9-1.24) Cochrane Review • 388,535 women represented in Russia and Shanghai studies • SBE vs no intervention • Twice as many benign biopsies in SBE

17. BSE Recommendations • Cochrane review of studies concluded increased # biopsies led to harm • USPSTF recommends against teaching SBE - D recommendation • ACS - American Cancer Society - SBE is an option for some women in order to know what is normal • Teach correctly if woman chooses BSE

18. Clinical Breast Exam - CBE • Studies suggest 5% of breast cancers are identified by CBE alone • Community-based study 4% of women with abnormal CBE had cancer • Canadian National Breast CA study used CBE with and without mammo and found similar mortality • USPSTF found insufficient evidence “I”

19. CBE Contribution • CBE contribution to breast cancer detection independent of mammogram • Variation in CBE technique affects outcomes (29% sens/ 33% spec) • Detection of small breast masses by residents improved with standardized training in a silicone breast model

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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

28. 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

29. Guidelines for Breast-Cancer Screening. Warner E. N Engl J Med 2011;365:1025-1032

30. 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 DCIS • Healthy volunteer bias: screened population may be healthier or more health conscious

31. Risks Mammography • False positive results • 11% abnormal, 3% CA • Increase anxiety, fear, healthcare visits • Overdiagnosis-ductal carcinoma in-situ • Pain • Radiation: 10 yrs x 10,000 women=1 breast CA • False negative results: more common in young women

32. Risks Associated with Mammography. Risks of Mammography Warner E. N Engl J Med 2011;365:1025-1032

33. Chances of False Positive Mammograms, Need for Biopsies, and Development of Breast Cancer among 1000 Women Who Undergo Annual Mammography for 10 Years Fletcher S and Elmore J. N Engl J Med 2003;348:1672-1680

34. Chances of Breast-Cancer-Related Outcomes among 1000 Women Who Undergo Annual Mammography for 10 Years Fletcher S and Elmore J. N Engl J Med 2003;348:1672-1680

35. Other Modalities • Ultrasonography • Considered as screening/diagnostic tool for younger women • European Group for Breast CA screening concluded no role for SCREENING • Not the same as work-up of abnormal findings

36. MRI ACS Recommendations • Women with a BRCA mutation • Women with first degree relative with BRCA mutation • 20-25% or greater lifetime risk for breast CA • Women exposed to chest radiation between ages of 10 and 30 yrs • Adjunct evaluation in complicated situations

37. What to Recommend • Shared decision making • Risk assessment • Begin discussions at age 40 • Collaborative decision making especially important from age 40-49 • What would you advise patient in clinical scenario - 42y/o healthy woman

38. CBE Proficiency

39. CBE Purpose: Early Detection • Correlate with mammogram for complete screening (w/in 3 mos) • Masses missed by mammography • Masses detected by women • Abnormalities in women who refuse mammography or are not age appropriate

40. Common Palpation Problems • Pattern of search does not adequately cover perimeter • Missing the axillary tail • Not palpating the nipple/areolar complex • No or inconsistent pressure

41. Sensitivity and SpecificityOR(Find it but don’t over call it) Early detection of abnormal masses will vary depending on: • Skill and experience of the examiner • Duration of exam (time) • Characteristics of breast being examined

42. An inadequate breast exam gives the woman a false sense of security!

43. PERIMETER • Mid-axilla • Inframammary ridge • Sternum • Clavicle • Connecting line

44. PATTERN Sternum Clavicle Inframammary Ridge START HERE Mid-axilla VERTICAL STRIP

45. PALPATION • Examine from same side as the breast • One hand for the examination • Body mechanics are important

46. PALPATION (cont) Pads of three middle fingers, hand bowed up Dime size circles JAMA, Vol. 282, No 13, Oct. 1999 Slide between palpations without lifting fingers

47. PRESSURE LIGHT (skin) MEDIUM (tissue) DEEP (bone) JAMA, Vol. 282, No 13, Oct. 1999

48. References • USPSTF Screening for Breast Cancer Recommendation Statement Nov 2009 Updated Dec 2009 • Fletcher, SW and Elmore, JG Mammographic Screening for Breast Cancer. NEJM 2003; 348:17 • Warner, E Breast Cancer Screening. NEJM 2011; 365:11 • Knutson D and Steiner E Screening for Breast Cancer: Current Recommendations and Future Directions. Am Fam Phy 2007; 75:11 • Allen S and Pruthi S The Mammography Controversy: When Should You Screen. J Fam Prac 2011; 60:9 • Steiner E Detection and description of small breast masses by residents trained using a standardized clinical breast exam curriculum. J Gen Intern Med 2008; 23:2 • Cochrane Reviews • Regular self-examination or clinical examination for early detection of breast cancer • Screening for breast cancer with mammography • Strategies for increasing the participation of women in community breast cancer screening

49. Contact Information:Marianne McKennett, MDmckennett.marianne@scrippshealth.org619 862-7587Kendra Brandstein, Ph.Dbrandstein.kendra@scrippshealth.org619 862-6601