Breast Cancer Screening ACR Breast Cancer Screening Leaders
Breast Cancer Screening ACR Breast Cancer Screening Leaders March 2019
Preview/Introduction • The Risk of Breast Cancer to Women • Does Mammography Save Lives? • When to Start and How Often Should Women Screen? • Risks Versus Benefits of Mammography
Breast Cancer: The Impact on Women
Breast Cancer Stats: 2019 • Most common cancer diagnosed in women • 12. 8% of women will be diagnosed during lifetime • More than 331, 000 new cases anticipated (268, 600 invasive) • 30% of all new cancer cases in women • 41, 760 women expected to die from breast cancer • 3, 477, 866 women are living with breast cancer (based on 2016 data) Source: https: //seer. cancer. gov/statfacts/html/breast. html
Has Mammography Reduced Breast Cancer Death?
Age-adjusted U. S. breast cancer mortality rates (per 100, 000) ~ 384, 000 -614, 500 Lives saved Mammography 42% mortality YES - MAMMOGRAPHY HAS REDUCED BREAST CANCER DEATHS Women aged 40– 84 by year 1969– 2015 Hendrick RE, Baker JA, and Helvie MA. Breast Cancer Deaths Averted Over 3 Decades. Cancer 2019; 0: 1 -7.
Evidence of Benefit: Overview
Decades of Evidence Prove Mammography Saves Lives • Randomized controlled trials of women ages 40– 74 show at least a 20% reduction in breast cancer deaths Note: RCTs test only the “invitation to screening” • Observational studies: show a mortality reduction of about 40% Note: test actual mammogram use • Observational studies show benefits for women over 74, as well as the 40– 74 age group
Evidence of Benefit: Randomized Controlled Trials (RCT)
24% mortality reduction Duffy SW, Tabár L, Smith RA. CA Cancer J Clin. 2002 Mar-Apr; 52(2): 68 -71.
Evidence of Benefit: Observational Data
Evidence of Benefit: Observational Trials (Europe) • Why observational data matters • Randomized controlled trials UNDERESTIMATE benefit of screening • What European observational data shows 1 • Magnitude of mortality reduction from screening mammography is greater than RCTs suggest, 38– 49% 1 Broeders et al J Med Sci 2012
Case-Control Studies (Ages 40– 75) 49% ↓ Mortality Cancer Epidemiol Biomarkers Prev 2012
Evidence of Benefit: Observational Trials (Europe) 38% mortality reduction Broeders et al J Med Sci 2012
Evidence of Benefit: The Pan-Canadian Study
Pan-Canadian Study • 1990– 2009 • 2. 8 million women • Compared breast cancer deaths in women who had screening mammograms to those who did not
Results Average breast cancer mortality reduction among all participants was 40% Mortality (95% CI, 0. 33 -0. 48)
Results by Age 40 to 49 years 44% Mortality 50 to 59 years 40% Mortality 60 to 69 years 42% Mortality 70 to 79 years 35% Mortality
Benefits of Screening: Additional Considerations
Benefits of Screening • 40% drop in breast cancer death • Less extensive surgery for screening detected cancers • Less chemotherapy for screening detected cancers • Chemotherapy is MORE EFFECTIVE for screened women Tabar, et al. Cancer 2018 125: 515 -523
Tabar, et al. Cancer 2018 November • 58 years of follow up • All women had either 10 or 20 years of follow up Using the same available treatments, SCREENED women had 60% LOWER mortality at 10 yrs follow up and 47% LOWER mortality at 20 yrs follow up than UNSCREENED women
Why Start Screening at 40?
Breast cancer is a serious problem for women in their 40 s • 1 in 6 breast cancers are found in women ages 40– 49 • The 10 -year risk for being diagnosed with breast cancer in a 40 year old woman is 1 in 69 • About 1/3 rd of the years of life lost from breast cancer are in women in their 40 s • >70% of the women dying from breast cancer in their 40’s belong to the 20% not being screened
Beginning screening at age 40 saves most lives • Starting yearly mammograms at age 40 has cut breast cancer deaths by 40% • Yearly screening starting at age 40 versus every other year age 50– 74 saves approximately 13, 770 more lives each year • Over 40% of years-of-life to breast cancer are lost to women diagnosed under age 50
How do alternative screening guidelines compare to the American College of Radiology®?
American Cancer Society and USPSTF • USPSTF uses limited and older data that underestimates the mortality reduction gained from screening mammography • Both the ACS and USPSTF count only ONE benefit: mortality reduction, and ignore all of the other benefits of screening, yet include all risks, all of which are NON-lethal • All acknowledge that screening mammography does reduce mortality in women 40– 74 AND that screening every year starting at age 40 would save the most lives • REMEMBER: The goal of screening is to find cancer as early as possible to save as many lives as possible! • There is evidence that women understand the risks of mammography and believe they are worth the benefit.
Comparison: Screening Recommendation Outcomes Number of women Reduction in Screening regimen, whose lives will be risk of dying of patient age (y) saved (per 1 breast cancer 100, 000)1 Number of life-years gained (per 100, 000)1 Yearly, 40 -84* 40% 1190 18, 900 (+72%)* Yearly, 45 -54; every other year, 5579˜ 31% 925 14, 900 (+35%)* Every other year, 5074ˠ 23% 695 11, 000 * % increase in life-years gained compared to biennial 50 -74
Distribution of Years of Life Lost due to Death from Breast Cancer by Age at Diagnosis Distribution of YLL from breast cancer by age at diagnosis 16% 15% 14% 13% 12% 10% 9% 8% 7% 6% 5% 5% 4% 4% 2% 2% 85+ 80 -84 75 -89 70 -74 65 -69 60 -64 Age at diagnosis 55 -59 50 -54 45 -49 40 -44 35 -39 30 -34 25 -29 0% 20 -24 0% 0% 15 -19 % of total YLL due to BC 12% ACS report JAMA 2015
Risks: Recall and Biopsy
Recall is uncommon = only 10% Biopsy is rare = 1 -2% per year
Risks: Recall & Biopsy • “False Positives” and anxiety are commonly presented as risks • Risks from recall and biopsy must be compared to the 40% reduction in breast cancer deaths due to screening mammography • Short-term anxiety from screening resolves, and women have no long term anxiety nor adverse health effects
Risks: Overdiagnosis
Overdiagnosis • Defined as breast cancer that would not kill a women in her lifetime • Can’t be measured directly; not possible to know which breast cancers are overdiagnosed without leaving cancer untreated • Is rare! Estimated at 1– 10% of all breast cancers • Underdiagnosis is NOT ideal
Summary for Average Risk Women • Screening mammography is a proven life-saver • 40% reduction in breast cancer death with regular screening • Most lives are saved with ANNUAL SCREENING at AGE 40
Summary for Average Risk Women • Modern treatments are most effective in saving lives when cancers are caught early on screening mammograms • Risks, such as recall for additional imaging, needle biopsy, anxiety and overdiagnosis – all NON-lethal – need to be considered against lives saved from breast cancer death
Breast Cancer Screening of Women at Higher Than Average Risk Recommendations from the American College of Radiology
All women, especially black women and women of Ashkenazi Jewish descent should be evaluated for breast cancer risk by age 30 to: • Identify those at higher risk than average • Benefit from supplemental screening
Higher risk women need supplemental and earlier screening Risk DM +/- DBT MRI+ Known genetic mutation or lifetime Annually starting at age 30 risk ≥ 20% Annually starting at age 25– 30 Breast cancer history and dense breasts at any age or breast cancer diagnosed <age 50 Annually starting at time of diagnosis History of chest radiation therapy before age 30 Annually starting at age 25 or 8 yrs after therapy (whichever is later) Annually starting at age 25– 30 History of ADH, ALH, LCIS or personal breast cancer history other than above Annually starting at time of diagnosis Consider annually starting at time of diagnosis +Ultrasound may be considered if women cannot undergo MRI. Monticciolo DL et al, J Am Coll Radiol 2018; 15: 408 -414
Questions?
Contributors KELLY W. BIGGS, MD, Committee Chair VILERT LOVING, MD, MMM CATHERINE M. APPLETON, MD DEBRA MONTICCIOLO, MD, FACR, FSBI LORA BARKE, DO, FACR MARY S. NEWELL, MD, FACR, FSBI PRAGYA DANG, MD ELISSA R. PRICE, MD FRCPC FSBI STAMATIA DESTOUNIS MD, FACR, FSBI, FAIUM JOCELYN RAPELYEA, MD, FSBI DIPTI GUPTA, MD KIMBERLY RAY, MD, FSBI JIYON LEE, MD SHADI AMINOLOLAMA-SHAKERI, MD JESSICA W. T. LEUNG, MD, FACR, FSBI
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