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Breast cancer screening dr.ayman jafar

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Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death in women.

Veröffentlicht in: Gesundheitswesen
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Breast cancer screening dr.ayman jafar

  1. 1. Objectives Demonstrate the incidence of breast cancer, facts and statistics Review the risk factors of breast cancer and the tools of risk estimation Outline the various current screening guidelines and related controversy Discuss the available modalities for breast cancer screening ( indication, benefits, harms…)
  2. 2. Introduction Worldwide, breast cancer is the most frequently diagnosed life- threatening cancer in women and the leading cause of cancer death in women. In the United States, breast cancer accounts for 29% of all cancers in women and is second only to lung cancer as a cause of cancer deaths 1 in 8 U.S. women (about 12%) will develop breast cancer over the course of her lifetime. Because of early detection, intervention, and postoperative treatment, breast cancer mortality has been decreasing. Mammography for screening has largely contributed to early detection
  3. 3. Incidence
  4. 4. Incidence
  5. 5. Incidence
  6. 6. Incidence
  7. 7. Incidence
  8. 8. Incidence
  9. 9. Incidence
  10. 10. Incidence
  11. 11. Incidence: Year
  12. 12. Incidence: Age
  13. 13. Incidence: Race
  14. 14. Mortality
  15. 15. Mortality
  16. 16. Mortality Percent of Deaths by Age Group The percent of breast cancer deaths is highest among women aged 55-64. Median Age at death 68
  17. 17. Mortality
  18. 18. Risk Factors
  19. 19. RISKFACTORS Risk Factors
  20. 20. Risk Factors Risk Factors Estimated Relative Risk Advanced age >4 Family history • Family history of ovarian cancer in women < 50y >5 • One first-degree relative >2 •Two or more relatives (mother, sister) >2 Personal history •Breast cancer history 3-4 •Positive BRCA1/BRCA2 mutation >4 •Breast biopsy with atypical hyperplasia 4-5 •Breast biopsy with LCIS or DCIS 8-10
  21. 21. Risk Factors Con. Risk Factors Estimated Relative Risk Reproductive history •Early age at menarche (< 12 y) 2 •Late age of menopause 1.5-2 •Late age of first pregnancy (>30 y)/Nulliparity 2 •Use of combined estrogen/progesterone HRT 1.5-2 •Current or recent use of oral contraceptives 1.25 Lifestyle factors •Adult weight gain 1.5-2 •Sedentary lifestyle 1.3-1.5 •Alcohol consumption 1.5
  22. 22. Risk Factors BRCA1, BRCA2: genes produce tumor suppressor proteins that help repair damaged DNA and stabilize the cell’s genetic material. When mutated, or altered, DNA damage may not be repaired properly. As a result, cells are more likely to develop additional genetic alterations that can lead to cancer. Specific inherited mutations in BRCA1 and BRCA2 increase the risk of breast and ovarian cancers Together, BRCA1 and BRCA2 mutations account for 20 to 25% of hereditary breast cancers and 5 to 10% of all breast cancers. Breast and ovarian cancers associated tend to develop at younger ages A harmful BRCA1 or BRCA2 mutation can be inherited from a person’s mother or father.
  23. 23. Risk Factors BRCA1 mutation increases the risk 55 to 65%, and BRCA2 45% Genetic testing considered Breast cancer diagnosed before age 50 years Bilateral breast cancer Both breast and ovarian cancers in either the same woman or the same family Multiple breast cancers Male breast cancer Ashkenazi Jewish ethnicity Management of positive genetic test: 1. Enhanced Screening; at younger ages, CBE, mammogram and MRI 2. Chemoprevention: Tamoxifen, Raloxifene 3. Prophylactic (Risk-reducing) Surgery.
  24. 24. Risk Factors Risk estimation models  Gail model  Claus model  BRCAPRO model  Cuzick–Tyrer model  BOADICEA model
  25. 25. Risk Factors Risk Assessment Model (Gail)
  26. 26. Risk Factors Risk Assessment Model
  27. 27. What is screening? Test and exam used to find a disease like cancer in people who do not have any symptoms. i.e. early detection Aiming at reduction of reduction of morbidity and mortality
  28. 28. What is screening?
  29. 29. What benefit to screening? Early detection remains the primary defense available to patients in preventing the development of life-threatening breast cancer For 50-74 year group, there is an intimated 30% reduction in mortality For 40-49 year group, there is an intimated 17% reduction in mortality
  30. 30. Guidelines
  31. 31. Guidelines
  32. 32. Guidelines
  33. 33. Guidelines Age 20+ Self-breast examination(optional) monthly Breast clinical examination every 3 yrs Age 40+ Mammography annually High Risk mammography annually + 30 + MRI
  34. 34. Guidelines (controversy) No requirement for clinicians to teach women how to perform BSE. Insufficient current evidence to assess the additional benefits and harms of CBE beyond mammography in women 40 years or older No requirement for routine screening mammography in women aged 40 to 49 years. the decision to start regular screening before 50 should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms Biennial screening mammography for women between 50 -74 years Stopping screening at age 74 as there is insufficient data to assess the benefits and harms in women > 75 November, 2009
  35. 35. Guidelines (controversy)
  36. 36. Guidelines (controversy)
  37. 37. Guidelines (controversy) 20-30% do not undergo screening
  38. 38. Screening Modalities
  39. 39. Breast Self-Examination (BSE) Potential Benefits Simple and non-invasive test Women gain a sense of control over their health Become comfortable with their own breasts Some breast cancer has been detected with BSE Increased awareness of breast changes Lumps can be palpated with a BSE
  40. 40. Breast Self-Examination (BSE) Potential Harms Increased number of healthcare visits Twice the number of benign breast biopsies Increased healthcare costs Increased levels of cancer-related anxiety No change in mortality from breast cancer with detection from BSE
  41. 41. Breast Self-Examination (BSE)
  42. 42. Breast Self-Examination (BSE) Organizations that recommend BSE ACOG Recommends monthly BSE AMA Recommends BSE, no age specified Susan G. Komen Foundation Recommends monthly BSE Organization that recommends against BSE Canadian Task Force for Preventive Healthcare Organizations that recommend further discussion or indicate insufficient evidence ACS Starting at age 20, pros and cons of BSE should be reviewed; it is the individual's choice US PSTF Insufficient evidence to recommend for or against BSE NCI No specific recommendation
  43. 43. Clinical Breast Examination (CBE)
  44. 44. Clinical Breast Examination (CBE) Benefits Not tested independently Clinical trial support combining CBE with mammography to enhance screening sensitivity, particularly in younger women in whom mammography may be less effective and in women who receive mammograms every other year as opposed to annually. Harms False-Positives  additional testing and anxiety. False-Negatives  potential false reassurance and delay in cancer diagnosis. Of women with cancer, 17% to 43% have a negative CBE. Sensitivity is higher with longer duration and higher quality of the examination by trained personnel.
  45. 45. Mammography 48 million mammograms are performed each year in US Special type of low-dose x-ray imaging used to create detailed images of the breast. Currently it is the best available population-based method to detect breast cancer at an early stage, when treatment is most effective Can demonstrate microcalcifications smaller than 100 µm. Often reveals a lesion before it is palpable by clinical examination and, on average, 1-2 years before noted by self-examination
  46. 46. Mammography Screening (asymptomatic) Diagnostic (symptomatic) Mammography
  47. 47. Mammography
  48. 48. Mammography •
  49. 49. False-positive Recalled examinations that does not lead to diagnosis of cancer. Estimated average false-positive rate in US is 11% Factors previous breast biopsies family history of breast cancer estrogen use Lack of a comparison mammogram(s).
  50. 50. False-negative Sensitivity range from 70-90%  false-negative 20% Factors:  Mammographically occult cancer.  Overlapping dense breast tissue  Poor technique  Reader variability
  51. 51. Mammography
  52. 52. Overdiagnosis A cancer never become clinically apparent without screening before a patient’s death. The median prevalence: an overview of 7 autopsy studies, occult invasive breast cancer 1.3% and of DCIS 8.9% A “perfect” screening would identify 10% of women as having breast cancer, even though most of those cancers would probably not result in illness or death. Treatment would constitute overtreatment. Currently, cancers that will cause illness and/or death cannot be confidently distinguished from those that will remain occult, so all cancers are treated.
  53. 53. Ultrasonography Useful adjunct to mammography Assist in suspicious lesion detected on mammography or physical examination Useful in the guidance of biopsies and therapeutic procedures. Originally, used as method of differentiating cystic from solid breast masses Limitations as screening test: Failure to detect microcalcifications Poor specificity (34%)
  54. 54. Ultrasonography Useful in detecting occult breast cancer in dense breasts. Highly operator-dependent
  55. 55. Ultrasonography somo-v Automated Breast Ultrasound System (ABUS)  FDA approved, Sep. 2012  Breast cancer screening specifically in women with dense breast tissue  Indicated as an adjunct to mammo for women with a negative mammogram, no breast cancer symptoms and no previous breast intervention
  56. 56. Magnetic Resonance Imaging (MRI) Explored in women at high risk and in younger women MRI found to be highly sensitive (99% when combined with mammography and CBE) An important adjunct screening tool for women BRCA1 or BRCA2 mutations, identifying cancers at earlier stages. MRI has limited use as a screening tool: Cost. 10-fold higher cost than mammography Poor specificity (26%)  false-positive reads
  57. 57. Magnetic Resonance Imaging (MRI)
  58. 58. Magnetic Resonance Imaging (MRI) American Cancer Society MRI screening criteria Annual breast MRI screening in patients with the following risk factors: BRCA mutation First-degree relative of BRCA carrier but untested Lifetime risk approximately 20-25% or greater, as defined by BRCAPRO or other risk models Radiation to chest when aged 10-30 years
  59. 59. Magnetic Resonance Imaging (MRI) American Cancer Society MRI screening criteria The ACS found insufficient evidence to recommend for or against MRI screening in patients with the following risk factors: Lifetime risk 15-20% LCIS or atypical lobular hyperplasia (ALH) Atypical ductal hyperplasia (ADH) Heterogeneously or extremely dense breast on mammography Personal history of breast cancer, including DCIS The ACS does not recommend MRI in women <15% lifetime risk For those with average risk, a combination of clinical breast examinations and yearly mammograms is recommended.
  60. 60. Conclusion Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of cancer death in women Screening breast cancer has proven benefits in reducing mortality and this is independent of the benefits of improved therapy. Various screening guidelines are currently being validated and followed by different medical organizations Mammography remains the mainstay of screening, and in women at high risk, annual MRI is recommended Understanding of the risks a benefits of a particular screening tool helps clinicians to make informed decision
  61. 61. • References • National Cancer Institute. Surveillance, Epidemiology, and End Results Program. SEER stat fact sheets: breast cancer. http://seer.cancer.gov/statfacts/html/breast.html. • American Cancer Society. What are the key statistics about breast cancer? http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. • National Cancer Institute. Breast cancer treatment (PDQ). General information about breast cancer. http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient. • American Cancer Society. What are the risk factors for breast cancer? • http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/Page8#_483 • http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors. • National Cancer Institute. Breast cancer screening (PDQ). http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional. • American Cancer Society. Breast cancer survival rates by stage. • http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-survival-by-stage. • http://www.medscape.org/viewarticle/583982 • US Preventive Services Task Force. About the USPSTF. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-can . • The American Congress of Obstetricians and Gynecologists. http://www.acog.org/About-ACOG/News-Room/News-Releases/2011/Annual-Mammograms • http://emedicine.medscape.com/article/1945498-overview • http://www.ncbi.nlm.nih.gov/books/NBK22311 • http://www.haad.ae/simplycheck/tabid/131/Default.aspx • http://www.cancer.gov/bcrisktool/ • http://www.slideshare.net/rajud521/breast-self-examination