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1. Kişiselleştirilmiş Tarama CY
1. PRADİGMA DEĞİŞİKLİĞİ
TOPLUM BAZLI KİŞİSELLEŞTİRİLMİŞ
Herkese aynı yöntem
• Cins ve yaş temelli arama
Her kişiye özgün yöntem
• RİSKE GÖRE TARAMA
• KİŞİSEL TERCİHLERE
GÖRE TARAMA
• YARAR/ZARAR
HESABININ YAPILDIĞI
Breast Cancer Screening in an Era of Personalized Regimens
A Conceptual Model and National Cancer Institute Initiative for Risk-Based and
Preference-Based Approaches at a Population Level Cancer October 1, 2014
2955
National Cancer Institute. PROSPR Research Sites & Principal
Investigators. appliedresearch.cancer.gov/networks/prospr/sites.html.
2. REHBERLER
• ACS 40-44 HT 45-54 yıllık 55 üstü 1-2 yılda bir
• ACR SBI 40 yaş üstü yılda bir
• NCCN 40 üstü yılda bir
• USPSTF 40-49 HT 50-74 2 yılda bir
4. 35-39
kişisel meme
ca öyküsü
varsa
40-49 Birinci
derece
akrabasında
meme ca varsa
50 ve üstü
yıllık
35-39
baseline
mamografi
40-49
klinisyenine
danışsın
50 ve üstü
yıllık
35-39
baseline
mamografi
40-49
Her 1-2 yılda
bir
50 ve üstü
yıllık
40-49
Her 1-2 yılda
bir
50 ve üstü
yıllık
40 yaş ve üzeri
Yıllık
40 yaş ve üzeri
Yıllık, sağlıklı
olduğu sürece
devam etmeli
40-44
hasta isterse
45 – 54
(Yıllık)
55 ve üzeri
Her 2 yılda bir
veya hasta
isterse yıllık
Lise
yıllarında
başlansın
(Aylık)
Lise
yıllarında
başlansın
(Aylık)
20 ve
üzeri
(Aylık)
20 ve
üzeri
(Aylık)
20 ve
üzeri
(Aylık)
20 ve üzeri
(İsteğe
Bağlı)
20 yaş
sonrasında
periyodik
yapılmalı
20-39 üç
yılda bir,
40 üstü
(Yıllık)
20-39 üç
yılda bir,
40 üstü
(Yıllık)
20-39 üç
yılda bir,
40 üstü
(Yıllık)
20-39 üç
yılda bir,
40 üstü
(Yıllık)
Genel sağlık
kontrolunun
bir parçası
olarak20-39
üç yılda bir
periyodik,
40 üstü
Yıllık periyodik
ACS GUIDELINES
Mamografi
Kendi Kendine
Meme
Muayenesi
(BSE)
Klinik Meme
Muayenesi
(CBE)
1976 1980-1982 1983-1991
1992-
March 1997
March 1997-
May 2003
May 2003-
October 2015
October 2015-
Present
Yapılmasın
Yapılmasın
5. Research does not show a clear benefit of
physical breast exams done by either a
health professional or by yourself for breast
cancer screening.
Due to this lack of evidence, regular clinical
breast exam and breast self-exam are not
recommended
ACS 2015
MEME MANSERİ TARAMASI
RADYOLOĞUN İŞİ
6. KİŞİSELLEŞTİRİLMİŞ TARAMADA
AMAÇ
TIBBİ AÇIDAN (RADYOLOJİK)
• İnterval kanser oranını azaltmak
• Yüksek riskli hastayı daha erken tarama
• Yüksek riskli hastayı daha sık tarama
• Yüksek riskli hastaya MG ye ilave
taramalar yapma
9. YÜKSEK RİSKLİ HASTALARDA MEME KANSERİ
• Daha hızlı büyüme eğilimindedir
• Daha erken yaşta ortaya çıkar
• Mamografilerde daha zor tanınır
• Tedaviye daha az yanıt verir
AMA DÜŞÜK RİSKLİ HASTALAR İÇİN
TERSİ DOĞRU DEĞİL
10. ACS/ACR X USPSTF
REHBERLERİ
KARŞILAŞTIRILDIĞINDA
mortalite düşüşü
% 39,6 dan
%23,6 ya geriliyor
Mortalite azalmasındaki
gerileme % 71 oluyor
Hendrick RE, Helvie MA. United States Preventive Services Task
Force screening mammography recommendations: science ignored.
AJR 2011; 196:[web]W112–W116
11. SADECE YÜKSEK RİSKLİ
HASTALAR TARANSA İDİ
• Risk kapsamına göre değişmekle birlikte
meme kanserlerinin sadece % 70-80 i
atlanacaktı
• Çünkü: En major risk faktörü kadın olmak
De Waard F, Collette JG, Rombach JJ, et al. Breast cancer screening with particular reference to the
concept of ‘high risk’ groups. Breast Cancer Res Treat 1988; 11:125–132
Paci E, Del Turco MR, Palli D, et al. Selection of high-risk groups for breast cancer screening:
evidence from an Italian multicentric case control study. Tumori 1988; 74:675–679
Destounis SV, Arieno AL, Morgan RC, et al. Comparison of breast cancers diagnosed in screening
patients in their 40s with and without family history of breast cancer in a community outpatient
facility. AJR 2014; 202:928–932
12. 40-49 YAŞ GRUBUNDA
TARAMADA SAPTANAN
KANSERLERİN % 88 İNDE
BİRİNCİ DERECE AKRABADA
MEME KANSERİ MEVCUT
DEĞİLDİ
Keedy AW, Price ER, Gidwaney R, Sickles EA, Joe BN. The
potential impact of risk-based screening mammography in women
40–49 years
old. AJR 2015 Jul 23
20. DENS MEMELERE
TOMOSENTEZ VEYA
SONOGRAFİNİN İLAVE
GÖRÜNTÜLEME OLARAK
KULLANILMASI
•
Interim results of the Adjunct Screening with
Tomosynthesis or Ultrasound in
Mammography-negative Dense Breasts
(ASTOUND) trial
21. • For intermediate-risk women, or those with
a lifetime risk of breast cancer that is 12 to
20 percent higher than the average
woman, Dr. Brem advocated for annual
screening after age 40 with both
mammography and ultrasound.
• Rsna 2016 keynote spekar
25. Yüksek riskli hastada MRG ile
tarama rehberleri
2007 ACS guidelines for breast screening with
MRI as an adjunct to mammography
2009 NCCN The role of MRI in breast cancer
screening
2010 SBI/ACR Breast cancer screening with
imaging
26. ACS 2007 (1)
Recommendations for Breast MRI Screening
as an Adjunct to Mammography
Recommend Annual MRI Screening (Evidence based)
•BRCA mutation
•First-degree relative of BRCA carrier, but untested
•Lifetime risk ~20–25% or greater, as defined by BRCAPRO or other
models that are largely dependent on family history
Recommend Annual MRI Screening (Expert Consensus Opinion )
•Radiation to chest between age 10 and 30 years
•Li-Fraumeni syndrome and first-degree relatives
•Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree
relatives
27. ACS 2015 (1)
Recommendations for Breast MRI Screening
as an Adjunct to Mammography
Recommend Annual MRI Screening (Evidence based)
•BRCA mutation
•First-degree relative of BRCA carrier, but untested
•Lifetime risk ~20–25% or greater, as defined by CLAUS or other
models that are largely dependent on family history
Recommend Annual MRI Screening (Expert Consensus Opinion )
•Radiation to chest between age 10 and 30 years
•Li-Fraumeni syndrome and first-degree relatives
•Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree
relatives
28. ACS 2007 (2)
Recommendations for Breast MRI Screening as an
Adjunct to Mammography
Insufficient Evidence to Recommend for or Against MRI Screening
•Lifetime risk 15–20%, as defined by BRCAPRO or other models that
are largely dependent on family history
•Heterogeneously or extremely dense breast on mammography
•Women with a personal history of breast cancer, including ductal
carcinoma in situ (DCIS)
•Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
•Atypical ductal hyperplasia (ADH)
29. ACS 2015 (2)
Recommendations for Breast MRI Screening as an
Adjunct to Mammography
Insufficient Evidence to Recommend for or Against MRI Screening
•Lifetime risk 15–20%, as defined by CLAUS or other models that are
largely dependent on family history
•Heterogeneously or extremely dense breast on mammography
•Women with a personal history of breast cancer, including ductal
carcinoma in situ (DCIS)
•Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
•Atypical ductal hyperplasia (ADH)
36. Hesaplanan en yüksek riske
göre değerlendirme yapılır
Risk Değerlendirme
Birden fazla model kullanıldığında
37. Recommend Against MRI Screening (Based
on Expert Consensus Opinion )
•Women at 15% or lower lifetime risk
ACS 2007 (3)
Recommendations for Breast MRI Screening as an
Adjunct to Mammography
38. TARAMADA AMAÇ
• ANA AMAÇ MEME KANSERİNDEN
ÖLÜMLERİ AZALTMAK
• RADYOLOJİK AMAÇ İNTERVAL KANSER
ORANINI AZALTMAKTIR
• YARAR MAKSİMİZASYONU / ZARAR
MİNİMİZASYONU
• DOĞRU KADINA, DOĞRU ZAMANDA,
DOĞRU TEST, İLE MÜMKÜN
• VE TÜM SORUMLULUK RADYOLOGTA
Hinweis der Redaktion
ACR published their guideline at 2010
ACR published their guideline at 2010
This is the last part of the ACS guideline
But I think it is the most important part
instead of recommendation it says something about not to do
This parts clearly prevent abuse of MRI screening by prohibiting MRI for women with lower 15 % lifetime risk