Breast Cancer Screening ACR Breast Cancer Screening Leaders - PowerPoint Presentation

1. Breast Cancer ScreeningACR Breast Cancer Screening LeadersMarch 2019

2. Preview/IntroductionThe Risk of Breast Cancer to WomenDoes Mammography Save Lives?When to Start and How Often Should Women Screen?Risks Versus Benefits of Mammography

3. Breast Cancer: The Impact on Women

4. Breast Cancer Stats: 2019Most common cancer diagnosed in women12.8% of women will be diagnosed during lifetimeMore than 331,000 new cases anticipated (268,600 invasive)30% of all new cancer cases in women41,760 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

5. Has Mammography Reduced Breast Cancer Death?

6. Women aged 40–84 by year 1969–201542% mortalityAge-adjusted U.S. breast cancer mortality rates (per 100,000) Hendrick RE, Baker JA, and Helvie MA. Breast Cancer Deaths Averted Over 3 Decades. Cancer 2019;0:1-7.Mammography~ 384,000-614,500 Lives savedYES - MAMMOGRAPHY HAS REDUCED BREAST CANCER DEATHS

7. Evidence of Benefit: Overview

8. Decades of Evidence Prove Mammography Saves LivesRandomized controlled trials of women ages 40–74 show at least a 20% reduction in breast cancer deathsObservational studies: show a mortality reduction of about 40%Observational studies show benefits for women over 74, as well as the 40–74 age groupNote: RCTs test only the “invitation to screening”Note: test actual mammogram use

9. Evidence of Benefit: Randomized Controlled Trials (RCT)

10. 24% mortality reductionDuffy SW, Tabár L, Smith RA.CA Cancer J Clin. 2002 Mar-Apr;52(2):68-71.

11. Evidence of Benefit: Observational Data

12. Evidence of Benefit: Observational Trials (Europe)Why observational data mattersRandomized controlled trials UNDERESTIMATE benefit of screeningWhat European observational data shows1 Magnitude of mortality reduction from screening mammography is greater than RCTs suggest, 38–49%1Broeders et al J Med Sci 2012

13. Case-Control Studies (Ages 40–75)49% ↓ MortalityCancer Epidemiol Biomarkers Prev 2012

14. Evidence of Benefit: Observational Trials (Europe)Broeders et al J Med Sci 201238% mortality reduction

15. Evidence of Benefit:The Pan-Canadian Study

16. Pan-Canadian Study1990–20092.8 million womenCompared breast cancer deaths in women who had screening mammograms to those who did not

17. ResultsAverage breast cancer mortality reduction among all participants was 40%40% Mortality(95% CI, 0.33-0.48)

18. 40 to 49 years 44% Mortality50 to 59 years 40% Mortality60 to 69 years 42% Mortality70 to 79 years35% MortalityResults by Age

19. Benefits of Screening:Additional Considerations

20. Benefits of Screening40% drop in breast cancer deathLess extensive surgery for screening detected cancersLess chemotherapy for screening detected cancersChemotherapy is MORE EFFECTIVE for screened womenTabar, et al. Cancer 2018 125: 515-523

21. Tabar, et al. Cancer 2018 NovemberUsing 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 women58 years of follow upAll women had either 10 or 20 years of follow up

22. Why Start Screening at 40?

23. Breast cancer is a serious problem for women in their 40s 1 in 6 breast cancers are found in women ages 40–49The 10-year risk for being diagnosed with breast cancer in a 40 year old woman is 1 in 69About 1/3rd of the years of life lost from breast cancer are in women in their 40s>70% of the women dying from breast cancer in their 40’s belong to the 20% not being screened

24. 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 yearOver 40% of years-of-life to breast cancer are lost to women diagnosed under age 50

25. How do alternative screening guidelines compare to the American College of Radiology®?

26. American Cancer Society and USPSTFUSPSTF uses limited and older data that underestimates the mortality reduction gained from screening mammographyBoth 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-lethalAll 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.

27. Comparison: Screening Recommendation OutcomesScreening regimen,patient age (y)Reduction in risk of dying of breast cancer1Number of women whose lives will be saved (per 100,000)1Number of life-years gained(per 100,000)1Yearly, 40-84*40%119018,900 (+72%)*Yearly, 45-54;every other year, 55-79˜31%92514,900 (+35%)*Every other year, 50-74ˠ23%69511,000* % increase in life-years gained compared to biennial 50-74

28. Distribution of Years of Life Lost due to Deathfrom Breast Cancer by Age at DiagnosisACS reportJAMA 2015

29. Risks: Recall and Biopsy

30. Recall is uncommon = only 10%Biopsy is rare = 1-2% per year

31. Risks: Recall & Biopsy“False Positives” and anxiety are commonly presented as risksRisks from recall and biopsy must be compared to the 40% reduction in breast cancer deaths due to screening mammographyShort-term anxiety from screening resolves, and women have no long term anxiety nor adverse health effects

32. Risks: Overdiagnosis

33. OverdiagnosisDefined as breast cancer that would not kill a women in her lifetimeCan’t be measured directly; not possible to know which breast cancers are overdiagnosed without leaving cancer untreatedIs rare! Estimated at 1–10% of all breast cancersUnderdiagnosis is NOT ideal

34. Summary for Average Risk WomenScreening mammography is a proven life-saver40% reduction in breast cancer death with regular screeningMost lives are saved with ANNUAL SCREENING at AGE 40

35. Summary for Average Risk WomenModern 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

36. Breast Cancer Screening ofWomen at Higher Than Average RiskRecommendations from the American College of Radiology

37. 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 averageBenefit from supplemental screening

38. Higher risk women need supplementaland earlier screeningRiskDM +/- DBT MRI+Known genetic mutation or lifetime risk ≥20%Annually starting at age 30Annually starting at age 25–30Breast cancer history and dense breasts at any age or breast cancer diagnosed <age 50Annually starting at time of diagnosisAnnually starting at time of diagnosisHistory of chest radiation therapy before age 30Annually starting at age 25 or 8yrs after therapy (whichever is later)Annually starting at age 25–30History of ADH, ALH, LCIS or personal breast cancer history other than aboveAnnually 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

39. Questions?

40. ContributorsKELLY W. BIGGS, MD, Committee ChairVILERT LOVING, MD, MMMCatherine m. Appleton, mdDebra Monticciolo, MD, FACR, FSBILora Barke, DO, FACRMary S. Newell, MD, FACR, FSBIPRAGYA DANG, MD Elissa R. Price, MD FRCPC FSBIStamatia Destounis MD, FACR, FSBI, FAIUMJOCELYN RAPELYEA, md, FSBIDipti Gupta, MDKimberly Ray, md, fsbi Jiyon lee, MDSHADI aminololama-SHAKERI, mdJESSICA W. T. LEUNG, MD, FACR, FSBI