Source US Cancer Statistics Working Group United States Cancer Statistics 19992011 Incidence and Mortality Webbased Report Atlanta GA Department of Health and Human Services Centers for Disease Control and Prevention and National Cancer Institute 2014 Available at httpwwwcd ID: 254785
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Slide1
Female Breast Cancer Death Rates/100,000 Women, Age Adjusted, by State, 2011†
†Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2011 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2014. Available at: http://www.cdc.gov/uscs. (full site) Slide2
Breast Cancer ScreeningSlide3
Tumors detected at an early stage that are small and confined to the breast are more likely to be successfully treated98% 5-year survival for localized disease89% of tumors measuring 1 cm or less cured by primary surgery (mastectomy and axillary dissection)
90% of patients 10+year disease free survival periods after tumors measuring 1 cm or less were detected by mammographyRationale for Mammogram ScreeningSlide4
Twenty five year follow-up for breast cancer incidenceand mortality of the Canadian National Breast
Screening Study: randomized screening trialOPEN ACCESSAnthony B Miller professor emeritus
1
, Claus Wall
data manager
1
, Cornelia J Baines
professoremerita 1, Ping Sun statistician 2, Teresa To senior scientist 3, Steven A Narod professor 1 21Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada; 2Women’s College Research Institute, Women’sCollege Hospital, Toronto, Ontario M5G 1N8, Canada; 3Child Health Evaluative Services, The Hospital for Sick Children, Toronto, Ontario, Canada
BMJ 2014;348:g366 doi: 10.1136/bmj.g366
Conclusion :
Annual mammography in women aged 40-59 does not
reduce mortality from breast cancer
beyond that of physical examination
or usual care when adjuvant therapy for breast cancer is freely available.
Overall, 22% (106/484) of screen detected invasive breast cancers were
over-diagnosed, representing one over-diagnosed breast cancer for
every 424 women who received mammography screening in the trial.Slide5
Other studies have shown decreased mortalityDid not look at differences in treatment morbidityOther StudiesSlide6
MammogramCBESBE
Best Recommendations for Breast Cancer ScreeningSlide7
National Breast and Cervical Cancer Early Detection Program752,081 clinical breast examinations in women age 40 and olderCBE aloneSensitivity 58.8%
Specificity 93.4%5 cases of cancer/1000 CBEIf mammogram normal 7.4 cancers/1000 CBEModest improvement in detectionClinical Breast ExaminationSlide8
When to Start Mammograms40Risk of cancer in next 10 years comparable to 50 (1.4 v 2.4/1000)
Mortality reduction similar to 50 (16% v. 15%)50,000 new breast cancers annually in US in women under 5050
USPSTF
Screening younger than 50 should be individualized based on “patient values regarding specific benefits and harms”Slide9
Breast
Cancer Screening Recommendations
Mammography
Clinical Breast Examination
Breast Self-Examination Instruction
Breast Self-Awareness
American College of Obstetricians and GynecologistsAge 40 years and older annuallyAge 20-39 years every 1-3 years
Consider for high-risk patients
Recommended
Age 40 years and older annually
American Cancer Society
Age 40 years and older annually
Age 20-39 years every 1-3 years
Optional for age 20 years and older
Recommended
Age 40 years and older annually
National Comprehensive Cancer Network
Age 40 years and older annually
Age 20-39 years every 1-3 years
Recommended
Recommended
Age 40 years and older annually
National Cancer Institute
Age 40 years and older every 1-2 years
Recommended
Not Recommended
—
U.S. Preventative Services Task Force
Age 50-74 years biennially
Insufficient evidence
Not Recommended
— Slide10
False PositiveUp to 20-30% of mammograms will require more evaluation to reach diagnosisDiagnostic mammograms with supplementary viewsUltrasound
BiopsyRadiation RisksFalse NegativeUp to 10% of breast cancers will not be found on mammogramPotential Harms of MammographySlide11
UltrasoundCan be adjunct to mammogramMRIHigh risk womenBRCA gene mutation
First degree relative with BRCA mutation and has not had testingLifetime breast cancer risk >20%Radiation therapy to the chest between ages of 10-30Other specific genetic syndromesPET, Thermography, etc.Selected clinical situations or adjunct to mammogram
Not for screening
Other ImagingSlide12
Ovarian Cancer ScreeningOvarian cancer has a low prevalence1 case per 2,500 women per year
If a screening test had 100% sensitivity and 99% specificityPositive predictive value would be 4.8% 20 of 21 women undergoing surgery would not have primary ovarian cancerSlide13
Potential Screening Tools in Low-Risk Women
Transvaginal UltrasoundTumor markersCA 125OVA 1Slide14
78,216 women randomly assigned to either annual screening with CA-125 and transvaginal ultrasound (n=39,105)or usual care (n-39,111)
From: Effect of Screening on Ovarian Cancer Mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial
JAMA. 2011;305(22):2295-2303. doi:10.1001/jama.2011.766Slide15
From:
Effect of Screening on Ovarian Cancer Mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial
JAMA. 2011;305(22):2295-2303. doi:10.1001/jama.2011.766Slide16Slide17Slide18
ConclusionObstetricsDon’t induce labor unless it is warranted
GynecologyScreen appropriate women at the appropriate age with the appropriate screening testSlide19
Breast cancer specific mortality, by assignment to mammography or control arms (all participants)Slide20
Breast cancer specific mortality from cancers diagnosed in screening period, by assignment to mammography or
control armsSlide21
Lifetime risk of colposcopySlide22
25 year survival (%)