Breast Screening and Risk Assessment Mike Elrod DO, FACOS First Surgical Care

Pre Question 47 yr. F presents to your office after she received a letter that her screening mammogram showed dense breasts and she may be at higher risk for breast cancer. She wants to know what she should do. What are appropriate steps?

Options (A) Tell her not to worry and continue her screening schedule (B) Get a good history and do a risk breast cancer risk assessment (C) Order a breast MRI (D) Start Tamoxifen

Pre Question Which is NOT an indication for genetic testing? (A) 59yr. F with triple negative breast cancer (B) Patient’s mother had breast cancer age 60 (C) Patient’s father had breast cancer (D) Patient’s sister had primary peritoneal carcinoma

We Will Discuss Screening recommendations What to do with dense breasts Identifying high risk patients and appropriate screening Indications for genetic testing and what to do with the results What biopsy to order and what to do with the results

Breast Cancer Screening Recommendations NCCN (National Comprehensive Cancer Network) ACS (American Cancer Society) USPSTF (US Preventative Services Task Force) ASBS (American Society of Breast Surgeons)

National Comprehensive Cancer Network (NCCN) Mammography Clinical Breast Exam Every year starting at age 40 For as long as a women is in good health Every 1-3 years ages 25-39 Every year starting age 40

USPSTF Mammography Breast Exam <50 based on discussions with patient Age 50-74 biennial screening >75 evidence insufficient to assess benefits or harms Recommends against teaching self breast exams Evidence insufficient to assess additional benefits and harms of CBE beyond screening mammography in women >40yrs

USPSTF “Recommendations apply to asymptomatic women age 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.”

2015 ACS Guidelines Mammography Breast Exam Shared decision making process for screening ages 40-44 Annual screening for women ages 45-54 Biennial screening for women over the age of 55 Continue screening as long as they have an estimated 10 year life expectancy “Breast exams, either from a medical provider or self-exams, are no longer recommended.”

American Society of Breast Surgeons Recommendations 1. Consider screening mammography age 40-44. Most studies show a decrease in breast cancer mortality from screening starting at age 40. Ages 40-49 have higher false positive rates 2. Annual screening for women ages 45-54. 3. Annual or biennial screening for women 55 and older based on shared decision making regarding the risks and benefits.

American Society of Breast Surgeons Recommendations 4. Biennial screening for women over the age of 75 if an estimated life expectancy is greater than 10 years. 5. Breast tomography may be considered for screening. Early data shows promise for higher sensitivity and specificity rates May increase detection rates and decrease false positive rates Especially in women with dense breast tissue

Special Screening Populations Older women None of the randomized prospective trials included women older than the age of 74. Therefore, the US preventative task force has not recommended screening mammography in this age group BUT… 26% of breast cancer deaths are in women over the age of 75. 50% of women over the age of 80 are expected to live another 10 years.

Special Screening Populations Younger women For women under the age of 39 there is no data supporting routine screening in this group. Mammography is less accurate in premenopausal women under the age of 45 for screening or if done for symptoms. The ACS does not recommend screening prior to the age of 44 for women of average lifetime risk.

Okay, lets keep it simple What To Do? Okay, lets keep it simple

What I Do Annual screening mammograms beginning at age 40 After age 75 discuss risks and the patients concerns and wishes Perform a risk assessment Offer screening based on breast cancer risk Offer aggressive screening for women with elevated lifetime risk

What To Do With Dense Breast Tissue?

Current Status of Supplemental Screening in Dense Breasts Strong evidence based guidelines are lacking Oh no. No guidelines with boxes to to check, what to do?

(ASTOUND) Adjunct Screening With Tomosynthesis or US in Women with Mammography – Negative Dense Breasts trial US detected more breast cancers than tomosynthesis with a similar false positive recall rate But tomosynthesis did detect about 50% of the additional breast cancers and could potentially be the primary screening modality

It Really Comes Down To Risk Stratification High risk Average risk MRI tomosynthesis US Tomosynthesis Nothing

How Do You Identify Patients That Are High Risk for Breast Cancer?

Risk Models Gail Claus BRCAPRO Tyrer-Cuzick

Hughes Risk Developed at Mass General Hospital Division of Surgical Oncology Includes multiple models Input into computer and spits out 5 year and lifetime percent risk Looking for lifetime risk of 20% or greater Indication for MRI 5 yr. Gail risk above 1.67 Consider hormone modulation

Risk Factors for Hereditary Breast Cancer Age onset breast cancer < 50 Triple negative breast cancer and age <60 Ashkenazi Jewish heritage with breast cancer any age First degree relative with breast cancer <50 2 or more primary breast cancers 2 relatives on same side of family w/ breast and/or pancreatic cancer Family or personal history ovarian, fallopian or primary peritoneal cancer Male breast cancer Know mutation carrier in the family

Keep It Simple Elevated risk Genetic Run Hughes assessment If lifetime risk >20% start high risk screening MRI / mammogram staggered at 6 month intervals If Gail is >1.67 discuss hormone modulation or consult oncology for this If patient has risk factors either do the test or send to genetic counseling

Genetic Testing Results

Positive Test Prophylactic surgery Aggressive screening BL mastectomy > 90% risk reduction Salpingo-oophorectomy BRCA1 (35-45) BRCA2 (40-45) MRI starting age 25 Start mammograms at age 30 Annual pelvic age 25 Annual pelvic US age 30-35 CA-125 annually Clinical breast exam Q6 months

Variant of Uncertain Significance This is reported when it is not known if the specific gene change affects a person’s risk for cancer Seen in up to 10% of tests Over time, it will be re-classified as either harmful for clearly not harmful. The vast majority are not harmful

BI-RADS 0 Need additional imaging 1 Negative 2 Benign 3 Probably benign cancer risk < 2% 98% are benign 4 Suspicious cancer risk: (a) 2-10% (b) 10-50% (c) 50-95% In general approximately 70% are benign 5 Highly suggestive of malignancy cancer risk: > 95% 6 Known malignancy

Breast Biopsy US Stereotactic MRI Excisional (surgical)

Which One?

What to do with the results

Concordance Discordance When the CNB shows benign histology while the clinical or imaging findings are suspicious for malignancy If discordant Biopsy it again under imaging Surgical excision

“Borderline” Benign Biopsies Atypical ductal hyperplasia (ADH) Up to 20% upgrade rate to DCIS or Invasive cancer Atypical lobular hyperplasia (ALH) Variable rate of upgrade, still needs excision Lobular carcinoma in situ (LCIS) Needs surgical excision Papillary lesions Especially with atypia Radial scars (complex sclerosing lesions) Fibroepithelial lesions (fibroadenoma and phyllodes) Columnar cell lesions with atypia Flat epithelial atypia 9% upgrade to DCIS Pseudoangiomatous stromal hyperplasia (PASH)

Case Scenarios