Breast Imaging Ravi Adhikary, MD

ACS Estimated Cancers Statistics 2014 New Cases in Women Deaths in Women Breast 232,670 (+67,570 in situ) 40,000 Colon 48,380 24,040 Cervical 12,360 4,020 Lung 108,210 72,330 Pancreas 22,840 19,420

Screening Mammography Women of average breast cancer risk Annually starting at age 40 Women with an increased risk BRCA1/2 mutations, or untested with first degree relatives with BRCA Yearly, starting by age 30, not before 25 >20% lifetime risk of breast cancer by family history, women with mothers and sisters with premenopausal breast cancer Starting by age age 30, or 10 years earlier than the diagnosis of the youngest affected relative, but not before age 25 History of mantle radiation (for Hodgkin’s disease) Yearly starting 8 years after radiation therapy, not before 25 Women with lobular neoplasia, ADH, DCIS, invasive cancer or ovarian cancer Yearly from time of diagnosis

Screening Mammogram Trial Age Follow-up years Mortality Reduction Health Insurance Plan of Greater NY (1963-1969) 40-64 18 23% Malmo Mammographic Screening (1976-1986) 45-69 18-24 19% Swedish Two County Trial (1979-1988) 40-74 20 32% Edinburgh Trial (1979-1988) 45-64 14 29% Canadian National Breast Screening Study (1980-1987) 50-59 13 -2% Stockholm trial (1981-1985) 8 20% Gothenburg Breast Screening Trial (1982-1988) 40-59 UK Age Trial (1991-2005) 39-41 10 17%

Mammogram Masses Calcifications Architectural distortion Asymmetries Other features

Breast Density A: Almost entirely fatty B: Scattered areas of fibroglandular density C: Heterogenously Dense D: Extremely dense

Potential Problems With Dense Breast Tissue Increased Relative Risk Category D vs A: 4 to 6 Category C vs average: < 1.2 Category D vs average: <2.1 Decreased sensitivity of mammography Category D vs A: Sensitivity decreased 26% Category C vs average: Sensitivity decreased 7% Category D vs average: Sensitivity decreased 13%

Breast Density Legislation Women with dense or heterogeneously dense breast tissue receive a letter New York State has passed legislation and letters have been going out since 2013

New York State Law Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.

Possible Approaches No further screening Additional screening with ultrasound and MRI Benefits may be found in those women who have other risk factors beyond just density

Ultrasound Screening In 6 studies conducted between between 1995 - 2008 evaluating ultrasound screening: Involving 40,544 women Cancer detection ranged from 2.3-4.6/1000 screened, overall 3.4/1000 Mean size of cancer ranged from 9.1-11 mm 83%-100% of cancers found to be invasive 86%-100% of cancers found to be node negative

Ultrasound Screening Cancers found in screeners: Low risk 1.6/1000 Intermediate Risk 6.7/1000 High risk 11.5/1000

Ultrasound Screening Pros Does not require ionizing radiation No intravenous contrast required Well tolerated by patient Availability Relatively inexpensive Cons Does depend on operator High rate of BI-RADS 3 lesions Positive predictive value of biopsies is low Yield of cancer in those women of low risk other than breast density is relatively low

Breast Ultrasound Masses Calcifications Other findings

MRI Screening Not just for dense breasts High risk groups Generally starting by age 30 10 years before >20-25% lifetime risk of breast cancer BRCA carriers, 1st degree relative of BRCA carrier Chest radiation (for Hodgkin’s disease)

MRI Screening EVA Trial Multicenter study Evaluate contribution of MG, US, MRI 687 women with >20% lifetime risk Cancer yield MG: 5.4 US: 6.0 MG + US: 7.7 MRI: 14.9 MG + MRI: 16.0 MG + MRI + US: 16.0

MRI Screening Those with claustrophobia may not be able to tolerate the exam Pacemaker Renal function Contrast allergy Limited availability Expensive

Breast MRI Mass Non mass enhancement Focus Other findings

BI-RADS Assessment Assessment Management Likelihood of Cancer Category 0: Incomplete Recall for additional imaging and/or comparison with priors N/A Category 1: Negative Routine Screening Essentially 0% Category 2: Benign Category 3: Probably benign Short interval follow-up >2% Category 4: Suspicious Tissue diagnosis 4C: 50-49% Category 5: Highly suggestive of malignancy Tissue Diagnosis >95% Category 6: Known biopsy-proven malignancy Surgical excision when appropriate