†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; Available at: (full site)

 Tumors detected at an early stage that are small and confined to the breast are more likely to be successfully treated ◦ 98% 5-year survival for localized disease  89% 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 mammography

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial OPEN ACCESS Anthony B Miller professor emeritus 1, Claus Wall data manager 1, Cornelia J Baines professor emerita 1, Ping Sun statistician 2, Teresa To senior scientist 3, Steven A Narod professor 1 2 1Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada; 2Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario M5G 1N8, Canada; 3Child Health Evaluative Services, The Hospital for Sick Children, Toronto, Ontario, Canada BMJ 2014;348:g366 doi: /bmj.g366 Conclusion : Annual mammography in women aged 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.

 Other studies have shown decreased mortality  Did not look at differences in treatment morbidity

 Mammogram  CBE  SBE

 National Breast and Cervical Cancer Early Detection Program ◦ 752,081 clinical breast examinations in women age 40 and older ◦ CBE alone  Sensitivity 58.8%  Specificity 93.4% ◦ 5 cases of cancer/1000 CBE ◦ If mammogram normal 7.4 cancers/1000 CBE ◦ Modest improvement in detection

 40 ◦ Risk 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 50  50 ◦ USPSTF ◦ Screening younger than 50 should be individualized based on “patient values regarding specific benefits and harms”

Breast Cancer Screening Recommendations Mammography Clinical Breast Examination Breast Self- Examination Instruction Breast Self- Awareness American College of Obstetricians and Gynecologists Age 40 years and older annually Age 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 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 years every 1-3 years Recommended Age 40 years and older annually National Cancer Institute Age 40 years and older every 1-2 years RecommendedNot Recommended— U.S. Preventative Services Task Force Age years biennially Insufficient evidence Not Recommended—

 False Positive ◦ Up to 20-30% of mammograms will require more evaluation to reach diagnosis  Diagnostic mammograms with supplementary views  Ultrasound  Biopsy  Radiation Risks  False Negative ◦ Up to 10% of breast cancers will not be found on mammogram

 Ultrasound ◦ Can be adjunct to mammogram  MRI ◦ High risk women  BRCA gene mutation  First degree relative with BRCA mutation and has not had testing  Lifetime breast cancer risk >20%  Radiation therapy to the chest between ages of  Other specific genetic syndromes  PET, Thermography, etc. ◦ Selected clinical situations or adjunct to mammogram ◦ Not for screening

 Ovarian cancer has a low prevalence  1 case per 2,500 women per year  If a screening test had 100% sensitivity and 99% specificity ◦ Positive predictive value would be 4.8% ◦ 20 of 21 women undergoing surgery would not have primary ovarian cancer

Potential Screening Tools in Low-Risk Women  Transvaginal Ultrasound  Tumor markers ◦ CA 125 ◦ OVA 1

 78,216 women randomly assigned to either annual screening with CA-125 and transvaginal ultrasound (n=39,105)or usual care (n-39,111)

 Obstetrics ◦ Don’t induce labor unless it is warranted  Gynecology ◦ Screen appropriate women at the appropriate age with the appropriate screening test

Breast cancer specific mortality, by assignment to mammography or control arms (all participants)

Breast cancer specific mortality from cancers diagnosed in screening period, by assignment to mammography or control arms