Controversies in Breast Cancer Allan Arkush, DO, FACOS

Overview 1 in 8 women will develop cancer in the breast. Over 200,000 new cases per year 35,000 deaths a year and decreasing

Controversy #1 Hormone Replacement Therapy (HRT) – Many different articles can cause confusion

Collaborative Reanalysis (UK) Jan ,000 postmenopausal women were studied Conclusion: studies “Failed to meet majority of nine criteria showing causality between HRT and development of breast cancer.” “Carefully designed studies are needed to determine whether HRT does indeed cause an increased risk of breast cancer.”

Most newer studies are showing just the opposite Risk of cancer increases the longer HRT is given.

Women's Health Initiative 25,000 women studied – Fewer cancer diagnoses in the HRT group than the placebo group in the first 2 years. – Breast cancer cases increase rapidly after 5.6 years but the risk rapidly decreased after stopping the HRT.

BRCA 1 and 2 Who gets tested? Advising BRCA positive patients Close observation verses preventative mastectomy

Breast Mass Palpable breast mass in a patient who is at risk for cancer with a negative mammogram still has a palpable breast mass Mammograms should be used for screening or evaluating both breasts in at risk patients with a palpable breast mass

Screening Mammograms When to start? When to stop? AMA, ACOG, ACR (Radiology), American Cancer Society and the National Cancer Institute

Over diagnosis of Breast Cancer New England Journal of Medicine (NEJM), Nov 2012 Cancer Epidemiology Biomarkers (Journal) 2010 – 1000 women, ages 40-49, with screening mammograms – 900 true negatives – 100 will not have breast cancer, but mammogram was positive for cancer (false positive). – 2 will accurately show invasive breast cancer (0.2%) – 1 will accurately show non invasive cancer (0.1%) – 1 will have cancer but will be missed (false negative)

Over diagnosis (continued) Cancer Causes Control – year olds are over diagnosed 40-42% of the time Cochrane Database System – Screening led to 30% over diagnoses – Of 2000 women evaluated every 10 years, 1 will have their life prolonged – 10 healthy women would not have been diagnosed; therefore they received unnecessary treatment

NEJM, Sept 2010 Norwegian study of over 40,000 women, screening accounted for only 1/3 of the 10% reduction in cancer deaths.

Breast Health Mills, MD, FACS – Recommends screening mammograms begin at age 50, if normal repeat every 2 years – No screening mammograms after age 74 – Other recommendations based on risk factors

Mills, MD, FACS (continued) Reasoning – Mammograms are painful – 10% show false positives – Unnecessary biopsies with in situ – Radiation exposure – Up to 30% false negatives

Malpractice American College of Radiology – Breast cancer related claims led to more payouts than any other entity except brain damaged infants Physicians Insurers Assoc of America (PIAA) – Increase in numbers and payouts (almost doubled) in the past 15 years

Recommendations Begin at the age of 40 if average risk Higher risk patients need more aggressive screening – ACR, AMA, ACOG, American Cancer Society, NCI Mammographic screening may be dictated by governmental national health.

Other Considerations Alcohol and Breast Cancer Team approach to breast cancer – Family Physician – Breast Surgeon or Clinic – Medical Oncologist/Radiation Oncologist – Plastic Reconstructive Surgeon – Nurse Navigator