What’s Next After an Abnormal Screening Mammogram? James A. Stewart, M.D. Beth Burnside, M.D. May 19, 2004.

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Presentation transcript:

What’s Next After an Abnormal Screening Mammogram? James A. Stewart, M.D. Beth Burnside, M.D. May 19, 2004

Goals for Today Review selected issues in breast screening Describe the current and planned services at UW Breast Center Discuss communication flow

Rate per 100,000 Female Population Year Adapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50: Uterus † Breast Pancreas Ovary Stomach Lung & bronchus Colon & rectum Evolution of cancer death rates, females

Why Reduction in BC Mortality ? Time of diagnosis (screening) Optimal “loco-regional” treatment –Surgery and Radiation Adjuvant chemo and endocrine Rx Treatment of overt systemic disease Swiss show same curves but <1/2 the mammography use Goldhirsch et al Annals of Oncology 14:1212, 2003

Case Scenarios 1.First impression? 2.Barriers? 3.Research question?

28yo woman with a family history of breast cancer wants to start routine mammography: ( 1 ST impression, barrier?, research?) 1.Just what is the family history? Is it suggestive of a BRCA family? 2.Will the radiologist do it? Is that the best test 3.I wish the researchers would identify people who won’t get breast cancer.

84yo woman who asks about continuing her regular mammography ( 1 ST impression, barrier?, research?) 1.How long is she likely to live? 2.What if the radiologist finds a very small cluster of calcifications? 3.I need a better way of “summing” her co-morbidities to plan her care.

Wisconsin Comorbidity Assessment Scale (WCAS) Comorbid Conditions Cognition / Mood Physical Function Assessment Instrument Validation Medication and Polypharmacy Falls/ Mobility

The Future of Residents’ Education in Internal Medicine ….evidence-based medicine, and judicious use of technology will be essential skills of the future ….management of large volumes of data with an ever-changing scientific knowledge base. LG Smith, et al AJM, May 1, 2004

Test and technology oriented culture Who puts things in context and gives advice?

The best communicators?

Computerized Health Enhancement Support System (CHESS) Breast

Breast Imaging Training: Who Will Sign Up? Promotion and increase compliance If > 40 mammo rate 29  67% (‘87-’98) Reimbursement, wait times, litigation Survey of 211 programs Majority of residents had Negative Attitude Malpractice exposure a leading reason Bassett, et al Radiology, June 2003

132 residents who would not choose breast imaging fellowship if offered

Breast Spectroscopy: PreChemo TE 144msTE 35ms Location of ROI Diffusion - Axial Maximal Slope of Increase

BSE in Shanghai Will intensive BSE instruction reduce breast cancer mortality? n = 266,064 women in 519 factories Accrual from (no mammograms) Randomize by factory Low back pain prevention BSE education with reinforcement Thomas et al, JNCI 2002;94

BSE Shanghai: Final Results (12/2000) BSE Control Breast Cancer Deaths Number of Cancers % Cancers Tis or T1 48.8% 44.8% Total biopsy specimens 3,620 2,395 Thomas et al, JNCI 2002; 94

Enthusiasm for Cancer Screening in the US National telephone survey n = 500 Finding cancer early saves lives (74%) 66% want testing even if nothing to do 73% would choose body CT over $1,000 in cash Schwartz LM et al, JAMA Jan 7, 2004

Screening as an Obligation Schwartz LM et al, JAMA Jan 7, % for mammography In 80yo woman

Challenges Where to put our resources for reducing breast cancer burden The population is aging Application and communication of technology Screening strategies in general

UW Breast Center 1 st Quarter 2004 Screening Mammogram2619 Ultrasound 556 Stereotactic core biopsy 110