1. Breast Cancer Screening and Diagnosis
Dr. Ruth Heisey
Family Physician/GP Oncologist
Women’s College Hospital/Princess Margaret Cancer Centre
Clinician Investigator/Associate Professor
University of Toronto
Sandy Fawcett RN(EC) NP-Adult
Gattuso Rapid Diagnostic Centre
Breast Disease Site
University Health Network- Princess Margaret Cancer Centre
Adjunct Lecturer University of Toronto
May 2, 2014

2. Canadian Breast Cancer Statistics
In 2013: 23,800 women will be diagnosed
5,000 will die
One in nine expected to develop breast cancer
Mortality rates declining 2

3. Objectives: Review current breast screening guidelines
Introduce personalized risk assessment tools
Review strategies for timely breast cancer diagnosis

4. Question
Which is the gold standard tool used to screen for breast cancer?
Breast ultrasound
Breast MRI
Mammogram
Clinical breast exam

5. Breast Cancer Screening Principles
Breast screening aims to detect cancer before palpable (pre-clinical phase)
Early detection leads to better outcome

6. ONCOLOGY - Cancer biology
Tumor growth and detection
1012
109
time
Diagnostic threshold (1cm)
Undetectable cancer
Detectable cancer
Limit of clinical detection
Host death
Number of cancer cells

7. 2011: Breast Cancer Screening Guidelines CMAJ 2012 Warner et al

8. The Canadian Task Force screening recommendations are for average risk women with no breast symptoms

9. Screening Mammography
Canadian Task Force Recommendations:
“For women aged 50-74, we recommend routinely screening for breast cancer every two to three years”

10. Screening Mammography
Canadian Task Force Recommendations:
“For women aged 40-49, we recommend not routinely screening for breast cancer with mammography”

11. Screening Mammography
Canadian Task Force Recommendations (40-49yo):
“this recommendation places a relatively low value on a very small absolute decrease in mortality… clinicians should discuss the benefits and harms with their patients and must help each woman to make a decision consistent with her values and preferences”

13. Effect of Mammographic Screening (1976-2008)
Early stage breast cancers-2 fold increase
Late stage breast cancers-small decrease
More than 30% of breast cancers detected were overdiagnosed (would never have resulted in clinical symptoms if left untreated)
NEJM Bleyer and Welch

14. Mammographic Screening-Polling Results
NEJM 2013 Feb 368;9, Colbert,Adler

15. Views on mammographic screening
Until we can determine which cancers will remain indolent we must “ treat all (cancers)as potential killers ”
Need to prioritize interventions that increase life expectancy and reduce disease burden
Agreement that women at greater risk need vigilant screening
NEJM 2013 Feb 368;9, Colbert,Adler

16. Clinical Breast Exam
Canadian Task Force Guidelines: “We recommend not routinely performing clinical breast examinations alone or in conjunction with mammography to screen for breast cancer”

17. Detection of breast cancer by physical examination versus mammogram for different age groups:
Unintended consequences of recommendation…delay in diagnosis data
Clinical Breast Cancer 2005;6(4):330-3

18. CBE
Continue as part of periodic health exam or antenatal visit (opportunistic approach)

19. What is average risk? No family history of breast cancer
No previous breast biopsies showing atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS)
No history of chest wall radiation
10% lifetime risk

20. What is higher than average?
Moderate/High:
History of breast biopsy showing ADH(atypical ductal hyperplasia), LCIS (lobular carcinoma in situ)
Previous history of breast cancer
Family history of breast cancer
16-25% lifetime risk

21. What is higher than average?
Very High:
BRCA carrier or untested first degree relative of BRCA carrier
Previous chest wall radiation
History of LCIS, ADH and family history

22. Role of Screening MRI
Definite role for very high risk patients such as BRCA mutation carriers in conjunction with mammography and CBE
MRI more sensitive for detecting breast cancers than mammography, ultrasound or CBE alone
MRI=77-100%
Mammography=16-40%
Check numbers-warner
JAMA 2004, 292 (11)
J Clin Oncol 2006, 23:

23. Magnetic Resonance Imaging ( MRI )
Bilateral breast MRI

24. American Cancer Society Recommendations for Screening MRI
Gene mutation (BRCA 1 or 2; Li-Fraumeni syndrome; Cowden syndrome; Bannayan-Riley-Ruvalcaba syndrome)
First-degree relative with one of these mutations (if the woman has not yet been tested)
History of radiation therapy to the chest between ages 10 and 30
Lifetime risk >20-25% based largely on family history
Saslow D, et al. CA Cancer J Clin 2007;57(2):75-89

25. Warner et al

27. OBSP High Risk Screening Program- 2011
MRI in addition to mammogram annually
for women ages 30-69:
known BRCA carrier
untested first degree relative of BRCA carrier
chest irradiation before age 30 and at least 8 years previously
≥ 25% lifetime risk of breast cancer (using IBIS or BODICEA risk calc)

29. Breast Screening in Clinical Practice
All women should be asked re: family history of breast, ovarian cancer or both
If concerns re: mutation carrier discuss implications and referral
Consider mammography screening in all women starting at age 40 (no woman should be denied!)

30. Breast Screening in Clinical Practice
The 50-74yo asymptomatic woman:
Mammogram q 2 years (annual if high risk)
Consider OBSP
Discuss breast awareness
Opportunistic CBE

31. Breast Screening in Clinical Practice
The 40yo asymptomatic woman:
Consider mammogram q1-2 years based on risk, density and patient preference
Discuss breast awareness
Opportunistic CBE

32. Breast Screening in Clinical Practice
The 75yo asymptomatic woman:
Continue to offer mammography until life expectancy is less than 10 years

33. Breast Screening in Clinical Practice
Moderate/High risk:
Annual mammography and CBE starting at age 40

34. Breast Screening in Clinical Practice
Very high risk: (e.g. BRCA carrier)
Annual mammography, MRI starting at age 30
CBE every 6 months

35. Personalized Risk Assessment
To determine who should be offered:
Referral for consideration of genetic testing
Enhanced screening
Preventive Therapy
Surgery

36. Lifestyle Modification
Figure 1:
Management of Women at Risk for Breast Cancer
Lifestyle Modification
Mammographic Screening
Referral for Genetic Counseling
Enhanced Screening
Preventive Therapy
Surgery
Average/
Moderate risk
R B-RST +ve
E IBIS > 20-25%
P GAIL > 3%
S BRCA carrier
High risk
Very high risk

37. Why determine candidates for genetic counseling?
33yo strong family history breast cancer, start screening digital mammography age 40
At age 42 presents with bloating irregular periods- Stage 3c ovarian cancer
You now take a more thorough family history-BRCA1 carrier

38. ref

39. Why Calculate Risk? Risk calculators useful in primary care
B-RST Tool: determine candidates for referral for genetic counseling
IBIS: determine candidates for enhanced screening
Gail model: determine candidates for preventive therapy

40. R: Referral (for genetic testing)
Two or more first degree relatives same side of family with breast cancer (maternal or paternal)
Family members with breast cancer diagnosed before the age of 50 (maternal or paternal)
Relative with bilateral breast cancer or breast and ovarian cancer
Multiple relatives with ovarian cancer
Male relative with breast cancer
Ashkenazic Jewish (Eastern European Jewish) ancestry
Relative known to be BRCA mutation carrier

41. Breast –Referral Screening Tool (B-RST)

42. B-RST

43. E: Enhanced screening Use IBIS tool to calculate lifetime risk
if lifetime risk ≥ 25% refer to OBSP high risk program for MRI screening in addition to mammographic screening

44. IBIS Risk Calculator:

45. IBIS: Calculated Risk

46. P: Preventive Therapy
Consider for women with strong family history, or history of atypical hyperplasia or LCIS.
Use Gail model to assess eligibility for chemoprevention
If 5 year risk ≥3% offer preventive therapy

47. Gail model: 47

48. Number of breast biopsies
Breast Cancer Risk Assessment Tool (GAIL MODEL)
Age
Age at menarche
Number of breast biopsies
5 year risk (>1.66 %)
Age of first live birth (or nulliparity)
Family Hx in first degree relative
Amy Degnim CP
CP Pruthi, S MN

49. Canadian Task Force Recommendations
Fair evidence to recommend counseling about the potential benefits and risks of using tamoxifen to reduce the likelihood of breast cancer in higher risk women (B)
Who qualifies?: A woman with >1.7% 5-year risk using Gail model

50. S: Prophylactic Surgery
For highest risk women: known BRCA carriers, or history of LCIS (lobular carcinoma in situ) or AH (atypical hyperplasia) and a significant family history
Always offer reconstruction

51. Lifestyle Modification
Management of Women at Risk for Breast Cancer
Lifestyle Modification
Mammographic Screening
Referral for Genetic Counseling
Enhanced Screening
Preventive Therapy
Surgery
Average/
Moderate risk
R B-RST +ve
E IBIS > 20-25%
P GAIL > 3%
S BRCA carrier
High risk
Very high risk

52. Question
Which is the gold standard tool used to screen for Breast Cancer:
Breast ultrasound
Breast MRI
Mammogram
Clinical breast exam

53. Clinical Presentation
Most often breast cancer is first noticed as a painless lump in the breast or armpit (55%)
Breast pain is not a red flag for breast cancer.
Most pain lumps are often cysts, however every lump should be checked- rather see you 10 times and have it be nothing.
Most lumps in young women are benign. 53

54. Question What is the most common type of breast cancer?
DCIS (Ductal carcinoma in situ)
LCIS (Lobular carcinoma in situ)
Invasive Ductal Carcinoma
Invasive Lobular Carcinoma

55. Signs and Symptoms 1. Breast lump
sometimes detected during a screening mammogram or clinical breast exam
constantly present and does not fluctuate with menstrual cycle
may feel like it is attached to the skin
may feel hard and irregular
may be tender but not usually painful
Breast cancers are mobile. 55

56. Signs and Symptoms 2. Thickening or lump in the axilla
enlarged lymph node – usually means that the lymphatic system is fighting an infection in that area
sometimes means that breast cancer has spread to the lymph nodes
3. Inverted nipple
may be a normal finding
nipples that become inverted
should be reported
Reactive lymph node, or rarely can be lymphoma
One of the best ways to check for inversion of asymmetry is to have patients raise their arms or hands on their hips and contract their pec muscles. 56

57. Signs and Symptoms 4. Nipple discharge
has many different causes and should always be reported
may be a sign of cancer if it occurs spontaneously, bloody, unilateral, uniductal
5. Persistent crusting, ulceration or eczema-type symptoms on the nipple
may be a sign of Paget's disease, a rare form of breast cancer
Pagets: eczema-like changes in the skin of the nipple, 1-2% of breast cancer
50% patients have an underlying lump
Nipple discharge- needs to be spontaneous, uniductal and reproducible

58. Signs and Symptoms 6. Changes in breast size and shape
a change in the outline or
contour of the breast
a change in the size of the breast
7. Changes in the skin of the breast
puckering of the skin
thickening and dimpling of the skin
redness, swelling and increased warmth in the
breast
Inflammatory breast cancer- 2%, very aggressive, often occurs in younger women (10 yeasrs

59. Mrs. B
77 yr old postmenopausal woman noticed a non-tender mass in the upper outer quadrant (UOQ) of the left breast. PMHx: Hypertension, obesity. Nulliparous. Menarche 11 Menopause 50. Mother and maternal aunt - breast cancer- diagnosed age 48 and 51 Clinical breast exam: Breasts are large and in the left breast there was a firm, mobile, 3.5 x 3.5cm mass palpable at 1 o'clock 6 cm FN. No palpable left axillary adenopathy. Right breast and axilla were unremarkable. Next step: Order diagnostic bilateral mammogram and left breast ultrasound

62. 62

64. Mrs. B
Imaging: Mammography reveals a 3cm mass in the UOQ left breast. Right breast unremarkable Left breast ultrasound- 3.3 X 3.2 X 2.0cm hypoechoic area 1 o’clock position 6cm FN. Left axilla ultrasound: nodes unremarkable Next step: Core biopsy

65. Diagnosis- Tissue Confirmation
Core needle biopsy is the preferred method
Ultrasound guided
Local freezing is used.
Fine needle aspiration for axillary lymph nodes 65

66. Pathophysiology & Anatomy
Breast is made of fat and fibrous connective tissue.
Located between the 2nd and 6th ribs, divided in 4 quadrants and breast cancer most commonly in the UOQ
Breast is made of lobes, each lobe is divided into several lobules.
Ducts coalesce into major ducts.
Coopers ligaments cause dimpling of the skin. 66

67. Types of Breast Cancer Invasive (70%) Ductal Lobular In-situ (30%)
Ductal (DCIS)
Lobular (LCIS)
Other:
Inflammatory
Paget’s, mucinous, medullary, tubular,
pregnancy induced
4 types of breast cancer are often described-
LCIS- not really a cancer, noninvasive condition that increases the risk of developing cancer in the future, 25 percent of patients who have LCIS will develop breast cancer. 67

68. Pathophysiology

69. Mrs. B Pathology: Invasive ductal carcinoma ER+ PR+ HER2- Next steps:
Core biopsy left breast 1 o’clock 6cm FN (3.2cm mass)
Pathology:
Invasive ductal carcinoma ER+ PR+ HER2-
Next steps:
Referral to surgeon
Consider referral to genetics
Healthy living education/ Survivorship program
Referrals to medical and radiation oncology

70. Question What is the most common type of breast cancer?
DCIS (Ductal carcinoma in situ)
LCIS (Lobular carcinoma in situ)
Invasive Ductal Carcinoma
Invasive Lobular Carcinoma

72. Questions?