1. Breast Screening and Risk Assessment
Mike Elrod DO, FACOS
First Surgical Care

2. Pre Question
47 yr. F presents to your office after she received a letter that her screening mammogram showed dense breasts and she may be at higher risk for breast cancer. She wants to know what she should do. What are appropriate steps?

3. Options (A) Tell her not to worry and continue her screening schedule
(B) Get a good history and do a risk breast cancer risk assessment
(C) Order a breast MRI
(D) Start Tamoxifen

4. Pre Question Which is NOT an indication for genetic testing?
(A) 59yr. F with triple negative breast cancer
(B) Patient’s mother had breast cancer age 60
(C) Patient’s father had breast cancer
(D) Patient’s sister had primary peritoneal carcinoma

5. We Will Discuss Screening recommendations
What to do with dense breasts
Identifying high risk patients and appropriate screening
Indications for genetic testing and what to do with the results
What biopsy to order and what to do with the results

6. Breast Cancer Screening Recommendations
NCCN (National Comprehensive Cancer Network)
ACS (American Cancer Society)
USPSTF (US Preventative Services Task Force)
ASBS (American Society of Breast Surgeons)

7. National Comprehensive Cancer Network (NCCN)
Mammography
Clinical Breast Exam
Every year starting at age 40
For as long as a women is in good health
Every 1-3 years ages 25-39
Every year starting age 40

8. USPSTF Mammography Breast Exam
<50 based on discussions with patient
Age biennial screening
>75 evidence insufficient to assess benefits or harms
Recommends against teaching self breast exams
Evidence insufficient to assess additional benefits and harms of CBE beyond screening mammography in women >40yrs

9. USPSTF
“Recommendations apply to asymptomatic women age 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.”

10. 2015 ACS Guidelines Mammography Breast Exam
Shared decision making process for screening ages 40-44
Annual screening for women ages 45-54
Biennial screening for women over the age of 55
Continue screening as long as they have an estimated 10 year life expectancy
“Breast exams, either from a medical provider or self-exams, are no longer recommended.”

11. American Society of Breast Surgeons Recommendations
1. Consider screening mammography age
Most studies show a decrease in breast cancer mortality from screening starting at age 40.
Ages have higher false positive rates
2. Annual screening for women ages
3. Annual or biennial screening for women 55 and older based on shared decision making regarding the risks and benefits.

12. American Society of Breast Surgeons Recommendations
4. Biennial screening for women over the age of 75 if an estimated life expectancy is greater than 10 years.
5. Breast tomography may be considered for screening.
Early data shows promise for higher sensitivity and specificity rates
May increase detection rates and decrease false positive rates
Especially in women with dense breast tissue

13. Special Screening Populations
Older women
None of the randomized prospective trials included women older than the age of 74. Therefore, the US preventative task force has not recommended screening mammography in this age group
BUT…
26% of breast cancer deaths are in women over the age of 75.
50% of women over the age of 80 are expected to live another 10 years.

14. Special Screening Populations
Younger women
For women under the age of 39 there is no data supporting routine screening in this group.
Mammography is less accurate in premenopausal women under the age of 45 for screening or if done for symptoms.
The ACS does not recommend screening prior to the age of 44 for women of average lifetime risk.

15. Okay, lets keep it simple
What To Do?
Okay, lets keep it simple

16. What I Do Annual screening mammograms beginning at age 40
After age 75 discuss risks and the patients concerns and wishes
Perform a risk assessment
Offer screening based on breast cancer risk
Offer aggressive screening for women with elevated lifetime risk

17. What To Do With Dense Breast Tissue?

18. Current Status of Supplemental Screening in Dense Breasts
Strong evidence based guidelines are lacking
Oh no. No guidelines with boxes to to check, what to do?

19. (ASTOUND)
Adjunct Screening With Tomosynthesis or US in Women with Mammography – Negative Dense Breasts trial
US detected more breast cancers than tomosynthesis with a similar false positive recall rate
But tomosynthesis did detect about 50% of the additional breast cancers and could potentially be the primary screening modality

20. It Really Comes Down To Risk Stratification
High risk
Average risk
MRI
tomosynthesis US
Tomosynthesis
Nothing

21. How Do You Identify Patients That Are High Risk for Breast Cancer?

22. Risk Models
Gail
Claus
BRCAPRO
Tyrer-Cuzick

23. Hughes Risk
Developed at Mass General Hospital Division of Surgical Oncology
Includes multiple models
Input into computer and spits out 5 year and lifetime percent risk
Looking for lifetime risk of 20% or greater
Indication for MRI
5 yr. Gail risk above 1.67
Consider hormone modulation

24. Risk Factors for Hereditary Breast Cancer
Age onset breast cancer < 50
Triple negative breast cancer and age <60
Ashkenazi Jewish heritage with breast cancer any age
First degree relative with breast cancer <50
2 or more primary breast cancers
2 relatives on same side of family w/ breast and/or pancreatic cancer
Family or personal history ovarian, fallopian or primary peritoneal cancer
Male breast cancer
Know mutation carrier in the family

25. Keep It Simple Elevated risk Genetic Run Hughes assessment
If lifetime risk >20% start high risk screening
MRI / mammogram staggered at 6 month intervals
If Gail is >1.67 discuss hormone modulation or consult oncology for this
If patient has risk factors either do the test or send to genetic counseling

26. Genetic Testing Results

27. Positive Test Prophylactic surgery Aggressive screening BL mastectomy
> 90% risk reduction
Salpingo-oophorectomy
BRCA1 (35-45)
BRCA2 (40-45)
MRI starting age 25
Start mammograms at age 30
Annual pelvic age 25
Annual pelvic US age 30-35
CA-125 annually
Clinical breast exam Q6 months

28. Variant of Uncertain Significance
This is reported when it is not known if the specific gene change affects a person’s risk for cancer
Seen in up to 10% of tests
Over time, it will be re-classified as either harmful for clearly not harmful.
The vast majority are not harmful

29. BI-RADS 0 Need additional imaging 1 Negative 2 Benign
3 Probably benign
cancer risk < 2%
98% are benign
4 Suspicious
cancer risk: (a) 2-10% (b) 10-50% (c) 50-95%
In general approximately 70% are benign
5 Highly suggestive of malignancy
cancer risk: > 95%
6 Known malignancy

30. Breast Biopsy US
Stereotactic
MRI
Excisional (surgical)

31. Which One?

32. What to do with the results

33. Concordance Discordance
When the CNB shows benign histology while the clinical or imaging findings are suspicious for malignancy
If discordant
Biopsy it again under imaging
Surgical excision

34. “Borderline” Benign Biopsies
Atypical ductal hyperplasia (ADH)
Up to 20% upgrade rate to DCIS or Invasive cancer
Atypical lobular hyperplasia (ALH)
Variable rate of upgrade, still needs excision
Lobular carcinoma in situ (LCIS)
Needs surgical excision
Papillary lesions
Especially with atypia
Radial scars (complex sclerosing lesions)
Fibroepithelial lesions (fibroadenoma and phyllodes)
Columnar cell lesions with atypia
Flat epithelial atypia
9% upgrade to DCIS
Pseudoangiomatous stromal hyperplasia (PASH)

35. Case Scenarios