1. Breast Cancer Screening
Rabindranath Bachan MD
Caribbean Hematology Oncology Center

2. Cancer statistics, 2018
Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, Estimates are rounded to the nearest 10 and cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. Ranking is based on modeled projections and may differ from the most recent observed data.
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Cancer statistics, 2018, Volume: 68, Issue: 1, Pages: 7-30, First published: 04 January 2018, DOI: ( /caac.21442)

3. Breast cancer statistics, 2015: Convergence of incidence rates between black and white women
Trends in Female Breast Cancer Incidence and Mortality Rates by Race/Ethnicity, United States, 1975 to Rates are per 100,000 females, age adjusted to the 2000 US standard population, and incidence rates are adjusted for reporting delay. †Rates are 3‐year moving averages. NH indicates non‐Hispanic; API, Asian/Pacific Islander; AI/AN, American Indian/Alaska Native. Sources: Incidence: Surveillance, Epidemiology, and End Results program, National Cancer Institute, Mortality: National Center for Health Statistics, Centers for Disease Control and Prevention, as provided by the Surveillance, Epidemiology, and End Results program, National Cancer Institute, For Hispanics, incidence data do not include cases from the Alaska Native Registry and mortality data exclude New Hampshire and Oklahoma. Data for American Indians/Alaska Natives are based on Contract Health Service Delivery Area (CHSDA) counties.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Breast cancer statistics, 2015: Convergence of incidence rates between black and white women, Volume: 66, Issue: 1, Pages: 31-42, First published: 29 October 2015, DOI: ( /caac.21320)

5. How do we screen for breast cancer?

6. Modalities to Image the Breast
Mammography
Film mammography – 1980’s
Digital mammography
Tomosynthesis – 3D mammography
Ultrasound of the breasts
MRI of the breasts

12. Mammography
The only screening modality of breast imaging that consistently has been found to decrease breast cancer related mortality
May detect cancer 1.5 to 4 years before a cancer becomes clinically evident
False-negative rate of 10% for a clinically suspicious lesion
Highest with markedly dense breast tissue
May need ultrasound and MRI for further imaging

13. Mammography Tomosynthesis Also known as 3-D mammography
Data suggested increased rates of cancer detection
Conflicting results on false-positive
No current universal guidelines for patient selection or frequency of use
Need more prospective large studies with survival outcomes
Shows promise in screening woman with dense breast and high risk for breast cancer
Exposed to twice the usual radiation dose
Costly and not widely available

14. Ultrasonography Not generally used for screening
Substantial risk for false positive
First-line for pregnant woman
Women less than 30 years with focal breast symptoms
Used as an adjunct to mammography
Diagnostic follow-up of abnormal screening mammogram
Can differentiate solid mass from a cystic lesion
Use to evaluate the extent of the lesion
Provide guidance for biopsies

15. MRI Breast Screening high risk a woman
BRCA mutation carriers
Family history of BRCA mutation
Strong family history with an estimated lifetime risk of breast cancer greater than 20-25% by BRCAPRO score, Tyrer Cuzick or equivalent risks model
Li-Fraumeni syndrome and first-degree relatives
Cowden syndrome and first-degree relatives
History of his chest radiation
Should be done in conjunction with annual mammography

18. Benefits and Harms of Screening
Decrease in breast cancer mortality
Harms
Overdiagnosis
False-positive mammogram
Anxiety associated with false-positive mammogram
Radiation
Small about 1-2 mGy per exposure
Not associated with increased risk of cancer
There are concern that BRCA1 and BRCA2 mutation is at increased risk for radiation-induced oncogenesis
Discomfort

19. Breast palpation as and adjunct to mammogram
Breast self examination
Generally not recommended
Increasing false-positive
increase in the rate of breast biopsy for benign breast disease
Clinical breast examination
Difficult to standardized
May pick up small percentage of breast cancer not detected on mammogram
Associated with increase false positive

20. Who should be Screened for Breast Cancer
Those most likely to develop breast cancer
Early treatment is more effective than later treatment in reducing mortality
Average risk – 15% lifetime risk of developing breast cancer
Moderate risk – 15-20% lifetime risk of developing breast cancer
High risk – greater than 20% lifetime risk of developing breast cancer

21. Average risk Majority of patients screened are at average risk
Do not have a personal history of ovarian, peritoneal or breast cancer
No family history of breast, ovarian or peritoneal cancer
No genetic predisposition
No radiotherapy to the chest wall between age 10 and 30 years

22. Average Risk- Age related screening approach
Age under 40 years
Screening not recommended
Age 40 to 49
Shared decision making – trade off between benefits and harms
Screening mammogram every 1 to 2 years
Age 50 to 74
Screening mammography every 1 to 2 years
Age 75 and older
Some groups may say stop at age 73 to 75
Some offer screening only if the life expectancy is at least 10 years
Screening mammogram every 2 years

25. Moderate risk
Most will have a family history of breast cancer in first-degree relatives
No known genetic syndrome
Screening recommendation is the same for average risk woman

26. High Risk Those with BRCA or other susceptible genes
History of chest radiation between the ages of years
Calculated lifetime risk of developing breast cancer greater than 20% with models largely dependent on family history
Tyrer-Cuzick model
Claus
Preferably referral to high risk screening clinic

27. BRCA carriers without cancers
Self-Breast Examination
Beginning at age 18
Clinical Breast Examination
Beginning at age 25 and performed every 6-12 months
Annual screening mammogram with consideration of tomosynthesis
Begin at age 30
May be individualized if the earliest age of onset in the family is under 25
Annual breast MRI
Begin at age 25 or earlier depending on the earliest age of onset in the family

28. BRCA carriers without cancers
Consider risk reduction treatment
Bilateral mastectomy
Risks reduction bilateral salpingo-oophorectomy
Chemoprevention
Screening for ovarian cancer
Screening for melanoma
Screening for pancreatic cancer

29. BRCA carriers without cancers - MEN
Breast self-examination every month beginning at age 35
Clinical breast examination every 12 months starting at age 35
Mammography – no data to support routine use
Prostate cancer screening should be started at age 40-45
Chemoprevention not recommended

30. Cowden syndrome (PTEN gene mutation)
Rare genetic disorder with increased risk of breast, endometrial, thyroid, kidney and colorectal cancers
Breast awareness starting at age 18
Clinical breast examination every 6-12 months starting at age 25 or earlier depending on breast cancer history in the family
Annual mammogram and MRI screening starting at age years or years before earliest known breast cancer in the family

31. Li-Fraumeni syndrome (TP53)
Increased risk for sarcoma, breast cancer, brain tumors, adrenocortical carcinoma
Breast awareness starting at age 18
Age annual screening breast MRI
Age annual screening breast MRI and screening mammogram with consideration for tomosynthesis
Age > 75 years – management individualize

32. Chest radiation between ages 10 and 30 years
Less than 25 years
Annual clinical encounter beginning 10 years after radiation
Breast awareness
25 years and older
Clinical encounter every 6-12 months beginning 10 years after radiation
Annual screening mammogram
Beginning 10 years after radiation but not prior to age 30 years
Consider tomosynthesis
Recommend Annual Breast MRI
Begin 10 years after radiation but not prior to age 25 years

33. Estimated lifetime risk of more than 20%
Clinical encountered every 6-12 months
Referral to genetic counselor
Annual screening mammogram
To begin 10 years prior to the youngest family member but not prior to age 30
Consider tomosynthesis
Recommend annual breast MRI
To begin 10 years prior to youngest family member but not prior to age 25 years
Recommend risk reduction strategies

34. Special Patient Population
Patients with breast implants
Routine screening mammogram recommended
Requires 4 views than the usual 2 views per breasts
Patient with breast reconstruction postmastectomy
Mammogram not routinely performed
Clinical examination recommended
Pregnancy and lactation
Ultrasound recommended to evaluate abnormalities in the breasts
Mammogram only performed if sonographic findings are suspicious for malignancy
Males
Screening mammogram not performed

35. Surveillance after diagnosis of breast cancer
Surveillance mammogram recommended annually
About 4% of patients treated with breast conserving surgery may develop ipsilateral local recurrence
Contralateral breast should also be imaged
Continue surveillance mammogram even in older patients
Routine use of ultrasound is not recommended
Routine use of breast MRI not recommended
Indicated in the follow-up performing at high risk for recurrent disease
Known BRCA1 mutation
Strong positive family history

36. Emerging Technologies
Positron emission mammography (PEM)
Breast specific gamma imaging (BSGI)
Stereoscopic digital mammography

37. Risks Reduction

38. Risk factors that are not modifiable
Increasing age
Female gender
Benign breast disease
Dense breast tissue
Early menarche
Late menopause
Personal history of breast cancer
Family history of breast cancer
Inherited genetic mutations

39. Risk factors that are potentially modifiable
Weight – high a BMI in perimenopausal and postmenopausal woman increased risk of breast cancer
Estrogen levels – highly endogenous estrogen levels increased risk of breast cancer in both postmenopausal and premenopausal woman
Chemoprevention in selected patients
Insulin growth factor 1 associated with increased breast cancer risk and pre-and postmenopausal woman
Exercise may help

40. Risk factors that are potentially modifiable
Nulliparity – Nulliparous woman at increased risk
Increase in age at first pregnancy – increased risk of breast cancer
Alcohol – Limit alcohol consumption to less than one drink per day
1 oz of liquor, 6 oz of wine, 8 oz of beer
Smoking
Night shift work
Breast-feeding has a protective effect
Regular physical exercise – provides modest protection against breast cancer particularly in postmenopausal woman
Likely by reducing serum estrogens, insulin and insulin growth factor 1 levels

41. Inconclusive Risk Factors
Dietary factors
Mediterranean diet
Soy/phytoestrogens
Fruits and vegetables
Fat intake
Red meat and processed meat
Environmental factors
Exposure to diagnostic radiation
Passive smoke exposure

42. Inconclusive Risk Factors
Medications
Calcium and vitamin D
Antioxidants
Nonsteroidal anti-inflammatory drugs
Bisphosphonates

43. References UpToDate National Comprehensive Cancer Network
American Cancer Society