2. Disclosure I am human and I have biases.
I am a breast cancer survivor.
I make my living in breast imaging and diagnosis.
I have met and come to know a few of the experts embroiled in the CNBSS controversy in my former university capacity in Texas.
I am a radiologist. I am not an epidemiologist, an oncologist, or a surgeon.

3. The practice of medicine is a human endeavor that uses science as a tool.

4. SCIENCE………….DOCTOR……………PATIENT

5. Breast cancer mortality is DOWN ~ 30%
Mammography is not perfect, but it is the BEST tool we have for screening to detect early clinically occult breast cancer.
YET----BREAST CANCER SCREENING IS ABOUT TO BE CUT BACK
Why all the fuss?

6. Major influences include:
USPSTF is about to finalize their new guidelines for breast cancer screening
(2014: Now “finalized” and incorporated into ObamaCare)
Major influences include:
Canadian National Breast Screening Study 25 years later
Economic factors

7. A Sampling of Controversy…
Reduction in breast cancer mortality
Screening Mammography?
Better Treatment?
(Evolving Knowledge….?)
Overdiagnosis?
Overtreatment?
Stage Shift?
Does mammography help in women <50yrs?
Does screening mammography cause harm?

8. Costs of Breast Cancer Diagnosis
Median Cost of Screening a Woman for Breast Cancer: $94
Median Cost Per Breast Cancer Detected:
$10,566
Ekwueme DU, Gardner JG, et al: Cost analysis of the National Breast and Cervical Cancer Early Detection Project: selected states, 2003 – Cancer 2008 Feb 1,112(3):

9. A Sampling of the Economic Factors
Screening Costs
Workup Costs
Approx 10 in 100
Followup Costs
Approx 5 in 100
Biopsy Costs
Approx 2 in 100
Breast Cancer - approx 4/1000

11. Costs of Breast Cancer Diagnosis
Median Cost of Screening a Woman for Breast Cancer: $94
Median Cost Per Breast Cancer Detected:
$10,566
Ekwueme DU, Gardner JG, et al: Cost analysis of the National Breast and Cervical Cancer Early Detection Project: selected states, 2003 – Cancer 2008 Feb 1,112(3):

13. Breast Cancer Screening (until now)
Annual Clinical Breast Exam (CBE) by physician or provider
Monthly Breast Self Exam (BSE) by patient beginning at age 20
Annual Screening Mammography beginning at age 40 on

14. USPSTF New Guidelines
Biennial screening mammography for women years
Screening mammography under age 50 individual decision, considering patient context and patient values regarding specific benefits and harms
Inconclusive evidence concerning benefits and harms of screening mammography in women age 75+

15. USPSTF New Guidelines, cont’d
Recommend against teaching BSE
Insufficient evidence to assess benefits or harms of CBE beyond screening mammography in women over age 40
Insufficient evidence to assess benefits or harms of screening with either digital mammography or MRI

16. Clinical Breast Exam Consider Skin changes Nipple changes Lymph nodes
Puckering/retraction
Focal redness…mastitis?....early inflammatory BC?
Nipple changes
Nipple erosion
Nipple adenoma
Nipple retraction
Lymph nodes

17. Breast Self Exam
At least 5% of breast cancers are ECCENTRIC in location; ie, NOT visible within the tissue seen on the standard mammogram images!

18. Accessory Breast Tissue

23. Breast Self Exam
At least 5% of breast cancers are ECCENTRIC in location; ie, NOT visible within the tissue seen on the standard mammogram images!
Aggressive cancers (30% of all cancers in young women and 10% of all cancers in older women) often arise BETWEEN SCREENING EXAMS and will be detected on BSE!

24. Esserman L, Shieh Y, Thompson I: Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA 2009;302(15):

25. Breast Cancer Subtypes

26. Appendix Table 3. USPSTF
Ave # Screening Exams & % Reduction in BC Mortality by Screening Strategy
Strategy Ave Screens Reduction in Breast Cancer Mortality
Per1000 Wom
Efficient Strategies D E G M S W
Biennial
Biennial
Biennial
Biennial
Biennial
Biennial
Biennial
Annual
Borderline Strategies
Biennial
Annual
Annual
Annual

27. Appendix Table 3. USPSTF
Ave # Screening Exams & % Reduction in BC Mortality by Screening Strategy
Strategy Ave Screens Reduction in Breast Cancer Mortality
Per1000 Wom
Efficient Strategies D E G M S W
Biennial
Biennial
Annual
Borderline strategies
Biennial

28. USPSTF Says
Screening mammography under age 50: individual decision, considering patient context and patient values regarding specific benefits and harms
PROBLEMS:
Breast cancer is a DEADLIER DISEASE in a younger woman
Breast cancer deaths affecting women ages will have a GREATER IMPACT on families, communities, and society
Approximately 70% of breast cancers occur in patients with NO known risk factors

29. Percent of Deaths by Age Group: Breast Cancer
SEER.cancer.gov/statfacts

30. USPSTF Says
Inconclusive evidence concerning benefits and harms of screening mammography in women age 75+
PROBLEMS:
The whole point of breast cancer screening, in older women (age 75+) is to MAINTAIN QUALITY OF LIFE, not necessarily to “cure” her cancer
Neglected breast cancer causes significant PAIN

33. Concept of Overdiagnosis
Based on expectation that increased diagnosis and treatment of early stage breast cancers should lead to fewer advanced breast cancers in later years. This has NOT been observed.
Remember---
Breast cancer is a biological process
Biological processes EVOLVE
--”Stage Shift” occurs due to technological advance in detection of early mets in lymph nodes
apparent increase in “advanced” cancers

34. Overdiagnosis/Overtreatment?
DCIS Controversy
Low Nuclear Grade 1
Intermediate Nuclear Grade 2
Mixed cell types and grades
Slow evolution----faster-----islands of INVASION
25% DCIS is High Nuclear Grade 3
ALWAYS goes on to invasive ductal carcinoma

35. CNBSS: Overdiagnosis/Overtreatment
Miller AB, Wall c, Baines CJ, et al: Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ 2014;348:g366.

36. Final Words on USPSTF
Clearly oriented toward decreasing consumption of resources now used in breast cancer screening
Embraced (troubled) Mammography Results from CNBSS
IGNORED Breast Self Exam (BSE) and Clinical Breast Exam (CBE) from same CNBSS study (!)
Too involved in “Safe” Science; too little consideration of the needs of the population they serve

37. Our meta-analysis of mammography screening trials indicates breast cancer mortality benefit for all age groups from 39–69 years, with insufficient data for older women. False-positive results are common in all age groups and lead to additional imaging and biopsies. Women age 40–49 years experience the highest rate of additional imaging whereas their biopsy rate is lower than older women.
Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and to society are not clearly resolved by available evidence.
US Preventative Services Task Force: Screening for Breast Cancer: Systematic Evidence Review Update for the US Preventive Services Task Force [Internet]. Nelson HD, Tyne K, et al. Nov, 2009.

38. The practice of medicine is a human endeavor that uses science as a tool.

39. Canadian National Breast Screening Study (CNBSS)
GOLDEN OPPORTUNITY LOST

40. CNBSS: All Cause Mortality
Miller AB, Wall c, Baines CJ, et al: Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ 2014;348:g366.

41. CNBSS--Problems NOT PREPARED for demands of screening
Images – technologists – radiologists – surgeons
Randomization –
Clinical breast exam BEFORE randomization
4x locally advanced cancers in screening group compared to controls
Only 2 mm difference between mean tumor size in control vs screening groups

42. Diagnostic “Chain” of Breast Cancer
Image quality -
Machine – Anode – Filter – Grid – Developer – Positioning - - -
Interpretation –
Detection – Workup – Diagnosis – Biopsy Guidance ?
Surgical Assessment –
Accuracy of Excision of Nonpalpable Tumors?