1. Breast Cancer Guideline Update – Sharp Focus on Who is at Risk
Christine Lauro, MD
Radiation Oncologist
April 21, 2018

2. Outline Epidemiology Breast Cancer Risk Factors/Symptoms
Benefits of Screening
Review of Guidelines

3. Epidemiology

5. Epidemiology
The chance of developing an invasive breast cancer at some time in a woman’s life is about 1 in 8 (12%).
In 2013, 232,340 new cases of invasive breast cancer will be diagnosed in women.
64,600 new cases of carcinoma in situ will be diagnosed.
39,620 women will die from breast cancer.

8. What may increase a patient’s breast cancer risk?
Breast cancer-related genes (BRCA 1 or BRCA2)
Menarche prior to age 12
Nulliparous
Starting menopause after 55
Hormone replacement therapy for more than 5 years
Birth control pills
Family history of breast cancer
Obesity

9. What are physical exam findings of breast cancer?
Mass in breast or axilla
Irritation or dimpling of breast skin (orange peel appearance or “Peau d’Orange”)
Redness or flaky skin of the nipple areolar complex (Paget’s disease)
Nipple inversion
Nipple discharge other than breast milk, including blood

10. Peau d’Orange

11. Paget’s Disease of the Breast

12. Breast Cancer Screening
A mammogram is an X-ray of the breast
Best method to find breast cancer early

13. Mammogram Annual screening MLO, CC
Diagnostic if something on screening US
Compression for density; magnification for calcifications

14. What is Tomosynthesis?

15. Digital Breast Tomosynthesis
Increases detection rates of small invasive cancers
Decreases false positive callback rates
Improves margin analysis & lesion conspicuity by decreasing effect of overlying breast tissue
Improves localization of “one view only” lesions
Helps distinguish skin lesions from breast lesions

16. Courtesy of Dr. Shannon MacDonald, ASTRO Spring Refresher 2018

18. Specimen radiograph after lumpectomy to confirm clip and radiographic lesion or calcifications
Rare to obtain post-lumpectomy mammogram

19. Skaane, Per, et al. "Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program." Radiology (2013):

20. MRI Breast
Used for selected patients & no clear consensus on how to select patients
Difficult to detect lesions on mammo or tomo (extremely dense breast tissue, ILC, assess feasibility of breast conservation)
Performed prone, difficult for claustrophobic patients, FALSE POSITIVE (anxiety, delay to definitive treatment, increased mastectomy rate, cost)

21. Who should undergo screening?
Prior to 2015….
Screening with mammography and clinical breast exam annually starting age 40.

22. Guidelines Since 2015… U.S. Preventative Services Task Force
Ages 40-49: Decision to start screening prior to age 50 should be individual; women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49.
Age 50-74: Biennial screening is recommended.

23. Guidelines Since 2015… American Cancer Society
Ages 40-44: Decision to start annual screening should be individual.
Ages 45-54: Annual mammography
Age 55+: Biennial screening, or choose annual mammogram

24. Summary of Guidelines

25. Breast Cancer Screening
Pros
Detect breast cancer earlier
Better cure rates
Less treatment for cure

26. Breast Cancer Statistics Since Start of Mammography

27. Collaboration of 6 simulation models using national data on incidence, digital mammography performance, treatment effects and other-cause mortality.
Conclusion: Bienniel strategies were most efficient for average-risk women.
Limitations: non-adherence not considered; other imaging technologies not considered; family history not considered.
Mandelblatt, Jeanne S., et al. "Collaborative Modeling of the Benefits and Harms Associated With Different US Breast Cancer Screening Strategies, Benefits and Harms of US Breast Cancer Screening Strategies." Annals of internal medicine (2016):

28. Berry, Donald A., et al. "Effect of screening and adjuvant therapy on mortality from breast cancer." New England Journal of Medicine (2005):

29. Cost of Screening vs. Chemotherapy in WY
Screening mammogram: $59.63
Herceptin x 12 doses: $18,898.56
= 316 mammograms
Perjeta x 12 doses: $53,877.60
= 903 mammograms
Medicare pricing, 2017

30. Clinical Pictures

31. Clinical Pictures

32. Summary Breast cancer is the most common cancer in American women
Mammograms have been shown to increase detection of breast cancers at an earlier, more curable stage.
Optimal frequency and start of mammograms are controversial.

33. Thanks!