Lots of Issues What does increased breast density mean? Who - PowerPoint PPT Presentation

10/19/2018 Prevention and Screening for Breast Cancer: What’s New? Disclosures- I am a Medical Advisor and on the Scientific Advisory Board of the Mindy Goldman, MD company, Madorra, that is developing a Clinical Professor medical device to treat vaginal dryness Dept. of OB/Gyn and Reproductive Sciences Director, Gyn Center for Cancer Survivors and At-Risk Women UCSF Helen Diller Comprehensive Cancer Center and UCSF Women’s Health University of California, San Francisco Lots of Issues What does increased breast density mean? Who should get MRI screening? 1

10/19/2018 Breast Cancer Epidemiology- Breast Cancer Epidemiology- Issues pertaining to Screening Issues pertaining to Screening • Approximately 12.3 % of women will be diagnosed with breast • Globally breast cancer is most common cancer at some point during their lifetime. 1/8 at age 85 diagnosed cancer in women and most • Number of new cases of breast cancer is 124.6 per 100,000 common cause of cancer death women per year • 14% all new cancers are breast • Almost 50% of breast cancers may be related to risk factors • 12% diagnosed in reproductive years (ages 20-44) • More than 25,000 cases per year in California Breast Cancer- What do Clinicians Breast Cancer – Risk Factors Need to Understand? • Age – increases as we age • What are the risk factors for breast cancer? • Female gender • Who should be screened? • Race and ethnicity – highest incidence in whites, but highest mortality in African Americans • What type of screening should be done? • Benign breast disease – particularly Atypical Ductal • Who should be offered preventative medications or Hyperplasia (ADH), Atypical Lobular Hyperplasia (ALH), or surgeries? proliferative breast lesion. With atypia RR 3.7 to 5.3 2

10/19/2018 Breast Cancer – Risk Factors Breast Cancer – Risk Factors • Lifestyle and dietary factors • Family history and genetic factors – 15-20% of women with breast cancer reported to have – May increase risk: obesity, smoking, high fat intake, red meat, alcohol use, family history in first degree relative soy phytoestrogens • Personal history of breast cancer increases risk of contralateral breast cancer – May be protective: regular exercise, greatest benefit seen in adolescence • Exposure to ionizing radiation – ?Vitamin D – some studies suggest low levels of Vit D associated with increased risk Why is alcohol use associated with Breast Cancer – Risk Factors breast cancer? • Reproductive and hormonal factors • Increases risk primarily of hormone positive cancer – Increased risk: early menarche, late menopause, • Alcohol can affect the way estrogen is metabolized and increase late age of first child or nulliparity, increased breast blood levels density, long-term HRT, ?endogenous hormone levels • Alcohol can reduce blood levels of folic acid which is involved in copying and repairing DNA. Low levels of folic acid may make it more likely that DNA is incorrectly copied when cells divide – No association: prior abortion causing errors that may lead to cancer – Decreased risk: breastfeeding, ?Estrogen • Women who have 2 - 5 drinks per day have about 1.5 x the risk of Replacement Therapy (ERT) developing breast cancer compared to non-drinkers 3

10/19/2018 Breast Cancer – Risk Factors Breast Cancer – Risk Factors • Factors that may increase risk: • Factors thought to be protective: – Environment exposures : PCB’s, hair dyes, etc. - no clear data – Night time light exposure - Exposure to light at night – Non-steroidal drugs - NSAIDs-especially aspirin suppresses nocturnal production of melatonin (thought to have antioxidant effects preventing damage to cells) and COX-2 inhibitors shown in recent meta- analysis to be protective for hormone positive breast cancer (likely via anti-inflammatory effects) • Factors without association: – Antibiotic use – Caffeine – Antiperspirants – Bras – de Pedro M, et al. Effect of COX-2 inhibitors and other non-steroidal inflammatory drugs – Breast implants on breast cancer risk: a meta-analysis. Breast Cancer Res Treat. 2015 Jan;149(2):525-36 Summarizing Risk Breast Cancer Risk Factors • Most women can be categorized based on history • Risk prediction models can be used to stratify risk • Bisphosphonates: meta-analysis have shown these drugs can reduce the rate of breast cancer if needed and take into consideration: recurrence in bone and improve survival in – Personal history of breast (and/or postmenopausal women with breast cancer - not in ovarian/tubal/peritoneal ca) premenopausal women and No clear data that it – Family history of breast cancer reduces the risk of getting breast cancer – Known genetic mutation (like BRCA) – Breast density – Prior radiation to the chest was between ages 10-30 4

10/19/2018 How Should Screening be Done? Issues pertaining to Screening? • Self Breast Exam (SBE) • How should screening should be done? – American Cancer Society no longer recommends • Should all women be screened? – ACOG recommends teaching breast self awareness – Many other organizations (USPSTF) do not recommend – WHO and NCCN talk about SBE to “raise breast awareness” • What age to begin screening? – Not great evidence that it helps • Few RCT, one of largest studies 2008 looked at 400,000 • Should screening stop at older ages? women in Russia and China showed no benefit in breast ca mortality and more biopsies done for benign disease • 2 case control studies showed less advanced disease if • Should screening differ based on risk factors? women taught appropriate SBE How Should Screening be Done? How Should Screening be Done? • Clinical Breast Exam (CBE) • Mammograms – Many US organizations recommend CBE every 3 years from age 20 to 39, annually thereafter • Screening mammogram clearly detects early stage breast ca – American Cancer Society new guidelines do not support CBE • Controversies are whether it improves breast cancer mortality (over – US Preventive Task force and WHO says not enough evidence to diagnosis) support regular CBE – 9 RCT looking at 650,000 women have looked at mortality – – ACOG says CBE can be offered with shared decision making mammo +/- CBE. Results show a benefit in women ages 40-69 – NCCN says annually for women over 40 – Older studies looking at mortality also affected by older treatments that weren’t as effective – Evidence not clear : – 25 yr. fu from randomized Canadian National Breast Screening • most studies combine CBE with mammography so Study did not show a benefit in mortality compared to exam independent effects less clear (only RCT did not show benefit) alone when adjuvant therapy is available 22% (106/484) of • Less standardization for CBE compared to mammography screen detected invasive breast cancers were over-diagnosed • 2009 review found no clear benefit BMJ. 2014;348 5

10/19/2018 Why the Difference of Screening Mammogram Screening Guidelines for Mammo every 1-2 years? Average Risk Women • All now talk about shared decision making • Many North American groups recommend annual screening for women under 55 because of evidence of more rapid tumor • ACOG - every 1-2 years beginning at age 40 growth in younger women • USPSTF -every 2 year screening should beginning at age 50 • Benefits of detecting more tumors in earlier stage in younger women needs to be balanced against increased harms associated with an increased rate of false-positives • WHO - every 2 years for women 50-69 • Every 2 year screening thought to decrease false positives, and • ACS -annually from 45-55 and every 2 years for women 55 and no overall differences in survival on a population basis older • NCCN- annually at 40 with consideration of tomosynthesis Mammogram Screening Should Mammogram Screening Stop at Older Ages? Common Areas • Controversy as many cancers in women over 80 are slow growing and not likely to affect survival, as other • All groups state mammogram screening useful for women over competing causes of death 50 • Groups agree that the benefits of mammography increase with • 25% of breast cancer are diagnosed in women 75 and age older but limited data on screening mammography in this population • Once mammogram screening begins offer every 1-2 years • Groups now say that clinical judgment and predictive • Differences in recommendations highlights need for models that combine age, comorbidities, and functional INDIVIDUALIZATION depending on risk status can be used to identify women who may continue to benefit from screening mammography 6