? Mai Elezaby, MD Big Picture Population Prospective Breast - PowerPoint PPT Presentation

? Mai Elezaby, MD

“Big Picture” Population Prospective

Breast Cancer  Most common cancer in women  2 nd leading cause of death  U.S. 2016 estimates ▪ 246,660 new cases ▪ 40,450 deaths from breast cancer https://seer.cancer.gov/statfacts/html/breast.html

2016 https://www.dhs.wisconsin.gov/publications/p01573a.pdf

• One in eight women will be diagnosed with breast cancer • ¾ of breast cancers occur in women without family history of breast cancer • One in six breast cancers occur in women in their forties

100 ✓ Smaller size 5-Year Survival (%) 80 ✓ Earlier stage 60 40 20 0 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5 Tumor size (cm) 100 5-Year Survival (%) More likely 80 60 to be curable 40 20 0 0 I IIA IIB IIIA IIIB IIIC IV Stage Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

100 ✓ Smaller size 5-Year Survival (%) 80 ✓ Earlier stage 60 40 20 0 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5 Tumor size (cm) 100 5-Year Survival (%) SCREENING 80 60 40 20 0 0 I IIA IIB IIIA IIIB IIIC IV Stage Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

Simple test to identify those who have disease, but do not yet have symptoms  Requirements: ▪ Readily available ▪ Low cost ▪ Can differentiate those that have the disease from those who don’t (high sensitivity, acceptable specificity)

100 5-Year Survival (%) 80 60 40 20 0 <1 1-1.9 2-2.9 3-3.9 4-4.9 >5 Tumor size (cm) 100 5-Year Survival (%) 80 60 40 20 0 0 I IIA IIB IIIA IIIB IIIC IV Stage Surveillance, Epidemiology, and End Results (SEER) Program Results https://www.ncbi.nlm.nih.gov/books/NBK65847/figure/CDR0000257530__268/ Courtesy of Dr. Amy Fowler

- 37% Screening Mammography Advancement in Treatments http://seer.cancer.gov/statfacts/html/ld/breast.html Surveillance, Epidemiology, and End Results Program (SEER), Cancer Statistics Review 1975-2013. Courtesy of Dr. Amy Fowler

 Can be scheduled without physician referral  20 min visit  Images read by radiologist  Patients receive summary letter by mail  Physician receives formal report

Study Design % Reduction in Breast Cancer Mortality Randomized control trials 20-22% Service screening studies 38-40% Case-control studies 48-49% Computer modeling 46% Fowler AM et al (2016) Society of Breast Imaging News 2:15-18

“ Individual Perspective ”  Radiation (minimal) ▪ ~ yearly background radiation if you live in Denver  False negative results (does not identify a cancer) ▪ 60% to 90% sensitivity for cancer, depending on a woman’s age and the density of her breasts

“Individual Perspective ”  Anxiety ▪ Subjective ▪ Recalls increase baseline anxiety…transient ▪ Patients with family history of breast cancer have lower levels of anxiety Gilbert FJ, Cordiner CM, Affleck IR, Hood DB, Mathieson D, Walker LG. Breast screening: the psychological sequelae of false- positive recall in women with and without a family history of breast cancer. European journal of cancer;34(13):2010-4.

“Individual Perspective”  False Positives ▪ Additional imaging/or biopsy, but do not have cancer (benign results)  For every cancer averted, 180 women will be called back  There is a 1 in 50 chance you will be called back once if you get annual screening mammograms for 10 years

90% Screening Pool (n=900) (n=1000) Negative

90% Screening Pool (n=900) (n=1000) Negative 10% (n=100) Additional imaging (mammogram and ultrasound)

90% Screening Pool (n=900) (n=1000) Negative 10% (n=100) Additional imaging (mammogram and ultrasound) 20% (n=20) Recommend biopsy

90% Screening Pool (n=900) (n=1000) Negative 10% (n=100) Additional imaging (mammogram and ultrasound) 20% (n=20) 30% 5/1000 Cancer

90% Screening Pool (n=900) (n=1000) Negative 10% (n=100) Back to Additional imaging imaging (mammogram and (n=80) ultrasound) False Positive 20% (n=95) (n=20) Benign Recommend biopsy biopsy (n=15) 30% Cancer

Call back Benign cyst Screening exam

“Individual Perspective ”  Overdiagnosis- overtreatment ▪ Cancers that are detected/ treated as a result of screening test, will not kill the patient ▪ Unavoidable harm to any screening test (prostate, lung, colon) ▪ Estimates (best guess) is 11% - 19%)

“Individual Perspective ”  Overdiagnosis- Overtreatment ▪ In situ-DCIS ▪ Proposes low grade DCIS will not progress ▪ There are currently no reliable individual indicators to guarantee which DCIS will progress and which will not

Benefits Harms

Screening Algorithms for Average risk Mammography Screening Interval Society • Starting at 40 years American College of Radiology (ACR) • Society of Breast Imaging (SBI) Every year (Annual) • The American Congress of Obstetricians and Gynecologists (ACOG) • National Comprehensive Cancer Network (NCCN) American Cancer Society ( NEW ) Baseline mammogram 40-45 Every year 45-55 Once every two years (Biennial) >55 • Individual decision 40-49 United States Preventative Services Task Force (USPSTF) 2009-Draft 2015 Once every two years (Biennial) 50-74 • American College of Family Practice (AAFP)

 We do not have the accurate tools to make individual decisions regarding best screening interval  Data from prior studies suggest that delaying screening till age 50 years will decrease lives saved by 6,500/year  Changing screening recommendations ratings will ultimately affect reimbursement

 High risk patients (≥ 20% risk) ▪ Annual Mammography +MRI  Moderate risk patients (> 12-<20%) ▪ Annual mammogram + (3D mammography or Ultrasound)

“ Precision Medicine ”

“ Precision Medicine ” ▪ Better screening tools ▪ TMIST: Tomosynthesis Mammography In Screening Trial ↑ ↑ Cancer detection ↓ False positives Digital Breast Tomosynthesis- 3D mammography

“ Precision Medicine ” ▪ Tailored screening intervals based on individual patient risks ▪ WISDOM: Women Informed to Screen Depending On Measures of risk

“ Precision Medicine ” ▪ Tailored treatment options based on individual cancer and patient biology ▪ COMET: Comparing surgery to Endocrine Therapy for Low-risk DCIS

 Must guarantee women’s access to basic mammography screening, protecting “ OUR RIGHT to CHOOSE ”  Big national studies are on the way to reach the goal of “Precision Medicine” , but… we are not there yet  The driving factor in choices in screening should be based on individual preferences on risk-benefit ratio

Emphasis on research to identify patient-specific factors to tailor treatment, rather than limit access to diagnosis