Population Prospective. Big Picture

Transcription

1 Mai Elezaby, MD?

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4 Population Prospective Big Picture

5 Breast Cancer Most common cancer in women 2 nd leading cause of death U.S estimates 246,660 new cases 40,450 deaths from breast cancer

6 2016

7 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

8 5-Year Survival (%) 5-Year Survival (%) Smaller size Earlier stage < >5 Tumor size (cm) More likely to be curable 100 Surveillance, Epidemiology, and End Results (SEER) Program Results 268/ Courtesy of Dr. Amy Fowler I IIA IIB IIIA IIIB IIIC IV Stage

9 5-Year Survival (%) 5-Year Survival (%) Smaller size Earlier stage < >5 Tumor size (cm) SCREENING 100 Surveillance, Epidemiology, and End Results (SEER) Program Results 268/ Courtesy of Dr. Amy Fowler I IIA IIB IIIA IIIB IIIC IV Stage

10 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)

11 5-Year Survival (%) 5-Year Survival (%) < >5 Tumor size (cm) 100 Surveillance, Epidemiology, and End Results (SEER) Program Results 268/ Courtesy of Dr. Amy Fowler I IIA IIB IIIA IIIB IIIC IV Stage

12 - 37% Screening Mammography Advancement in Treatments Surveillance, Epidemiology, and End Results Program (SEER), Cancer Statistics Review Courtesy of Dr. Amy Fowler

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

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15 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

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17 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

18 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):

19 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

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22 90% (n=900) Negative Screening Pool (n=1000)

23 90% (n=900) Negative Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound)

24 90% (n=900) Negative Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 20% (n=20) Recommend biopsy

25 90% (n=900) Negative Screening Pool (n=1000) 10% (n=100) Additional imaging (mammogram and ultrasound) 20% (n=20) 30% Cancer 5/1000

26 90% (n=900) Negative Screening Pool (n=1000) Back to imaging (n=80) 10% (n=100) Additional imaging (mammogram and ultrasound) False Positive (n=95) Benign biopsy (n=15) 20% (n=20) Recommend biopsy 30% Cancer

27 Call back Screening exam Benign cyst

28 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%)

29 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

30 Benefits Harms

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

32 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

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

34 Precision Medicine

35 Precision Medicine Better screening tools TMIST: Tomosynthesis Mammography In Screening Trial Cancer detection False positives Digital Breast Tomosynthesis- 3D mammography

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

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

38 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

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

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