Breast Density. Update 2018: Implications for Clinical Practice

Transcription

1 Breast Density Update 2018: Implications for Clinical Practice Matthew A. Stein, MD Assistant professor Breast Imaging Department of Radiology and Imaging Sciences University of Utah Health

2 Disclosures No commercial interests, financial relationships, conflicts of interest. 2

3 References 1. D Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; Freer PE, Slanetz PJ, Haas JS, et al. Breast Cancer Screening in the Era of Density Notification Legislation: Summary of 2014 Massachusetts Experience and Suggestion of An Evidence-Based Management Algorithm by Multi-disciplinary Expert Panel. Breast cancer research and treatment. 2015;153(2): doi: /s Cappello, Nancy M. Decade of Normal Mammography Reports The Happygram. Journal of the American College of Radiology, Volume 10, Issue 12, Are You Dense, Inc. is a 501(c)(3) public charity. IRS Tax ID Berg WA. Supplemental Breast Cancer Screening in Women with Dense Breasts Should be Offered with Simultaneous Collection of Outcomes Data. Annals of internal medicine. 2016;164(4): doi: /m Melnikow J, Fenton JJ, Whitlock EP, et al. Supplemental Screening for Breast Cancer in Women with Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force. Annals of internal medicine. 2016;164(4): doi: /m Freer PE. Mammographic Breast Density: Impact on Breast Cancer Risk and Implications for Screening. RadioGraphics :2, Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group [published erratum appears in N Engl J Med 2006;355:1840]. N Engl J Med 2005;353: Carney PA, Miglioretti DL, Yankaskas BC, Kerlikowske K, Rosenberg R, Rutter CM, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography [published erratum appears in Ann Intern Med 2003;138:771]. Ann Intern Med 2003;138: Sickles EA. The use of breast imaging to screen women at high risk for cancer. Radiol Clin North Am 2010;48: Mainiero MB, Moy L, Baron P, et al. ACR Appropriateness Criteria Breast Cancer Screening. Available at American College of Radiology. Accessed 1/28/

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5 Breast Density Relevance Dense breast tissue may mask abnormal tissue on a mammogram, making mammographic signs of breast cancer more difficult to detect. Dense breast tissue is an independent risk factor for development of breast cancer.(7) Patients, providers, advocacy groups, legislators all are looking for information and guidance. 5

6 Definitions Breast density (composition). Proportion of radio-dense tissue to radio-lucent fat on a mammogram. No correlation between CBE and mammographic density. (2) Roughly 50% of women in the screening population have dense breasts at mammography.(1) BI-RADS Methodology. Subjective, visual, volumetric assessment of dense tissue relative to fat in the breast. Four categories ( almost entirely fatty > extremely dense ). Indicator of relative probability that a cancer could be obscured by normal tissue. 6

7 Density Data Summary Table* BI-RADS Breast Composition Categories The breasts are almost entirely fatty. There are scattered areas of fibroglandular density. The breasts are heterogeneously dense, which may exclude small masses. % Population Mammographic Sensitivity RR Breast Cancer (compared to average density = 53%) RR Breast cancer (compared to averagelow only = 9%) 9% 88 Average - low Average - low 44% 82 Average -- 38% The breasts are extremely dense, which lowers the sensitivity of mammography. 9% *References: (1), (7), (8), (9), (10) 7

8 Breast Density Variance Subjective intra- and inter-observer variation. Quantitative methods exist; not used in routine clinical practice. Mammographic technique. Physiologic factors. BMI Age Hormonal status/tamoxifen Potential for year-to-year variance > confusion. Patients should be informed/educated. 8

9 Breast Density - Variance 9

10 Advocacy Rationale Breast density is the strongest predictor of the failure of mammography screening to detect cancer. (3) To withhold a woman s breast density composition from her, which may affect her health care, is denying her the right to make an informed decision. (3) The doctrine of informed consent exists independent of a consensus to the challenges of detecting early invasive cancers in dense breasts. (3) Voluntary measures will not ensure that every woman receives this critical breast health information. (3) 10

11 Breast Density Legislation (4) 11

12 Advocacy Work (4) 12

13 Guidance Summary Table Average Risk * Freer PE. Mammographic Breast Density: Impact on Breast Cancer Risk and Implications for Screening. RadioGraphics :2,

14 Guidance Summary Table Average Risk BI-RADS Breast Composition Categories USPSTF* NCCN (AC)* ACR (AC) ACS The breasts are almost entirely fatty. MG, BA DBT, CBE SBE CBEnc, MG, DBT, BA MG, DBT MRI, MBI MG/DBT, BA MRI, CBE*, SBE There are scattered areas of fibroglandular density. MG, BA DBT, CBE SBE CBEnc, MG, DBT, BA MG, DBT MRI, MBI MG/DBT, BA MRI, CBE*, SBE The breasts are heterogeneously dense, which may exclude small masses. MG, BA DBT, CBE, SS SBE CBEnc, MG, DBT, BA Counsel re SS MBI MG, DBT US MRI, MBI MG/DBT, BA US MRI, CBE*, SBE The breasts are extremely dense, which lowers the sensitivity of mammography. MG, BA DBT, CBE, SS SBE CBEnc, MG, DBT, BA Counsel re SS MBI MG, DBT US MRI, MBI MG/DBT, BA US MRI, CBE*, SBE *Update in progress. 14

15 Take home points Shared decision making is a high goal in medicine. Breast density is a complex issue: knowledge base is expanding/evolving. The answer is not simply recommending another/better test. True shared decision making will require nuanced understanding by both providers and by patients. Risk tolerance. 15

16 Thank you. QUESTIONS? 16