Screening mammograms in women <50 years of age: Low risk is NOT protective
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1 Screening mammograms in women <50 years of age: Low risk is NOT protective Jennifer R. Garreau, MD Legacy Cancer Institute Legacy Medical Group Surgical Oncology Portland, OR
2 History of Mammography 1913 Albert Salomon German surgeon Used radiological studies to identify breast cancer Evaluated 3000 mastectomy specimens
3 History of Mammography 1949 Raul Leborgne Radiologist from Uruguay Reported seeing Ca2+ in 30% of breast cancers on mammography Emphasized good compression and spot/magnification to better see small structures Reports findings in a landmark in 1951
4 History of Mammography MD Anderson started working on developing an x-ray technique for women with breast cancer Dr. Robert Egan Radiologist at MD Anderson Cancer Center Recruited by his mentor, Dr. Gerald Dodd from Thomas Jefferson University to finish his residency at MDACC
5 History of Mammography Egan had an engineering background Experimented with an x-ray device from Kodak to develop mammograms Original dedicated mammography system from 1966
6 History of mammography Takes films of 1,000 women who did not have obvious cancer on physical exam 238 cancerous masses identified by mammography alone
7 History of mammography In 1965, article in American Journal of Surgery stated that radiologists could identify breast cancer with 79% accuracy
8 History of mammography First large scale controlled study on role of mammograms in reducing deaths Involved 24 institutions Showed mammography reduced breast cancer deaths by a third
9 History of Mammography 1969 Modern day film mammogram is invented X-ray units dedicated to breast imaging are available
10 History of Mammography 1976 Mammography is recommended as a screening tool by the American Cancer Society
11 By the 1980s, ACR and the American Cancer Society had both issued recommendations that women 40 or older should obtain yearly mammograms
12
13 1992 Congress enacts the mammography quality standards act to ensure that all women have access to mammography for breast cancer detection
14 FDA approves first digital mammography system American Cancer Society notes breast cancer deaths are down 30% since their peak in 1991 Due to early detection and treatment USPSTF issues new guidelines regarding screening mammograms
15
16 Background 2009: United States Preventative Services Task Force (USPSTF) changed recommended age for routine annual screening mammography from 40 to 50 years of age for non- high risk patients 2015: American Cancer Society suggested 45 years of age, with high risk at 40 Assumption: Most women who develop breast cancer under these ages can be identified as high risk and undergo selective screening 16
17
18 Objectives Determine proportion of women under 50 with breast cancer belonging to low risk category Investigate risk distribution across this population We hypothesized that most women under 50 with breast cancer would be classified as low risk under current predictive models 18
19 Methods Retrospective review of Legacy Health System Breast Cancer Database from January 2013 to December 2015 Less than 50 years of age at diagnosis Ductal carcinoma in situ, lobular carcinoma is situ, infiltrating ductal carcinoma, or infiltrating lobular carcinoma Prior diagnosis of breast cancer excluded Risk assessed post-hoc with standardized risk assessment tools (Modified Gail, BRCAPRO, Tyrer-Cruzik) Lifetime risk of breast cancer 20% using any of these models classified as high risk, <20% classified as low risk 19
20 Results 249 women identified 192 (77.2%) between years of age 74% detected on routine screening mammography 20
21 Results: Age <50 Low Risk High Risk Stage 0 39 (23%) 12 (15%) Total 51 (20%) Descriptive Statistics by Risk Group Stage I 60 (35%) 35 (44%) 95 (38%) Stage II 53 (31%) 23 (29%) 76 (30%) Stage III 15 (9%) 5 (6%) 20 (8%) Stage IV 4 (2%) 139 (82%) 4 (5%) 8 (3%) ER+ PR + Her2/ neu+ 66 (84%) 205 (82%) 135 (79%) 63 (80%) 198 (80%) 20 (12%) 7 (9%) 27 (11%) Mean Age (years) Total (68%) (32%)
22 Age Subgroups Age women 46 (74.2%) low risk Age women 102 (78.4%) low risk 22
23 Cumulative Risk: Age Lifetime Risk Distribution (40-49 Years) Lifetime Risk of Breast Cancer (%) Cumulative Frequency 23
24 Conclusions Minority of breast cancer diagnoses under 50 are in high risk patients Low risk is not protective: 77.1% underscreened per USPSTF recommendations 74.2% underscreened per ACS recommendations Recommendations: Screening at 40 Re-evaluate threshold for high risk 24
25
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