Telephone: Learning objectives

Transcription

1 BreastScreen WA Breast Cancer Screening Investigation of a New Breast Symptom Dr Eric Khong, Liaison GP Telephone: Learning objectives Increased understanding of the availability, benefits and limitations of screening and prevention for breast cancer. To competently manage breast issues in general practice, including the assessment of new lumps. 1

2 BreastScreen Australia Program BreastScreen WA BreastScreen Victoria BreastScreen NSW BreastScreen SA BreastScreen NT BreastScreen Tasmania BreastScreen Queensland Breast Cancer Screening Early detection and intervention increases the probability of survival If breast cancer is detected early, whilst localised to the breast, chances of 5 year survival are around 90% 2

3 Breast Cancer Screening Mammography screening has been shown in field trials to reduce death rates from female breast cancer. Estimated by an WHO Expert Group of the International Agency for Research on Cancer to approximate 35% among year old women who participate in regular screening. Source: Cancer Australia < BreastScreen Australia Evaluation Report 2009 The Program has been successful in reducing mortality from breast cancer at the current participation rate of 56% in the target age group (women aged years) by approximately 21 28%. Source: 3

4 What is a Mammogram? Mammograms Screening Diagnostic for the early detection of breast cancer for women with NO problems or symptoms for women with breast problems or symptoms Who and when? Who? Women aged (target group) Women aged Women aged 74 and over When? Every two years * Women with a strong family history of breast cancer are eligible for screening every year 4

5 Making an appointment First invite letter sent at 50 years Reminder letters By phone By the internet Where? Metropolitan clinics: Cannington Cockburn Wanneroo Midland Mirrabooka Perth Rockingham Padbury Rose Clinic (David Jones) Rural mobile service: Outer metropolitan Mandurah NEW South east South west Bunbury clinic Northern region 5

6 Screening outcomes Woman with no breast symptoms has a screening mammogram Normal screen Abnormal screen Assessment End of screening process. See in 2 years. Outcome, and end of screening process Telephone: How common is breast cancer? Most common cancer in Australian women. Uncommon in men, <1% of all breast cancers. Women have 1 in 8 risk of developing breast cancer in their lifetime. (M = 1 in 688) In WA (2014): 1737 women diagnosed (31.3% of all cancers in F) Source: WA Cancer Registry 6

7 Most frequently occurring cancers in WA women, 2014 Incidence - cases Breast 1737 (31.3%) Colorectal 560 (10.1%) Melanoma 530 (9.6%) Lung 484 (8.7%) Lymphoma 263 (4.7%) Source: WA Cancer Registry Lifetime risk of breast cancer for Australian women If a woman is now Her risk in the next 10 yrs 20 years 1 in in in in in in Age (years) Calculated from AIHW 2002 statistics 7

8 What are the risk factors? Being a woman Increasing age Previous diagnosis of breast cancer Previous diagnosis of ovarian cancer Family history Other risk factors Early onset of periods (before the age of 12) Late menopause (after the age of 55) First pregnancy after 30 yrs Not having children Breastfeeding is considered a protective factor the more months spent breastfeeding lowers the risk of developing breast cancer 8

9 Lifestyle risk factors Obesity in adulthood (especially after menopause) HRT OCP Heavy alcohol use (more than 2 standard drinks per day) Low physical activity Possibly smoking Breast Density 9

10 Breast Density Increased breast density is associated with an increased risk of breast cancer. Breast density also has an impact on screening mammography, as it can lead to a lower accuracy or sensitivity for cancer detection. 10

11 What does it mean to have a family history of breast cancer? A family history means having one or more relatives (male or female) who have been diagnosed with breast cancer. 9 out of 10 women who develop breast cancer DO NOT have a family history of breast cancer. Familial breast cancer Most breast cancer Breast Cancer Genes BRCA 1 and BRCA 2 (1997) Increase risk of breast ca by 40-80% Increase risk of ovarian ca by 10-50% It s complicated!...li-fraumeni syndrome (TP53 gene), Fanconi Anemia (PALB2 gene), Women affected may have Additional screening Risk reducing surgery 11

12 What does it mean to have a significant family history of breast cancer? 1. At or slightly above average risk = one 1 st degree relative diagnosed with breast cancer at 50 yrs or older. 2. A moderate risk = one 1 st degree relative with breast cancer before the age of 50 yrs. 3. A high risk = two or more 1 st or 2 nd degree relatives (male or female) who have been diagnosed with breast ca at any age. Risk assessment Cancer Australia Familial Risk Assessment Breast and Ovarian Cancer (FRA-BOC) REPLACES Cancer Australia Advice about familial aspects of breast cancer and epithelial ovarian cancer: a guide for health professionals (December 2010) These tools are a starting point, need to consider confounding factors 12

13 National consensus guidelines. A login is required. Register for free at Primary purpose: To provide evidence-based information to support health professionals in the delivery of cancer treatments. General recommendations, to be tailored to individual patients by managing specialists. Cancer Genetics Resources: Other resources: Referral guidelines for clinicians Breast and ovarian cancer Genetic testing guidelines BRCA1/2 Risk management guidelines High/moderate-risk **High-risk breast similar to BRCA1/2 (excluding ovarian)** BRCA1/2 male/female Information for people and families BRCA1/2 Triple Test Aims Optimise diagnostic accuracy in breast disease Maximise pre-operative diagnosis of breast cancer Minimise need for diagnostic excision biopsies 13

14 Triple Test Investigating a new breast symptom e.g. lump, nipple discharge 1. History & clinical examination 2. Imaging mammo and / or US 3. Pathology image / palpation guided biopsy Perform in sequence History of problem Onset of problem Family history of breast problem or cancers? Any medications? eg. olanzapine causing galactorrhoea Cyclic changes? Unilateral/bilateral? Nipple discharge? Spontaneous/expressed bloodstained single or multiple ducts 14

15 What are you likely to find on examination? Rib lump Skin lesion, eg sebaceous cyst, minor infection Lymph node Lipoma Fibroadenoma (breast mouse) Breast cyst Fibrocystic changes Suspicious mass ALL THE ABOVE REQUIRE IMAGING Triple Test TT positive if any component is Indeterminate Suspicious Malignant Detects 99% cancers (in symptomatic women) The sensitivity of the TT is greater than each individual component. 15

16 Triple Test Negative TT = cancer unlikely (<1%) Limits need for further Ix It is the responsibility of the managing clinician to correlate the pathological results with the clinical and imaging findings. No Single test detects all cancers. The TT diagnostic triad achieves an accuracy approaching 100%. 16