Learning and Earning with Gateway Professional Education CME/CEU Webinar Series. Breast Cancer Screening September 21, :00pm 1:00pm

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1 Learning and Earning with Gateway Professional Education CME/CEU Webinar Series Breast Cancer Screening September 21, :00pm 1:00pm Robert A. Smith, PhD Vice President, Cancer Screening American Cancer Society Joe Mastalski Senior Clinical Quality Management Analyst Gateway Health

2 Today s Presenters: Robert A. Smith PhD Vice President, Cancer Screening Joe Mastalski Senior Clinical Quality Management Analyst American Cancer Society Quality Improvement Gateway Health 2

3 Breast Cancer Screening Best practices in the private practice setting Gateway Health Webinar Series September 21, 2017 Robert A. Smith, PhD Vice-President, Cancer Screening American Cancer Society Adjunct Professor of Epidemiology Emory University Rollins School of Public Health

4 The Evolving Evidence for Early Detection

5 RCTs of screening mammography: Overall results in terms of breast cancer mortality Study ID Canadian NBSS-1 Canadian NBSS-2 Edinburgh HIP Two-County Trial Malmo-1 Malmo-2 Stockholm Gothenburg UK Age Trial Overall RR (95% CI) 1.06 (0.80, 1.40) 1.02 (0.78, 1.33) 0.71 (0.53, 0.95) 0.77 (0.62, 0.97) 0.69 (0.56, 0.84) 0.82 (0.67, 1.00) 0.64 (0.39, 1.06) 0.91 (0.65, 1.27) 0.76 (0.56, 1.04) 0.83 (0.66, 1.04) 0.79 (0.73, 0.86) Overall RR = 0.79 (95% CI: 0.73, 0.86) Tabar, et al. Breast J, 2014 Heterogeneity p = 0.3

6 It is Important to Remember the Principle Goal of Cancer Screening Successful breast cancer screening Reduction in incidence rate of advanced disease Which contributes to an eventual reduction in cancer mortality

7 The Breast Journal, In the RCTs, among women invited to screening: trials that achieved a reduction in advanced stage disease of 20% or greater, observed an an average breast cancer mortality reduction of 28% the trials that achieved a reduction in advanced stage disease of less than 10%, observed no reduction in breast cancer mortality

8 Cumulative Mortality in the Breast Cancer RCTs Cumulative mortality outcomes reflect trial performance in reducing the risk of being diagnosed with an advanced breast cancer

9 Incidence Based Breast Cancer Mortality among Participants in the Norwegian Breast Cancer Screening Program, Hofvind, et al. Cancer 2013;119:17

10 Crude cumulative breast cancer mortality rates for screened and unscreened cohorts among women invited to the Norwegian Breast Cancer Screening Program, 1996 to Note In this analysis there are no deaths from cases diagnosed before % fewer breast cancer deaths Fifteen after the start of the program, the screened cohort had 43% lower breast cancer mortality rate compared with the unscreened cohort. Hofvind, et al. Cancer 2013;119:17

11 Standardized mortality ratios (SMRs) by Canadian province for ages at entry: Summary estimates are based upon random effects models. All statistical tests were two-sided % fewer deaths JNCI 2014;106(11) 40% fewer deaths

12 EUROSCREEN Incidence-based mortality estimates for breast cancer mortality reduction in women ages 50-69, exposed versus not-exposed to screening J Med Screen 2012;19 Suppl1:14 25

13 EUROSCREEN Estimates of the Absolute Benefit from 7 Incidence Based Mortality Studies Based on: 20 of screening (10 rounds) ages of follow-up (from age 50-80) 96 women need to be screened to prevent 1 breast cancer death

14 Trend in Age-Adjusted Breast Cancer Mortality Rates, U.S. Women, Breast cancer mortality rates in U.S. women have fallen 38% since 1989 Source:

15 Total Number of Female Breast Cancer Deaths Averted From 1990 to ,300 The red line represents the number of breast cancer deaths that would have been expected if breast cancer death rates had remained at their peak rate in 1989 The blue line represents the actual number of breast cancer deaths recorded in each year Source: DeSantis CE, et al. Cancer J Clin 2016;66:31-42, updated

16 Do improvements in treatment make screening less important? Consider the Consequences of early vs. advanced stage at diagnosis Increased probability of requiring mastectomy Increased risk of lymphedema Adverse effects of radiation therapy Near and long-term adverse effects of adjuvant therapy Near and long-term adverse effects of chemotherapy Upper-body impairments Increased risk of death

17 Global Breast Cancer Screening Guidelines for Average Risk Women At what age should average risk women start, and how often should screening take place? Country Starting Age Screening Interval United States ACS ACR USPSTF Highly Variable 45, with option to begin at , with option to begin at 40 Highly Variable 40-54: 12 months; mos 12 months 24 months Sweden 40, or months months U.K months Taiwan months

18 Breast Cancer in Younger Women Breast cancer in younger women Incidence rate per Probability of being diagnosed in the 1 year interval b % of BC deaths by age at 100,000 a % 1 in N diagnosis c % 2,212 1% % 1,943 1% % 1,713 1% % 1,440 1% % 1,232 1% % 1,076 1% % 954 1% % 857 1% % 774 1% % 706 2% % 648 2% Risk between ages is 9 in 10,000. The recall rate is 1,600 2,000 per 10,000 (about 1 in 5) a. Delay-adjusted incidence rates, SEER 18, b. SEER 18, c. Distribution of BC deaths ( ) from a BC diagnosis up to 15 prior, S

19 Age Distribution of Invasive Female Breast Cancer Cases, % 12% 13% 12% 12% 12% 10% 10% 9% 8% 8% 6% 6% 6% 6% 4% 3% 2% 0% <1% <1% % Source: SEER 18 registries.

20 No. of breast cancer deaths Distribution of Breast Cancer Deaths by Age at Diagnosis, ,000 1,800 11% 11% 11% 1,600 1,400 1,200 7% 10% 9% 9% 9% 8% 8% 1, % % <1% 1% Age at diagnosis Source: SEER 9 registries, patients followed for 15 after diagnosis.

21 The Screening Interval There have been no trials that have compared annual screening with biennial screening The screening interval has been influenced by estimates of tumor growth rates & interval cancer rates Screening intervals also have been recommended based on tradeoffs between estimated mortality rates and false positive rates

22 RR (95% CI) of Less-favorable Invasive Cancer Characteristics for Biennial versus Annual Screeners, by Age, Menopausal Status, and Current Hormone Therapy Use, Adjusted for Race/Ethnicity, First-Degree Family History of Breast Cancer Statistically significant elevated risks of being diagnosed with an advanced cancer associated with biennial vs. annual screening are in bold 22

23 Adverse Outcomes Associated with Screening (aka harms ) In recent there has been growing concerns about harms associated with screening Guideline developers are obliged to scrutinize harms as well as benefits This is a challenge because there are not equivalent metrics for measuring benefits and harms 23

24 New data of the rate of False Positive Mammography results from digital mammography. First mammogram not included. Women in their 40s have the highest rate. (Source, BCSC data, Pacific NW EPC, 2015) 24

25 % Overdiagnosed Overdiagnosis Estimates Based on Adjustment for Incidence Trends and Lead-time Puliti, et al. JMS 2012;19(1) Adjusted Estimates Not Adequately Adjusted Estimates

26 The Marmot Report concluded that approximately 19% of cancers were overdiagnosed [This estimate was judged by many to be too high] Of the 307,000 women aged who are invited to screening each year, [approximately] 1% would have an overdiagnosed cancer during the next 20. Given the uncertainties around the estimates, the figures quoted give a spurious impression of accuracy. Source: Marmot MG, et al. BMJ (2013) 108,

27 Evidence-based Medicine Has Placed New & Growing Demands on Primary Care Providers A growing number of recommended preventive services are expected to be delivered This is a challenge Too little time Too few incentives Existing systems are not very useful for the delivery of preventive care

28 Mammography Screening in the U.S.--The Target Population Leading guidelines differ Starting age (40, 45, 50) Stopping age (No stopping age vs. 75) Screening interval (1 vs. 2 ) State and federal legislation influences payment by health insurance Doctors often deviate from recommendations

29 Opportunistic vs. Organized Preventive Health Regular Checkups have been replaced by Prioritization of Preventive Services during incidental encounters with healthcare professionals Under the current model, most preventive care in the U.S. is opportunistic Opportunistic care depends on a coincidence of encounters, circumstances, interests, and opportunity between patient and provider

30 How well is this working?

31 Mammography screening in the U.S. is strongly influenced by socioeconomic status and insurance coverage, National Health Interview Study, women 40+, 2013 SES Measure Rate (%) SE Health Insurance Education Yes No < High School College graduate

32 Age-Specific Adjusted Proportion of Women Reporting Screening Mammography By Age 70 Mammography in the Past Year, BRFSS, Series 1 Self Reports are 15-25% higher than actual screening rates AGE Am J Prev Med 2015;49(3):

33 What defines best practices for breast care in the primary care setting? Assess family history early, and update regularly Discuss the importance of increased awareness about symptoms Discuss risk, prevention, and benefits and limitations of mammography screening Identify high performing centers for referral to mammography Discuss screening at age 40 Be prepared to tailor the screening interval to risk Have a reminder system Track your patients adherence with screening recommendations Be prepared to discuss stopping screening when longevity < 10

34 Assessing family history of breast cancer Historically, primary care providers have not achieved high rates of competent family history taking, and referral Shortcomings include: No, or irregular family history taking Incomplete family history Failure to identify high risk patients Failure to refer to genetic counseling and assessment Failure to refer to MRI for women at high risk

35 Key Information for Informed Decisions about Breast Cancer Screening Begin Early Women should be informed about Opportunities for prevention Symptom awareness Individual risk, near term and long term Limits of risk prediction Benefits of screening Limitations of screening Sensitivity & Specificity Stress associated with false positives Overdiagnosis

36 Mammography Quality Matters Does the facility specialize in mammography and track performance?

37 Mammography Quality Matters Management of recalls? Routinely utilize prior images in interpretation? Quality of communication With your patients? With your office? Do the radiologists participate in treatment decision making with other specialists?

38 Informed Decisions Both the ACS & USPSTF endorse a woman having an opportunity to choose to begin mammography screening at age 40 Key issues Benefits of mammography are well established Regular screening is important Early detection matters Mammography is not perfect it has limitations A recall for further evaluation is more common on the first mammogram. The large majority of women who are recalled do not have cancer. Being recalled can cause stress

39 Risk Factors & the Screening Interval Breast Density Menopausal Hormone Replacement Therapy Family History Annual screening from age 40 onward is advised for women with these risk factors

40 BIRADS Categories of Breast Density Density category Percent of the population A: Almost entirely fatty 10% B: Scattered fibroglandular density 40% C: Heterogeneously dense 40% D: Extremely dense 10%

41 Density Menopausal Hormone Therapy

42 Odds ratio estimates of the relative risk (95% confidence intervals) of the four breast cancer types, by family history, adjusted for age Duffy SW, et al. Seminars in Breast Disease 1999.

43 Improving Breast Cancer Screening Rates Take Advantage of Checkups to Refer for Mammography Screening

44 Cancer Screening & the Periodic Preventive Health Exam Retrospective cohort study 64,288 adults ages in a managed care plan Outcomes focused on completion of: CRC screening Breast cancer screening Prostate cancer screening

45 Adjusted Incidence of 3 Cancer Screening Tests by Receipt of Preventive Health Exam (PHE) CRC Screening Mammography PSA Testing Received PHE Did Not Receive PHE Approximately 70% of women who had received a PHE completed mammography creening within 5 annual visits

46 Increase Screening Rates in Your Practice This 8 page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit Contains links to the full Toolkit, tools and resources Not colorectal-specific; practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical) Available at

47 Communication

48 Steps of Population Management 1. Who? - Identify population to be managed 2. What? Identify conditions to be managed 3. How? Develop protocol management for conditions 4. How to Monitor? Select EHR Management tool 5. Who manages? Dedicated Population managers 6. When? PDSA cycles with intervention time frame

49 AAPHC TOTAL RESULTS Who is being managed and What we are managing

50 At What Age Should We Stop Screening?

51 Number of Breast Cancer Deaths Distribution of breast cancer deaths in the U.S. by age at diagnosis, ,000 1,800 11% 11% 11% 34% 1,600 1,400 1,200 7% 10% 9% 9% 9% 8% 8% 1, % % <1% 1% Age at diagnosis Source: SEER 9 registries, patients followed for 15 after diagnosis.

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53 Conclusions The age to begin screening should be based on careful consideration of relevant measures of disease burden based on age at diagnosis Mammography has similar effectiveness in younger vs. older women when screening intervals are tailored to menopausal status Annual screening appears to be more effective in women with significant breast density, women taking HRT, and women with a family history Health status and longevity should be considered when deciding when to stop screening 53

54 Conclusions-1 There are important differences in current guidelines, but also important similarities All organizations emphasize that benefits outweigh harms at all ages All organizations endorse informed decision making All organizations endorse the importance of women being informed about benefits and limitations of screening

55 Conclusions-2 High adherence to even the least aggressive guideline would save more lives than the current weak adherence to regular screening The new ACS guideline allows clinicians and women to choose to follow the old ACS guideline, and provides stronger evidence to support that choice

56 Thank you

57 HEDIS Measure and Initiatives

58 Breast Cancer Screening (BCS) HEDIS Measure The percentage of women of age as of December 31 of the measurement year who had a mammogram to screen for breast cancer between October 1 two prior to the measurement year and December 31 of the measurement year. Rate is measured every calendar year Women with a history of surgical removal of both breasts are excluded from the measure. *Note* the HEDIS specification is in line with the USPSTF recommendation for breast cancer screening

59 GPE Incentive How to Earn the GPE Incentive Women ages who have not had surgical removal of the breasts are eligible $20 payout made for a mammogram in 2017 A claim for a mammogram must be received by Gateway Any provider can submit the code for the mammogram, but the incentive payment is made to the PCP only Medicare only

60 BCS Codes That Count Codes for BCS Incentive Code Type Description Codes CPT Mammography 77055, 77056, HCPCS Mammography, screening or diagnostic G0202, G0204, G0206 MRIs, ultrasounds, and biopsies alone do not count toward HEDIS or the GPE bonus. These procedures are typically completed in conjunction with a mammogram.

61 How to Improve HEDIS Scores Document and code exclusions for this measure so our records are up to date Z90.11 absence of left breast Z90.12 absence of right breast Z90.13 absence of both breasts Notify your Clinical Transformation Consultant if a member is up to date or excluded so we can update our records. Provide some guidance for members to help them wade through information that can be confusing or scary, such as false positives, so they can understand risks and benefits Have a list of facilities on hand to assist in making an appointment or referral

62 Gateway Health BCS Initiatives Population based programs: Goodness Rewards - Medicare members earn rewards for taking steps towards a healthy lifestyle IVR, text, and campaign for education and assistance with appointment scheduling Reminder letters Targeted Interventions: Mammography events in partnership with Radiology facilities Member care gap discussion during telephonic outreach or in person at certain practices with embedded staff Education at Health Awareness events Looking into partnerships with faith based organizations and other community organizations Provider-focused Initiatives Provider Education via Provider Engagement Team GPE Incentive Resources: Provider Manual, Practice Reference Guide

63 Thank You!

64 Access slides by navigating to: Provider>Provider Resources> Educational Tools>What s New (CME credit only for enrolled participants in live webinar) 64