Examine breast cancer trends, statistics, and death rates, and impact of screenings. Discuss benefits and risks of screening

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Juniper Gaines
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2 Define Breast Cancer Screening Examine breast cancer trends, statistics, and death rates, and impact of screenings Discuss benefits and risks of screening Compare and contrast Screening Guidelines Optimal recommendation

3 Evaluation of asymptomatic individuals, in a defined population Premise: early detection (by screening) and early treatment interrupts natural history of disease and prevents death To benefit patients, screening must positively impact prognosis ACaS and NIH: Process of looking for cancer in a person who has no symptoms

4 Stratification of patients into groups or risk levels Individually tailor medical decisions, practices, interventions Basis is the predicted response or risk of disease Goal is improved patient-centered care Examples: Genetic sequencing (e.g., BRCA, TP53) Oncogenomics (e.g., Her2neu, BCR-ABL fusion gene) Screening modification in high risk patients

5 Both patients and Primary Care providers benefit Many different recommending groups American Cancer Society US Preventive Services Task Force National Comprehensive Cancer Network American College of Radiology American Society of Breast Surgeons Different rationales and perspectives, using RCTs and evidence-based medicine

6 An independent, volunteer panel of national experts in prevention and evidence-based medicine Works to improve health of all Americans by making evidence-based recommendations about clinical preventive services Intends to guide primary care clinicians Does not consider cost of preventive service Does take into consideration both overdiagnosis and the anxiety/harm to patient by screening as significant factors ut-the-uspstf

7 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) Breast Cancer Screening and Diagnosis Version June 2, 2017 Genetic/Familial High-Risk Assessment: Breast and Ovarian Version October 3, 2017 NCCN.org

8 And yet, only 50% women have annual imaging Only 67% have biennial screening All guidelines agree that beginning breast cancer screening at age 40 reduces mortality Since the 1980 s, mortality is decreased 36% with increased screening Imperative to encourage clinicians and patients Guidelines are confusing Consensus is lacking, esp y/o

12 Age Percent of Breast Cancer Deaths < >

14 Age range n/10,000 (95%CI) (0-9) (2-17) (11-32) (0-32) Annals of Internal Medicine Vol. 164 No February 2016

15 RCTs consistently demonstrate 18-29% mortality reduction related to screened women Evidence-based data Some older data is based upon screenings performed with xeromammography and screen mammography Technology is rapidly progressing Tomosynthesis (3D) holds great promise for better imaging and fewer false positive exams

18 Frequent characteristics smaller tumor size lower stage node negative confined to breast Advantage of detection lower morbidity lower costs of treatment less surgery lower mortality

19 More favorable prognosis lower stage at diagnosis Easier treatment Less aggressive surgery Less frequent and less toxic adjuvant therapy Less psychosocial impact

20 Radiologic Clinics of North America.Vol 55, Issue 3, , pp

21 False positive tests Additional imaging Additional costs, including absence from work Anxiety secondary to call back and biopsy personal and subjective Possible complications of benign biopsy Pain Hematoma Healing concerns, scarring (Peace of mind) False negative tests False reassurance Possible delay in diagnosis Pain/discomfort from the exam

22 Any age: % risk of recall Higher Cancer detection if >10% Ages 40-49: 8% recall rate/year 0.67% biopsy risk/year 86% pts accept recall to achieve early diagnosis

23 Test may not find cancer early enough to improve survival Test exposes patient to radiation Overdiagnosis: The detection of a cancer that would not become clinically evident or become a threat to one s health, during one s lifetime Estimates and assumptions, some include DCIS Generous estimate is <10%

25 Radiation Source Coast to Coast airline flight (round trip) Annual Natural Background USA Digital Mammography 3D Mammography (Tomo) Radiography Chest CT abdomen/pelvis PET/CT Dental X-rays Ultrasound and MRI Radiation Dose (Millisieverts) 0.03 msv 3 msv 0.4 msv 0.7 msv 0.1 msv 10 msv 25 msv msv 0 msv

26 Tumors are generally smaller, localized, node neg, non-metastatic Lower stage at diagnosis Generally lower morbidity and mortality Less extensive surgery Less toxic adjuvant therapy Less psychosocial impact More favorable prognosis Estimated median sojourn time is months Biennial screening misses pre-clinical Dx in 63% Triennial screening will ultimately diagnose same number, but at more advanced stage

27 Radiologists create medical record documents Sent to clinicians Letters to patients Radiology reports endorse annual mammographic screening, beginning at 40 y/o Clinicians tend to follow these recommendations Cancer centers are formally accepting guidelines Minimize confusion and maximize early detection

30 Screening in 2010 for cost $7.8 billion. Estimated 2016 value of lost productivity from dying of breast cancer is $9.6 billion

31 NCCN Guidelines Older Adult Oncology Adapted from 2008 CDC life tables Age Top 25% Mid 50% Lowes t 25%

32 Multiple studies: older women often do not receive standard of care treatment, and do not do as well as younger women with the same Women >75 years receive less aggressive treatment and have higher mortality from early-stage breast cancer than younger women. Biologic as well as chronologic age should be considered in selecting treatments for older women with breast cancer.

Untangling the Confusion: Multiple Breast Cancer Screening Guidelines and the Ones We Should Follow

Untangling the Confusion: Multiple Breast Cancer Screening Guidelines and the Ones We Should Follow Debra A. Walz, RN, MS, AOCNP, WHNP-BC, RNFA Advanced Oncology & Women s Health Nurse Practitioner Oneida