Imaging Guidelines for Breast Cancer Screening Sarah Colwick, MD Dr. Sarah Colwick was born and raised in Sikeston, MO. She attended college and medical school at the University of Missouri-Kansas City before moving to Yale New Haven Hospital for general surgery residency. Disclosures: None
Breast Cancer Screening Guidelines Sarah E Colwick, MD 11/10/2018 Disclosures Nothing to disclose Objectives Review imaging guidelines Exceptions to guidelines Role of additional imaging modalities 1
Early detection and screening WHAT IS THE PURPOSE OF SCREENING? Screening tests can find breast cancer early, when the chances of survival are highest Clinical breast exams Mammogram Ultrasound MRI Why is screening important As of the 2016 American Cancer Society data: About 246,660 new cases of invasive breast cancer will be diagnosed in women About 61,000 new cases of non-invasive breast cancer will be diagnosed About 40,450 women will die from breast cancer Breast cancer is the second leading cause of cancer death in women Only lung cancer kills more women each year The chance that a woman will die from breast cancer is about 1 in 36 (about 3%) Death rates from breast cancer have been dropping since about 1989 With larger decreases in women younger than 50 At this time there are more than 2.8 million breast cancer survivors in the United States 2
Mammography 1970 s Mammography allowed breast cancer screening to become routine By the mid-1980s nearly 1/3 rd of women >40 y/o were screened By 2008 screening is widely available Increased screening and therefore early detection has lead to ~27% reduction in breast cancer mortality in the US since 1975 Digital mammography was introduced in early 1990 s 3D mammography was introduced in 2010 s Digital vs Analog Mammogram 3
What can a mammogram show? The Shape of the Mass Matters! Malignant masses have a more spiculated appearance Benign masses tend to be smoother Calcifications show up as small white spots on mammogram Round well-defined larger calcifications are more likely benign Tight clusters of tiny, irregularly shaped calcifications may indicate cancer Microcalcifications 4
X-ray of the breast Fat appears black Relatively radiolucent Tumors appear as shades of white to grey Calcifications look white Cranial-Caudal Mediolateral-Oblique 5
Density of breast tissue A B C D 0-25% 25-50% 50-75% > 75% Self Breast Exams Examining your breasts every month is a way to find a breast cancer early Not every cancer can be found this way Many woman don t want to do a breast self-exam the experience is frustrating May feel things and not know what they mean However more a patient does it (monthly) they will know if something has changed Self Breast Exams Rashes of the nipple Nipple retraction Spontaneous nipple discharge New mass Change in the size or shape of the breast Dimpling or puckering of the skin ~75% of palpable masses are self discovered 6
Breast Signs and Symptoms Paget s disease of the nipple Skin Dimpling Nipple discharge Peau d orange Non-Cancerous Conditions Fibrocystic changes: Lumpiness, thickening and swelling Often changes along with menses Cysts: Fluid-filled lumps can range from very tiny to about the size of an egg Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occurring most in young women Infections: The breast will likely be red, warm, tender and lumpy Trauma: a blow to the breast or a bruise can cause a lump 7
Mammogram Screening Guidelines Average risk patient 1 in 8 12% Lifetime risk of breast cancer NCCN, ACS, and USPTF Risk factors Female gender Age Personal history of breast cancer Family history of breast cancer Known BRCA/genetic mutation In patient or in the family Prior breast biopsy Atypia ADH, ALH, LCIS Previous chest wall radiation (prior to age 30) Nulliparity Early menarche Late menopause Post menopausal obesity 8
Calculating risk Many risk calculators 2 easy online risk calculators used most commonly Gail Model Calculates a 5 year and lifetime risk of developing breast cancer for those 35 and older Uses the following: Any history of DCIS/LCIS or chest wall radiation Age Age at Menarche Age at 1 st child Any 1 st degree relatives with breast cancer Ever have a breast biopsy How many biopsies Any with ADH Race/ethnicity Calculating risk Tyrer Cuzick Model Calculates a 10 year and lifetime risk of developing breast cancer Can be calculated no matter the age of the patient More detailed than Gail Model - Includes all the data points of the Gail model plus History of aunts and grandmothers Age at which family was diagnosed Any male relatives diagnosed with breast cancer Menopausal status HRT use Any history of ovarian cancer in the family Height and weight 9
NCCN Guidelines for Breast Cancer Screening Clinical Breast exam -Age 25-39 every 1-3 years -Age 40+ every year Mammography -Age 40+ every year as long as in good health 10
American Cancer Society Guidelines for Breast Cancer Screening Clinical Breast Exam -Not recommended Mammography -Age 40-44 Discuss with healthcare provider -Age 45-54 Every year -Age 55+ Every 2 years as long as in good health (Life expectancy 10+ years) US Preventative Task Force Clinical Breast exam -Not enough evidence to recommend for or against Mammography -Age 40-49 Discuss with your healthcare provider -Age 50-74 Every 2 years -Age 75+ Insufficient Evidence to recommend for or against 11
Calculating risk Other models: Claus Model and BRCAPRO Model Not used as often If lifetime risk is >20% = high risk Patients can be at increase risk but not qualify for genetics Women at higher risk may need to get screening earlier than average risk A woman is considered at higher risk if she has factors that increase the risk of breast cancer BRCA1 or BRCA2 gene mutation Strong family history of breast cancer, especially if diagnosed at a young age Personal history of breast cancer Personal history of atypia History of radiation treatment to the chest between ages 10 30 Li-Fraumeni syndrome or Cowden syndrome A p53, PTEN, ATM, CHECK2, or PALB2 gene mutation Recommendations for Higher Risk Women NCCN Guidelines Clinical Breast Exam Mammogram MRI Hx of Atypia Every 6-12 months Yearly starting at age 30 Discuss with your doctor BRCA 1 or 2 or family with a BRCA mutation Every 6-12 months Hx of chest radiation Every 6-12 months Starting 8-10 years after tx Patient with lifetime risk >20% Every 6-12 months starting 10 years before the earlier case of breast cancer *Ultrasound added if dense breasts < age 25: CBE only 25-29: -Mammo only if NO MRI Age 30+ - yearly CBE only if < 25 years old 25+ years - yearly starting 8-10 years after radiation treatment 30+ years old: Yearly starting 10 years before the earliest case of breast cancer in the family Yearly starting age 25 25+ years - yearly starting 8-10 years after radiation treatment 30+ years old: Yearly starting 10 years before the earliest case of breast cancer in the family 12
Recommendations for Higher Risk Women American Cancer Society Recommendations CBE Mammogram MRI Hx of Atypia Not recommended Yearly starting at 30 Discuss with your doctor BRCA 1 or 2 or family with a BRCA mutation Not recommended Yearly starting at 30 Yearly starting at 30 Hx of Chest radiation Not recommended Yearly starting at 30 or 8-10 Yearly starting 8-10 years after radiation treatment years after radiation if older than 25 Patient with lifetime risk >20% Not recommended <40 discuss with your doctor on when to start screening Discuss with your doctor Ultrasound Recommend the use ultrasound in those with dense breast tissue Grade C and D See if there are any cystic or solid lesions Ultrasound uses sound waves to make images of the breast Ultrasound US complements other tests Mammogram or physical exam Ultrasound cannot determine if a solid lump is cancerous or benign Cannot detect calcifications If under 35 and has a palpable mass Can get US before mammogram to see if solid vs cystic Mammograms can be difficult to interpret in young women because often extremely dense 13
Breast MRI Uses magnetic fields to create an image of the breast It can sometimes find cancers not seen on mammogram in dense breasts Often used with mammography for screening some women at a high risk of breast cancer Breast MRI The sensitivity of breast MRI for cancers >3 mm approaches 100% High negative predictive value helps excludes cancers Does have a higher false positive findings 14
Questions? Thank-you 15