Transcript Controversies in Breast Cancer

Controversies in Breast Cancer
Allan Arkush, DO, FACOS
Overview
• 1 in 8 women will develop cancer in the
breast.
• Over 200,000 new cases per year
• 35,000 deaths a year and decreasing
Controversy #1
• Hormone Replacement Therapy (HRT)
– Many different articles can cause confusion
Collaborative Reanalysis (UK) Jan 2012
• 800,000 postmenopausal women were
studied
• Conclusion: studies “Failed to meet majority
of nine criteria showing causality between
HRT and development of breast cancer.”
• “Carefully designed studies are needed to
determine whether HRT does indeed cause an
increased risk of breast cancer.”
• Most newer studies are showing just the
opposite
• Risk of cancer increases the longer HRT is
given.
Women's Health Initiative
• 25,000 women studied
– Fewer cancer diagnoses in the HRT group than the
placebo group in the first 2 years.
– Breast cancer cases increase rapidly after 5.6 years
but the risk rapidly decreased after stopping the
HRT.
BRCA 1 and 2
• Who gets tested?
• Advising BRCA positive patients
• Close observation verses preventative
mastectomy
Breast Mass
• Palpable breast mass in a patient who is at
risk for cancer with a negative mammogram
still has a palpable breast mass
• Mammograms should be used for screening or
evaluating both breasts in at risk patients with
a palpable breast mass
Screening Mammograms
• When to start?
• When to stop?
• AMA, ACOG, ACR (Radiology), American
Cancer Society and the National Cancer
Institute
Over diagnosis of Breast Cancer
• New England Journal of Medicine (NEJM), Nov
2012
• Cancer Epidemiology Biomarkers (Journal) 2010
– 1000 women, ages 40-49, with screening
mammograms
– 900 true negatives
– 100 will not have breast cancer, but mammogram
was positive for cancer (false positive).
– 2 will accurately show invasive breast cancer (0.2%)
– 1 will accurately show non invasive cancer (0.1%)
– 1 will have cancer but will be missed (false negative)
Over diagnosis (continued)
• Cancer Causes Control
– 50-60 year olds are over diagnosed 40-42% of the
time
• Cochrane Database System
– Screening led to 30% over diagnoses
– Of 2000 women evaluated every 10 years, 1 will
have their life prolonged
– 10 healthy women would not have been
diagnosed; therefore they received unnecessary
treatment
NEJM, Sept 2010
• Norwegian study of over 40,000 women,
screening accounted for only 1/3 of the 10%
reduction in cancer deaths.
Breast Health
• Mills, MD, FACS
– Recommends screening mammograms begin at
age 50, if normal repeat every 2 years
– No screening mammograms after age 74
– Other recommendations based on risk factors
Mills, MD, FACS (continued)
• Reasoning
– Mammograms are painful
– 10% show false positives
– Unnecessary biopsies with in situ
– Radiation exposure
– Up to 30% false negatives
Malpractice
• American College of Radiology
– Breast cancer related claims led to more payouts
than any other entity except brain damaged
infants
• Physicians Insurers Assoc of America (PIAA)
– Increase in numbers and payouts (almost
doubled) in the past 15 years
Recommendations
• Begin at the age of 40 if average risk
• Higher risk patients need more aggressive
screening
– ACR, AMA, ACOG, American Cancer Society, NCI
• Mammographic screening may be dictated by
governmental national health.
Other Considerations
• Alcohol and Breast Cancer
• Team approach to breast cancer
– Family Physician
– Breast Surgeon or Clinic
– Medical Oncologist/Radiation Oncologist
– Plastic Reconstructive Surgeon
– Nurse Navigator