Transcript Breast Cancer Presentation

Population Management
Breast Cancer Screening
October 2013
Breast Cancer: Incidence
• Excluding skin cancers, breast cancer is the
most common cancer among women.
 Accounts for nearly 1 in 3 cancers diagnosed
in US women
 Second most common cause of cancer
death in US women
• 1 in 8 women in the U.S. will develop
invasive breast cancer in their lifetime
Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American
Cancer Society, Inc.
Early Detection and Prevention
• Early detection and prevention programs
have enabled the survival rates for breast
cancer to increase and the death rates to
steadily decline over the past several
years.
Misconceptions
• Women will often decline screening and
when asked why, will comment that they
have no family history or risk factors for
breast cancer and so don’t need screened. In
reality:
– 50% of women who develop breast cancer are
not at elevated risk
– 80-85% of women diagnosed with breast
cancer have NO family history of breast cancer
Breast Cancer Risk Factors:
High Relative Risk (>4-fold)
• Age (65+ vs. < 65 yrs)
• Atypical hyperplasia confirmed by biopsy
• Certain inherited genetic mutations for breast
cancer (e.g., BRCA1 and/or BRCA2)
• Dense breasts(on mammography report)
• Personal history of breast cancer
Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American
Cancer Society, Inc.
Breast Cancer Risk Factors: Relative
Risk (2.1-4.0)
• High endogenous estrogen or testosterone
levels
• High bone density
• High-dose radiation to chest
• Two first-degree relatives with breast cancer
Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American
Cancer Society, Inc.
Breast Cancer Risk Factors: Relative
Risk (1.1-2.0)
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Alcohol consumption
Ashkenazi Jewish heritage
Early menarche (<12 years)
High socioeconomic status
First full-term pregnancy > 30 years of age
Late menopause (> 55 years)
Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American
Cancer Society, Inc.
Breast Cancer Risk Factors: Relative
Risk (1.1-2.0) (continued)
Never breastfed a child
No full-term pregnancies
Obesity (post-menopausal)/adult weight gain
One first-degree relative with breast cancer
Personal history of endometrium, ovary, or
colon cancer
• Recent & long-term use of menopausal
hormone therapy containing estrogen and
progestin
• Recent oral contraceptive use
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.Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American
Cancer Society, Inc.
Issues and Controversies
• Guidelines on mammography screening are controversial.
They are issued at different times by different authorities and
MAY analyze different data. The result is different
recommendations from various organizations. These will be
reviewed today.
• The recommendations presented by the different
organizations are for women at an average risk for breast
cancer. Women with risk factors may require more frequent
screening and women with a longer life expectancy may
choose to continue with screening beyond the upper age
recommendations presented today.
Bottom Line: Your best clinical judgment
must prevail.
USPSTF Grade Definitions
Grade
Definition
Offer or provide this service.
A
The USPSTF recommends the service. There
is high certainty that the net benefit is
substantial.
The USPSTF recommends the service. There
is high certainty that the net benefit is
moderate or there is moderate certainty that
the net benefit is moderate to substantial.
Offer or provide this service.
The USPSTF recommends against routinely
providing the service. There may be
consideration that support providing the
service in an individual patient. There is at
least moderate certainty that the net benefit is
small.
Offer or provide this service only if
other consideration support the
offering or providing the service in
an individual patient.
B
C
Suggestions for Practice
Assignment
USPSTF Grade Definitions (Cont.)
Grade
D
I statement
Definition
Suggestions for Practice
Assignment
The USPSTF recommends against the
service. There is moderate or high certainty
that the service has no net benefit or that the
harms outweigh the benefits.
Discourage the use of this service.
The USPSTF concludes that the current
evidence is insufficient to assess the balance
of benefits and harms of the service. Evidence
is lacking, or poor quality, or conflicting, and
the balance of benefits and harms cannot be
determined
Read the clinical considerations
section of USPSTF
Recommendations. If the service
is offered, patients should
understand the uncertainty about
the balance of benefits/harms.
USPSTF Breast Cancer Screening:
Summary of Recommendations (2009)
• Recommends biennial screening mammography for
women aged 50 to 74 years.
– Grade B Recommendation.
• Decision to start regular, biennial screening
mammography before age 50 should be individual one
and take patient context into account, including patient’s
values regarding specific benefits and harms.
– Grade C Recommendation
• Concludes current evidence insufficient to assess
additional benefits and harms of screening
mammography in women ≥ 75 years.
– Grade I Statement
Other Breast Cancer Screening
Recommendations
• ACOG 2011: recommends screening mammography every year
starting at age 40
• ACS 2003: Women at average risk should begin annual
mammography at age 40
• AAFP 2009:
– Mirrors USPSTF recommendation
• HEDIS/QHP
–Mammography every 2 years ages 40-69(2013)
–Mammography every 2 years ages 50-74(2014)
• Bottom Line: Certain patients will fall into a different screening
recommendation. Use your best clinical judgment.
Mammography
• Film versus digital
– Full-field digital mammography is similar to
traditional film-screen mammography except
that the image is captured by an electronic
detector and stored on a computer
– Studies show digital may be better in
accuracy for women with dense breasts and
pre/perimenopausal women but also
associated with a higher false positive rate
MRI
• May be considered for use in high risk
women
– Recommended by ACS in women with a
lifetime risk of >= 20-25%
• More sensitive, but also less specific
– More likely to detect an abnormality if one
exists
– More women with false positives
3D
Mammography/Tomosynthesis
• It is a modification of digital mammography
• Uses a moving x-ray source and digital detector
to provide data for computer-reconstructed thin
sections of images
• Only can be used in conjunction with
conventional mammogram
• Exposes the patient to 2x the radiation
• May be beneficial in women with dense breasts
• Not covered by most insurance at this time
Breast Ultrasound
• Used mainly as diagnostic follow-up of an
abnormal mammogram or physical exam
finding
Insurance Coverage for
Mammography
• While recommendations differ,
Medicare/Medicaid and other insurance
carriers will cover mammography annually
starting at age 40
• Low-income, uninsured or underinsured
women may qualify for free mammography
via the Illinois Breast and Cervical Cancer
Screening Program
– http://www.idph.state.il.us/about/womenshealt
h/owhmap.htm
Barriers for Patients
in Obtaining Mammogram
•
Patient misconceptions regarding risks
– “I don’t have a family history, so I’m not at risk”
•
Relying on patients to schedule mammogram
– Offer to schedule during rooming process
•
“Too busy”
– The Breast Center has early morning hours(7:30-5pm)/Saturday hours
– Offer to schedule 1-2 months out
•
Insurance coverage or no coverage
– Previous slide
•
Transportation
•
Other?
Clinical Breast Examination
(CBE)
• May identify 4.5 – 10.7% of breast cancers that
mammography misses
– Clinician proficiency impacts effectiveness
• High rate false positives
• Recommendations vary
– ACS and ACOG 2011 recommend one every 3 years
for average risk women ages 20-30; annually for
women > 40
– USPSTF 2010: current evidence insufficient to assess
additional benefits and harms of CBE beyond
screening mammography in women ≥ 40. Grade I
Statement
Breast Self-Examination (BSE)
• Recommendations vary
– ACS and others: teach women the procedure
to provide to them as an option
– USPSTF 2010 recommends against teaching
BSE.
Grade D Recommendation
• Not shown to have an effect on breast CA
mortality rate
The Breast Center
• Locations in Carbondale and Herrin
• Services offered at The Breast Center:
– Digital and 3D mammography
– Minimally invasive biopsy technique
– Risk assessment: Personal breast cancer risk
is estimated. Options for enhanced
screenings and/or prevention can be
evaluated.
– Genetic Counseling
– Breast MRI
The Breast Center
• Breast Cancer Care Team meets weekly
to review treatment planning for every
newly diagnosed cancer patient.
• Team: Surgeon, radiologist, medical
oncologist, pathologist, radiation
oncologist, and nurse navigator
The Breast Center
• Hours: 7:30-5:00pm and Saturday
appointments available
– Patients may be more likely to get the
screening performed if they can go before
work or on a Saturday.
• Only Medicaid patients need a order from
their provider to have a screening
mammogram
• Risk assessment and genetic counseling
require a referral
How are we currently doing on
Breast Cancer Screening?
Organization Performance
• Insert slide comparing your organization’s
performance to other organizations within
QHP. Explain any performance issues
related to data for your organization
Site Performance
• Insert the slide on the different facilities
within your organization
– Make sure to explain any data issues with
individual sites within your organization
Provider Performance
• Insert slide on provider performance
• Review performance issues that may be
related to data.
• Discuss what “best practices” may already
be utilized by some of the top performers
and where things are going well.
How can we do better?
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•
Add content to this slide for your organization’s ideas and implementation
plan to improve breast cancer screening rates and illicit suggestions from
the group at large.
Items to consider:
– How does mammogram data come into your EHR from the screening
center?
– Display of mammogram performance within the provider/staff area
during October
– Discussion at huddles/planning for the day. Gap report utilization
– How is data entered into the EHR at point-of-care? Is there standard
work for this process regarding who enters it and where it is entered
into the EHR?
– Utilization of the registry for outreach to patients overdue on
mammogram screening
– Patient education/displays for the month of October
• Waiting room, exam rooms – posters, weblinks, handouts
• T-shirts for staff