Transcript Screening for breast cancer

Dr. Julia Flukinger
Breast Radiologist,
Director Breast MRI,
Advanced Radiology
[email protected]
May 21, 2106
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Breast density on mammography
Tomosynthesis (3D mammography)
What does cancer look like?
current recommendations for screening
Should I undergo supplemental screening tests?
Screening recall 11 cancer!
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Breasts are composed of glandular, fibrous supportive tissue, fat
and ductal structures.
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Defined by mammogram
Glandular + fibrous supportive tissues = dense
Individuals have different proportions of fat and fibroglandular
tissues, leading to different appearances on mammography.
We assign 1 of 4 density categories to each patient’s
mammogram:
Almost entirely fat
 Scattered fibroglandular elements
 Heterogeneously dense
 Extremely dense
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Masking
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Higher risk of cancer in dense breasts?
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The density of cancer is similar to fibroglandular tissue
The cancer may not be visible because it blends in with the background
Most data shows no significant difference
Maryland is one of 24 states which have enacted legislation
requiring patients be informed of their breast density
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Patients are told they are “dense” or “not dense”
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Accuracy of density categorization
Not a precise measurement
 Gives an idea of what the picture looks like
 Based on the radiologist’s judgement
 Can change over time in an individual
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Is this law a good idea?
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My opinion: it causes more confusion for patients
There are no official recommendations about what to do with the
information
• 3D mammogram
• You can choose to
have this for your
regular screening
exam instead of 2D.
• The radiologist may
use this during your
diagnostic exam.
• Digital
• Tomosynthesis
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Strengths
Slightly increased sensitivity
for subtle cancers
 Slightly decreased callback rate
 Same radiation amount as 2D
digital mammography *
 Most helpful in dense and
extremely dense breasts
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Weaknesses
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Limited insurance coverage;
may need to pay out of pocket
Limited number of machines;
may need to wait
Bad for calcifications
Take longer to interpret
Learning curve for radiologists
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Most cancers can be seen on 2D
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*as of January 2016, true in our practice but not for many private practices at this time.
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In the 1980’s, mammography was shown to detect breast cancer
before it could be felt, leading to earlier treatment and reduced
number of deaths.
One of the best studied tests
Proven to reduce death from breast cancer
All women 40 and over should have yearly screening
mammograms.
Organization
Age
Frequency
USPSTF
50-74
Biennial
ACS
45-54
Annual
55 +
Biennial
ACR
40 +
Annual
SBI
40 +
Annual
NCCN
40 +
Annual
ACOG
40 +
Annual
AMA
40+
Annual
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Data shows most lives saved when screening is done each year
starting at age 40
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“risks” listed are not true risks.
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“anxiety” is not as important as finding a cancer
No breast cancer experts included in decision making
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6500 extra lives lost if the recommendations are followed
30% of cancers would be missed if screening is done every other year
Experts consider these recommendations “disastrous”
USPSTF may cause loss of insurance coverage
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Mammography 0.4 mSV
Tiny dose with very little
scatter to other body parts
Mammography does not
cause cancer!!
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Images heat given off by breasts
In theory, cancer should give off more heat
The technology has been studied and does not detect breast
cancer effectively
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It was abandoned by the scientifically-driven medical community
Still offered by some “holistic doctors”
Plays on irrational fears of radiation
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Not a substitute for mammography; must do both
Shown to detect a few more cancers than
mammography alone in dense, high risk patients
…but there were many false positives
Additional follow-ups of nodules
 Biopsies which showed no cancer
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Images inconsistency one year to next
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In contrast to mammography which is more consistent
No picture record of whole breast
Very tedious
Often not covered by insurance
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Performed in addition to mammography each year
Most sensitive imaging test for breast cancer
Sometimes “opens a can of worms,” leading to more biopsies and
followups
Very expensive, not covered for most patients
Uses intravenous contrast agent
Currently used to screen very high risk patients
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BRCA 1 : 80% lifetime risk
BRCA 2 : 40% lifetime risk
Others
An abbreviated screening protocol is being studied which is faster
and less expensive.
2010
2014
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This is part of the normal process of looking for breast cancer
Most “callbacks” do NOT lead to a cancer diagnosis
When you come back you will have a “diagnostic” exam,
tailored by the radiologist to your finding
The radiologist will be there to interpret the images, decide if
any additional views or ultrasound is needed, and provide
same-day results
The radiologist may or may not come speak with you, but you
can ask to speak to him or her if you have more questions about
your finding.
2015
2014
1000 Screening Mammograms
100 Callbacks (BIRADS 0)
56 Resolved
(normal or
benign)
25 need
followup
(probably
benign)
19 need a
biopsy
13 benign
6
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Get a yearly mammogram starting at age 40. The ACS and
USPSTF recommendations are wrong.
Mammography saves lives—scientifically proven!
Recall from screening mammogram
cancer diagnosis!
Radiation from mammography is insignificant and does not
cause cancer.
If you are at very high risk of breast cancer, you should get a
yearly mammogram + breast MRI.
If you might be at high risk, ask your doctor about risk
assessment or genetic counseling, to determine if you should get
MRI + mammo.
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Dense breasts are normal
Dense tissue can cause mammography to be a little less sensitive
for breast cancer.
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For many “dense” women, it does not significantly limit the exam
If your breasts are “dense” and you would like to do something
additional to screen for breast cancer, then tomosynthesis (3D
mammography) is the best choice over ultrasound and MRI.
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www.mammographysaveslives.org
www.breastdensity.info
www.sbi-online.org