Transcript Breast Density-Black, White and Shades of Gray | Jennifer Rusiecki

Breast Density:
Black, White and
Shades of Gray
Jen Rusiecki, MD
VA Pittsburgh Health System
Women’s Health Fellow
AMWA Hot Topic 2016
Janice
Janice is a 60 year old patient of
yours who comes to your office
to talk to you about a notification
she received in the mail.
She recently had her screening
mammogram done and received
a letter stating that she had
“heterogeneously dense breasts”
and recommending she discuss
supplemental screening with you.
She is confused about what this
means…
What is the next step for Janice’s
breast cancer screening?
A.
B.
C.
D.
E.
Digital mammography with tomosynthesis
Ultrasonography
Magnetic resonance imaging
Yearly screening mammography
Further risk stratification
Breast Density: Why Do We Care?
• Breast density makes screening more
complicated
– Decreased sensitivity with mammography
– Increased recall rates
• Breast density is an independent risk factor for
breast cancer
• 40% of women 40 to 74 have dense breasts
NOT DENSE
A
Machida. Breast Cancer. March 2015
B
DENSE
C
Sprague, Ann Internal Med 2015
D
BI-RADS 5th ed 2013
Breast Density: Timely but
Controversial
• Legislation enacted in 24 states
– Requiring notification of women with dense
breasts of their breast density
– Additional state and federal legislation
proposed
– Notification also tells patients: discuss
supplemental screening with physician
• Unclear what “supplemental screening”
should be
BSCS Risk Score
• Components:
–
–
–
–
–
–
Prior cancer or DCIS history
Age
Race
History in 1st degree relatives
Prior biopsy
Breast density
• 5 yr risk:
–
–
–
–
Low < 1%
Average 1 – 1.66%
Intermediate 1.67-2.49%
High > 2.5%
BSCS Score and Invasive Cancer
Invasive Cancer Cases (95% CI) per 1000 Women
BSCS Score
Almost Entirely
Scattered
Fat
Fibroglandular
Densities
Heterogeneously
Dense
Extremely
Dense
Low (00.99%)
0.14 (0.060.26)
0.21(0.14-0.31) 0.63 (0.46-0.84)
0.72 (0.331.37)
Average (1.01.66%)
0.31 (0.130.65)
0.03 (0.270.52)
0.58 (0.44-0.76)
0.89 (0.541.37)
Intermediate
(1.67-2.49%)
0.48(0.13-1.22) 0.43 (0.290.61)
0.83(0.66-1.03)
1.17 (0.681.87)
High (>2.5%)
0.90 (0.621.25)
1.48 (1.2-1.81)
1.62 (1.082.34)
Kerlikowske, Annals of Inter Med, 2015
BCSC Score and Imaging
Supplemental
Imaging
Discussion
Interval
cancer cases
Discussion/Int
erval Cancer
All with heterogeneously or
extremely dense
100,00
89
1124
All with extremely dense
16,956
19
892
50-74 y with extremely or 70-74 13,470
y with heterogeneously dense
16
842
Risk ≥1.67% and extremely
dense or risk≥ 2.5% with
heterogeneously
24,412
35
694
40-74y with extremely or 4049y with heterogeneously
46,412
41
1132
Risk ≥1.67% and
heterogeneously or extremely
dense breast
48,722
56
870
Strategy
Kerlikowske, Annals of Inter Med, 2015
Supplemental Screening Options
• Digital mammography with tomosynthesis
• Ultrasonography
• MRI
Head to Head Comparison
Breast cancer detection rates of supplemental screening
Recall Rates:
US 14%
MRI 12-14%
DBT 7-11%
PPV:
US 3%
MRI 3-30%
Melnikow, Annals Inter Med, 2016
Tomosynthesis Improved Mammography
Performance: Friedewald et al
Rates per 1000
cases
Digital
Digital
Mammography Mammography
Alone
+ Tomo
Percent
Change
P value
Recall
106
89
-17
<0.001
Biopsy
18
19
0.9
0.004
Cancer
Detection
4.3
5.5
1.2
<0.001
Invasive Cancer
2.9
4.1
1.2
<0.001
DCIS
1.4
1.4
0
0.95
Supplemental Digital Mammography
with Tomosynthesis
• Advantages
– Decreased recall rate
– Increase in cancer
detection rate
– Improved positive
predictive values for
recall and biopsy
– Cost effective
Friedewald. JAMA. 2014
Lee. Radiology. 274(3)
McCarthy JNCI. 2014
• Disadvantages
– May increase radiation
dosage patient receives
– May require new
equipment/training for
techs and radiologists
Supplemental Ultrasonography
• Potential Advantages
– Non-invasive
– Low risk procedure for
patients (no radiation)
– Minimal improvement in
screening with
additional gains in
cancer deaths and QALYs
compared to
mammography alone
Sprague. Annals of Internal Medicine 2015
• Disadvantages
– Cost effectiveness data:
>$100,000 per QALY
gained
– High false positive rate
– Low positive predictive
value
Supplemental MRI
• In average risk women, no studies address MRI in
women with dense breasts specifically
– In contrast to women with increased risk (Gail score
>20%) in which MRI is recommended
• High false positive rate, low PPV
• Expensive
• Requires contrast which may be poorly tolerated by
patients
Freer, Breast Imaging, 35(2)
Clinical Recommendations
Breast density alone should not prompt the need for supplemental
imaging
Screening mammogram at age 40 (or 45) and calculate BSCS Score
• Dense breast:
– If score >1.65% and extremely or >2.5% and heterogeneously dense
breast discuss supplemental screening with tomosynthesis
• Normal breast density:
– Engage in shared decision making about further screening frequency
– Screening mammogram at age 50 and continue every other year
Ultrasonography and MRI are not cost effective with high false
positives and low PPV
What is the next step for Janice’s
breast cancer screening?
A.
B.
C.
D.
E.
Digital mammography with tomosynthesis
Ultrasonography
Magnetic resonance imaging
Yearly screening mammography
Further risk stratification
What is the next step for Janice’s
breast cancer screening?
A.
B.
C.
D.
E.
Digital mammography with tomosynthesis
Ultrasonography
Magnetic resonance imaging
Yearly screening mammography
Further risk stratification
Acknowledgments
• Dr. Rohr-Kirchgraber
• Dr. McNeil
• Drs. Karmo and Mieczkowski
Breast Density:
Prevalence and Risk
BI-RADS
BREAST
DENSITY
Almost entirely
fat
Scattered
fibroglandular
densities
Heterogeneously
dense
PREVALENCE (PERCENT)
RELATIVE RISK FOR BREAST
CANCER
Age <50
Age >50
Age <50
Age>50
4.3
10.2
0.49
0.59
34.3
49.0
1.00
(reference)
1.00
(reference)
47.0
35.5
1.55
1.46
14.4
5.3
2.00
1.77
Extremely dense
Sprague, Ann Internal Med 2015
USPTSF Guidelines 2015
• Current evidence is insufficient to assess the
benefits and harms of adding tomosynthesis
to conventional screening mammography
• For women with radiologically dense breast,
current evidence is insufficient to assess the
benefits and harms of adjunctive ultrasound,
MRI or tomosynthesis
States with Mandatory Notification
Head to Head Comparison
Supplemental
Imaging Mode
Sensitivity
Specify
PPV
Cancer Detection
(per 1000 women)
Recall
Rates
Ultrasound
80-83%
86-94%
0.03
4.4
14%
MRI
75-100%
78-94%
0.03-0.33
3.5-28.6
12-14%
Tomosynthesis
93%*
70%*
0.35*
5.4-6.9
7-11%
*
G
i
l
b
e
r
Ultrasound vs MRI
Sensitivity: US 80-83%
MRI 75-100%
Specificity: US 86-94%
MRI 78-94%
PPV: US 0.03
MRI 0.03-0.33
Tomosynthesis Improves
Mammography Performance
• European prospective studies (Skaane et al &
Ciatto et al)
– Improved invasive cancer detection
– Reduced false positive rate
– Reduced recall rate
• Observational studies in United States (McDonald
et al)
– Reduced recall rate
– Recalled patients were more likely to have invasive
cancer