Personalized Breast Screening Service

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1 Frequently Asked Questions WHAT IS BREAST DENSITY? Breasts are made up of a mixture of fibrous, glandular and fatty tissue. Your breasts are considered if you have predominantly fibrous or glandular tissue and proportionately less fat (Illustration A). Breast density may decrease with age, however there is usually little change in most women. Having breast tissue may increase your risk of getting breast cancer. Dense breast tissue may cause increased difficulty in identifying a cancer on your mammogram. The only way to assess breast density is with mammography which reveals that 50% of women have breasts. These women might consider additional or adjunctive breast imaging to reduce the chance of early cancer going undetected at annual mammography. ILLUSTRATION A Radiologists classify breast density using a 4-level density scale WHAT IS THE NEW ARIZONA BREAST DENSITY LAW? The law requires that a health care institution or facility that categorizes a patient as having heterogeneously or extremely breasts based on breast image reporting and the data system (BIRADS) established by the American College of Radiology, must include the following in the summary of the mammography report sent to the patient: Your mammogram indicates that you have breast tissue. Dense breast tissue is common and is found in fifty percent of women. However, breast tissue can make it more difficult to detect cancers in the breast by mammography and may also be associated with an increased risk of breast cancer. This information is being provided to raise your awareness and to encourage you to discuss with your health care providers your breast tissue and other breast cancer risk factors. Together, you and your physician can decide if additional screening options are right for you. A report of your results was sent to your physician. This law will be in effect from October 1st, Almost entirely fatty Scattered fibroglandular Heterogeneously Extremely For more information regarding the etiology of this law please see the following link: HAPPYGRAM : 50% of women in the U.S. have breasts ] 10% of women have almost entirely fatty breasts ] 10% have extremely breasts Scattered fibroglandular 40% Almost entirely fatty NOT DENSE DENSE Heterogeneously 40% Extremely IS SCREENING DIGITAL MAMMOGRAPHY ENOUGH FOR WOMEN WITH DENSE BREASTS? Conventional mammographic screening is the only early cancer detection strategy that has been shown in randomized trials to reduce the chance of death from breast cancer. Fourteen of the more recently published studies, between 2001 and 2010, have shown a 25-50% reduction in breast cancer-related mortality for women aged years who had mammographic screening (Ref. 1). 10% 10% CONTINUED... Updated 12/14

2 Frequently Asked Questions (continued...) The American Cancer Society, the National Comprehensive Cancer Network, the American Congress of Obstetricians and Gynecologists, the American College of Radiology and other organizations recommend screening mammography annually for women older than 40 years. The Affordable Care Act, signed into law in 2010, mandated insurance coverage of annual mammograms for women commencing age 40. Digital mammography is less effective at finding cancers in women with breasts as the superimposition of breast tissue can obscure cancers or make normal structures appear suspicious. This reduction in sensitivity and specificity for the detection of breast cancers is more pronounced as breast density increases (Illustration B). Breast density is assessed by your radiologist, at the time of your screening mammogram, using the breast image reporting and the data system (BIRADS), developed by the American College of Radiology. 50% of women have breasts. In these women, adjunctive imaging might be considered to increase the likelihood of detecting early cancers. Adjunctive imaging may however, also result in additional costs, unnecessary anxiety and biopsies, which must be taken into consideration. For more information regarding recent controversies about screening mammography please see the following link Mammograms Save Lives Opinion WSJ: mammogramssavelives.pdf WHAT ADJUNCTIVE IMAGING OPTIONS ARE AVAILABLE FOR WOMEN WITH DENSE BREASTS? 1. 3D Mammography (Tomosynthesis): Tomosynthesis takes multiple x-ray images of the compressed breast using different projections, and from this data reconstructs multiple thin images representing the breast volume. These images are then dynamically viewed by your radiologist, one after another, like a movie. Tomosynthesis helps to increase the conspicuity of cancers by removing the layers of overlapping breast tissue that occur with conventional digital mammography. It is most effective in breasts of mixed density as we see in women with heterogeneously breasts (Illustration C). Tomosynthesis detects on average an additional 1.9 cancers per 1000 screens when used in addition to digital mammography (Ref. 2-4). To put that into context, screening digital mammography alone, detected 5.2 cancers per 1000 screens in the same studies. The use of tomosynthesis in addition to screening digital mammography does increase the radiation dose to the breasts by a factor of 2. The total combined dose however, is still below the U.S. Food and Drug Administration (FDA) radiation dose limits allowed for mammograms and is similar to the dose patients received before the introduction of digital mammography. The radiation dose of a digital mammogram examination is however negligible, being equivalent to that received from normal background radiation over a period of two months. To see an illustration on how 3D mammography works, go to this YouTube link: How 3D Mammography Works :

3 Frequently Asked Questions (continued...) 2. Bilateral Whole Breast Sonography: Ultrasound (sonography) uses sound waves to image the breast. Ultrasound does not require compression of the breast, nor an intravenous injection of contrast. Bilateral whole breast sonography has been extensively evaluated as a potential screening test. In women with breasts, screening ultrasound detects additional cancers to those discovered with digital mammography. The number of new cancers found, is similar to that seen with 3D mammography. Unfortunately, employing ultrasound as a screening tool increases the number of unnecessary biopsies to an unacceptable level (Ref. 5). For this reason ultrasound is not used in the general population as a screening test. Ultrasound does however have a limited role in a more select population of women with extremely (solid fibrous) breasts. In these women the conspicuity (contrast resolution) of cancer (which appears black) is greatest, as the background breast parenchyma is white (Illustration D). Both conventional digital mammography, and 3D mammography (tomosynthesis) use X-rays to detect cancer. X-rays have a reduced ability to detect cancer in solid breasts due to poor conspicuity (contrast resolution) between the cancer and surrounding breast tissue. Both the cancer and the breast tissue are white on an X-ray image (Illustration B). Ultrasound is the adjunctive imaging of choice in some patients with implants, as occasionally implants can prevent adequate mammographic visualization of breast tissue. 3. Bilateral Breast Magnetic Resonance Imaging: Breast MRI is our most sensitive tool for the detection of breast cancer. Across 9 scientific studies MRI detected an additional 11 cancers per 1000 screens in high risk women (Ref. 6). Its performance is not affected by breast density nor the presence of breast implants. It is not associated with X-ray radiation, however, MRI does require an intravenous injection of contrast. MRI is indicated in women who are at high risk for breast cancer, as determined by their personal and family history. At Radiology Ltd. all patients referred for screening have their breast cancer risk estimated using the Tyrer-Cuzick statistical model as part of our Personalized Breast Screening Service. A woman with a greater than or equal to 20% lifetime risk of breast cancer, is considered at high risk. The American Cancer Society recommends annual breast MRI for women at high risk for breast cancer, in addition to mammography. DO I HAVE A CHOICE REGARDING ADJUNCTIVE IMAGING? Women with breasts or a high lifetime risk of breast cancer should discuss adjunctive breast imaging with their healthcare provider. Together you can decide which, if any, adjunctive imaging is right for you. You might also consider contacting our Patient Education Specialist, Marghi. Please refer to page 5 for her information. Conventional screening with digital full field mammography is the only early cancer detection strategy that has been shown in randomized trials to reduce the chance of death from breast cancer. Adjunctive imaging does identify additional early cancers which will likely save lives, however, there is no specific scientific evidence to support this currently. Adjunctive imaging may also result in additional costs, unnecessary biopsies and associated anxiety, which must be taken into consideration.

4 WHY IS IT IMPORTANT TO ASSESS LIFETIME RISK FOR BREAST CANCER? Breast cancer risk assessment identifies the small percentage of women who are at high risk for breast cancer and may not be aware of it. Personal and family history is incorporated into the Tyrer-Cuzick statistical model for all women referred to our Personalized Breast Screening Service at Radiology Ltd. The Tyrer-Cuzick model estimates the percentage chance the patient will develop breast cancer in her lifetime. A greater than or equal to 20% lifetime risk of developing breast cancer is considered high risk. Women at high risk should be offered more intensive high risk screening and may benefit from other options such as preventative surgery and chemoprevention. GENETIC COUNSELING FOR HEREDITARY BREAST AND OVARIAN CANCER SYNDROME (BRCA GENE) HAS BEEN RECOMMENDED. WHAT DO I DO NEXT? Genetic counseling for Hereditary Breast and Ovarian Cancer Syndrome is recommended in women who have an unusually strong personal and/or family history of breast and/or ovarian cancer as outlined by the USPSTF guidelines released in December Genetic counselors examine your family history in detail and help you decide if testing for the BRCA or other high risk genes is appropriate for you. A positive test for a high risk gene has important implications for you and your family. We advise you discuss our recommendation with your doctor to ensure this test is right for you. SUMMARY 50% of women have breasts. Conventional digital mammography may not detect an early cancer in breasts. Women with breasts could consider adjunctive imaging to increase the likelihood of detecting a cancer when it is small. 3D mammography (tomosynthesis) is the adjunctive imaging test of choice in the vast majority of cases. Breast MRI is indicated in women who are assessed to be at high risk for breast cancer. REFERENCES 1. Coldman A, Phillips N. Population studies of the effectiveness of mammographic screening. Prev Med. 2011;53(3): Friedewald SM, Rafferty EA, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA June 25;311(24): Skaane P, Bandos AI, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population based screening program. Radiology April;267(1): Ciatto S, Houssami N,et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol Jun;14(7): Berg WA, Zhang Z, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA April 4;307(13): Berg WA. Tailored supplemental screening for breast cancer. AJR 2009;192(2):

5 Patient Care Meet Marghi! Radiology Ltd. is pleased to announce we now have a Patient Education Specialist for Women s Imaging, who will be solely dedicated to support you and your patients. As your Patient Education Specialist, Marghi brings a wealth of knowledge to both patients and the referring physician community. Having worked at our Wilmot Center for Women s Imaging for more than eight years, she says, Often times, patients have questions about our recommendations or reports, or want more information about the different technologies, or just don t know what to expect. We want to empower patients to have a full understanding of our recommendations, so that, in consultation with their doctors, they can make informed decisions about their health care. If you have questions and would like to speak with Marghi, she can be reached at (520)

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