Learning Objectives. Breast Density, Risk Assessment and Supplemental Screening Options. Breast Density. What is Breast Density??

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1 , Risk Assessment and Supplemental Screening Options ASCLS ND Convention May 2016 Christina Tello Skjerseth, MD Sanford Health Bismarck Radiology Learning Objectives Understand what breast density is and the breast imaging screening implications. Identify and describe the various types of supplemental breast cancer screening options available. Understand what constitutes high risk breast cancer screening and the specific patient criteria that need to be met. What is?? Measure used to describe the proportion of the different tissues that make up a woman s breasts. Breasts are made up of fat and fibroglandular tissue. NOT a measure of how the breasts feel, but rather how the breasts look on a mammogram. Look for heterogeneously dense or extremely dense in the body of the radiology report, which will classify patient as having dense breasts. 50% of women have dense breasts NOT a major risk factor for breast cancer NOT clear that lowering breast density will decrease risk Getting older and gaining weight after menopause are both related to a decrease in breast density, but are also related to an increase in breast cancer risk 1

2 Sensitivity of mammography is reduced as background breast tissue density increases Harder to see abnormalities (masking) May delay finding cancer and treatment When mammography is the only screening test performed, sensitivity decreases by 10 20% for women with dense breasts Breast density is not a major cancer risk factor 10% of all women have extremely dense breasts relative risk of ~ 2 compared with average breast density (similar to having 1 st degree relative with post menopausal breast cancer) 40% of women have heterogeneously dense breasts relative risk of ~1.2 Legislation Growing concern regarding accuracy of mammography for dense breasts Multiple advocacy groups dense breast notification laws May seem helpful but there are no universally accepted special recommendations or screening guidelines for women with dense breasts. When Legislation Precedes Science Which supplemental screening test to order? Will supplemental screening reduce breast cancer mortality? Will take 15+ years to answer Patients and legislation not willing to wait Who will pay??? What is the cost burden to healthcare system? Sanford s Response Dense breast notification laws in ND (2015) and MN (2014) Sanford in 2014 began informing all women enterprise wide if they have dense breasts on screening mammography Those interested in additional screening should get a breast cancer risk assessment Good starting point in the discussion of whether supplemental tests will be beneficial and what tests, if any, to order 2

3 Optimal Supplemental Screening Test Sensitive even in dense breasts Low false positive rate Reasonable cost No/low radiation exposure Widely available Easy/quick to interpret Acceptable to patients No single test meets all these criteria Supplemental Screening Options Bilateral Whole Breast Ultrasound (SOFIA 3D) Digital Breast Tomosynthesis (3D Mammography) Molecular Breast Imaging (MBI) Breast Specific Gamma Imaging (BSGI) Contrast Enhanced Digital Mammography (CEDM) Breast MRI ***May be an out of pocket cost *** SOFIA 3D Breast Ultrasound The ivu SOFIA Automated Whole Breast Ultrasound Tomography System Acquires 2D and 3D images of the entire breast in 2 3minutes per breast If an abnormality is identified, patient may be called back for a diagnostic targeted ultrasound performed the standard way Great for dense breasts, young women and those with radiation concerns High false positive biopsy and short term follow up rates Increased patient anxiety 3D Mammography FDA approved for screening and diagnostic use in February 2011 Typically used in conjunction with 2D mammo Same exam experience as 2D X ray arm moves in arc over breast generating slices that computer stacks for scrolling through thin slices instead of one flat 2D image 3 4 seconds per view (2 views per breast, CC and MLO) 3

4 3D Mammography Virtually eliminates detection challenges associated with overlapping structures in the breast (primary drawback of 2D mammo) Considerable reduction in recall rates (20 40%) Extra mammography views, ultrasound, anxiety Increase in overall cancer detection (27%) including invasive cancer (40%) 10 year survival rate is >90% if early detection 3D Mammography Digital Mammography Limitations Mammography With Digital Breast Tomosynthesis (DBT) DBT minimizes the effects of overlap by allowing visualization of tissue within the breast. Lesion superimposed on DM Lesion obscured due to superimposition on DM DM DBT Lesion isolated in DBT 3D Mammography Summary Increased sensitivity Earlier cancer detection Smaller tumor size at detection Earlier and more effective disease management Reduction in unnecessary false positives Lower recall rates Reduction in patient anxiety Reduction in healthcare costs Cons: radiation, increased interpretation time 3D Mammography at Sanford Sanford Bismarck Recommendations Any woman may get it for screening All Diagnostic mammography (callbacks, palpable lumps, focal pain, biopsy or surgical follow up, cancer follow up) Palpables and focal pain also need ultrasound 4

5 3D Mammography at Sanford Sanford Bismarck Recommendations Screening Triage Dense breasts Women younger than 50 years old Specific patient request Intermediate risk patients Inconclusive evidence for Breast MRI Lifetime risk 15 20% History of breast/ovarian cancer History of breast atypia Family history BSGI and MBI Nuclear medicine Radiotracer given IV Tracer accumulates in metabolically active cells Detector(s) detect radiation form the radiotracer and create images Not affected by density Routine mammo views 2 views per breast, 10 minutes per view Great for patients with MRI contraindication or equivocal findings MBI and BSGI MBI Two head detector Reduced dose Tracer and radiation =4 mammograms Quick interpretation No biopsy capability BSGI Single head detector High dose Tracer and radiation =8 mammograms Quick interpretation Biopsy capability Contrast Enhanced Digital Mammography CEDM combines the high sensitivity of contrast enhanced MRI and the fast/cheap advantages of mammography Dual energy subtraction technique Work in progress, research phase, looks promising No current biopsy capability Higher radiation (similar to DBT) IV contrast 5

6 Breast MRI Highly sensitive tool providing very detailed images compared with other imaging modalities Breasts, chest wall, axilla, liver, lungs Contrast injection No radiation Long exam time Claustrophobia Long interpretation time High recall rate $$$$$$ Screening Breast MRI Women with high risk (greater than 20% lifetime risk) of breast cancer Breast MRI AND a mammogram every year regardless of breast density Not recommended for screening the general low or average risk population even if they have dense breasts Defining the High Risk Threshold High risk: >20% lifetime risk Intermediate risk 15 20% lifetime risk Low risk <15% lifetime risk Many risk assessment models/calculators Age, family history, ethnicity, density, biopsy history High Risk Screening Breast MRI Criteria Lifetime risk greater than 20 25% (based on BRCAPRO model dependent on family history) BRCA 1 or 2 carrier Untested first degree relative of BRCA carrier Chest radiation between ages 10 and 30 Syndrome with high risk of breast cancer (Cowden s, Li Fraumeni, etc.) and first degree relatives Intermediate Risk Criteria Lifetime risk 15 20% (based on BRCAPRO modeldependent on family history) Personal history of breast cancer (invasive or DCIS) Personal history of high risk, non cancerous lesions (ADH, LCIS, ALH) Dense breasts May still consider screening MRI Inconclusive evidence Screening with Mammo and MRI Staggering mammo and MRI every 6 months may reduce the rate of interval cancers Performing both exams on the same day annually allows both tests to be interpreted together No data to support one vs. the other approach 6

7 Diagnostic Breast MRI Staging of known breast cancer Evaluating for residual disease after a lumpectomy Problem solving or next step following an abnormal mammogram or physical finding and a negative ultrasound exam Assessing for silicone implant rupture Assessing response to chemotherapy Why do I still need a mammogram?? Only breast cancer screening modality proven to reduce breast cancer mortality Randomized controlled trials Gold standard No test is perfect May be the only positive exam Supplemental screening Only modality to see calcifications reliably Early cancer, small cancer, DCIS Summary 50% of women have dense breasts may make it harder to see cancer on mammo Many options for supplemental screening Availability, insurance coverage No national consensus or long term data Individualized medicine/screening: risk based approach to shared decision making No one size fits all for breast cancer screening No test is perfect Get your annual mammogram! Thank you! Questions??? For more information: 7

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