The EBM of Screening for Breast Cancer: What do I recommed? Elena Bissell

Transcription

1 The EBM of Screening for Breast Cancer: What do I recommed? Elena Bissell

2 It is Friday am and one of your favorite patients, Mrs. Ponce comes in with her husband. Her chief complaint is wants a mammogram

3 Mrs. Ponce is a 45 year old female. She has hypothyroidism controlled with levothyroxine 75mcg. She is otherwise healthy. Her only surgery was a tubal ligation. Her family medical history is positive for diabetes, HTN and CAD. She has no hx of breast cancer in her immediate family (sisters/mother).

4 PICO Question Patient-45 yo female with average risk factors for breast cancer Intervention-mammogram for breast cancer screening Comparison-no mammogram Outcome-decrease in morbidity/mortality and effect on QOL

5 In 2011 the USPTF came up with new recommendations that had some people up in arms: * The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation. * The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation. * The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement. * The USPSTF recommends against teaching breast self-examination (BSE). Grade: D recommendation. * The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement. * The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

6 American Cancer Society Guidelines for the Early Detection of Cancer * Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health * Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over * Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-exam (BSE) is an option for women starting in their 20s. Some women because of their family history, a genetic tendency, or certain other factors should be screened with MRI in addition to mammograms. (The number of women who fall into this category is small: less than 2% of all the women in the US.) Talk with your doctor about your history and whether you should have additional tests at an earlier age.

7 Detailed ACR (American College of Radiologists) Statement on Ill Advised and Dangerous USPSTF Mammography Recommendations Mammography screening for women ages 40 and above is one of the major health care advances of the past 40 years. With the onset of mammography screening, the death rate from advanced breast cancer, that had been unchanged for the preceding 50 years, has decreased by 30 percent since Moreover, early mammography screening means cancers can be caught sooner, often allowing women to choose less invasive treatments that help to preserve the quality of women s lives as well. Newly revised U.S. Preventive Services Task Force (USPSTF) recommendations could reverse this decline in breast cancer morbidity and mortality, causing undue suffering to women facing breast cancer and their families. In a decision that dismisses thousands of scientific studies and data analysis, ignores the physical and psychological harms of the more aggressive treatment required for advance cancers, and prioritizes dollars saved over lives saved the AHRQ-supported taskforce rescinds recommendations for regular mammography screening for women years of age and those over 74, and reduces the frequency of screening from annually to every other year for women between 50 and 74.

8 Search: screening, breast cancer, mammogram Gotzsche PC, Nielsen M. Screening for breast cancer with mammography (Review) Cochrane Review. The Cochrane Library, 2011, Issue 4

9 Validity Review addressed the effect of breast cancer screening utilizing mammography on mortality and morbidity. Outcomes: mortality from BC,other mortality, use of surgical interventions, adjuvent therapy, harms of mammography

10 Authors searched PubMed utilizing Mesh tool and author search. Latest search in No language restrictions Each author (2) looked at trials independently

11 Inclusion criteria Randomized clinical trials-8 were included Three trials deemed to have adequate randomization received intention to treat analyses. 4 trials with suboptimal randomization was included for data. One trial not adequately randomized and was only included in one graph for completeness

12 Multiple trials: 8 were accepted Multiple age ranges-combined Mammogram per defined interval (ranged among studies) vs no mammogram. Women in control group were offered mammogram if breast cancer became suspected and after studies were complete.

13 Results The 3 trials with adequate randomization did not show significant reduction in breast cancer mortality at 13 years. RR 0.9, 95% CI 0.79 to The four trials with suboptimal randomization showed a significant reduction with RR 0.75, 95% CI 0.67 to Combined RR was 0.81 with CI of 0.74 to 0.87 Studies were varied on Age, screening intervals

14 Other outcomes Increased surgery rate in study groups compared to controls Increased radiation therapy No studies included psychological morbidity

15 Authors Conclusion Screening with mammography does reduce mortality: ARR of 0.05%. Screening led to 30% overdiagnosis and overtreatment or ARI of 0.5%. Every 2000 women screened in 10 years one will have decreased mortality and 10 will be treated unnecessarily.

16 Problems: Assessing mortality Postrandomization-exlusion of women who already had breast cancer at entry Trials heterogenous in age and screening intervals

17 Applicability The study was similar to my patient in gender/age and mammogram screening. Duration of follow up was 7 and 13 years Pt outcomes including psychological effects of false positives were not reported in trials.

18 Risk of breast cancer in US according to CDC Percent of U.S. Women Who Develop Breast Cancer over 10-, 20-, and 30-Year Intervals According to Their Current Age Current Age 10 years 20 years 30 years

19 What do I tell Mrs. Ponce? Assessing her risk Risks vs Benefits

20 A way to look at this patient s risk So her chance of dying of breast cancer in the next 10 years is 0.42%. So she has a 99.58% chance of not dying of breast cancer in the next 10 years. If she gets screened, supposing the most optimistic estimates, it will decrease her risk of dying from breast cancer from 0.42% to 0.357% (15% RRR) or instead of having a 99.58% chance of not dying of breast cancer in the next 10 years, she will have a % chance of not dying of breast cancer.

21 Questions?

22 References U.S. Preventive Services Task Force. Screening for Breast Cancer: Clinical Summary of U.S. Preventive Services Task Force Recommendation. AHRQ Publication No EF-3, November CDC Breast Cancer Risk by Age. Accessed 9/23/2012. Detailed ACR Statement on Ill Advised and Dangerous USPSTF Mammography Recommendations. November 16, 2009 GotzschePC, Nielsen M. Screening for breast cancer with mammography (Review) Cochrane Review. The Cochrane Library, 2011, Issue 4

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