2015 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations

Transcription

1 2015 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations The decision to start screening mammography in women before age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms, may choose to begin screening every 2 years between the ages 40 and 49 years. (Grade C Recommendation) Siu et al, Ann Intern Med.2016;164:

2 2015 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations Recommends screening mammography every 2 years for women ages 50 to 74 years (Grade B Recommendation) Siu et al, Ann Intern Med.2016;164:

3 2015 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations Insufficient evidence to assess the balance of benefits and harms of: Screening mammography in women age 75 years or older Digital breast tomosynthesis (3D mammography) as a primary screening method for breast cancer Adjunctive screening with ultrasound, MRI, 3D/tomosynthesis or other methods for women identified with dense breasts but a negative mammogram Siu et al, Ann Intern Med.2016;164:

4 American Cancer Society Guideline for Breast Cancer Screening 2015

5 MD Anderson s response to new ACS Breast Cancer Screening Guidelines Crafted and approved by the MD Anderson Breast Cancer Screening guideline panel convened on 10/19/15 MDA continues to recommend that women at average risk for breast cancer obtain Annual screening mammogram Clinical breast exam beginning at age 40 Continuing as long as she has a 10 year life expectancy.

6 MD Anderson s response to new ACS Breast Cancer Screening Guidelines The ACS breast cancer screening recommendations affirm the importance of annual mammography screening beginning in the 40s and starting screening mammograms at age 40 is stated as an opportunity. Annual mammographic screening at all ages yields a larger mortality reduction than does biennial.

7 MD Anderson s response to new ACS Breast Cancer Screening Guidelines The clinical breast exam will remain as part of practice (no new data to support a change in practice recommendations). We feel strongly that the clinical encounter is critical to ensure that activities such as risk assessment and healthy lifestyle recommendations are conducted.

8 MD Anderson s response to new ACS Breast Cancer Screening Guidelines Patients should be informed of emerging screening technology that has fewer drawbacks such as decreasing false positive results (e.g., tomosynthesis).

9 MDACC Position on ACS Guidelines If considered as stated, ACS guidelines are similar to MDACC Breast Cancer Screening recommendations and are very divergent from USPSTF current and draft guidelines. If one combines ACS strong and qualified recommendations, it is annual screening beginning at age 40 It is important to understand what Qualified Recommendation means to a patient The majority of individuals in this situation would want the suggested course of action, but many would not. The designation of qualified provides latitude in the recommendations

10 MDACC Comments on ACS Guidelines Reaffirm that breast cancer screening is associated with fewer women dying of breast cancer Support that annual screening yields a larger mortality reduction Support annual screening for women in their 40s (specifically, age 45 but note that women should have the opportunity to begin at age 40) Support screening for women 70 and older who have a 10 yr life expectancy This recommendation has been part of MDACC Breast Cancer Screening guideline for a number of years Confirmed gross uncertainty of overdiagnosis/overtreatment issue. Endorsed insurance coverage for screening at all ages and intervals (not just USPSTF A or B) Affirm the importance of patient involvement in informed decisionmaking

11 Breast Cancer Screening Recommendations-MDACC For average risk women: Beginning at age 40 Annual clinical breast exam Annual screening mammogram

12 Breast Screening Considerations- MDACC Breast cancer screening may continue as long as: A woman has a 10-year life expectancy No co-morbidities that would limit the diagnostic evaluation or treatment of any identified problem Women should be counseled about the benefits, risks and limitations of breast screening

13 Breast Cancer Screening Recommendations-NCCN For average risk women: Beginning at age 40 Annual clinical breast exam Annual screening mammogram

14 Breast Screening Considerations- NCCN Women should be counseled about the potential benefits, risks and limitations of breast screening Consider severe comorbid conditions limiting life expectancy and whether therapeutic interventions are planned Upper age limit for breast cancer screening has not been established

15 Age Benefit: Biennial vs Annual; 4 CISNET Models Median per 1,000 Women Biennial Annual % Increase with Annual Deaths Averted % LYG % van Ravesteyn et al. Ann Intern Med 2012;156(9):

16 Age Mortality Reduction: Biennial vs Annual; CISNET Median per 1,000 Women Digital Biennial Annual Increase with Annual (%) % mortality Reduction (28%) Mandelblatt et al. AHRQ Publication No EF-4, 2015

17 10 Year cumulative probability of FP test result or biopsy recommendation : USPSTF s 50s FP Biopsy (annual) 7.0 % 9.4% FP Biopsy (biennial) 4.8% 6.4% FP test result (recall) (annual) 61.3% 61.3% Siu et al, Ann Intern Med.2016;164:

18 Overdiagnosis Primarily an over-treatment issue Distinguish between DCIS and invasive cancer only 11% of OD cases are invasive ca = 2-3% invasive cancer overdiagnosis CISNET 2015 (Age 40-74) Importance of improving understanding DCIS Mandelblatt et al. AHRQ Publication No EF-4, 2015

19 Harms of screening analysis Absence of screening does not mean absence of breast related problems Non-screened women develop signs and symptoms which frequently lead to diagnostic investigation and benign biopsies Harms profile should be NET harms - not compared to absence of harm Screened women may have fewer symptomatic investigations (P < 0.001)* *Barton et al. Ann Intern Med 1999;130(8):

20 Mammographic Screening Annual screening beginning at age 40 achieves greatest benefit but requires more mammograms and associated testing Screening decisions which reflect balances of benefits and burdens is necessarily a subjective assessment Lives saved are not equivalent to testing harms