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2 No disclosures Off Label Use: None

3 Historical Current Guidelines: Screening for women of average risk Screening for women of high risk for breast cancer Diagnosis for cancer Advanced imaging strategies USPSTF study, controversies of screening for breast cancer

4 Mammography, has evolved over the decades Analog ( Film Screen) replaced by Digital Mammography CAD augments the accuracy of mammography Tomosynthesis: Emerging technology Ultrasound: Problem solving technique Cyst vs. Solid Biopsy guidance Screening Time consuming High false positive rates MRI Breast Screening for women at high risk for breast cancer New diagnosis for breast cancer MBI ( Molecular Breast Imaging) Problem solving tool

5 Mammography : Early reports in 1930 s Progressively developed to the 1980 s Multicenter studies show an overall reduction in mortality by 31% from Screening Mammography Improved therapies Over the same period, 36.7% decline in all cancer deaths

6 s: Screen-film ( Analog) Mammography 1998: FDA approves CAD ( Computed aided detection) 2000: FDA approves Digital Mammography 2005: DIMIST, Digital Mammography evolves 2007: ACS guidelines for MRI in women at high risk for breast cancer 2011: FDA approves Tomosynthesis

7 Film-screen ( Analog ) to Digital Mammography DIMIST study published in 2005 Multicenter study, 49,500 women screened underwent digital or analog mammography Results: Digital superior to analog Mammography Younger ( pre menopausal) women with dense breasts Characterization and detection of calcifications Analog and digital comparable In older (greater than 50) women In women with fatty breasts

8 FDA Approval: 1998 Used as a second read Flags suspicious calcifications Areas of architectural distortion Abnormal masses Final call by Radiologist to accept or reject CAD marks Not all marks can be accepted Critics: Higher false positive rates* Benefits Helps in detection of malignant calcifications

9 Radiologists involved in Breast cancer detection have transformed: Radiologists to Mammographers to Breast Imagers Breast Imagers provide Comprehensive Breast Diagnosis Mammography Screening and Diagnostic Ultrasound MRI Biopsy: Stereo, US guided and MRI guided Molecular Breast Imaging Consultants to Tumor Boards

10 Patient Interaction: Key to success of the process Patients are anxious Listening skills are key to the success of Breast Imaging Plays a central role in the diagnosis of breast cancer

11 Annual Screening Mammography starting age 40, till in good health CBE (clinical breast examination): Every 3 years during 20 s and 30 s Every year starting age 40 BSE (Breast self examination) Option for all women starting in their 20 s Be aware of the changes in breasts Report and changes to their primary care providers as soon as possible

12 Requirements Answers to all specific questions on mammography order forms Assign side Right or Left Location: reference a quadrant: UO, UI, LO, LI Assign an o-clock position for directed evaluation 6% cancers are detected by CBE

13 Randomized Controlled Trials: Cancers detected by CBE: 3 per 10,000 Higher percentage of negative biopsies 1% of those with a clinically palpable mass represent cancer diagnosis Patients annual physical examination may be scheduled at different time than mammography Accurate input nedded from the primary care provider

14 ACS guidelines are neutral for BSE USPSTF discourages BSE Randomized Control Trials: No change in mortality between women involved with BSE or not Most cancers are detected by BSE Palpable lumps require a diagnostic evaluation Unilateral or Bilateral Mammography Directed Ultrasound

15 Most cancers found on palpation are between cm Lymph node positivity can be as high as 40% A majority of women who do not undergo screening will present with a palpable mass Palpable masses need to be evaluated It is still the commonest way breast cancer is detected

16 Higher False Positives Increases Benign Biopsy Rate

17 DMIST *Trial Multicenter study: Compares Analog and Digital mammography Recruited 49,5000 women of average risk Results Overall sensitivity: 70% Women with dense Breasts: Analog 55% Digital: 70% Digital more effective in detection of early breast cancer carcinoma in-situ Most had no lymph node involvement *NEJM, 2005; NCI

18 Analog: Dose: 2.37mGy per view Sensitivity: Fatty breasts and scattered fibro glandular tissue: 88% Dense Breasts: 35-55% Less expensive Digital: Dose: 1.86mGy per view (22% reduction over Analog) Sensitivity: Fatty Breasts: No improvement over analog Dense Breasts: 70% (DMIST, 2005) Minnesota: 80% exams digital Nation wide: 35% exams digital

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21 Report In Department Answer Questionnaire Check referring Physician Information Insurance Information Personal address Greeted By Technologist Confirms all personal information, medical history, medication use, history of pregnancy, addresses all questions

22 Digital Mammography, 2 views each breast Technologist : Check for quality Radiologist Interpretation, Results reporting Result Reports (MQSA) As quickly as possible* *ACR guidelines

23 Indications: Palpable Lump Point tenderness, not cyclical Nipple Discharge: Spontaneous, unilateral, blood tinged Women at high risk for breast cancer Personal history of breast cancer: 3-5 years after lumpectomy Follow up after benign biopsy Screening mammography recalls

24 Patient reports to department Transferred to care of Technologist Personal history Reason for visit Obtains required images Presents images to Radiologist Radiologist evaluation No further imaging needed Biopsy needed Further imaging evaluation

25 Further Imaging Evaluation: Ultrasound Masses/ Densities/ Architectural Distortion Palpable lesions Solid or Cystic Solid: Image Guided Biopsy Cystic: Atypical: Image guided aspiration Typical : Return Annual screening mammography

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28 FDA approval in 2011 Dense Breast: Higher sensitivity in women with dense breasts for masses and architectural distortion Higher radiation dose Time consuming, limited use for screening Calcifications are hard to see and characterize, need further improvement in protocols No CPT codes yet

29 MRI and MBI are finding utility in screening for breast cancer in women at high risk Used as a problem solving tool to guide further management, when needed Most lesions can be biopsied by Stereotatic or ultrasound guidance MRI be used when lesion visibility is a problem as with lobular cancers Lesion shows no enhancement, follow up or no further follow up may be needed Lesion enhances, not visible by ultrasound: MRI guided biopsy used for problem solving

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33 Screening Breast MRI in conjunct with mammography : >20-25% annual risk for developing breast cancer based on family and personal history Chest wall radiation between the ages of years Known BRCA mutation Untested first degree relatives of women with BRCA mutation Newly diagnosed breast cancer: bilateral or multifocal disease

34 Cost vs Benefits of screening discussion Genetic consultation Formal assessment for genetic risk Detailed models outline: Need for chemoprevention Need for genetic testing for BRCA markers Breast Imagers and providers identify women who would benefit from supplemental screening Identify techniques and the intervals at which each patient is screened

35 Risk Factors: Age: Minimal at age <30 years Family History: Lifetime risk No Family History: 7.8% (1 in 13) One affected 1 st degree relative: 13.3% (1 in 7.5), risk at 35 is the same of risk at 40 Two affected 1 st degree relatives 21.1% (> 1 in 5), equivalent risk at 32 BRCA mutation Chest wall Radiation

36 Models for calculating the risk of carrying BRCA gene: BRCAPRO IBIS or Tyrer-Cuzick BOADICEA Who should be tested? First degree relatives of BRCA carriers Family history of both breast and Ovarian cancer Family member diagnosed before the age of 35 At least 2 family members on the same side of the family diagnosed before 50 Women with Ashkenazi Jewish heritage

37 No Family History: Screening mammography at age 40 One first degree Relative with breast cancer: Screening at 35 or 10 years before the age at which relative was diagnosed with cancer > 20% lifetime risk for breast cancer: supplemental MRI < 20% lifetime risk: No MRI 2 affected first degree relatives: Screening at age 32 Screening before 30 not advisable due to risk of radiation exposure

38 BRCA 2 mutation : Commence mammography between based on NCCN guidelines Screening MRI and Mammography(ACS 2007) : BRCA 1Mutation Untested 1 st degree relative of a BRCA carrier 8 years after mantle chest Radiation therapy or at 25 which ever is later Diagnostic Mammography and MBI Biopsy diagnosis of ALH or ADH Personal History of breast cancer 6-12 months after lumpectomy and Radiation therapy Then at every 6-12 month intervals for 1-2 years

39 Cancers in BRCA positive women: More aggressive ( Triple negative in a higher frequency) Present at a younger age More often node positive Staggered approach or concurrent studies at yearly intervals

40 15-20 % lifetime risk Previous LCIS or ALH diagnosis Dense Breasts Intermediate risk based on family history Personal History of Breast cancer ACS: Studies show no added advantage for screening breast MRI Higher False Positives Lower cost effectiveness NCCN: Annual Screening MRI for prior LCIS

41 Currently, this is not a standard screening tool (ACR consensus statement) False Positives are more common Shortage of Trained personnel Time constraints, cannot be used as a screening tool for all women with dense breasts

42 MBI: Evolving technology Not all insurances recognize it as a problem solving tool High radiation dose Biopsy devices less available Used as a problem solving tool for diagnostic workups Screening for women of intermediate risk or where MRI is not possible ie pacemakers or in patients with renal impairment

43 USPSTF*, 2009: Women in the age group of are advised against screening mammography Should discuss screening with their providers if they are at high risk Women between the ages of should have screening every other year For women over 74, little data is available *US Preventive Service Task Force

44 Study Authors: Epidemiologists with no experience in Surgery, Oncology or Radiology: To eliminate bias Flaws: Meta analysis heavily based on Randomized controlled trials: Poorly designed Computer models are confusing Inviting women to mammography does not mean that it was the number of women screened Recommends against teaching women Self Breast Examinations Most studies show no benefit in lives saved. Breast lumps found on BSE is the most common way to detect cancer in women who do not routinely undergo screening mammography

45 Over diagnosis refers to this minimally invasive cancers (DCIS or LCIS) which would have remained occult if a woman had not been subjected to mammography No pathologic markers to assess the biologic behavior of minimally invasive cancers Over diagnosis remains an issue not resolved at present

46 Early detection: Better long term outcomes Multiple treatment options Median size of cancer on Mammography: cm Median size of cancer on SBE or CBE: cm Risk for a woman to develop cancer in their 40 s: 1 in 69 Likelihood of Lymph Node Metastases to cancer size: Size of Cancer 1cm 10 2cm 35 > 4cm 60 % Positive Lymph Nodes

47 2 year screening intervals will lead to a 20% jump in mortality: Swedish National Board of Health Benefits of yearly screening intervals Women in the have the most mortality reduction with yearly screening year 36% 46% 44% 2 year 18% 39% 39% 3 year 4% 34% 34%

48 Swedish Two-County trial, over 3 decades* Decrease in Breast cancer specific Mortality Absolute number of breast cancer deaths prevented increases with follow up time Screening 300 women for 10 years prevents 1 death: For every 1000 women screened every 2 years between the ages of 40-69, 8-11 lives are saved Reduction in cancer mortality is associated with reduction in incidence of advanced disease ( Stage II or higher)

49 Women of Average Risk* Commence annual screening mammography at age 40 Women of High Risk* Genetic consultation to assign lifetime risk Lifetime risk > 20%: Screening Mammography and MRI at age 35 Or 10 years prior to the age at which cancer was first detected Lifetime risk< 20%: Screening Mammography, no MRI BRCA positive, Mantle chest wall radiation Screening Mammography and breast MRI examination *ACR, ACS, SBI, ACOG

50 Breast Imagers are consultants for Diagnostic Mammography Targeted Ultrasound Direct biopsy guidance MRI MBI Interactions with patients are important for the success of the Breast cancer detection program

51 Thank You. Questions?

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