Breast Cancer Screening Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, California

Breast Cancer Breast Cancer ScreeningScreening

Steven Stanten MDSteven Stanten MD

Rupert Horoupian MDRupert Horoupian MD

AltaBates Summit Medical AltaBates Summit Medical CenterCenter

Oakland, CaliforniaOakland, California

IncidenceIncidence

USA - 2008USA - 2008 184,450 new cases of invasive ca184,450 new cases of invasive ca 40,930 deaths40,930 deaths 3 decade increase3 decade increase Wide spread screeningWide spread screening Increased dx of non-invasive and pre-Increased dx of non-invasive and pre-

malignant lesionsmalignant lesions

BREAST CANCER BURDENBREAST CANCER BURDEN

Breast cancer is the most common Breast cancer is the most common malignancy diagnosed in women malignancy diagnosed in women (excluding cancers of the skin)(excluding cancers of the skin)

In the United States breast cancer is In the United States breast cancer is the second most common cause of the second most common cause of death from cancerdeath from cancer

BREAST CANCER SCREENING IS AN BREAST CANCER SCREENING IS AN INTEGRAL PART OF WOMEN’S INTEGRAL PART OF WOMEN’S PREVENTATIVE HEALTHPREVENTATIVE HEALTH

Signs and SymptomsSigns and Symptoms

The The earliest earliest sign is an abnormality sign is an abnormality that shows up on a mammogram that shows up on a mammogram before it can be felt by the woman or before it can be felt by the woman or health care provider.health care provider.

Early stages of breast cancer usually Early stages of breast cancer usually do not produce symptoms.do not produce symptoms.

Signs and Symptoms Signs and Symptoms

When breast cancer grows to the point where When breast cancer grows to the point where physical symptoms exist, these may include:physical symptoms exist, these may include:

- A painless mass (up to 10 percent of - A painless mass (up to 10 percent of patients have breast pain and no patients have breast pain and no

mass).mass).

- Breast changes: thickening, swelling, - Breast changes: thickening, swelling, and and skin irritation or distortion. skin irritation or distortion.

- Nipple changes: discharge, erosion, - Nipple changes: discharge, erosion, inversion, or tenderness. inversion, or tenderness.

TreatmentTreatment

Treatment Treatment - most successful when the cancer is - most successful when the cancer is detected early, before it has spread.detected early, before it has spread.

Treatment Treatment -depends on the situation and the -depends on the situation and the

patient’s patient’s choices.choices. SurgerySurgery

- Breast conservation surgery - Breast conservation surgery (lumpectomy) (lumpectomy) removes the tumor and removes the tumor and surrounding tissue.surrounding tissue. - Mastectomy removes the breast.- Mastectomy removes the breast.

Treatment Treatment

Radiation therapyRadiation therapy ChemotherapyChemotherapy Hormone therapyHormone therapy Monoclonal antibody therapyMonoclonal antibody therapy Often, two or more methods are Often, two or more methods are

used inused in

combination with each other.combination with each other.

MortalityMortality

One in six diagnosed with breast One in six diagnosed with breast cancer will die from itcancer will die from it

Directly related to stage of diseaseDirectly related to stage of disease Varies according to geography, Varies according to geography,

culture, ethnicity, race, and culture, ethnicity, race, and socioeconomic statussocioeconomic status

DeathsDeaths

An estimated 40,200 deaths will An estimated 40,200 deaths will

occur from breast cancer occur from breast cancer in 2003. in 2003.

More than 39,000 of these deaths More than 39,000 of these deaths will be among women.will be among women.

Only lung cancer accounts for more Only lung cancer accounts for more cancer deaths in women.cancer deaths in women.

SurvivalSurvival

0 20 40 60 80 100

Switzerland

Finland

France

Italy

Netherlands

Germany

Denmark

England

Spain

Scotland

Estonia

Poland

Five-year survival (%)

J Nat Cancer Inst 1995; 87: 1209J Nat Cancer Inst 1995; 87: 1209

5-year5-yearsurvival (%)survival (%)

No. ofNo. ofpatientspatients

75.775.773.573.571.471.470.870.869.969.968.468.468.168.162.562.562.562.561.861.858.858.843.943.9

2,2432,24311,12311,123

2,4982,4983,5953,5952,6532,6533,3593,359

17,49817,49860,39060,390

1,0431,04311,26111,261

2,3872,3871,0891,089

SurvivalSurvival

Five-year Five-year localized localized survival rate…….97%survival rate…….97%

Five-year Five-year regional regional survival rate…..…78%survival rate…..…78%

Five-year Five-year distant distant survival rate……….21% survival rate……….21%

Five-year overall survival rate….……..86%Five-year overall survival rate….……..86%

Ten-year overall survival rate..……….76%Ten-year overall survival rate..……….76%

Risk FactorsRisk Factors

DirectDirect AgeAge Family hxFamily hx Early menarcheEarly menarche Late 1Late 1stst birth birth Proliferative benign breast diseaseProliferative benign breast disease Thoracic radiationThoracic radiation

Risk FactorsRisk Factors

As age increases, so does risk. Of all the As age increases, so does risk. Of all the women with breast cancer, 77% are 50+ women with breast cancer, 77% are 50+ years old.years old.

Genetic risk factors/personal or family history.Genetic risk factors/personal or family history.

Early menarche (< 12 years) or late Early menarche (< 12 years) or late menopause (>55 years)menopause (>55 years)

Late age at first full-term pregnancy Late age at first full-term pregnancy (> 30 years).(> 30 years).

Risk Factors Risk Factors

No children/not breast feeding = slight risk.No children/not breast feeding = slight risk. Oral contraceptives use or hormone Oral contraceptives use or hormone

replacement therapy = slightly greater risk.replacement therapy = slightly greater risk. Risks increase with alcohol consumption.Risks increase with alcohol consumption. Even moderate physical activity can Even moderate physical activity can

decrease risk.decrease risk. Obesity = increased risk in post-Obesity = increased risk in post-

menopausal women.menopausal women.

Risk Factors Risk Factors

AssociationsAssociations Radiographically dense breastsRadiographically dense breasts

ObesityObesity Alcohol intakeAlcohol intake Menopausal hormone useMenopausal hormone use

Risk Factors for Breast CancerRisk Factors for Breast Cancer

Family History/genetic factorsFamily History/genetic factors Reproductive/hormonalReproductive/hormonal Proliferative benign breast diseaseProliferative benign breast disease Mammographic densityMammographic density

Risk AssessmentRisk Assessment FACTORS USED IN NCI BREAST CANCER FACTORS USED IN NCI BREAST CANCER

RISK PREDICTION MODELRISK PREDICTION MODEL -Age-Age -Number of 1st degree female relatives -Number of 1st degree female relatives with a with a history of breast cancerhistory of breast cancer -Number of breast biopsies-Number of breast biopsies -Age at first live birth or nulliparity-Age at first live birth or nulliparity -History of atypical hyperplasia-History of atypical hyperplasia -Age at menarche-Age at menarche -Race-Race

Risk Assessment Risk Assessment ORIGINAL GAIL MODELORIGINAL GAIL MODEL Gail Gail et al et al Journal National Cancer Institute Journal National Cancer Institute

1989; 81: 1879-18861989; 81: 1879-1886 Model based and derived from extremely Model based and derived from extremely

large large data setsdata sets Estimates the risk of:Estimates the risk of:

invasiveinvasive in situ in situ (DCIS)(DCIS) or lobular carcinoma in situ (LCIS)or lobular carcinoma in situ (LCIS) over a defined interval in women having over a defined interval in women having

annual screeningannual screening

Risk AssessmentRisk Assessment

LIMITATIONS OF GAIL MODEL – LIMITATIONS OF GAIL MODEL –

MAY OVERPREDICT RISK IN PRE-MAY OVERPREDICT RISK IN PRE-MENOPAUSAL WOMEN WHO DO NOT MENOPAUSAL WOMEN WHO DO NOT ADHERE TO GUIDELINES FOR ADHERE TO GUIDELINES FOR ANNUAL SCREENINGANNUAL SCREENING

Risk AssessmentRisk Assessment

CLAUS MODEL - CLAUS MODEL -

The Claus model takes into account The Claus model takes into account 1st and 2nd degree relatives 1st and 2nd degree relatives effected by breast cancer and effected by breast cancer and accounts for their ages at the time of accounts for their ages at the time of diagnosisdiagnosis

Concepts of ScreeningConcepts of Screening

Merely finding a cancer earlier does not mean the patient Merely finding a cancer earlier does not mean the patient will benefitwill benefit

A different level of proof is required for a screening test as A different level of proof is required for a screening test as compared to applying a test to someone who is already ill, compared to applying a test to someone who is already ill, because the vast majority of those who will be screened will because the vast majority of those who will be screened will not have the disease most will not benefit from the test, but not have the disease most will not benefit from the test, but many may have false positives studies which may ‘harm many may have false positives studies which may ‘harm them’.them’.

Since there are cancers that never kill and cancers that areSince there are cancers that never kill and cancers that are destined to kill before they can be discovered only a destined to kill before they can be discovered only a

randomized control trial (randomized control trial (RCTRCT) in which one group is ) in which one group is screened and the other has the ‘usual’ care can prove a screened and the other has the ‘usual’ care can prove a screening test is efficaciousscreening test is efficacious

RCTRCT

The statistical power of the The statistical power of the RCT is crucial.RCT is crucial.

ScreeningScreening

Current screening Current screening methodologies rely heavily on methodologies rely heavily on imaging with proof from RCTsimaging with proof from RCTs

CalcificationsCalcifications

ScreeningScreening

Cancers detected by periodic Cancers detected by periodic screening are likely to be slower screening are likely to be slower growing, more indolent cancers. growing, more indolent cancers. Faster, more aggressive cancers Faster, more aggressive cancers become clinically evident between become clinically evident between screens.screens.

Sojourn TimeSojourn Time

The period of time during which a The period of time during which a cancer is detectable by a test before cancer is detectable by a test before it is clinically evident is called the it is clinically evident is called the ‘‘sojourn timesojourn time’.’.

Sojourn TimeSojourn Time

In order to intercept the most In order to intercept the most cancers earlier, the screening cancers earlier, the screening interval should be less than half the interval should be less than half the sojourn timesojourn time

Screening MammographyScreening Mammography

Basic definitionsBasic definitions UsesUses SpecificitySpecificity SensitivitySensitivity

MammographyMammography

BasicsBasics Identify breast cancer too small to palpateIdentify breast cancer too small to palpate Identify non-invasive and pre-malignant lesionsIdentify non-invasive and pre-malignant lesions Ionizing radiationIonizing radiation Medial-lateral oblique viewMedial-lateral oblique view Cranial-caudal viewCranial-caudal view Nipple to pectoralisNipple to pectoralis FDA approved sitesFDA approved sites Screen film vs. digitalScreen film vs. digital

Mammography Mammography

Category Assessment Follow-upCategory Assessment Follow-up Breast Imaging Reporting and Breast Imaging Reporting and

Database System (BI-RADS)Database System (BI-RADS)


BIRADSBIRADS0 – more info0 – more info

1 – normal1 – normal

2 – benign2 – benign

3 – probably benign3 – probably benign

4 – suspicious4 – suspicious

5 - malignant5 - malignant


UsesUses Diagnose small, early stage breast caDiagnose small, early stage breast ca Favorable clinical courseFavorable clinical course Better cancer related survival Better cancer related survival Interpreting studies has some biasesInterpreting studies has some biases

Lead-time biasLead-time bias Length biasLength bias Overdiagnosis biasOverdiagnosis bias Healthy volunteer bias Healthy volunteer bias


CAD – computer aided diagnosisCAD – computer aided diagnosis-Aids radiologist in detecting -Aids radiologist in detecting

abnormalitiesabnormalities

-3 available commercial systems-3 available commercial systems

-500 CAD systems in US-500 CAD systems in US

Clinical Trial – Clinical Trial – - Increase overall recall rateIncrease overall recall rate- Increase in # of detected cancersIncrease in # of detected cancers

Considerations in Choosing a Considerations in Choosing a Mammography SiteMammography Site

- FDA certification of technician, - FDA certification of technician, medical physicist, radiologistmedical physicist, radiologist

- BIRAD reporting- BIRAD reporting

- CAD system- CAD system

- Digital Mammography- Digital Mammography

MAMMOGRAPHYMAMMOGRAPHYDIGITAL VS FILMDIGITAL VS FILM


SpecificitySpecificity Likelihood of test being normal when Likelihood of test being normal when

cancer is absentcancer is absent We want this highWe want this high If low then false positives lead to If low then false positives lead to

unnecessary tests.unnecessary tests. Exceeds 90%Exceeds 90% BIRADS categoriesBIRADS categories


SensitivitySensitivity Proportion of breast cancer detected Proportion of breast cancer detected

when cancer is presentwhen cancer is present Lesion sizeLesion size Lesion conspicuityLesion conspicuity Breast tissue densityBreast tissue density Patient agePatient age Hormone status of tumorHormone status of tumor Image qualityImage quality Skill of radiologistSkill of radiologist


SensitivitySensitivity

Overall 75%Overall 75%

54-58% in age <4054-58% in age <40

81-94% in age >6581-94% in age >65


Factors influencing Specificity and Factors influencing Specificity and SensitivitySensitivity Radiologist interpretationRadiologist interpretation High breast densityHigh breast density Centralized screening systemsCentralized screening systems National QA programsNational QA programs Interval between mammogramsInterval between mammograms Post-menopausal hormone usePost-menopausal hormone use Prior breast surgeryPrior breast surgery BMIBMI


Evidence of BenefitEvidence of Benefit Randomized controlled studiesRandomized controlled studies 4 countries4 countries 500,000 women500,000 women 9 studies9 studies Different designsDifferent designs Effect on mortalityEffect on mortality Conflicting resultsConflicting results


Harms of screeningHarms of screening False negativesFalse negatives False positivesFalse positives Radiation exposureRadiation exposure AnxietyAnxiety Over diagnosisOver diagnosis


Cochrane ReviewCochrane Review- Review of 7 trials- Review of 7 trials- Screening mammography likely - Screening mammography likely reduces reduces breast cancer breast cancer mortalitymortality- magnitude uncertain- magnitude uncertain- ~20% reduction – or 15% relative risk - ~20% reduction – or 15% relative risk reductionreduction- screening leads to over diagnosis and - screening leads to over diagnosis and over treatmentover treatment


For 2000 women invited to screening For 2000 women invited to screening for 10 yearsfor 10 years 1 will have her life prolonged1 will have her life prolonged 10 will be treated unnecessarily10 will be treated unnecessarily

Conclusion – “It is thus not clear whether Conclusion – “It is thus not clear whether screening does more good than harm. screening does more good than harm. Woman invited to screening should be Woman invited to screening should be fully informed of both benefits and fully informed of both benefits and harms.”harms.”

UTZUTZ

As adjunct to mammographyAs adjunct to mammography InexpensiveInexpensive Widely availableWidely available Targeted evaluationTargeted evaluation

Solid vs. cystSolid vs. cyst Benign vs. malignantBenign vs. malignant

UTZ UTZ

Image guided biopsyImage guided biopsy Limited screening useLimited screening use

Needs a skilled operatorNeeds a skilled operator Lack of standard exam techniquesLack of standard exam techniques Lack of standard interpretation criteriaLack of standard interpretation criteria No microcalcificationsNo microcalcifications

BREAST MRIBREAST MRI

THE BASIC STRENGTH OF BREAST THE BASIC STRENGTH OF BREAST MRI LIES IN THE DETECTION OF MRI LIES IN THE DETECTION OF CANCER THAT IS CANCER THAT IS OCCULT OCCULT ON ON CONVENTIONAL IMAGING SUCH AS CONVENTIONAL IMAGING SUCH AS MAMMOGRAPHY AND SONOGRAPHYMAMMOGRAPHY AND SONOGRAPHY

Background: What is MRI?Background: What is MRI? Uses magnetic fields to produce detailed cross- Uses magnetic fields to produce detailed cross-

sectional images of tissue structuressectional images of tissue structures Uses injected contrast agents to distinguish fat, Uses injected contrast agents to distinguish fat,

glandular tissue, lesions, etc. in the breastglandular tissue, lesions, etc. in the breast Different factors contribute to the measured Different factors contribute to the measured

signal that determines the brightness of the signal that determines the brightness of the tissues in the imagetissues in the image

Contrast agent provides reliable detection of Contrast agent provides reliable detection of cancers and other lesions.cancers and other lesions.

Screening MRI requires appropriate techniques Screening MRI requires appropriate techniques and equipment (including dedicated and equipment (including dedicated

breast breast MRI equipment) and experienced MRI equipment) and experienced staffstaff

MRIMRI

MRI is not a screening technique for MRI is not a screening technique for average risk patientsaverage risk patients

MRIMRI

With IV gadoliniumWith IV gadolinium 83-100% sensitive with cancer above a 83-100% sensitive with cancer above a

few mmfew mm Average 96% sensitiveAverage 96% sensitive

MRI MRI

Pros and consPros and cons CostCost Lack of standard examLack of standard exam Lack of standard interpretation criteriaLack of standard interpretation criteria No micro Ca++No micro Ca++ Variability of equipmentVariability of equipment Increase in false + rateIncrease in false + rate Availability of equipmentAvailability of equipment

MRIMRI

Sensitivity - 71-100%Sensitivity - 71-100% Specificity - 37 - 97%Specificity - 37 - 97% Not recommended for screeningNot recommended for screening

Breast implantsBreast implants Masses after surgery or XRTMasses after surgery or XRT Occult lesions with metastasisOccult lesions with metastasis Pre-operative planning?Pre-operative planning?

RationaleRationale New evidence supporting MRI screeningNew evidence supporting MRI screening Ability of MRI to detect cancers is much higher Ability of MRI to detect cancers is much higher

(double) than mammography(double) than mammography MRI plus mammography detects more cancers MRI plus mammography detects more cancers

than MRI alonethan MRI alone High false positive rate of MRI makes it High false positive rate of MRI makes it

inappropriate for screening women at average inappropriate for screening women at average riskrisk

Strong evidence for MRI screening of women at Strong evidence for MRI screening of women at increased risk based on family history/geneticsincreased risk based on family history/genetics

Insufficient evidence to recommend for or against Insufficient evidence to recommend for or against MRI screening of women at moderately increased MRI screening of women at moderately increased risk based on clinical factorsrisk based on clinical factors

Insufficient evidence for other technologiesInsufficient evidence for other technologies

Limitations and Potential HarmsLimitations and Potential Harms

False negativesFalse negatives False positivesFalse positives Anxiety, psychological distressAnxiety, psychological distress More call-backsMore call-backs More biopsiesMore biopsies CostCost Limited access to high quality MRI screening and MRI-Limited access to high quality MRI screening and MRI-

guided biopsiesguided biopsies Variation in performance, interpretation, recall rates, and Variation in performance, interpretation, recall rates, and

expertiseexpertise Little or no data on recurrence, survival rates, age, when to Little or no data on recurrence, survival rates, age, when to

start and stop screening, screening intervalsstart and stop screening, screening intervals Variation in insurance coverageVariation in insurance coverage

BREAST CANCER SCREENINGBREAST CANCER SCREENINGWITH MRIWITH MRI

Individuals with BRCA1 or BRCA2 mutationIndividuals with BRCA1 or BRCA2 mutation Individuals with a 1st degree relative of a BRCA1 or BRCA2 carrier Individuals with a 1st degree relative of a BRCA1 or BRCA2 carrier

but have not been testedbut have not been tested Individuals with a lifetime risk of breast cancer of >20%Individuals with a lifetime risk of breast cancer of >20% Individuals that have had radiation therapy to the chest between Individuals that have had radiation therapy to the chest between

the ages of 10 and 30 years oldthe ages of 10 and 30 years old Breast cancer in a male relativeBreast cancer in a male relative One first degree relative with bilateral breast cancerOne first degree relative with bilateral breast cancer Individuals consider at high familial risk:Individuals consider at high familial risk: Two or more first degree relatives with breast cancer Two or more first degree relatives with breast cancer oror One 1st degree relative and two or more 2nd or 3rd degree One 1st degree relative and two or more 2nd or 3rd degree

relatives with breast cancer relatives with breast cancer oror One 1st degree relative with breast cancer before the age of 45 One 1st degree relative with breast cancer before the age of 45

years and one other relative with breast cancer years and one other relative with breast cancer oror One first degree relative with breast cancer and one or more One first degree relative with breast cancer and one or more

relatives with ovarianrelatives with ovarian

Other modalitiesOther modalities

Not FDA-approved for screeningNot FDA-approved for screening Ductoscopy/ductal lavageDuctoscopy/ductal lavage TomographyTomography ScinitimammographyScinitimammography PETPET ElastographyElastography SpectroscopySpectroscopy Optical imagingOptical imaging Electrical impendence measurementsElectrical impendence measurements ThermographyThermography Etc.Etc.

Ductoscopy/LavageDuctoscopy/Lavage

The majority of breast cancers The majority of breast cancers originate in the breast duct system originate in the breast duct system so evaluating this system visually so evaluating this system visually with ductoscopy, or studies to with ductoscopy, or studies to evaluate the cells from the ducts evaluate the cells from the ducts may help detect transformation from may help detect transformation from healthy to malignant cells.healthy to malignant cells.

Ductal LavageDuctal Lavage

Asymptomatic womenAsymptomatic women High riskHigh risk Use alone or in combination with Use alone or in combination with

mammographymammography

High Risk PatientsHigh Risk Patients

Identify High Risk patientsIdentify High Risk patients

2 or more relatives with breast or 2 or more relatives with breast or ovarian caovarian ca

Breast ca before age 50 in a relativeBreast ca before age 50 in a relative Male relative with breast caMale relative with breast ca Genetic profilesGenetic profiles Chest radiationChest radiation

Who is at High Risk?Who is at High Risk? Three approaches:Three approaches:

#1 - Family history suggestive of inherited gene mutation; #1 - Family history suggestive of inherited gene mutation; risk is risk is calculated by assessment models/toolscalculated by assessment models/tools

#2 - Genetic testing for mutation in #2 - Genetic testing for mutation in BRCA1/2, TP53, BRCA1/2, TP53, or or PTENPTEN

#3 - Review of clinical history#3 - Review of clinical history-Treated for Hodgkin disease-Treated for Hodgkin disease -LCIS, ALH-LCIS, ALH-ADH, DCIS-ADH, DCIS-High mammographic density-High mammographic density-Personal history of breast cancer-Personal history of breast cancer

High Risk High Risk

Screening optionsScreening options

Initiate screening at age 30Initiate screening at age 30 Shorter intervalsShorter intervals MRIMRI UTZUTZ

Insufficient evidence existsInsufficient evidence exists

High Risk High Risk

Who is at high risk?Who is at high risk? Family HistoryFamily History Clinical IndicatorsClinical Indicators MRI screening studiesMRI screening studies Evidence of efficacyEvidence of efficacy Benefits, limitations, and potential Benefits, limitations, and potential

harmsharms

EvidenceEvidence Since the 2003 guideline, at least 6 prospective, Since the 2003 guideline, at least 6 prospective,

non-randomized studies were conducted, in 6 non-randomized studies were conducted, in 6 different countriesdifferent countries

All studies measured benefit of adding annual All studies measured benefit of adding annual MRI to mammographyMRI to mammography

All study participants had either a All study participants had either a BRCA BRCA mutation mutation or a strong family historyor a strong family history

Some studies included women with a personal Some studies included women with a personal history of breast cancerhistory of breast cancer

Some studies also included ultrasound and/or CBESome studies also included ultrasound and/or CBE All 6 studies reported significantly higher All 6 studies reported significantly higher

sensitivity for MRI compared to mammography sensitivity for MRI compared to mammography (and US, CBE), and lower specificity (i.e. more (and US, CBE), and lower specificity (i.e. more false positives)false positives)

High Risk High Risk Current ACS Recommendation for Women at Current ACS Recommendation for Women at

Increased Risk for Breast Cancer (2003)Increased Risk for Breast Cancer (2003)

-In the absence of sufficient evidence to recommend -In the absence of sufficient evidence to recommend specific screening strategies that might benefit specific screening strategies that might benefit women at increased risk, options are provided:women at increased risk, options are provided:

-earlier initiation of screening (30 years or younger)-earlier initiation of screening (30 years or younger)

-the addition of MRI and/or Ultrasound to screening -the addition of MRI and/or Ultrasound to screening mammography and physical examination.mammography and physical examination.

Early DetectionEarly Detection

There is no certain way to prevent There is no certain way to prevent breast cancer.breast cancer.

The best plan for women at average The best plan for women at average risk is to follow the American Cancer risk is to follow the American Cancer Society guidelines for early detection.Society guidelines for early detection.

Nine out of 10 women can survive Nine out of 10 women can survive breast cancer simply by detecting it breast cancer simply by detecting it earlyearly

Bottom LineBottom Line

Age and gender are the main risk factors.Age and gender are the main risk factors. Early detection increases survival and Early detection increases survival and

treatment options.treatment options. All women 40+ should talk to their doctorsAll women 40+ should talk to their doctors

about annual mammograms and CBEs. about annual mammograms and CBEs. TheyThey

can also perform monthly BSEs.can also perform monthly BSEs. Mammograms can save lives.Mammograms can save lives.

Early Detection/GuidelinesEarly Detection/Guidelines

Age 40+: Annual mammogram, annual clinical Age 40+: Annual mammogram, annual clinical breast exam (CBE) by a health care professional, breast exam (CBE) by a health care professional, and an optional monthly breast self-exam (BSE).and an optional monthly breast self-exam (BSE).

Ages 20-39: Every three years a CBE by a health Ages 20-39: Every three years a CBE by a health care professional and an optional monthly BSE.care professional and an optional monthly BSE.

Women with a family history of breast cancer Women with a family history of breast cancer should talk to their doctor about when to start should talk to their doctor about when to start screeningscreening

American Cancer SocietyAmerican Cancer Society

GUIDELINES FOR THE EARLY DETECTION OF CANCERGUIDELINES FOR THE EARLY DETECTION OF CANCER

-Yearly mammograms are recommended starting at age 40 and continuing -Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.for as long as a woman is in good health.

-Clinical breast exam (CBE) should be part of a periodic health exam, about -Clinical breast exam (CBE) should be part of a periodic health exam, about every 3 years for women in their 20s and 30s and every year for women 40 every 3 years for women in their 20s and 30s and every year for women 40 and over.and over.

-Women should know how their breasts normally feel and report any breast -Women should know how their breasts normally feel and report any breast change promptly to their health care providers. Breast self-exam (BSE) is change promptly to their health care providers. Breast self-exam (BSE) is an option for women starting in their 20s.an option for women starting in their 20s.

- Women at high risk (- Women at high risk (greater than 20% greater than 20% lifetime risk) should get an lifetime risk) should get an MRI MRI and a and a mammogram every yearmammogram every year. Women at moderately increased risk . Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than breast cancer is less than 15%.15%.

Documents

Breast Cancer Screening Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, California