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Breast Cancer Screening What’s New to Know? The Issue of Breast Density Catherine Babcook MD Partner, Mountain Medical Physician Specialists Medical Director of Breast Imaging McKay Dee Hospital Center

Breast Cancer Screening What’s New to Know? The Issue of Breast Density

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Breast Cancer Screening What’s New to Know? The Issue of Breast Density. Catherine Babcook MD Partner, Mountain Medical Physician Specialists Medical Director of Breast Imaging McKay Dee Hospital Center. Disclosure. - PowerPoint PPT Presentation

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Page 1: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Breast Cancer ScreeningWhat’s New to Know?

The Issue of Breast Density

Catherine Babcook MDPartner, Mountain Medical Physician Specialists

Medical Director of Breast Imaging McKay Dee Hospital Center

Page 2: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

DisclosureThis presentation has no commercial content,

promotes no commercial vendor and is not supported financially by any commercial vendor.

I receive no financial remuneration from any commercial vendor related to this presentation.

Page 3: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Screening Recommendations• ACS, ACR, ACOBGYN, Intermountain

HC– Annual mammographic screening

beginning at age 40

– Continue screening if a woman is in good health and has a life expectancy of 5 years or more

Page 4: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Mammography Facts• < Screening 1980’s, the death rate for breast cancer in

the U.S. was unchanged for 50 years• Since 1990 the death rate from breast cancer has

decreased by 30%• In women ages 50-74, 15- 20% more lives saved by

screening every year instead of every two years When analyze appropriately performed RCTs and service

screening data - 30 to 40% decrease in mortality in the 40-49 year-old group.

Page 5: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

More Facts• Update of the Swedish Trials by Lazlo Tabar, when

“no shows” were placed in the control group, there was a 63% decrease in the death rate of the screened group.

• Anxiety of a false positive mammogram or invasive procedure - Recent study of 1171 women, 97% indicated a false positive result would not deter them from screening.

Page 6: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Many Components of Cancer detection

• Woman has to get a screening mammogram

• Radiologist factors: Interpretation variability

• Woman factors: Breast density, implants

Page 7: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Radiologist Factors

Recall Rate PPV1 PPV2 Cancer Detection Rate

ACR Guidelines

< 12% 5-10% 25-40% 2-10/1000

Interpretive Ability:

Page 8: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Woman Factors

Clinically “dense” = Mammographically Dense

Breast Tissue – Pattern and Density:

Page 9: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Breast Density on Mammography

• Density = How much White tissue

White tissue - glandularDark tissue – fat

Page 10: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Breast DensityFatty Breast Extremely Dense Breast

Page 11: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

4 Categories of Density• Mammography Report

– Parenchymal Density:• Almost Entirely Fatty (< 25% Glandular )• Scattered Fibroglandular Densities (25-50%

Glandular)• Heterogeneously Dense (51-75% Glandular)• Extremely Dense (> 75% Glandular)

Page 12: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Almost Entirely Fat (< 25% Glandular

Page 13: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Scattered Fibroglandular Densities (25-50% Glandular)

Page 14: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Heterogeneously Dense (51-75% Glandular

Page 15: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Extremely Dense (>75% Glandular

Page 16: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Why Does it Matter?• Cancer is WHITE on

mammograms• Amount of WHITE glandular

tissue impacts visibility of WHITE cancer

Page 17: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Mass visibility on Mammo

Page 18: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Dense Tissue – White Cancer

Page 19: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Dense Tissue – White Cancer

Page 20: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cancer Can be Hidden by Glandular Tissue on Mammo

• ‘Snowflakes in a snowball’, ‘polar bear in a snowstorm’

• What do we do:– Wait until it’s big enough to feel– Add a test that improves cancer

detection in white glandular tissue

Page 21: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

White on White Mammo Cancer Problem

• Mammographic Sensitivity Varies with Breast Density– Fatty – 85%– Dense – 70% with Digital Mammo

• NOT USELESS BY A LONG WAY

Page 22: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Density Issue Not New• Awareness of Density Issue Is New

– Nancy Cappello PhD– Dx with advanced stage breast cancer after years

of normal annual screening mammography from age 40

– 34 yrs as an educator, administrator and state dept. consultant in Connecticut

– “Nancy’s Law” 2009; Areyoudense.org

Page 23: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Magnitude of Density Issue

• 40% of Women have dense breasts– 65% of premenopausal women– 25% of postmenopausal women

Page 24: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Adjunctive Screening Tests

• Tomosynthesis – Oslo,N=13000,27% CA,15% FP• Longer compression, increased dose, exp. capital, no reimbursement, doubled

interpretation time

• Whole Breast Ultrasound: handheld, automated

• MRI – not indicated for density alone, cost, annual gadolinium risk, FP

• BSGI – expensive capital, space, sig additional dose, no reimburse

• PEM – expensive capital, space, sig additional dose, no reimburse

Page 25: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Breast Ultrasound

• Glandular Tissue is WHITE on ultrasound just like mammography

• Cancer is DARK on ultrasound

Contrast advantage

Page 26: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cancer on UltrasoundNot visible in dense tissue on mammo Visible dark cancer on

ultrasound

Page 27: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cancer on UltrasoundNot visible in dense tissue on mammo Visible dark cancer on

ultrasound

Page 28: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Screening Breast Ultrasound

– Kolb et al Radiol 2002;225(1):165-175– Crystal et al AJR 2003;1818(1):177-182– Gordon et al Cancer 1995:76(4):626-630– Kaplan Radiology 2001;221 (3):641-649– All criticized:

• Single center studies• Retrospective studies• Not blinded to mammo findings etc.

Page 29: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Screening Breast US Studies

• ACRIN 6666: N= 2600, Berg et al 2008 JAMA, Vol 299(18)2151-2163

– 60 % increase in cancer detection over mammo alone– Low PPV for biopsy: 11%, mammo 25-40%, – radiologist handheld scanning, too much time to be practical– No documentation to allow for future comparison

Page 30: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Automated Whole Breast US

• Efficient – rad not scanning, tech not interpreting

• Large Volume of patients• Standardized, reproducible• Comparison capability

Page 31: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

AWBU Studies• Kelly et al 2010 Eur Radiology 20:734-742

• N= 4500• 23 additional Cancers found on US• 100% Increase in cancer detection• 22/23 invasive cancers, ave size 0.9

cm

Page 32: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

AWBU Studies: Kelly et al 2010 Eur Radiology 20:734-742

• Mammography alone found 23 • AWBU found 38 • 23 mammographically occult• Recall Rate: ACR < 10% for Mammo

– Mammo 4.2%– AWBU 6.5%

• Positive Predictive Value Bx (PPV) ACR 25-40%– Mammo 39%– AWBU 38.4%– AWBU + Mammo 62.5%

Page 33: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

AWBU Studies

• USys FDA study submission:– 30% increase in cancer detection over

mammography alone– RSNA presentation: 25% increase in CA

detection

Page 34: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

AWBU: Our Experience

• 15,000 Screening Mammograms/yr– 5 cancers/1000 women screened

• 600 AWBU/yr– 4/600 ~ 6/1000 additional cancers

Page 35: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cases – 51 year old

Page 36: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cases – 51 year old

Page 37: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Cases – 53 year oldMammo AWBU

Page 38: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Dense Breast Tissue 40% of Women

40% x 15,000 scr mammos = 6000 eligible women seen at McKay Dee Breast Center

600 AWBU exams/yr.

Page 39: Breast Cancer Screening What’s New to Know? The Issue of Breast Density

Breast Density and AWBU

• Women don’t have to get it• Not covered by insurance – $275, $200

– Flex spending acct etc.

• Women do need to be informed – our job• Women need the opportunity to make

the choice