Update on screening for breast and lung cancer

Update On Screening For Breast And Lung Cancer

Antje L Greenfield, MD PhDClinical Associate of Radiology

Breast CancerFacts

Most frequently diagnosed cancer in women

2016: estimated 246,660 new dx in women, 2,600 in men, additional 61,000 new DCIS dx (Rate stable in white women, slight increase in AA women since 2008)

2016: 40,890 death expected

American Cancer Society 2016

Should We Screen For Breast Cancer?YES, because

decreased mortality of 36 % from 1989-2012 due to early detection with mammography and better treatment options

= estimated 250,000 lives saved


The Debate

What is the best balance of screening?

What age, how many women, false- positive mammograms, negative biopsies, overtreatment/potential harm

vs # of lives saved

Mammography saves lives

Mammography overdiagnoses breast cancer

USPSTF Recommendations

• Women 50-74 yo : screening mammography every 2 years

• Women before 50 yo: individual decision when to start with screening mammo every 2 years

• Women older than 75 yo: no specific recommendation, based on risk assessment

• No breast self exams

USPSTF update Jan 2016

ACS Recommendations

• Women 40-44 yo: choice of mammography• Women 45-54 yo: annual mammography• Women 55 yo and older: every 1-2 years

(good overall health, life expectancy 10 years or greater)

• Women with high risk profile: annual screening mammo plus MRI, start around 30 yo


ACR Recommendations-Average risk (less than 15 %): screening for all women starting at age 40 yo with annual mammography-Intermediate risk (15-20%): annual mammo at any age if biopsy proven lobular neoplasia, ADH or other factors-High risk ( greater than 20%): BRCA gene mutation, family history (8 year rule) , personal h/o DCIS or invasive cancer screen with annual mammo plus other exam such as MRI

Whhhhaaattt?

The Real Question Is:

• How much should society spend on saving one life?

• What is a reasonable balance of cost and benefit?

What do we agree on?• Yes, we need to screen for breast cancer

with mammography, ideally with 3D (shows increased detection rates up to 40% over digital mammo)-

• Women between 50-54 yo screening at least every two years

• Individualized screening for women before age 50 and after 55, risk factors to be considered

Beyond The Differences:• One does NOT fit all.• Education of patients about risks, symptoms and

options for prevention and screening• Recommendations are guidelines, need to be

individualized based on:– Risk factors (BRCA, family history, personal medical

history)– Breast density– Age– Life style (smoking, ETOH, obesity)

Maintain A Perspective:• Risk of breast cancer is relatively high,

approximately 1 in 9 women• Treatable and potentially curable when dx early

with better functional outcomes • Premenopausal breast cancer is often more

aggressive• Risk of radiation induced breast cancer from

mammo is extremely low (86 ca/ 11 death in 100000 in women 40-49 yo = 0.1 %) Radiology. 2011 Jan

Until There Is A Better Solution:

• Patient education and awareness• Talk to your doctor• Assess your risk profile

(http://www.cancer.gov/bcrisktool)• Make an individual decision based on knowledge• Reduce your risk factors and optimize your health

status• Follow through on your personalized screening

schedule

Lung Cancer

Facts2nd most commonly diagnosed cancer (male/female)

2016: estimated 224,390 new (14% of all ca dx)Rate declining by 3% per yr since 2008 due to decrease in smoking and change of environmental factors and life style

2016: 158,000 death expected (1 in 4 cancer death)


National Lung Screening Trial

• Screening LDCT of the chest reduces the risk of dying from lung cancer (20% lung-cancer specific mortality benefit)

• Not all cancers will be detected• Relatively high false-positive rate, can result

in additional testing and some invasive procedures

• Smoking cessation has high priority in LC prevention

CA Cancer J Clin 2013

ACS LC Screening Recommendationsbased on results of NLST

• Screening with low-dose spiral CT (LDCT) of the chest in apparently health patients 55 to 77 yo with at least 30 pack-year smoking history (currently smoking or quit within 15 years)

• Shared and informed decision of patient with physician

• Similar recommendations issued by USPSTF


Pearls

• LDCT not appropriate for patients with– Diagnosis and /or current treatment for

lung cancer– Lung symptoms such as SOB,

hemoptysis, infection– Had a CT chest within one year

How to determine PPY history?

Pearls

• LDCT radiation exposure is about equivalent to radiation dose of a screening mammogram

• Cost: if meeting high risk criteria usually covered by insurance, if no coverage at UPENN $125 self-pay rate

Health & Medicine

Update on screening for breast and lung cancer