Cancer Screening

1
Cancer Screening

• Current Practice and
• New Technologies

Gerald F. Farnell M.D. Salem Clinic P.C. Salem, OR
2
Cancer Screening Problems
3
Cancer Screening Problems

• Multiple screening strategies from various
  authorities

4
Cancer Screening Problems

• Multiple screening strategies from various
  authorities
• Inconsistent evidence to show impact on disease
  stage or mortality

5
Cancer Screening Problems

• Multiple screening strategies from various
  authorities
• Inconsistent evidence to show impact on disease
  stage or mortality
• Patient reluctance to follow through with
  recommended screening protocols

6
Optimal Screening Program

• Decrease Mortality
• Disease specific
• All-Cause
• Minimize false-positives
• Unnecessary work-up/biopsy
• Patient stress
• Minimize cost
• Increase participation in target population

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Cancer ScreeningFactors in Decision Making

• Traditional Practice/Bias

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Cancer ScreeningFactors in Decision Making

• Traditional Practice/Bias
• Evidence

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Cancer ScreeningFactors in Decision Making

• Traditional Practice/Bias
• Evidence
• Availability

10
Cancer ScreeningFactors in Decision Making

• Traditional Practice/Bias
• Evidence
• Availability
• Patient Request
• Consumer Choice

11
Objectives

• Current Recommendations for average and high risk
  patients
• Colon Cancer
• Breast Cancer
• New Technologies impact on current screening
  recommendations
• Identify challenges to screening
• Areas where we can make the greatest impact for
  our patients

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Colon Cancer Screening
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Colon Cancer Facts

• Lifetime risk 5.4
• 4th most common cancer
• 2nd leading cause of cancer death
• 5 year survival rate 64
• Whites 65
• Blacks 55

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Colon Cancer Screening Challenges

• Patient acceptance and compliance
• Availability of trained providers
• Flexible sigmoidoscopy
• Colonoscopy
• CT colonography
• Identification of patients at higher risk
• Warranting more aggressive screening

15
Colon Cancer Screening Modalities

• Hemoccult
• Flexible Sigmoidoscopy
• Colonoscopy
• Double Contrast Barium Enema
• CT Colonography
• Altered DNA Stool Testing

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Hemoccult

• Proven to reduce mortality in randomized
  controlled trials

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Hemoccult

• Proven to reduce mortality in randomized
  controlled trials
• Yearly screening
• 2 samples of 3 consecutive stools

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Hemoccult

• Proven to reduce mortality in randomized
  controlled trials
• Yearly screening
• 2 samples of 3 consecutive stools
• Positive hemoccult should lead to colonoscopy
• Only 1 in 3 of these patients is undergoing
  colonoscopy

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Hemoccult

• Re-hydration no longer recommended
• Increased false positive results

20
Hemoccult

• Re-hydration no longer recommended
• Increased false positive results
• Reducing dietary restrictions can increase
  compliance
• Dietary restrictions not needed with older guiac
  (Hemoccult/II) or newer immunochemical assays
  (Hemeselect-R)
• Restrict red meat only with newer more sensitive
  guiac based assays (Hemoccult Sensa)
• No need to avoid oral iron supplements

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Flexible Sigmoidoscopy

• Proven to reduce mortality

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Flexible Sigmoidoscopy

• Proven to reduce mortality
• Proximal cancers will be missed
• 20 - if screened to splenic flexure
• 32 - if screened only through sigmoid

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Flexible Sigmoidoscopy

• Proven to reduce mortality
• Proximal cancers will be missed
• 20 - if screened to splenic flexure
• 32 - if screened only through sigmoid
• Allows biopsy of abnormalities
• Hyperplastic polyps - no further evaluation
• Adenomatous polyps - may need further evaluation

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Flexible Sigmoidoscopy

• Referral for single adenoma lt1cm in size is
  controversial

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Flexible Sigmoidoscopy

• Referral for single adenoma lt1cm in size is
  controversial
• Adenomatous polyps should be referred to
  colonoscopy if
• Age gt65 y/o
• Villous histology or high grade dysplasia
• gt1cm in size
• Multiple adenomas
• Family history of colon cancer

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Colonoscopy

• Allows visualization of the entire colon

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Colonoscopy

• Allows visualization of the entire colon
• Substantial indirect evidence of effectiveness
  via colonoscopys use as the gold standard

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Colonoscopy

• Allows visualization of the entire colon
• Substantial indirect evidence of effectiveness
  via colonoscopys use as the gold standard
• No direct studies to prove efficacy of screening
  colonoscopy on incidence or mortality in patients
  at average risk

29
Colonoscopy

• 10 year follow up interval for routine screening
• Less than 1 of patients will have a polyp or
  cancer at a 5 year follow-up
• More expensive and less available than flexible
  sigmoidoscopy

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Double Contrast Barium Enema
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Double Contrast Barium Enema

• No randomized studies of efficacy in mortality or
  incidence in average risk patients
• Case control study associated with 33 reduction
  in death but CI was high

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Double Contrast Barium Enema

• No randomized studies of efficacy in mortality or
  incidence in average risk patients
• Case control study associated with 33 reduction
  in death but CI was high
• Less sensitive than colonoscopy
• 95 vs. 85 for detecting cancer
• Detects half of large polyps

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Double Contrast Barium Enema

• Offers an alternative to imaging the entire
  colon, albeit less sensitive

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Double Contrast Barium Enema

• Offers an alternative to imaging the entire
  colon, albeit less sensitive
• Abnormal tests require colonoscopy

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Colon Cancer Screening Modalities

• Hemoccult
• Flexible Sigmoidoscopy
• Colonoscopy
• Barium Enema
• CT Colonography
• Altered DNA Stool Testing

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CT Colonography
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CT Colonography

• Non-invasive imaging of entire colon
• Produced by thin section, helical CT imaging
• Multidetector scanners offer better performance
• Scans can be completed in 15 seconds

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CT Colonography

• Non-invasive imaging of entire colon
• Produced by thin section, helical CT imaging
• Multidetector scanners offer better performance
• Scans can be completed in 15 seconds
• Air insufflation and standard bowel prep required

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CT Colonography

• Non-invasive imaging of entire colon
• Produced by thin section, helical CT imaging
• Multidetector scanners offer better performance
• Scans can be completed in 15 seconds
• Air insufflation and standard bowel prep required
• Barium tagging of stool and retained fluids
• Allows for electronic cleansing of the colon

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CT Colonography

• Non-invasive imaging of entire colon
• Produced by thin section, helical CT imaging
• Multidetector scanners offer better performance
• Scans can be completed in 15 seconds
• Air insufflation and standard bowel prep required
• Barium tagging of stool and retained fluids
• Allows for electronic cleansing of the colon
• Reasonable detection rates in high risk patients
  at select centers

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CT ColonographyResearch Trials

• Multiple trials reveal very different results
• For lesions gt1cm
• Sensitivity 32-92
• Polyps lt1cm Sensitivity 39-63
• (vs. Colonoscopy Sensitivity 75-88)

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CT ColonographyResearch Trials

• Multiple trials reveal very different results
• For lesions gt1cm
• Sensitivity 32-92
• Polyps lt1cm Sensitivity 39-63
• (vs. Colonoscopy Sensitivity 75-88)
• Disparity may be explained by
• Differences in patient populations
• CT technique
• Radiologist variability

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CT ColonographyLimitations

• Lack of availability outside of research centers
• Latest generation of CT scanners/software
• Radiologist expertise

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CT ColonographyLimitations

• Lack of availability outside of research centers
• Latest generation of CT scanners/software
• Radiologist expertise
• Colonic abnormalities require follow up
  colonoscopy

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CT ColonographyLimitations

• Lack of availability outside of research centers
• Latest generation of CT scanners/software
• Radiologist expertise
• Colonic abnormalities require follow up
  colonoscopy
• Extracolonic abnormalities require further work
  up/imaging

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CT ColonographyLimitations

• Significant radiation exposure
• Recent article in NEJM
• Up to 2 of all cancers in 20 years could be
  related to radiation from CT scans

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CT ColonographyCost-Effectiveness

• 2005 Canadian Cost Analysis
• Increased Cost
• 2.7 million per 100,000 patients screened vs.
  colonoscopy
• Marginally increased death rate
• Projected deaths from missed adenomas exceeding
  deaths prevented from perforation

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CT ColonographyAdvantages
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CT ColonographyAdvantages

• Ability to be performed without sedation
• Minimized time away from work
• Simplified travel to and from appointment

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CT ColonographyAdvantages

• Ability to be performed without sedation
• Minimized time away from work
• Simplified travel to and from appointment
• Increased patient acceptance
• Perceived less discomfort
• Short duration

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CT ColonographyAdvantages

• Ability to be performed without sedation
• Minimized time away from work
• Simplified travel to and from appointment
• Increased patient acceptance
• Perceived less discomfort
• Short duration
• Extracolonic abnormalities can be identified

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CT ColonographyAdvantages

• Ability to be performed without sedation
• Minimized time away from work
• Simplified travel to and from appointment
• Increased patient acceptance
• Perceived less discomfort
• Short duration
• Extracolonic abnormalities can be identified
• Relative safety in patients with comorbities

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CT ColonographyIndications

• Patients with elevated endoscopic risk
• Sedation risk
• Anticoagulated patients

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CT ColonographyIndications

• Patients with elevated endoscopic risk
• Sedation risk
• Anticoagulated patients
• After incomplete endoscopy
• 1-3 of colonoscopies
• Can be done the same day, avoiding repeat bowel
  preps in 90 of cases

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CT ColonographyIndications

• Patients with elevated endoscopic risk
• Sedation risk
• Anticoagulated patients
• After incomplete endoscopy
• 1-3 of colonoscopies
• Can be done the same day, avoiding repeat bowel
  preps in 90 of cases
• Detection of proximal lesions in patients with
  distal occlusive colon cancer

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CT ColonographyIndications

• Patients with elevated endoscopic risk
• Sedation risk
• Anticoagulated patients
• After incomplete endoscopy
• 1-3 of colonoscopies
• Can be done the same day, avoiding repeat bowel
  preps in 90 of cases
• Detection of proximal lesions in patients with
  distal occlusive colon cancer
• Patients with aversion to endoscopy

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CT ColonographyIndications

• But
• NOT currently ready for widespread screening in
  average-risk patients.

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Altered DNA Stool Testing

• Detects DNA alterations acquired during
  carcinogenesis
• Performed by collecting an entire bowel movement
  and shipping it on ice

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Altered DNA Stool Testing

• Detects DNA alterations acquired during
  carcinogenesis
• Performed by collecting an entire bowel movement
  and shipping it on ice
• Found to be more sensitive than FOBT

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Altered DNA Stool Testing

• Detects DNA alterations acquired during
  carcinogenesis
• Performed by collecting an entire bowel movement
  and shipping it on ice
• Found to be more sensitive than FOBT
• Unclear what to do if no lesion found on
  colonoscopy after abnormal result

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Altered DNA Stool Testing

• Detects DNA alterations acquired during
  carcinogenesis
• Performed by collecting an entire bowel movement
  and shipping it on ice
• Found to be more sensitive than FOBT
• Unclear what to do if no lesion found on
  colonoscopy after abnormal result
• NOT recommended for screening due to high cost

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Current RecommendationsColon Cancer Average
Risk Patients
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High Risk Patients

• Familial adenomatous polyposis (FAP)
• Hereditary non polyposis colorectal cancer
  (HNPCC)
• Also known as Lynch Syndrome
• Inflammatory bowel disease
• History of colon adenomas or cancer
• Family history of adenoma or cancer

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Current RecommendationsColon Cancer High Risk
Patients

• Family history of colon cancer or polyp
• Highest risk
• One first degree relative at age lt60 y/o, or
• 2 first degree relatives at any age
• Colonoscopy every 5 years starting at 40 y/o or
  10 years younger than youngest affected family
  member

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Current RecommendationsColon Cancer High Risk
Patients

• Family history of colon cancer or polyp
• Highest risk
• One first degree relative at age lt60 y/o, or
• 2 first degree relatives at any age
• Colonoscopy every 5 years starting at 40 y/o or
  10 years younger than youngest affected family
  member
• Moderate risk
• One first degree relative gt60 y/o, or
• 2 second degree relatives
• Colonoscopy every 10 years starting at 40 y/o

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Breast Cancer Screening
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Breast Cancer Facts

• Lifetime risk 12.3
• 3rd most common cancer
• 3rd leading cause of cancer death
• 5 year survival rate 88.6
• Whites 90
• Blacks 77

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Breast Cancer Screening Challenges

• Overdiagnosis
• Ductal Carcinoma In-Situ
• Cancers found that would not have become
  clinically significant

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Breast Cancer Screening Challenges

• Overdiagnosis
• Ductal Carcinoma In-Situ
• Cancers found that would not have become
  clinically significant
• False positives
• Leading to additional imaging/biopsy
• Increased patient stress

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Breast Cancer Screening Challenges

• Overdiagnosis
• Ductal Carcinoma In-Situ
• Cancers found that would not have become
  clinically significant
• False positives
• Leading to additional imaging/biopsy
• Increased patient stress
• Patient participation

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Breast Cancer Screening Modalities

• Self Breast Exam (SBE)
• Clinical Breast Exam(CBE)
• Mammography
• Breast Ultrasound
• MRI
• Scintimammography

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Self Breast Exam

• Recommended heavily in 1990s

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Self Breast Exam

• Recommended heavily in 1990s
• Efficacy questioned since Chinese study in 2002
• No difference in mortality or tumor stage found
  in this and 8 other studies
• Increased rate of breast biopsy for benign
  disease

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Self Breast Exam

• Recommended heavily in 1990s
• Efficacy questioned since Chinese study in 2002
• No difference in mortality or tumor stage found
  in this and 8 other studies
• Increased rate of breast biopsy for benign
  disease
• Not recommended by any group
• Discouraged by Cochrane Collaboration

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Clinical Breast Exam

• Identifies 50 of breast cancers

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Clinical Breast Exam

• Identifies 50 of breast cancers
• A study showed no effect on mortality
• Used a standardized 10 minute exam

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Clinical Breast Exam

• Identifies 50 of breast cancers
• A study showed no effect on mortality
• Used a standardized 10 minute exam
• Community based study showed that 5-16 of all
  cancers would be missed without CBE as part of
  screening

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Clinical Breast Exam

• Identifies 50 of breast cancers
• A study showed no effect on mortality
• Used a standardized 10 minute exam
• Community based study showed that 5-16 of all
  cancers would be missed without CBE as part of
  screening
• Cost of CBE per additional cancer detected was
  122,598 in one study

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Mammography
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Mammography

• Uses very low dose radiation
• 100-1,000 times higher dose needed to see an
  increase in breast cancer frequency

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Mammography

• Uses very low dose radiation
• 100-1,000 times higher dose needed to see an
  increase in breast cancer frequency
• Involves uncomfortable breast compression
• Some scanners allow patient to control amount of
  compression

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MammographyMortality Benefit
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MammographyMortality Benefit

• 50-69 years old
• 8 randomized studies showed 34 reduction in
  mortality
• Relative risk .78 (CI .7-.87)

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MammographyMortality Benefit

• 50-69 years old
• 8 randomized studies showed 34 reduction in
  mortality
• Relative risk .78 (CI .7-.87)
• 40-49 years old
• Recent ACP review supported smaller benefits of
  screening in this group
• Relative risk .85 (CI .73-.99)

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MammographyMortality Benefit

• 50-69 years old
• 8 randomized studies showed 34 reduction in
  mortality
• Relative risk .78 (CI .7-.87)
• 40-49 years old
• Recent ACP review supported smaller benefits of
  screening in this group
• Relative risk .85 (CI .73-.99)
• Screening past age 69 not well studied
• Consider screening until life expectancy lt10
  years

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Mammography

• Number Needed to Screen (NNS) to prevent one
  death from breast cancer (over 14 years)

87
Mammography

• Number Needed to Screen (NNS) to prevent one
  death from breast cancer (over 14 years)
• Age 40-49 1792 women
• Age 50-69 838 women

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Mammography

• Number Needed to Screen (NNS) to prevent one
  death from breast cancer (over 14 years)
• Age 40-49 1792 women
• Age 50-69 838 women
• Cost per year life saved

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Mammography

• Number Needed to Screen (NNS) to prevent one
  death from breast cancer (over 14 years)
• Age 40-49 1792 women
• Age 50-69 838 women
• Cost per year life saved
• Age 40-49 105,000
• Age 50-69 21,400
• Age 75-80 34,000 to 88,000

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Digital Mammography
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Digital Mammography

• Multiple studies show minimal difference in
  diagnostic accuracy vs. film

92
Digital Mammography

• Multiple studies show minimal difference in
  diagnostic accuracy vs. film
• Small advantage over film in younger women with
  dense breasts

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Digital Mammography

• Multiple studies show minimal difference in
  diagnostic accuracy vs. film
• Small advantage over film in younger women with
  dense breasts
• 1.5-4 x as expensive as film

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Digital Mammography

• Multiple studies show minimal difference in
  diagnostic accuracy vs. film
• Small advantage over film in younger women with
  dense breasts
• 1.5-4 x as expensive as film
• Significant advantage in storage and transmission
  of images

95
Computer-Assisted Detection Mammography
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Computer-Assisted Detection Mammography

• No studies to show mortality benefit

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Computer-Assisted Detection Mammography

• No studies to show mortality benefit
• Large studies show
• Reduced specificity
• Increased biopsy rates (by 20)
• Nonsignificant trend to increased sensitivity,
  but typically identifying DCIS

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Breast Cancer Screening Modalities

• Self Breast Exam (SBE)
• Clinical Breast Exam(CBE)
• Mammography
• Breast Ultrasound
• MRI
• Scintimammography

99
Breast Ultrasound

• Current trial to determine role in high risk
  patients
• Involves whole breast imaging
• May have advantage in dense breast tissue
• Very technician dependant

100
Breast Ultrasound

• Current trial to determine role in high risk
  patients
• Involves whole breast imaging
• May have advantage in dense breast tissue
• Very technician dependant
• No current role in screening except
• Follow up of abnormal mammogram

101
Breast MRI
102
Breast MRI

• Two MRI Scanner types
• Standard MRI - Patient lays down with breasts
  hanging freely in cushioned openings surrounded
  by a breast coil
• Newer Standing Breast MRI

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Breast MRI

• Two MRI Scanner types
• Standard MRI - Patient lays down with breasts
  hanging freely in cushioned openings surrounded
  by a breast coil
• Newer Standing Breast MRI
• No radiation exposure

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Breast MRI

• Two MRI Scanner types
• Standard MRI - Patient lays down with breasts
  hanging freely in cushioned openings surrounded
  by a breast coil
• Newer Standing Breast MRI
• No radiation exposure
• Potential claustrophobia issues

105
Breast MRI

• Two MRI Scanner types
• Standard MRI - Patient lays down with breasts
  hanging freely in cushioned openings surrounded
  by a breast coil
• Newer Standing Breast MRI
• No radiation exposure
• Potential claustrophobia issues
• Currently used in further work up of breast
  masses/abnormalities

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Breast MRI

• American Cancer Society (2007)

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Breast MRI

• American Cancer Society (2007)
• Not recommended for screening in
• Women with lt15 lifetime risk

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Breast MRI

• American Cancer Society (2007)
• Not recommended for screening in
• Women with lt15 lifetime risk
• Recommended for screening in
• Women with gt20 lifetime risk
• Strong family history for breast/ovarian cancers
• Women treated with chest irradiation for
  Hodgkins disease

109
Breast MRI

• Intermediate risk patients without clear
  recommendations from ACS (2007)
• 15-20 lifetime risk of breast cancer
• Very dense breasts or unevenly dense breasts
  (when viewed on a mammogram)
• History of breast cancer, including ductal
  carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS) or atypical
  lobular hyperplasia
• Atypical ductal hyperplasia

110
Breast MRI

• Limited utility in general population

111
Breast MRI

• Limited utility in general population
• Decreased specificity

112
Breast MRI

• Limited utility in general population
• Decreased specificity
• Increased cost 1,000
• Mammogram 100
• Increased time 30-60 minutes
• Mammogram 10-15 minutes

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Scintimammography
114
Scintimammography

• Uses Tc-99 and gamma camera
• Limited sensitivity without breast specific gamma
  camera
• Patient lays on table with breast freely hanging
  through opening
• Time 45-60 minutes
• Cost 200-600/exam

115
Scintimammography

• Uses Tc-99 and gamma camera
• Limited sensitivity without breast specific gamma
  camera
• Patient lays on table with breast freely hanging
  through opening
• Time 45-60 minutes
• Cost 200-600/exam
• Used in work up of palpable abnormality and
  negative mammogram

116
Scintimammography

• Uses Tc-99 and gamma camera
• Limited sensitivity without breast specific gamma
  camera
• Patient lays on table with breast freely hanging
  through opening
• Time 45-60 minutes
• Cost 200-600/exam
• Used in work up of palpable abnormality and
  negative mammogram
• No current role in screening

117
Current RecommendationsBreast Cancer Average
Risk Patients
118
Current RecommendationsBreast Cancer Average
Risk Patients
119
Current RecommendationsBreast Cancer Average
Risk Patients
120
High Risk Patients
121
High Risk Patients

• BRCA-1 or BRCA-2 mutation or present in first
  degree relative

122
High Risk Patients

• BRCA-1 or BRCA-2 mutation or present in first
  degree relative
• Exposure to chest irradiation

123
High Risk Patients

• BRCA-1 or BRCA-2 mutation or present in first
  degree relative
• Exposure to chest irradiation
• gt20 lifetime risk for breast cancer

124
Breast Cancer Risk Calculator

• http//www.cancer.gov/bcrisktool/Default.aspx

125
Breast Cancer Risk Calculator

• Includes
• Current age/ethnicity
• Age at menarche
• Age at first child
• Family history of breast cancer
• History of breast cancer
• History of breast biopsies/results
• http//www.cancer.gov/bcrisktool/Default.aspx

126
Current RecommendationsBreast Cancer High Risk
Patients

• American Cancer Society 2007

127
Current RecommendationsBreast Cancer High Risk
Patients

• American Cancer Society
• Annual Mammogram and MRI at age 30

128
Cancer Screening Summary
129
Cancer Screening Summary
130
Cancer Screening Summary
131
Final Thoughts
132
Final Thoughts

• Reflexive screening is not appropriate
• Identify high risk patients

133
Final Thoughts

• Reflexive screening is not appropriate
• Identify high risk patients
• Better patient involvement/education
• Decision making
• Improve compliance

134
Final Thoughts

• Reflexive screening is not appropriate
• Identify high risk patients
• Better patient involvement/education
• Decision making
• Improve compliance
• Newer technologies have not yet proven to be
  superior to older methods for average risk
  patient screening

135
Final Thoughts

• we must make decisions about todays screening
  with the information of today and not wait for
  something better to possibly come along later.