Breast Cancer Screening

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Breast Cancer Screening

• Dr. Paul Ferner, MD, CCFP
• Medical Coordinator,
• Ontario Breast Screening Program
• South West Region

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Is There a Conflict of InterestAnywhere

• In keeping with the Main Pro 1 Credit
  Requirements of the College, I have to tell you
  that I have no conflict of interest in giving
  this talk
• No animals were harmed in the making of this
  slide presentation

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Here Is What We Are Going To Talk About

• Epidemiology of Breast Cancer
• Breast Cancer Screening
• Breast Assessment Programs
• MRI and Screening

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Epidemiology - Incidence

• One in three women will develop cancer in their
  lifetime (living to 85)
• Breast cancer makes up one third of all cancers
  in women
• Lifetime risk of breast cancer is one in nine

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Canadian Cancer Statistics

• Cancer stats for 2006
• 22,300 new breast cancer cases
• Breast cancer incidence rising by 0.3 per year

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Mortality

• Breast Cancer is a good prognosis tumor
• Five year disease free survival is 81
• Lifetime overall survival is 66

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Prognosis Depends On

• 1) Nodal Status
• The cancer spreads out to the lymph nodes
• Once it gets out of the breast it goes to other
  parts of the body
• You want the cancer to be found before it spreads

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• 2) Size
• A cancer can be felt at about 2 cm, just under an
  inch
• Once it gets bigger than 2 cm it seems to become
  more aggressive and more likely to spread

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• Grade
• Grade describes how aggressive the tumor is
• Low, intermediate and high grade
• The pathologist makes the determination by what
  is seen under the microscope

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5 Year Survival Size versus Node Status
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We Seem to Be Winning
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We Seem to be Winning

• From 1988 to 2004 there has been a 29 reduction
  in mortality in breast cancer
• People were wondering why the big drop in
  mortality
• Two competing reasons
• Finding the cancer earlier
• Better Treatments once you find the cancer

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Why Are We Winning?

• Effect of Screening and Adjuvant Therapy on
  Mortality from Breast Cancer NEJM 35317
  1784-92, Oct 27, 2005
• The NIH sent data on screening and treatment
  studies to seven different statistical groups
  around the US and Europe
• Looked at studies from 1975 to 2000
• Mammography, Adjuvant Chemo and Tamoxifen were
  introduced in a significant way in the late 70s
• Asked the question What proportion of the
  decrease in mortality is because of early
  detection and what part is from better treatments

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Mortality versus Time
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We Are Winning Because.

• Reduction in Mortality from 1975 to 2000 was 24
• With no treatment or screening, the mortality
  rate in 2000 was estimated to be about 62/100,000
  vs 37/100,000
• Better treatments (54)
• Early detection through screening (46)

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Screening for Breast Cancer

• Ontario Breast Screening Program
• Provincially funded breast cancer screening
  program
• CAR accredited mammography
• Consistent Reading Radiologist
• Consists of a Breast Exam and a two view
  screening mammogram

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Benefits of OBSP

• Women can self refer if no FP
• Can automatically book assessment and follow up
  investigations
• Screening is being linked to Breast Assessment
  Programs
• Utilization rates can be generated by the program
  for FHNs, FHTs and FHGs

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Family Practice Model

• Biggest tool for recruiting new women
• Shown to be effective in many screening programs
• Nice to know that women really listen to us as
  family physicians

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How It Works

• The physicians office generates a list of
  eligible women
• A letter is sent to these women asking them to be
  screened
• If a woman books her name is removed from the
  list
• The process is repeated two more times

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Current Screening Recommendations

• If at Usual Risk
• Age 50-74 biennial mammogram and yearly breast
  exam
• Age 40-49 screening not done at OBSP
• If you are going to screen this group it must be
  done yearly

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Screening Recommendations

• High Risk screen annually
• One first degree relative under 50 with breast
  cancer
• Two first degree relatives with breast cancer at
  any age
• One first degree relative or personal history of
  ovarian cancer
• Family history of male breast cancer

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• High Risk continued
• Pathologic diagnosis of atypical ductal or
  lobular hyperplasia, radial scar, phylloides
  tumor or lobular carcinoma in situ
• Breast density greater than 75

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Here is What it Looks Like
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Benefit To Screening

• For 50-74 year old group there is an estimated
  30 reduction in mortality
• For 40-49 year old group, there is an estimated
  17 reduction in mortality

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Breast Assessment The Other Part of the Equation

• This is the process of getting women from the
  abnormal screen to the diagnosis
• Tremendous time of anxiety for women
• Very work intensive for the system
• Has traditionally been done in an uncoordinated
  way involving patient, family doctor, radiologist
  and surgeon

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DIAGNOSTIC PROCEDURES RECEIVED by Participants
with Abnormal Screens2002

FNA
Diagnostic Mammogram
Ultrasound
MD Visit
Surgical Consult
Open Biopsy
Core Biopsy
Procedures after date of diagnosis have been
excluded
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Breast Assessment Program

• Coordinated investigation of abnormal screens
• A Navigator helps women through the process
• Coordination of Radiologists, Surgeons and
  Pathologists
• Specific Timelines for assessment

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DIAGNOSTIC INTERVAL 2002
Benign Breast
Cancers Diagnostic
Cumulative Cumulative Interval__ Frequency
Percent Frequency Percent_ 1 month
11,713 67.15 455 41.78 2
months 3,124 85.06 346
73.55 3 months 990 90.74
172 89.35 4-6 months 1,183
97.52 101 98.62 gt6-12 months
433 100.00 15 100.00

Excludes 49 benign screens with no assessment
procedures entered
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Assessment Targets

• gt90 having initial first assessment
• in lt3 weeks
• gt90 having definite diagnosis in 4 weeks if no
  biopsy
• gt90 having definite diagnosis in 5 weeks if
  there is a biopsy
• gt90 having definitive diagnosis or treatment in
  7 weeks if seen by surgeon

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The BAP Here

• The Waterloo Wellington Breast Centre, which is
  at Freeport Health Centre in Kitchener, is the
  Breast Assessment Program for this region
• State of the art integrated facility for breast
  health
• Opened February 2007

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The Process

• A woman has an abnormal screen
• Recommended diagnostics are automatically booked
• The FP and woman are notified
• The woman is contacted by the Navigator to answer
  questions
• Tests are performed

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The Process

• The results are given to woman and FP
• If further testing or biopsy is necessary, this
  is automatically arranged
• BAP will arrange surgical consult if necessary
• Regular case conferencing with Radiologist,
  Surgeon and Pathologist

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Risk Factors

• Not all people are created equal
• There are many factors that increase or decrease
  your risk of developing breast cancer
• The most important risk factors are things you
  cant do anything about

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Relative Risk

• Risk is measured by the increase in Relative Risk
• For a normal risk 50 year old woman, the
  likelihood of finding a cancer is 5 per 1000
• If the risk doubles, then the relative risk is 2
  and the risk has increased from 5 per 1000 to 10
  per 1000

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Gender

• Gender is, of course, the biggest risk factor for
  breast cancer
• For 2006
• 22,100 cases in women
• 160 in men

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For Women, Age is the Single Biggest Risk Factor

• As women get older, the risk increases
• 40 1 per 1,000
• 50 5 per 1,000
• 60 10 per 1,000
• 74 16 per 1,000

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Family History

• For a sporadic family history, the increase in
• RR is in the order of 2-5, depending on how
• strong the connection is (25-30 of cancers)
• Two first degree relatives 4-5
• One first degree relative 2-3
• One second degree relative 1.2-1.5

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Genetic Risk Factors

• 5 of all breast cancers have genetic component
  with an identifiable gene mutation
• You are going to hear about it at 1025 in a talk
  by Dr. Bahl

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Other Risk Factors (Minor)Increase in RR of 1.1
to 1.3

• Lack of exercise
• BMI greater than 30
• More than 2 drinks per day
• Early menarche, late menopause
• No children and no breast feeding
• BCP if for more than 5 years
• HRT with Estrogen and Progesterone

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A Few Words About MRI and Screening

• MRI has a very high sensitivity and low
  specificity in screening.
• It picks up lots of abnormalities and many of
  them are not cancer
• False positive rate is high, leading to lots of
  unnecessary diagnostic tests

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Who Do You Screen

• The American Cancer Society explicitly recommends
  not screening women at usual risk.
• Need to have a life time risk of greater than 25
  of developing breast cancer
• Too many false positives with increase in
  diagnostic tests and biopsies

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Who Do You Screen

• 1) Women with identified genetic abnormalities
• 2) Women with previous Hodgkin's Lymphoma
  treated with mantle radiation
• Need to be followed in an organized program with
  regular CBE, mammogram and MRI through the RCP

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Bottom Line

• Breast Cancer is common
• There has been a signification reduction in
  Mortality in the past 20 years
• Identifiable risk factors
• If at high risk screen yearly, other wise
  biennially
• We are aiming for integrated care through the BAP

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For the Closest OBSP Near You

• There is a prescription pad in you package giving
  all the locations in Cambridge, Fergus, Guelph
  and Kitchener
• Add Belgage X-ray and Ultrasound in Kitchener to
  the list
• Guelph General Hospital will be affiliating by
  the end of the year

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Bottom Line

• A palpable cancer is a late cancer
• If you can feel the cancer yourself it likely
  will already have spread
• Get your patients screened