Transcript Breast Disease: Diagnosis and Management of Breast Cancer

Breast Cancer Screening
Dr. Paul Ferner, MD, CCFP
Medical Coordinator,
Ontario Breast Screening Program
South West Region
Is There a Conflict of Interest
Anywhere
• 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
Here Is What We Are Going
To Talk About
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Epidemiology of Breast Cancer
Breast Cancer Screening
Breast Assessment Programs
MRI and Screening
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
Canadian Cancer Statistics
25,000
20,000
15,000
10,000
5,000
0
number
Breast
Lung
Colon
• Cancer stats for 2006
• 22,300 new breast cancer
cases
• Breast cancer incidence
rising by 0.3% per year
Mortality
• Breast Cancer is a “good prognosis” tumor
• Five year disease free survival is 81%
• Lifetime overall survival is 66%
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
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
3) Grade
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Grade describes how aggressive the tumor is
Low, intermediate and high grade
The pathologist makes the determination by
what is seen under the microscope
5 Year Survival – Size versus Node
Status
negative
1-3 nodes
>4 nodes
<2 cm
96%
87%
66%
2-5 cm
89%
80%
59%
>5 cm
82%
73%
46%
We Seem to Be Winning
120
100
80
Incidence
Mortality
60
40
20
04
20
99
19
93
19
87
19
81
19
19
75
0
We Seem to be Winning
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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:
1) Finding the cancer earlier
2) Better Treatments once you find the cancer
Why Are We Winning?
Effect of Screening and Adjuvant Therapy on Mortality from
Breast Cancer NEJM 353;17: 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 70’s
• Asked the question: What proportion of the decrease in
mortality is because of early detection and what part is from
better treatments
Mortality versus Time
70
60
50
No M or T
With M Only
With T Only
Both M & T
40
30
20
10
0
1975 1980 1985 1990 1995 2000
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%)
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
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
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
How It Works
• The physician’s 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
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
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
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%
Here is What it Looks Like
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
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
DIAGNOSTIC PROCEDURES*
RECEIVED
by Participants with Abnormal Screens
2002
% 70
60
50
40
30
20
10
0
Ultrasound
Diagnostic
Mammogram
MD
Visit
Surgical
Consult
Core
Biopsy
Open
Biopsy
* Procedures after date of diagnosis have been excluded
FNA
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
DIAGNOSTIC INTERVAL
2002
Benign
Diagnostic
Interval__
Breast Cancers
Cumulative
Percent
Frequency
Cumulative
Percent_
11,713
67.15
455
41.78
2 months
3,124
85.06
346
73.55
3 months
990
90.74
172
89.35
1,183
97.52
101
98.62
433
100.00
15
100.00
1 month
4-6 months
>6-12+ months
Frequency
* Excludes 49 benign screens with no assessment procedures entered
Assessment Targets
• >90% having initial first assessment
in <3 weeks
• >90% having definite diagnosis in 4 weeks if no
biopsy
• >90% having definite diagnosis in 5 weeks if
there is a biopsy
• >90% having definitive diagnosis or treatment
in 7 weeks if seen by surgeon
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
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
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
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
can’t do anything about
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
Gender
• Gender is, of course, the biggest risk factor for
breast cancer
• For 2006
– 22,100 cases in women
– 160 in men
For Women, Age is the Single
Biggest Risk Factor
• As women get older, the risk increases
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40 : 1 per 1,000
50 : 5 per 1,000
60 : 10 per 1,000
74 : 16 per 1,000
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
• One first degree relative
• One second degree relative
4-5
2-3
1.2-1.5
Genetic Risk Factors
• 5% of all breast cancers have genetic
component with an identifiable gene mutation
• You are going to hear about it at 10:25 in a talk
by Dr. Bahl
Other Risk Factors (Minor)
Increase in RR of 1.1 to 1.3
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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
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
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
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
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
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
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