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Screening for Breast Cancer Information For Primary Care Providers in Michigan
Renee W. Pinsky, MD Assistant Professor
Department of Radiology University of Michigan Health System
Screening Mammography • Module 4: Agreement over screening
– Screening Mammography reduces breast cancer mortality • Module 5: Controversies in screening
– When to start? – When to end? – How often?
• Module 6: Negative consequences of screening
Module 4 Agreement over screening
• Intended Learning Outcomes – Be familiar with the extensive research demonstrating
mortality reduction resulting from screening mammography
– Counsel patients regarding the utility of mammography including evidence for mortality and morbidity reduction
Agreement over Screening
• Outline: – Screening mammography introduction – Breast Cancer (BC) mortality rates – Scientific support of screening mammography
• RCT • Observational studies • Computerized models
Screening Mammography in Average Risk Women
• Purpose: – To decrease mortality and morbidity from breast cancer
(BC) • To detect cancers at an earlier stage than when clinically
apparent • To allow more limited surgery and medical treatment
• Asymptomatic women
ACS 2014, SEER 2015
Declining USA Female Breast Ca Mortality Rate
ê2 % / year 1990-2011 = 35%
Screening and Treatment Greater decline if Mortality trend used
Randomized Controlled Trials (RCT) • 1970s-1990s-old studies • Invitation not as treated • Allowed screening in control arm (contamination) • Variable mammogram methodologies:
– Age range – Frequency of screening 12,18, 24 month intervals – Number of rounds of screening – Length of follow up
Smith RA. The randomized trials of breast cancer screening: What have we learned? Radiol Clinics of NA 2004
Marmot MG et al, The benefits and harms of breast cancer screening: an independent review. British Journal of Cancer (2013) 108, 2205–2240
RCT: RR= 0.80 (0.73-0.89) UK Review
RCT Long Term Follow Up Studies Swedish Two County Trial
• 29 years • RR of BC death 0.69= 31% mortality reduction • Most prevented deaths occurred after 10 years of follow up
Tabár, L et al, Swedish Two-County Trial: Impact of Mammographic Screening on Breast Cancer Mortality during 3 Decades Radiology 2011 260:3, 658-663
Invited
Not invited
Canadian National Trial – Original study:
• Mammography did NOT reduce BC mortality • Ages 40-59 • Outlier from other RCTs
– 25 year follow up • Mammography did NOT reduce BC mortality
Miller AB et al Twenty five year follow up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. Br. Med. Journal 2014 Feb 11:348
10 observational studies: Meta-analysis 49% Mortality Reduction
Nickson C et al. Cancer Epidemiol Biomarkers Prev 2012 ;21:1479-1488 ©2012 by American Association for Cancer Research
• 40% MORTALITY REDUCTION – ~2.8 million screening studies – Age 40-79 – All age decades similar (40s-70s)
Coldman A et al Pan-Canadian Study of Mammography Screening and Mortality Image from Breast Cancer JNCI (2014)106 (11)
Biennial 50-74 (USPSTF) vs Annual 40-84 (ACS, NCCN)
(mean 6 CISNET models)
LYG/1000
Mortality Reduction (%)
B 50-74
110
23
A 40-84
189
40
Difference(%) 79 (72% ) 16.3 (71% ) Hendrick and Helvie, AJR 2011 Derived from: Mandelblatt J S et al. Ann Intern Med 2009;151:738-747
Screening vs. treatment effect
46% mortality reduction attributed to
mammography
Low screening compliance (< 50%)
Berry DA, Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353(17) 1784-92
Screen impact at 100% relative to SCR +TX Model S 74% due to annual screen (39.0% of 52.5%) Model E 69% due to annual screen (35.6% of 51.8%)
Munoz D et al, Effects of Screening and Systemic Adjuvant Therapy on ER-specific US Breast Cancer Mortality JNCI Vol. 106, Nov 2014
Morbidity: Age 40-79, British Columbia
46% less Chemotherapy among screened 47% higher use of BCT among screened
Coldman AJ,et al. A retrospective study of the effect of participation in screening mammography on the use of chemotherapy and breast conserving therapy, Int J Cancer: 120, 2185-2190 (2007)
Decreased Morbidity Screen vs Palpable Detection
Age 40-49
Screened Symptoms Mastectomy 25% 47%
Chemotherapy 45% 81%
Malmgren J A et al. Impact of mammography detection on the course of breast cancer in women aged 40-49 years. Radiology 2012 ;262:797-806
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