Population Management

Breast Cancer Screening

October 2013

Breast Cancer: Incidence • Excluding skin cancers, breast cancer is the

most common cancer among women.Accounts for nearly 1 in 3 cancers

diagnosed in US womenSecond most common cause of cancer

death in US women• 1 in 8 women in the U.S. will develop

invasive breast cancer in their lifetime

Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer Society, Inc.

Early Detection and Prevention

• Early detection and prevention programs have enabled the survival rates for breast cancer to increase and the death rates to steadily decline over the past several years.

Misconceptions • Women will often decline screening and

when asked why, will comment that they have no family history or risk factors for breast cancer and so don’t need screened. In reality:– 50% of women who develop breast cancer are

not at elevated risk– 80-85% of women diagnosed with breast

cancer have NO family history of breast cancer

Breast Cancer Risk Factors: High Relative Risk (>4-fold)

• Age (65+ vs. < 65 yrs)

• Atypical hyperplasia confirmed by biopsy• Certain inherited genetic mutations for breast

cancer (e.g., BRCA1 and/or BRCA2)

• Dense breasts(on mammography report)

• Personal history of breast cancerSource: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer Society, Inc.

Breast Cancer Risk Factors: Relative Risk (2.1-4.0)

• High endogenous estrogen or testosterone levels

• High bone density

• High-dose radiation to chest

• Two first-degree relatives with breast cancerSource: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer Society, Inc.

Breast Cancer Risk Factors: Relative Risk (1.1-2.0)

• Alcohol consumption• Ashkenazi Jewish heritage• Early menarche (<12 years)• High socioeconomic status• First full-term pregnancy > 30 years of age • Late menopause (> 55 years)

Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer Society, Inc.

Breast Cancer Risk Factors: Relative Risk (1.1-2.0) (continued)

• Never breastfed a child• No full-term pregnancies• Obesity (post-menopausal)/adult weight gain• One first-degree relative with breast cancer• Personal history of endometrium, ovary, or

colon cancer• Recent & long-term use of menopausal

hormone therapy containing estrogen and progestin

• Recent oral contraceptive use

. Source: American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer Society, Inc.

Issues and Controversies• Guidelines on mammography screening are controversial.

They are issued at different times by different authorities and MAY analyze different data. The result is different recommendations from various organizations. These will be reviewed today.

• The recommendations presented by the different organizations are for women at an average risk for breast cancer. Women with risk factors may require more frequent screening and women with a longer life expectancy may choose to continue with screening beyond the upper age recommendations presented today.

Bottom Line: Your best clinical judgment Bottom Line: Your best clinical judgment must prevail.must prevail.

USPSTF Grade Definitions

Grade Definition Suggestions for PracticeAssignment

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer or provide this service.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

C

The USPSTF recommends against routinely providing the service. There may be consideration that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.

Offer or provide this service only if other consideration support the offering or providing the service in an individual patient.

USPSTF Grade Definitions (Cont.)

Grade Definition Suggestions for PracticeAssignment

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I statement

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined

Read the clinical considerations section of USPSTF Recommendations. If the service is offered, patients should understand the uncertainty about the balance of benefits/harms.

USPSTF Breast Cancer Screening:Summary of Recommendations (2009)

• Recommends biennial screening mammography for women aged 50 to 74 years. – Grade B Recommendation.

• Decision to start regular, biennial screening mammography before age 50 should be individual one and take patient context into account, including patient’s values regarding specific benefits and harms. – Grade C Recommendation

• Concludes current evidence insufficient to assess additional benefits and harms of screening mammography in women ≥ 75 years. – Grade I Statement

Other Breast Cancer Screening Recommendations

• ACOG 2011: recommends screening mammography every year starting at age 40

• ACS 2003: Women at average risk should begin annual mammography at age 40

• AAFP 2009:– Mirrors USPSTF recommendation

• HEDIS/QHP– Mammography every 2 years ages 40-69(2013)– Mammography every 2 years ages 50-74(2014)

• Bottom Line: Certain patients will fall into a different screening recommendation. Use your best clinical judgment.

Mammography• Film versus digital

–  Full-field digital mammography is similar to traditional film-screen mammography except that the image is captured by an electronic detector and stored on a computer

– Studies show digital may be better in accuracy for women with dense breasts and pre/perimenopausal women but also associated with a higher false positive rate

MRI

• May be considered for use in high risk women– Recommended by ACS in women with a

lifetime risk of >= 20-25%

• More sensitive, but also less specific– More likely to detect an abnormality if one

exists– More women with false positives

3D Mammography/Tomosynthesis

• It is a modification of digital mammography

• Uses a moving x-ray source and digital detector to provide data for computer-reconstructed thin sections of images

• Only can be used in conjunction with conventional mammogram

• Exposes the patient to 2x the radiation

• May be beneficial in women with dense breasts

• Not covered by most insurance at this time

Breast Ultrasound

• Used mainly as diagnostic follow-up of an abnormal mammogram or physical exam finding

Insurance Coverage for Mammography

• While recommendations differ, Medicare/Medicaid and other insurance carriers will cover mammography annually starting at age 40

• Low-income, uninsured or underinsured women may qualify for free mammography via the Illinois Breast and Cervical Cancer Screening Program– http://www.idph.state.il.us/about/womenshealt

h/owhmap.htm

Barriers for Patients in Obtaining Mammogram

• Patient misconceptions regarding risks– “I don’t have a family history, so I’m not at risk”

• Relying on patients to schedule mammogram– Offer to schedule during rooming process

• “Too busy”– The Breast Center has early morning hours(7:30-5pm)/Saturday hours– Offer to schedule 1-2 months out

• Insurance coverage or no coverage– Previous slide

• Transportation

• Other?

Clinical Breast Examination (CBE)

• May identify 4.5 – 10.7% of breast cancers that mammography misses– Clinician proficiency impacts effectiveness

• High rate false positives• Recommendations vary

– ACS and ACOG 2011 recommend one every 3 years for average risk women ages 20-30; annually for women > 40

– USPSTF 2010: current evidence insufficient to assess additional benefits and harms of CBE beyond screening mammography in women ≥ 40. Grade I Statement

Breast Self-Examination (BSE)

• Recommendations vary– ACS and others: teach women the procedure

to provide to them as an option– USPSTF 2010 recommends against teaching

BSE.

Grade D Recommendation

• Not shown to have an effect on breast CA mortality rate

The Breast Center• Locations in Carbondale and Herrin

• Services offered at The Breast Center:– Digital and 3D mammography– Minimally invasive biopsy technique– Risk assessment: Personal breast cancer risk

is estimated. Options for enhanced screenings and/or prevention can be evaluated.

– Genetic Counseling – Breast MRI

The Breast Center

• Breast Cancer Care Team meets weekly to review treatment planning for every newly diagnosed cancer patient.

• Team: Surgeon, radiologist, medical oncologist, pathologist, radiation oncologist, and nurse navigator

The Breast Center• Hours: 7:30-5:00pm and Saturday

appointments available– Patients may be more likely to get the

screening performed if they can go before work or on a Saturday.

• Only Medicaid patients need a order from their provider to have a screening mammogram

• Risk assessment and genetic counseling require a referral

How are we currently doing on Breast Cancer Screening?

Organization Performance

• Insert slide comparing your organization’s performance to other organizations within QHP. Explain any performance issues related to data for your organization

Site Performance

• Insert the slide on the different facilities within your organization– Make sure to explain any data issues with

individual sites within your organization

Provider Performance

• Insert slide on provider performance

• Review performance issues that may be related to data.

• Discuss what “best practices” may already be utilized by some of the top performers and where things are going well.

How can we do better?

• Add content to this slide for your organization’s ideas and implementation plan to improve breast cancer screening rates and illicit suggestions from the group at large.

• Items to consider:

– How does mammogram data come into your EHR from the screening center?

– Display of mammogram performance within the provider/staff area during October

– Discussion at huddles/planning for the day. Gap report utilization

– How is data entered into the EHR at point-of-care? Is there standard work for this process regarding who enters it and where it is entered into the EHR?

– Utilization of the registry for outreach to patients overdue on mammogram screening

– Patient education/displays for the month of October• Waiting room, exam rooms – posters, weblinks, handouts

• T-shirts for staff