Population Management Breast Cancer Screening October 2013

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<ul><li><p>Population Management</p><p>Breast Cancer ScreeningOctober 2013</p></li><li><p>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 women1 in 8 women in the U.S. will develop invasive breast cancer in their lifetime</p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p></li><li><p>Early Detection and PreventionEarly 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.</p></li><li><p>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 dont need screened. In reality:50% of women who develop breast cancer are not at elevated risk80-85% of women diagnosed with breast cancer have NO family history of breast cancer</p></li><li><p>Breast Cancer Risk Factors: High Relative Risk (&gt;4-fold)</p><p>Age (65+ vs. &lt; 65 yrs)</p><p>Atypical hyperplasia confirmed by biopsyCertain inherited genetic mutations for breast cancer (e.g., BRCA1 and/or BRCA2)</p><p>Dense breasts(on mammography report)</p><p>Personal history of breast cancerSource: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p></li><li><p>Breast Cancer Risk Factors: Relative Risk (2.1-4.0)</p><p>High endogenous estrogen or testosterone levels</p><p>High bone density</p><p>High-dose radiation to chest</p><p>Two first-degree relatives with breast cancer</p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p></li><li><p>Breast Cancer Risk Factors: Relative Risk (1.1-2.0)</p><p>Alcohol consumptionAshkenazi Jewish heritageEarly menarche ( 30 years of age Late menopause (&gt; 55 years)</p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p></li><li><p>Breast Cancer Risk Factors: Relative Risk (1.1-2.0) (continued)</p><p>Never breastfed a childNo full-term pregnanciesObesity (post-menopausal)/adult weight gainOne first-degree relative with breast cancerPersonal history of endometrium, ovary, or colon cancerRecent &amp; long-term use of menopausal hormone therapy containing estrogen and progestinRecent oral contraceptive use</p><p>. Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p></li><li><p>Issues and ControversiesGuidelines 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.</p><p>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. </p><p>Bottom Line: Your best clinical judgment must prevail.</p></li><li><p>USPSTF Grade Definitions</p><p>GradeDefinitionSuggestions for PracticeAssignment AThe USPSTF recommends the service. There is high certainty that the net benefit is substantial.Offer or provide this service.BThe 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.CThe 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.</p></li><li><p>USPSTF Grade Definitions (Cont.)</p><p>GradeDefinitionSuggestions for PracticeAssignment DThe 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 statementThe 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 determinedRead the clinical considerations section of USPSTF Recommendations. If the service is offered, patients should understand the uncertainty about the balance of benefits/harms.</p></li><li><p>USPSTF Breast Cancer Screening:Summary of Recommendations (2009)Recommends biennial screening mammography for women aged 50 to 74 years. Grade B Recommendation.</p><p>Decision to start regular, biennial screening mammography before age 50 should be individual one and take patient context into account, including patients values regarding specific benefits and harms. Grade C Recommendation</p><p>Concludes current evidence insufficient to assess additional benefits and harms of screening mammography in women 75 years. Grade I Statement</p></li><li><p>Other Breast Cancer Screening RecommendationsACOG 2011: recommends screening mammography every year starting at age 40</p><p>ACS 2003: Women at average risk should begin annual mammography at age 40</p><p>AAFP 2009:Mirrors USPSTF recommendation</p><p>HEDIS/QHPMammography every 2 years ages 40-69(2013)Mammography every 2 years ages 50-74(2014)</p><p>Bottom Line: Certain patients will fall into a different screening recommendation. Use your best clinical judgment.</p></li><li><p>MammographyFilm versus digitalFull-field digital mammography is similar to traditional film-screen mammography except that the image is captured by an electronic detector and stored on a computerStudies 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</p></li><li><p>MRIMay be considered for use in high risk womenRecommended by ACS in women with a lifetime risk of &gt;= 20-25%More sensitive, but also less specificMore likely to detect an abnormality if one existsMore women with false positives</p></li><li><p>3D Mammography/TomosynthesisIt is a modification of digital mammographyUses a moving x-ray source and digital detector to provide data for computer-reconstructed thin sections of imagesOnly can be used in conjunction with conventional mammogramExposes the patient to 2x the radiationMay be beneficial in women with dense breastsNot covered by most insurance at this time </p></li><li><p>Breast UltrasoundUsed mainly as diagnostic follow-up of an abnormal mammogram or physical exam finding</p></li><li><p>Insurance Coverage for MammographyWhile recommendations differ, Medicare/Medicaid and other insurance carriers will cover mammography annually starting at age 40Low-income, uninsured or underinsured women may qualify for free mammography via the Illinois Breast and Cervical Cancer Screening Programhttp://www.idph.state.il.us/about/womenshealth/owhmap.htm</p></li><li><p>Barriers for Patients in Obtaining MammogramPatient misconceptions regarding risksI dont have a family history, so Im not at risk</p><p>Relying on patients to schedule mammogramOffer to schedule during rooming process</p><p>Too busyThe Breast Center has early morning hours(7:30-5pm)/Saturday hoursOffer to schedule 1-2 months out</p><p>Insurance coverage or no coveragePrevious slide</p><p>Transportation</p><p>Other?</p></li><li><p>Clinical Breast Examination (CBE)May identify 4.5 10.7% of breast cancers that mammography missesClinician proficiency impacts effectivenessHigh rate false positivesRecommendations varyACS and ACOG 2011 recommend one every 3 years for average risk women ages 20-30; annually for women &gt; 40USPSTF 2010: current evidence insufficient to assess additional benefits and harms of CBE beyond screening mammography in women 40. Grade I Statement</p></li><li><p>Breast Self-Examination (BSE)Recommendations varyACS and others: teach women the procedure to provide to them as an optionUSPSTF 2010 recommends against teaching BSE. Grade D RecommendationNot shown to have an effect on breast CA mortality rate</p></li><li><p>The Breast CenterLocations in Carbondale and HerrinServices offered at The Breast Center:Digital and 3D mammographyMinimally invasive biopsy techniqueRisk assessment: Personal breast cancer risk is estimated. Options for enhanced screenings and/or prevention can be evaluated.Genetic Counseling Breast MRI</p></li><li><p>The Breast CenterBreast 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</p></li><li><p>The Breast CenterHours: 7:30-5:00pm and Saturday appointments availablePatients 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 mammogramRisk assessment and genetic counseling require a referral</p></li><li><p>How are we currently doing on Breast Cancer Screening?</p></li><li><p>Organization PerformanceInsert slide comparing your organizations performance to other organizations within QHP. Explain any performance issues related to data for your organization</p></li><li><p>Site PerformanceInsert the slide on the different facilities within your organizationMake sure to explain any data issues with individual sites within your organization</p></li><li><p>Provider PerformanceInsert slide on provider performanceReview 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.</p></li><li><p>How can we do better?Add content to this slide for your organizations 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 OctoberDiscussion at huddles/planning for the day. Gap report utilizationHow 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 screeningPatient education/displays for the month of OctoberWaiting room, exam rooms posters, weblinks, handoutsT-shirts for staff</p><p>*Breast Cancer Incidence</p><p>According to data compiled in 2011 by the American Cancer Society, breast cancer is the most common cancer among women (excluding skin cancers). Accounting for nearly 1 in 3 cancers diagnosed in US women, breast cancer is second only to lung cancer as a cause for death among US women. In 2011, an estimated 290,000 new cases of breast cancer were diagnosed in the United States, and breast cancer caused approximately 39,500 deaths among US women.</p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. Online at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf. Accessed January 31, 2012.*Breast Cancer Risk Factors: High Relative Risk (&gt; Four-fold)</p><p>This slide lists risk factors for breast cancer with a relative risk of greater than 4.0. Relative risk compares the risk of disease among people with a particular exposure to the risk among people without that exposure. If the relative risk is above 1.0, then risk is higher among exposed than unexposed persons. Relative risks below 1.0 reflect an inverse association between the exposure and the disease, or a protective effect. However, while relative risks are useful for comparisons, they do not provide information about the absolute amount of additional risk experienced by the exposed group. </p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p><p>*Breast Cancer Risk Factors: Relative Risk of 2.1-4.0</p><p>This slide lists risk factors for breast cancer with a relative risk between 2.1 and 4.0. Relative risk compares the risk of disease among people with a particular exposure to the risk among people without that exposure. If the relative risk is above 1.0, then risk is higher among exposed than unexposed persons. Relative risks below 1.0 reflect an inverse association between the exposure and the disease, or a protective effect. However, while relative risks are useful for comparisons, they do not provide information about the absolute amount of additional risk experienced by the exposed group. </p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p><p>*Breast Cancer Risk Factors: Relative Risk of 1.1-2.0</p><p>This slide lists risk factors for breast cancer with a relative risk between 1.1 and 2.0. Relative risk compares the risk of disease among people with a particular exposure to the risk among people without that exposure. If the relative risk is above 1.0, then risk is higher among exposed than unexposed persons. Relative risks below 1.0 reflect an inverse association between the exposure and the disease, or a protective effect. However, while relative risks are useful for comparisons, they do not provide information about the absolute amount of additional risk experienced by the exposed group. </p><p>Regarding Height In the majority of studies, increased height has been associated with a higher risk of both premenopausal and postmenopausal breast cancer [37,38,49,50]. This was illustrated in the previously described pooled analysis of seven prospective cohort studies: women who were at least 175 cm (69 inches) tall were 20 percent more likely to develop breast cancer than those less than 160 cm (63 inches) tall [37]. The exact mechanism underlying this association is not known but may include prenatal as well as childhood exposures, such as birth weight and diet/energy balance, or the components of the insulin-like growth factor (IGF) axis. </p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p><p>*Breast Cancer Risk Factors: Relative Risk of 1.1-2.0 (continued)</p><p>This slide lists more risk factors for breast cancer with a relative risk between 1.1 and 2.0. Relative risk compares the risk of disease among people with a particular exposure to the risk among people without that exposure. If the relative risk is above 1.0, then risk is higher among exposed than unexposed persons. Relative risks below 1.0 reflect an inverse association between the exposure and the disease, or a protective effect. However, while relative risks are useful for comparisons, they do not provide information about the absolute amount of additional risk experienced by the exposed group. </p><p>Source: American Cancer Society. Breast Cancer Facts &amp; Figures 2011-2012. Atlanta: American Cancer Society, Inc. </p><p>A schedule design for optional periods of time/objectives. *A schedule design for optional periods of time/objectives. **As of January 1,...</p></li></ul>

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