mammographic breast screening · the mammogram high standard good technique optimal positioning...
TRANSCRIPT
MAMMOGRAPHIC BREAST SCREENING
K Gower ThomasBreast Test Wales
Breast cancer stats
� Commonest female malignancy� UK 2000� 40,707 breast cancers (Wales 2,055 F)� (240 in men) (Wales 16)� Most commonly diagnosed tumour (30% of
all female Ca)
Cancer research UK 2004
Breast cancer
� Many symptoms and signs� lump, thickening, distortion, nipple discharge,
pain, (metastases)� Screen detected cancers usually
asymptomatic, often impalpable
Risks for breast cancer
� Young menarche� Late menopause� No children� Late children� No breast feeding� Obesity� alcohol
� High fatty acids� Lower social class� Little physical activity� No stress!!� FH� HRT� (smoking – no risk)
� Nancy Reagan� Elaine Page� Dusty Springfield� Diana Moran� Olivia Newton John� Anastasia
� Kylie Minogue� Koo Stark� Linda McCartney� Kate Jackson� Caron Keating� Roxanne Blenkin
Biggest risk factors
�� Being femaleBeing female�� Getting olderGetting older� That’s YOU and ME� >1/3 occur after 70y
Middle age – reverse height chart
NHSBSP -The facts
� Began 1988 in UK� Invites 50 -70 every 3 years� Screen 1.3 million pa (25% don’t attend)� Yields 10,000 breast cancers
aims
� To reduce the mortality from breast cancer in the population screened
� Health of the nation target has been met� Currently saves 1400 lives pa
Bone metastases
Fungating carcinoma
screening
� Finds 50% of cancer in the 50- 70 age group (smaller and fewer mastectomies)
� Brings forward diagnosis by 5 years (lead time bias) ??over diagnosis
� The rest occur in women who do not attend screening or as interval cancers these are symptomatic
NHSBSP
� 1988 single view for women 50 – 64y� 50% more cancer registrations now ( half
due to screening and half back ground incidence increase)
� Now 2 view mammography and age extended up to 70y
� older women on request
Screening tool - requirements of a screening programme
� Safe� Easily performed� Acceptable� Specific� Good uptake� Good coverage
� Simple� Reliable� Cost effective� Reproducible� Sensitive
Screening method
� Mammography – film screen� Mammography –digital� Ultrasound� MRI� Clinical examination
Film / screen mammography
� Only method proven in RCT to significantly reduce cancer mortality in 1988
� (MRI has been shown to find more cancers since)
Risks - mammography
� radiation risk� equivalent to flying to Australia, 2 days in NY,� Being a 60 y old man for 20 mins� Inconvenience, anxiety� 1 in 14,000 screened 3x in 10 years will get a
fatal breast cancer
Risks - assessment
� False positive assessment� missing a cancer – false negative � Worry, unnecessary biopsy,� Inconvenience, anxiety� Over diagnosis
Over diagnosis
� Some say up to 30% of screen detected cancers are ‘irrelevant’
� ? conservative estimate� > 10% would not affect woman in her lifetime� Further 10% may be diagnosed then die of
another illness still in the lead time
BMJ March 2006
The mammogram
� High standard� Good technique� Optimal positioning� Optical density� Processing� Labelling etc
Signs on a mammo
� Mass� Distortion� Asymmetric density� Small spiculate density� Micro-calcification
Benign lumps can look very malignant and malignant lumps can look very
benign
Beware!!
dimple
distortion
The assessment
� 1 in 8 recalled at least once in 10 y� Further mammography� Specialised views� Clinical examination� Ultrasound� biopsy
spiculate density
DCIS
� Ductal carcinoma in situ� Not an invasive tumour (yet)
Biopsy techniques
� Ultrasound guided (or freehand)� Stereotactic� Mammotome 8F or 11F
treatment
� Surgery� Radiotherapy� Neo adjuvant chemotherapy� Post op chemo� Hormonal manipulation� …….more later
Family history
� 13% clinic referrals (symptomatic)� Only 5% of all breast cancers have a FH
(also 5% <50y cancers have gene)
� BrCa1 and BrCa 2 genes (ov on BrCa1) gene carriers high % life time risk
� Others genes awaited
FH screening
� Pedigree assessed� Moderate or high risk offered screening� Annual 35y – 50y then…� Moderate into normal screening � High have 18monthly till 60y (Wales)
FH High risk
� > 4 relatives any age ( Br or Ov)� 3 relatives <40 y� If gene identified (only half have it)� 87% life time risk for Br Cancer� Prophylactic Mx� Life assurance etc
Moderate risk
� Br or Ov 1st / 2nd degree any age� Br 1st degree <40y� Male breast 1st degree� Bilateral breast 1st degree� Screening 1000 annually prevents 6 deaths
after 15y
� NB risk changes with time UP or DOWN
FH screening results
� Cohort Royal Marsden - 55 cancers� Annual screening BrCa 1 gene holders� Screen detected 56% � Palpation only 26%� Interval 11%� (DCIS 11%) ( grade lll commoner)
Powles 1997
Hodgkins screening
� Mantle irradiation for chest / neck nodes� Huge risk of breast cancer as a result� Breast vv radiosensitive < 19 yrs� Need screening – MR best, (mammo)
MRI
� Expensive� Limited availability� High sensitivity for ca breast� 77 % vs mam 40%� 94% if both MR and mam� Esp useful in BrCa 1 carriers
MRI
� 649 women (high risk ) annual sceen� 35 cancers occurred� 19 seen MR only� 6 seen mam only� 8 seen on both� (2 intervals)
Interval cancer
� Inevitable part of breast screening� Various types� True positive� False negative� Occult� unclassifiable
HRT
� Widespread use� Less now� Oetrogen + / - progesterone� Increase risks of breast cancer
HRT
� UK Million women study (UK) and Womens’ Health Initiative (USA)
� Risks higher on combined (RR=2.0) seen from 2 y
� 32 cancers non HRT group / 38 on combined (33.5 on Oest only) after 5years
� BUT 51 cases after 10 yearsCSM 2003
Treatment options
� Wide local excision or segmentectomy with radiotherapy post op
� Mastectomy +/- reconstruction (implant, lat dorsi flap, tram, Dieppe, etc)
� Chemotherapy neo-adjuvant or post surgical� hormonal
Wide local excision
� Palpable� Impalpable� Skin mark� Wire guided� Intra-operative x ray of excised specimen
Wire insertion – USS guided
Wire guided wide local excision
Mastectomy + / -
Rt mast / implant / nipple recon
Mast / implant /reconst nipple
Later… after tattoo
Reduction + mastectomy, implant etc
Sentinel node biopsy
SNB
� Single sentinel node removed� Reduces surgical morbidity� Reduces lymphoedema� Blue dye assisted - injected� Technetium labelled particles – injected� Do breast first � Then axilla
Indications for Chemotherapy
� Age� High grade (G3)� Nodal involvement� ER-ve� Vascular invasion� Size/ multifocaltiy� Co-morbidity
Risks/Benefits of Therapy
� The risks of any treatment must be balanced with the benefits for any individual
Benefits:� To prevent local recurrence of breast cancer� To prevent secondary disease� To effect a “cure”
Risks:� Physiological, mild to severe (death)� Psychological� Effect on QOL
HERCEPTIN
herceptin
� EXPENSIVE� £44,000 pa cf £73 for tamoxifen� Given IV� mg / kg basis� Oral preparation in the pipeline
THE TRIALS
� 4 MAJOR TRIALS (HERA in the UK)� Recruited 22,000 women
� Reduced the risk of first breast cancer event by 52% at 3 years
� Reduced the probability of a distant metastasis by 53% at 3 years
Herceptin
� Monoclonal antibody� Targets HER2 receptor (20% of breast
cancer)� HER receptors are a group of receptors that
regulate cell growth� When over-expressed in a breast cancer cell
causes uncontrolled growth� Herceptin targets the specific receptor and
switches of cell growth
Types of hormonal therapy
� Tamoxifen
� Aromatase inhibitors, anastrazole, letrozole, exemestane
� Ovarian ablation (surgery, RT, Zoladex),recent studies(ABC) no benefit
Side effects of hormone therapy
� Menstrual disturbance/affect on fertility� Weight gain� Hot flushes� Vaginal dryness� Loss of libido� GI upset� Endometrial cancer (tamoxifen)� Osteoporosis (AI’s)� Cardiac effects� Thromboembolytic episodes
Tamoxifen
� Tamoxifen is actually a very, very weak oestrogen, but it does not affect all oestrogen receptors in the same way
� Selectively INHIBITS oestrogen receptors on breast cells, stopping them from sending out the "grow and multiply" message
� Can STIMULATE oestrogen receptors in other organs � Tamoxifen may also very weakly inhibit the formation of new
blood vessels � Tamoxifen may even cause breast cancer cells to destroy
themselves, a process called apoptosis, or programmed cell death.
AROMATASE INHIBITORS
� STEROIDAL/IRREVERSIBLE; these include EXEMESTANE and irreversibly inactivates the enzyme
� NON-STEROIDAL/REVERSILBLE; these include ANASTROZOLE and LETROZOLE reversibly bind to the enzyme
� Compete with the enzyme aromatase that coverts androstenedione to oestrone and testosterone to oestradiol in the peripheral tissues
Bone protocol for AI use
� Significant increase in osteoporosis and fracture
� Fracture of femur carries significant mortality rate
� ? Need for screening e.g. DEXA scan� ? Need to omit those with a family history� ? Need for prophylactic bisphosphonates
NEW LICENCE INDICATIONS
� Anastrozole can be used in place of tamoxifen following diagnosis
� Exemestane can be used following 2-3 years of tamoxifen
� Letrozole can be prescribed following 5 years of tamoxifen for a further 5 years
thankyou