during this presentation the learner will be able to: 1. understand current breast cancer screening...
TRANSCRIPT
During this presentation the learner will be able to:
1. Understand current breast cancer screening guidelines for mammography.
2. Compare and contrast the current breast cancer screening guidelines for clinical breast exam and breast self exam.
3. Do a clinical breast exam according to the most current recommendations.
According to ACS :
•Most common cancer among American women, except for skin cancers.
•Is the second leading cause of cancer death in women, exceeded only by lung cancer.
•About 1 in 8 (12%) women in the US will develop invasive breast cancer during their lifetime( Life time risk 12%)
•
• The chance that breast cancer will be responsible for a woman's death is about 1 in 36 (about 3%).
• Since 1989, breast cancer deaths have been declining . Larger decreases in women <50 yrs old.
• 2.9 million breast cancer survivors in the United States.
• 10 Year Risk for breast cancer :• Age 40- 1 in 69• Age 50 1 in 42• Age 60 1 in 29
According to ACS , In 2013:• 232,340 new cases of
invasive breast cancer• 64,640 new cases of in situ
breast cancer• 39,620 breast cancer
deaths.
Susan G. Komen for the Cure
American Cancer Society
National Cancer
Institute NCCN
U.S Preventive Services Task
Force
ACOG
Mammography
Every year beginning at age 40.
Every year beginning at age 40.
Every 1-2 years beginning at age 40.
Every year beginning at age 40.
Informed decision-making with a health care provider
ages 40-49- although (C recommendation) USPSTF
recommends against.
Every 2 years ages 50-74.
Screening mammography every 1-2 years for women
aged 40-49 years
Screening mammography every year for women
aged 50 years or older.
Clinical Breast Exam
At least every 3 years ages 20-39.
Every 3 years ages 20-39.
No specific recommendation
Every 1-3 years ages 20-39. Use as supplement. Not enough
evidence to recommend for or against.
CBE every year for women aged 19 or older
Every year beginning at age 40.
Every year beginning at age 40.
Every year beginning at age 40.
Breast Self Exam
Not recommended as screening tool. However rec: patients become familiar with
their breasts
Providers should discuss benefits &
limitations. Patient may choose to do BSE or
choose not too.
Recommends “breast awareness”
Moderate certainty harm>benefit (based on 2 trials
outside US).
Recommends against teaching breast self-examination (BSE).
BSE has the potential to detect palpable breast
cancer and can be recommended.
USPSTF Breast Cancer Screening 2009 :
Recommendations Rational
MMG
Ages 40-49- Recommend against routine screening.
Informed decision-making with a health care provider
Moderate certainty that the net benefit is small.
(routine MMG benefit is same for 40’s/50’s but harm is greater for those in their 40’s. Incidence
increased for those in 50-59 group)
Ages 50-74-Every 2 years
(every 2 year screening decreased “harm” by 50%)
Moderate certainty that the net benefit is moderate
Ages >/=75- no screening Evidence is lacking and the balance of benefits and harms can not be determined
The US preventive services task force (USPSTF) is an independent panel of experts in prevention and primary care appointed by the federal Department of Health and Human Services
In 2009, they released new screening mammography guidelines which reignited the debate surrounding appropriate breast cancer screening guidelines
Age At least one false positive
result
Need for a biopsy
Diagnosis of breast cancer
Lives saved by mammography
40 years560 190 15 2
50 years470 190 28 4
60 years360 190 37 6
Adapted from Fletcher and Elmore, 2003 (8)
One breast cancer death is prevented for every 1,904 women aged 40 to 49 who receive annual screening mammograms for 10 years
One breast cancer death is prevented for every 1,339 women aged 50 to 59 who receive annual screening mammograms for 10 years
One breast cancer death is prevented for every 377 women aged 60 to 69 who receive annual screening mammograms for 10 years
Screening mammograms can trigger unnecessary further tests, like biopsies, that can create extreme anxiety.
Mammograms can find slow growing cancers that would never be noticed in a woman’s lifetime; i.e.- we are treating cancers that would not result in the patient’s death if they were left in the body.
DCIS: in 1983- 4,900 cases; in 2008- 67,700 cases (2)
When screening detects early-stage IBC & DCIS Older- probably to die of another cause Younger- finding non aggressive lesions which would
never progress to invasive cancer. A 2012 journal article (Annals of Internal
Medicine- April) analyzed different counties in Norway – screened & unscreened.
* Since science cannot accurately predict which tumors are harmless and which are more aggressive, it’s necessary to treat any tumor that's found as if it's deadly.
According to ACOG (7)
▪ Screening mammography every 1-2 years for women aged 40-49 years
In 2008 – 10 yr expected breast cancer deaths over 10 yr period for women aged 40-49 - 204 out of 100,000= 45,492
RR: 0.85 breast cancer mortality in women in their 40’s by MMG~ an estimated 38,668 deaths would occur in a screened population over 10 yrs
6800 fewer deaths than the expected 10 yr death rate.
Fewer deaths expected with screening compared to the predicted deaths demonstrates the significant benefit of screening on mortality in this age group.
According to ACOG : Studies on CBEs suggest they can help detect breast cancer early, particularly
when used in conjunction with mammograms. MMG sensitivity @ 85-90%- age >50; MMG sensitivity @ 75% - age 40-50. MMG will miss 1 in every 4 breast cancers in women between the ages
of 40 and 50. CBE addresses gaps in screening sensitivity . CBE + MMG= > detection of breast cancer ages >/=40 Recommends: Women ages 19-39 should have a CBE every 1-3yrs by their
provider. Recommends: Women age >/=40 should have an annual CBE by their
provider.
According to USPTF : Not Enough Evidence for or against. May use as supplemental.
Challenges Identified:
False positive/ false negativesLack of standardization (terminology, format, interpretation
& reporting) No randomized trials / Limited availability of data to address
questions about CBE in its role in breast cancer detection
According to ACOG: BSE has the potential to detect palpable breast cancer and can be recommended. "The goal is for women to be alert to any changes, no matter how small, in
their breasts, and report them to their doctor," Jennifer Griffin, MD, MPH,co-author of the ACOG guidelines
According to USPSTF: Recommends against BSE- Moderate certainty harm>benefit (based on 2 trials
outside US).**
Challenges Identified: Fear of “doing it right” False positive/ false negative Unnecessary biopsies & additional diagnostic resources
Recommendations by supporters: Performing them regularly
Newer concept called "breast self-awareness.“
BSE techniques should be reviewed during PE with provider and warning signs of breast cancer should be reviewed.
Reporting changes to health care professional
Patient education Clinical Breast Exam Video:
http://vimeo.com/36117114
•Why is all of this important?
•Healthcare reform•Patients •Others•What if it was your mother, sister/ friend?
•Questions to ponder?
Which of these statements would a nurse include in her teaching to a 42 year old at her annual exam?
a.She does not have a family history of breast cancer so she should wait until she is 50 to have her first MMG.b.She should be given information regarding the various recommendations for breast cancer screening and she can choose to have a baseline MMG now. c.She should be taught breast awareness. d.She should begin her MMG at age 50 and should have a MMG every 5 years.
American Cancer Society (2014). American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. Retrieved on June 9, 2014 from http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs
American Cancer Society (2014). What are the key statistics about breast cancer? Retrieved on June 9, 2014 from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics
American College of Obstetrics & Gynecology. (2009). Interpreting the U.S. Preventive Services Task Force Breast Cancer Screening Recommendations for the General Population. Retrieved on June 9, 2014 from http://www.acog.org/About_ACOG/News_Room/News_Releases/2009/Interpreting_the_US_Preventive_Services_Task_Force
Fletcher SW and Elmore JG (2009). Clinical practice. Mammographic screening for breast cancer. N ew England Journal of Medicine, 348: 1672-80.
National Cancer Institute (2010) Seer Stat fact Sheets: Breast Cancer. Retrieved on June 9, 2014 from http://seer.cancer.gov/statfacts/html/breast.html
National Comprehensive Cancer Network. (2013). Patient Guidelines. Retrieved on April 10, 2013 from http://www.nccn.org/patients/patient_guidelines/breast/index.html
Susan B. Komen (2014). Breast cancer Screening Recommendations for Women at Average Risk. Retrieved on June 9, 2014 from http://ww5.komen.org/BreastCancer/GeneralRecommendations.html
United States Preventative Services Task Force (2009). Screening for Breast Cancer. Retrieved on June 9, 2014 from http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcanrs.htm