To help PCPs address patients’ breast cancer screening concerns, surgeon Shoko Emily Abe, MD, FACS, breaks down the multitude of screening directives and modalities, with a focus on the needs of those at average risk and those with dense breast tissue. She offers current data informing when to start mammograms; discusses the advantages of tomosynthesis; and clarifies when other methods, such as MRI and ultrasound, are useful. Bonus: Empower patients to find their own screening schedules through the WISDOM Study.
thank you for having me. Um first of all um kudos to you all and thank you. I think a lot of you are our primary care physicians correct And I know you are all the ones faced with this conundrum of what is the right screening modality and timing and age to start. And I think it's it's such a heated topic because it's true that there is no right answer. And just to jump to the conclusion in the end it is an individualized decision making process. Um But hopefully I can answer or at least kind of give some different types of insight to the idea of breast cancer screening and then specifically also talk about what to do with patients with dense breast. Um So to start off with again we'll talk about um reviewing recent guidelines um briefly. Um but talk about mammograms with total synthesis or three D. Mammograms breast M. R. I. And other breast imaging for breast cancer screening. And then again talk about how that may apply to a woman with dense breast tissue. So I put this up here from the CDC only because you can see that there's so many guidelines out there that we can follow. And it's broken down here. You know these are for average risk women and it's broken down here by age group 40-49, and also women above 75. And what to do about women with dense breasts. So I'm not gonna go through these one by one. Obviously you can see this on the CDC website but they're very somewhat disparaging different recommendations. Um and a lot of this is based on what is kind of the data that they looked at. Um and what is the ultimate idea about what they want to achieve for women um in terms of breast cancer screening. So with all that said uh you know breast cancer screening for average risk women um I know a lot of you follow the US preventative Services task force recommendation um which I think is what what most primary care physicians follow in this day and age. Um Talk about individualized decision making from age 40 to 49 then biennial screening from age 50 to 74 then consideration about not necessarily recommending and saying that there's no real evidence to say that women after age 74 should or should not get mammograms. And it's really again an individualized decision at that point as well. And these recommendations are basically based on kind of this idea that annual screening can cause a lot of anxiety. Um there's the thing to consider, especially in the women starting at age 40 of the radiation radiation exposure early. Um Again, in that age group there are more false positives which lead to increased biopsies over diagnoses and possibly over treatment. And that's been always a controversial topic in breast cancer to begin with as well, I do want to point out that there are some things that are kind of flawed in the US preventive services task force kind of analysis of the data but um so basically there was underestimation of benefit in the age 40 49 group um because they used more heavily the flawed Canadian trial data and excluded some of the large population based studies. But they did update their recommendation in 2016 to include these observational studies. Some of the biggest studies that we have out there that did show a benefit To mammogram screening and in that woman in the 40- 49 age group. Um and so they did acknowledge acknowledge that starting annual screening at age 40 did save lives. But again still remains the issue of more false positive rates leading to increased biopsies over diagnoses over treatment. So again it's always kind of this balance of you know the risks and benefits which is I think a conversation that as physicians we always have with our patients because of course you can do everything under the sun. But is it really going to be beneficial for you? Um And I know that's kind of the hard part for talking to my primary care colleagues and friends, you know having the time to go through this and do a risk assessment is I'm sure the difficult part because you have to talk about everything else. I'm sure the colon cancer screening are your vaccinations up to date. All the other things that you have to cover during a wellness visit. It's it's it's quite extreme. I think my visit myself with my doctor was you know definitely close to an hour for that. She might have gone over just to go over everything. Um She didn't touch upon the breast cancer screening part as much with me but it's a lot to go over and to go over. This kind of individualized screening process would be a lot. Um Nevertheless some of the recommendations that you know we as breast surgeons follow kind of follow the american College of Radiology in the american Society of breast surgeons which starts with that simple annual starting at age 40. Um And then consider even supplemental imaging if they have dense breasts meaning either M. R. I. Screening or ultrasound screening. Now a lot of people will say in that little bit of conflict of interest. Um I've heard uh people make comments especially when maybe a radiologist is giving this talk about. Well isn't it a conflict of interest for you to say you should all start mammograms at 40 when obviously these people are coming to you and your department for imaging. Um But nevertheless that that has been the recommendation for a long time. The N. C. C. N. Guideline. The National Comprehensive Cancer Network guideline which is kind of the cancer treatment bible if you will. Um Also talks about annual screening for average women. Um Once they reach 40. Um And to always consider photosynthesis or three D. Mammogram. Um And I'll touch upon that a little bit in terms of dense breasts. And I feel like the american cancer society recommendation kind of is a kind of a good in between point between these recommendations and the US preventive services task force recommendation. In terms of saying from 40 to 45 an individualized decision making process definitely makes sense because the risk of a woman in their early 40s getting breast cancer is statistically pretty low. But to consider annual mammograms starting at age 45 and at 55 go on to bi annual mammograms. I do want to stop and talk about the biennial mammogram recommendation once you reach your 50's or 55. Um I don't know if you all do this but I definitely have been over the years telling patients that this recommendation for biennial mammograms seems like makes it sound like your risk is decreasing as you get older. Um and therefore you can do it every other year. But the fact of the matter is the patient's breast cancer risk as they get older continues to creep up. You know that 12% lifetime risk is really a statistic we're talking about when they're reaching you know their um 80s and so I tell patients I don't want you to get a false sense that oh my risk is going down as I got older and therefore I could just go every other year. The fact of the matter is the risk is actually creeping up gradually as they get older and older. But the type of breast cancer they tend to get tend to be slow growing and therefore biennial mammograms every other year, mammograms should be fine in terms of catching a slow growing mammogram, which is not going to suddenly become a stage two breast cancer in a matter of months or even a year. Having said that obviously there are a portion of postmenopausal women um who do develop more aggressive breast cancers um that developed even before, you know, their next annual mammogram is doing, meaning six months after their mammogram there. Like I was told, it was all clear and suddenly had this lump and you're telling me it's cancer. And a little bit surprised now, granted that population in the postmenopausal women population is probably somewhere around 10 to 15%. So it is true that it's not the majority, but there will be women who if they twitched a biennial will have aggressive breast cancer mists or at least they're only going to detect it because they felt it themselves. So, um I think the big question is, is breast cancer a significant health problem for women in their forties? You know, who tend to have dense breast tissue. So 45,000, cases of breast cancer were found in women aged 40 49 and 2019. So that's one in seven total cases of breast cancers in this country. And it's interesting to note that there's a younger age peak in minority women or women of color. And I'll show you a graph in a second that will kind of really drive this home. But you see these lines here um women hispanic women asian women and black women, their peak is here before the age of 50 person in white women. We are talking about that, you know 65 or so average age that um they get breast cancer. So that's another kind of piece that we want to keep in mind when we talk about when should you start screening mammogram. And I know this is shifted also as well in terms of colon cancer screening, especially for um are black patients. So um keep that in mind also in terms of breast cancer screening. So they are diagnosed with more advanced stage um even under the age of 50 when they're diagnosed and among women dying of breast cancer, minority women are 100 and 27% more likely to die before the age of 50. So again, the reason for this population specifically to maybe consider starting early. Um and we'll talk about other again, the supplemental imaging but um I don't want to go into this too heavily. It might be a little bit of a plug, it's not a UCSF study but when we talk about personalized screening. Um and how do you determine? And and figure that out. This wisdom study which is a study offered nationwide. It is not specific to UCSF and it's not specific to women having to come to UCSF for imaging, but we are kind of spearheading this. Um The question has been, you know, how do you personalize the screening regimen? And this study um basically assesses someone's personal risk by looking at breast density, lifestyle, family history and genetic factors. They will do genetic testing if the patient qualifies and it's a randomized trial. However, patients can be, can choose to kind of choose their screening modality and be in an observational cohort. So this is something that um you might want to consider telling patients about. So they could actually go ahead and have their own personalized um breast cancer screening regimen figured out. So I have the website on here here, the wisdom study dot org. Um That is something that you could direct the patients to it as patient facing website. And again, it is offered nationwide um patients get their mammogram anywhere they choose to and it just asked for surveys to be filled out for them to undergo this risk assessment and then for them to turn in their uh mammogram screening results. Um So I want to jump into kind of dense breast tissue um and I'll talk about a little bit more about some of the more recent trials but um three D. Mammogram or almost in this mammogram has been a big big positive um especially in women with dense breast tissue because the problem has always been in the even in the days of digital mammography, women with dense breast extremely dense breasts which are usually women who are premenopausal, you can't really tell what's what because it's just almost a complete wide out. But you can see kind of in this mammogram over here, that's a three D. Mammogram. There's a lot of dense breast tissue as when it scrolls back out. I'll kind of point out this whole widened out area and you can't tell what's what until you scroll through with this three D. Mammogram and you saw this area of distortion here what we call kind of a rare architectural distortion with maybe a more distinct mass here. With some speculations. So three D. Mammograms first and foremost decrease the callback rates. Um that was one of the first important things. So essentially potentially decreasing the false positive rate. And then we're finding furthermore that it has improved cancer detection. So it definitely has made mammogram more specific uh and more sensitive. So that was a big big um positive for for mammography and especially for women who have dense breast tissue. And again even the NCC guideline says to consider total synthesis and I would say in our bay area it's pretty much the gold standard. Almost any breast center or uh place that offers mammography is gonna order three offer three D. Mammogram or total synthesis mammogram. Again the american society of breast surgeon consistency consensus statement also states that photosynthesis is the preferred modality especially in younger women and women with dense breasts. Um But it's sure that it hasn't been studied sufficiently to determine if it actually improves improves disease specific mortality. Uh There are a lot of questions about the higher radiation dose potentially with three D. Mammograms but it's actually pretty minimal. And it's it can be minimized with synthesized two D. Reconstructions meaning the patient doesn't have to get a regular two D. Digital mammogram and then get the three D. Mammogram on top of that. Um And of note it is still much lower radiation than other breast cancer screening modalities that are being developed like um breast specific gamma imaging system, maybe scanner pet scans. So when it comes to dense breasts really. M. R. I. Has been probably the biggest kind of positive if you will. And again as I showed in the earlier kind of guidelines that are out there there aren't really any of that specifically say yes at Emory screenings dense breasts. But we do know the benefit of uh memory screening for women with dense breasts. And this certainly has been um a little bit more well studied in women who are considered high risk. So again the american society breast surgery consensus statement says consider supplemental imaging such as breast M. R. I. And women with dense breasts. Um Again it's not currently standard of care for average risk women, so obtaining insurance authorization etcetera could be difficult. Um We also recommend screening for women diagnosed with breast cancer under the age of 50 or who do have dense breasts. And otherwise it is utilized in women who are high risk. Now the the I guess the issue with breast MRI's is that it's also not offered everywhere or is not easily accessible for all women. And so a lot of our consensus statements for instance say, you know, supplemental imaging with breast M. R. I. Is the preferred modality if you have dense breasts. However if that is not available um potential consideration for ultrasound screening um would be another option. However, this again is recommendations for high risk women. And from my understanding at least in this area bilateral screening, breast cancer screening for breast with ultrasound. It's not something that's recommended or offered at radiology centers and it has to do with the fact that there's actually very little data to say that it's a good screening modality. Um Ultrasounds on the breast are a good uh diagnostic tool meaning if there is a palpable mass or a very specific point on a mammogram that looks abnormal that looks like a mass. And ultrasound is a targeted study is very good. But as a screening study when they're just kind of screening all you know over the breast through the entire breast on both sides. There are a lot of false positive and a lot of artifact, it's very operator too dependent. So in that sense it's not the best screening modality. And even in women with dense breast tissue um I will say there was a study out of japan that added um ultrasound. Uh screening on top of mammogram for women with dense breast tissue. So this is a very very specific population of japanese women but they did find that the addition of supplemental ultrasound increased the cancer detection rate. Um I think we have to take that with a grain of salt in our patient population in the US. Because japanese women tend to be a lot smaller, much more petite. Usually their breasts are much smaller. So ultrasound screening, just the technical feasibility of it is much different as well as just kind of the time that it takes. So that might not really apply to our patient population in the U. S. So that's something to keep in mind. Um Oh I just kind of talked about the screening breast ultrasound. Um But thermo grams are another thing that you might hear patients ask about. Like is this is this good, is this better than mammograms since mammograms aren't good for dense breast tissue. Unfortunately there is no real evidence showing that it's equivalent in sensitivity or specificity to mammograms. So it is not a modality that we recommend. It is FDA approved in terms of its safe. Um But ultimately if anything is picked up on therm a gram they're gonna tell you you know to go get a mammogram anyway. Um Unfortunately the sensitivity and specificity of this is is pretty low in terms of comparing head to head to mammograms. Um Oh you know what, I didn't have the last slide on in here. Sorry. Um So specifically talking about some of the more recent data that's out there regarding dense breast tissue um there was a study called the dense trial out of the Netherlands. Um That looked at again supplemental M. R. I. Screening on top of mammography. And so it was a randomized multi center trial. And just to jump to the conclusion it did show that there was a higher cancer detection rate of what we call interval cancers meaning the M. R. I was able to detect cancers that mammograms were not detecting. Now. I know this doesn't quite answer the question that you had about what do we do about just mammogram screening when this report comes back as Dense breast tissue. You should you know, consider yearly mammograms. When you otherwise told this average woman who's maybe 45 to just you know consider maybe every other order to not even start. But nevertheless I think this is where I guess that conversation about what what does it mean for the patient to undergo the mammogram and potentially have a higher chance of false positive meaning telling them you have a higher chance that they're gonna maybe think something see something and they're gonna ask you to come back and do a diagnostic mammogram and ultrasound and possibly say yeah that's probably benign. But let's biopsy just to make sure or yeah that's probably benign. But let's still have you come back, come back in six months for another diagnostic mammogram and ultrasound. And so they're put into this cycle of potentially undergoing a biopsy that perhaps will show a benign result. But nevertheless they have to go through this process of procedure which has its attendant risk which although minimal, are still risks. Um as well as just the anxiety that that it does cost. And I think these are conversations I have with patients to who typically are sent to me because they are potentially high risk, meaning they have family history or some other issue that you know warranted a visit with a breast surgeon. But it's still conversations I have when we talk about, well you're not high risk but what should your screening, um frequency and modality be. And I think these are hard conversations and you know, the patient response runs the gamut from, well if you're telling me, you know, I'm average risk I'm okay just you know, starting at 45 or 50 and I'll make sure I get my mammogram and I'll still check myself periodically and then I certainly have a lot of women women who are like you know what I'd rather know than not know. So I'm gonna do my yearly mammogram. So you know, it's still again puts you all in a in a difficult position of how do you recommend without going into like a 30 minute conversation. But it certainly comes down to look in the end. Both are not wrong or you know, whatever guideline you choose to follow. But it is really about understanding what is the potential downside of potentially starting at a younger age versus what's the downside of maybe starting at an older age um or not doing it nearly. And again it just falls back to kind of that individualized decision making process. And again, if you have patients who might be potentially higher risk, whether it be from family history, um had uh an odd biopsy showing a tipi at some point. Um they haven't had Children etcetera. Anything that might make you think they might be high risk. You know, refer them to perhaps your local breast center or breast surgeon or your O. B. G. Y. N. Colleagues who may do risk assessments to really figure out what is the rain screening interval and modality for your patients