Breast Screening Guidelines Elizabeth (Lizzy) K. Young, M.D.

Assistant Professor, UNM Department of Radiology

What is a Radiologist? • Medical doctor • 5 year residency • May have an additional year of subspecialty fellowship training • Overall, rigorous training in diagnostic imaging • Imaging experts/diagnosticians • Special training in imaging physics, including radiation/radiation

safety

Who can interpret mammograms?

• A.) Mammography technologist • B.) Radiology PA • C.) General practice M.D. with interest in Mammography • D.) Radiology resident • E.) Any board-certified Radiologist • F.) Radiologist with special criteria per the FDA

Answer • F.) A Radiologist, with special criteria per the FDA.

• DEPARTMENT OF HEALTH AND HUMAN SERVICES: FDA: 21 CFR Part 900: Quality

Mammography Standards :Subpart B—Quality Standards and Certification Sec. 900.12: • (i) Initial qualifications: Must be licensed to practice medicine in a State; • (1) Be certified in an appropriate specialty by a body determined by FDA to have

procedures and requirements adequate to ensure competency to interpret radiological procedures, including mammography; or

• (2) Have had at least 3 months of documented formal training in the interpretation of mammograms and in topics related to mammography.

• (C) Have a minimum of 60 hours of documented medical education in mammography; and

• (D) Have read at least 240 mammograms within the 6-month period immediately prior to the qualifying date, under the direct supervision of an qualified physician.

• (ii) Continuing qualifications: every 2 years, must read 960 mammograms. • Every 3 years, must have 15 CME hours in mammography

Do you order breast imaging studies? • Show of hands? • Do you find it confusing? • Can be complicated • Screening vs Diagnostic • Different modalities depending on patient age, risk profile, possible

symptoms • Screening controversy • Patients don’t really like it

Clinical Breast Examinations (CBE)

• Do you perform CBE? • Value of screening increased after a negative CBE

• Truly asymptomatic patient

• Negative screening mammogram before a CBE can lead to doubting your exam findings

• Abnormal CBE leads to a targeted diagnostic exam- improves chances of cancer detection by using targeted ultrasound, etc.

1st Step: Screening vs Diagnostic Exam?

• Screening: Asymptomatic woman age 40 and older • And, younger high-risk woman (≥ 20-25% lifetime risk of breast cancer)

• (10 years before 1st degree relative if strong family history, or BRCA or other gene mutations, or history of chest XRT, etc., may begin screening mammograms as early as 30 and MRI examinations earlier)

• Diagnostic: Symptomatic woman of any age

Screening Mammography- Who?

• Screening guidelines: yearly bilateral mammograms for all women age 40 and over of average risk, for as long as they are in good health.

• In elderly women: clinical judgment/ clinician-patient discussion based on overall life expectancy given co-morbidities, etc. No hard age cut-off for when to end screening.

Screening Mammography- Why? • Average risk of breast cancer in women is 1 in 8 during their lifetime. • Risk factors for developing breast cancer:

• Female gender • Increasing age • Personal history of breast cancer • Family history

• 85% of breast cancers develop in women with NO family history of breast cancer • Genetic mutations (BRCA, etc.) • Lifetime exposure to estrogens • Smoking/drinking/other carcinogens • Race/ethnicity • Presence of atypia or LCIS on biopsy • Chest wall radiation therapy age 10-30, dose >4 Gray

Screening Mammography- Why?

• Since beginning screening mammogram programs, the risk of dying from breast cancer has decreased by 30%

• Screening asymptomatic women allows us to find cancers before they are palpable/detected by CBE

• Smaller size of cancers= lower stage, more likely to be a candidate for lumpectomy, less likelihood of axillary lymph node involvement, better overall prognosis.

Mortality reduction with early detection

Screening Mammography • What is involved? • Bilateral CC and MLO views, Tomosynthesis at some institutions • Equipment, image quality regulated by credentialing bodies including

the FDA (MQSA) • Breast compression

• Ouch, but has a purpose

• Radiation dose limit requirements • Standardized reporting (BI-RADS) • Patient communication requirements

Screening Mammography • Is not a perfect test. • Sensitivity- Can range between 62-88%, improves with yearly screening,

also improved with tomosynthesis • Specificity- Ranges between 90-97% • Has limitations:

• Dense breasts • Implants • Potential limitations of perception, for example, a very slow-growing cancer may not

be evident without perceptible change • Cancers with otherwise benign features • Rapidly-growing/true interval cancer

4 Categories of Breast Density

Screening Mammography • Most are negative, recommend they return next year. • Patients usually get the result as a letter in the mail a few days after

their examination, due to the workflow of these exams. • 10 out of 100 (overall national average) get “called back”

• BI-RADS 0- Need additional imaging. • Patient returns, additional views performed as a Diagnostic Exam

• Calcifications • Asymmetries/Focal Asymmetries/Architectural Distortion • Masses

• May perform ultrasound

Screening Mammography • A few of the call-backs will have persistent, suspicious abnormalities

warranting biopsy (about 30%) • Calcifications- may require a stereotactic biopsy • Masses- usually an ultrasound-guided biopsy

• Biopsies: under local anesthesia, minimally invasive, minimal pain in

majority of patients, minimal risks (minor bleeding, rare infection) • We try to accommodate call-backs and biopsies as quickly as possible,

to minimize the anxiety of waiting.

Screening Mammography

• Some of the biopsies performed will reveal benign tissue (fibroadenoma, fibrocystic change, etc.)

• Was the biopsy therefore unnecessary? • Risk of participating in screening mammography • Often impossible to predict which biopsies will be benign

prospectively • Most women celebrate the good news and thank us for being careful

with their health

Diagnostic Mammography • Ordered to evaluate a concerning breast symptom

• Patient may find at breast self-exam • Physician may find at clinical breast exam

• Usually ordered as Bilateral Diagnostic Mammography with Ultrasound • The study that the patient actually receives will be tailored to the individual

patient by the Radiologist, considering her age and symptoms • likely some combination of mammograms with or without special views,

tomosynthesis, and/or ultrasound. May be unilateral or bilateral based on different factors.

The Radiologist will discuss the findings and recommendations with the patient at the end of the examination.

Diagnostic Mammography • When to order a diagnostic study? • A new lump or mass, or other breast change.

• A mass that is painless, hard, and has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded, even painful.

• Other possible signs of breast cancer: • · Swelling of all or part of a breast • · Breast or nipple pain

• (unilateral, usually focal pain, more likely constant than intermittent) • · Nipple retraction (turning inward) • · Redness/irritation, scaling, or thickening of the nipple or breast skin, or dimpling • · Nipple discharge other than breast milk/physiologic discharge

• Clear or bloody, unilateral, spontaneous, uniductal • Lump or swelling in axilla or supraclavicular region.

Diagnostic Mammography • When to order a diagnostic study? • A new lump or mass, or other breast change.

• A mass that is painless, hard, and has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded, even painful.

Diagnostic Mammography • When to order a diagnostic study? • · Swelling of all or part of a breast

Diagnostic Mammography • When to order a diagnostic study? • · Nipple retraction (turning inward)

Diagnostic Mammography • When to order a diagnostic study? • · Nipple discharge other than breast milk/physiologic discharge

• Clear or bloody, unilateral, spontaneous, uniductal

Diagnostic Mammography • When to order a diagnostic study? • Lump or swelling in axilla or supraclavicular region.

Diagnostic Mammography • Helpful clinical information when ordering studies • Where is the lump? Example: 3 o’clock, 5 cm from the nipple • Other descriptors

• Size • Palpable features • Number

Tomosynthesis • New technology for Breast Imaging • Can be used in screening and/or diagnostic settings • Improved cancer detection in screening

• Decreased false-positive recall rate in screening • (decreased need for additional imaging studies, less unnecessary radiation,

lower costs, less anxiety, overall good thing)

• Problem solver in diagnostic- improved diagnostic accuracy

How does 3D-DBT compare to 2D digital mammography? • 16.1% lower recall rate with tomo screening. • The overall cancer detection rate (CDR- #cancers/1000 screened), was

28.6% greater for tomo. • The CDR for invasive cancers with tomo was 43.8% higher. • The positive predictive value for recalls from screening was 53.3% greater

for tomo.

• AJR- 9/ 2014, Volume 203, Number 3. Clinical Performance Metrics of 3D Digital Breast Tomosynthesis Compared With 2D Digital Mammography for Breast Cancer Screening in Community Practice. Greenberg et al.

References Society of Breast Imaging website American Cancer Society website Michael Linver, MD, Mammography review course materials, 2012 Mammography Saves Lives Campaign materials AJR- 9/ 2014, Volume 203, Number 3. Clinical Performance Metrics of 3D Digital Breast Tomosynthesis Compared With 2D Digital Mammography for Breast Cancer Screening in Community Practice. Greenberg et al.

• Thank you for your attention