NWT Clinical Practice Information Notice

Upon receipt, please file this notice in Section C, Clinical Practice Information Binder for future reference.

The information contained in this document is a Departmental:

Policy X Standard Protocol Procedure Guideline

The following Clinical Practice has been approved for use in the Northwest Territories Health and Social Services system, and has been distributed to:

X Hospitals X Community Health Centers X Homecare X LTCF X Pharmacists

X Doctors’ Offices Social Services Offices X Public Health Units X

This clinical practice is approved. (Signature)

Deputy Minister X Chief Public Health Officer

Director, Child & Family Services

Director, Adoptions

2013 Department of Health and Social Services Pg. 117

Title: NWT Breast Cancer Screening Clinical Practice Guidelines (2013) Effective Date: October 2013 Statement of approved Clinical Practice: The Chief Public Health Officer, the NWT Medical Directors and the NWT Breast Health Advisory Committee have approved and are recommending the implementation of the updated 2013 NWT Breast Cancer Screening Clinical Practice Guidelines as a standard of practice throughout the NWT. Breast cancer is the most common cancer diagnosed in NWT women and the third leading cause of all cancer deaths. Screening can help prevent deaths. These guidelines include information as follows:

Immediate referral and risk assessment

Age of screening onset

Recommendations on self-breast exam, clinical breast exam and magnetic resonance imaging

Known risk factors for breast cancer

Tips for patients

Breast cancer screening algorithm for average risk women These October 2013 Breast Cancer Screening Clinical Practice Guidelines, contain the approved clinical practice standard for the NWT, and supersede all previous Breast Cancer Screening guidelines. Attachment: NWT Breast Cancer Screening Clinical Practice Guidelines NWT Breast Cancer Screening pamphlet for patients

(Date)

Oct. 17/13

NWT Breast Cancer Screening

Clinical Practice Guidelines

Immediate Referral

Refer everyone to Stanton Territorial Hospital for diagnostic work-up for breast cancer if the following signs are present (nipple discharge, breast lump, new onset of nipple retraction or inversion, dimpling of the breast, peau d’orange or abnormal skin thickening of the breast).

Assess Risk The two strongest risk factors for breast cancer are being a woman and aging.

Please see “Known Risk Factors …” below to assess Average Risk versus High Risk

Average Risk Women

Age of Screening Onset

Age 40-49 Discuss the benefits and harms of mammography. (See Risk Factors below)

Age 50-74 Screening mammography recommended every 2 years.

Age 75 + Discuss the benefits and harms of mammography. (See Risk Factors below)

Breast Self-Exam

It is recommended not to advise women to routinely practice breast self-exam. Women should be advised to look for any changes to their breast and report these findings to their healthcare provider. See Tips for Patients below.

Clinical Breast Exam

Clinical breast exam is not recommended for breast cancer screening in asymptomatic average risk women.

MRI It is recommended not to routinely screen average risk women with magnetic resonance imaging .

Known Risk Factors for Breast Cancer

Tips for Patients

Breast tissue covers an area larger than just the breast. It extends up to the collarbone and from the armpit across to the breastbone in the centre of the chest (see diagram above). Women should be advised to check this entire area and become familiar with how their breast tissue feels and what their breast normally look like. There is no right or wrong way to do this. Make patients aware that their breasts can be lumpy or tender before their monthly cycle. Breast tissue also changes with age.

Helping your patient understand what is normal for them will help them recognize changes and know what to report to their healthcare provider. Nipple discharge, lump, nipple inversion, skin dimpling (indrawing), peau d’orange, skin thickening and new onset of pain not related to any other strain or injury are some examples of changes to report.

Major Risk Factors (High Risk)

Mammographic screening yearly for patients with any of these risk factors and/or consult with a specialist (radiologist/surgeon) for other breast imaging/screening.

Confirmed mutations of BRCA1 or BRCA2 genes*

Radiation treatment to the chest area (treatment of Hodg-kin’s lymphoma) especially before age 30*

First degree family history breast cancer (mother, sister,daughter particularly if diagnosed before menopause)

Personal or first degree family history of ovarian cancer

Highly dense breast tissue > 75% (as shown on mammo-gram)

Personal history of breast biopsies showing Atypical Duc-tal Hyperplasia (an increased number of abnormal cells)

* Annual MRI screening may be beneficial for these patients

Minor Risk Factors

For patient with any of these risk factors listed below, average risk (age 50 to 74) mammographic screening every two years applies.

An above average exposure to estrogen, which the bodynaturally produces, especially if a woman- has never given birth or gave birth for the first time after

age 30 - began menstruating at a young age (before age 12) - reached menopause age 55 or later - taking hormone replacement therapy (HRT)

Drinking more than one drink of alcohol per day

Being overweight or obese after menopause

Smoking, especially if started at a young age and beforethe birth of first child

October 2013

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Taking the next step...

Step 3: Understand the importance you place on the possible benefits and harms of having a mammogram.

Which of the following possible benefits are important to you? (Select all that apply)

Peace of mind

Catching cancer earlier and having simpler treatment

Reducing the chance of dying from cancer

Other benefits:

Which of the following possible harms are important to you? (Select all that apply)

Cancer may not be found

Extra tests and worry

No improvement in length of quality of life and unnecessary diagnosis

Other harms:

Step 4: Describe how you feel about screening mammograms.

Which statement best reflects how you feel?

I want to start or continue mammograms

Not sure

I do not want to start or continue mammograms

Step 5: Describe your feelings towards decision making.

Who should decide whether or not you start or continue mammograms?

I should, after thinking about advice from my health care provider

I want to share the decision-making with my health care provider

I want my health care provider to decide

I am not sure

Step 6: Write down any questions you have about mammograms and screening.

Step 7: Please share your answers with your health care provider at your next visit.

If you would like a mammogram or think you should be screened you have several options. In the Yellowknife area, call the Breast Screening Program at 867-765-4020. In the Hay River area, call 867-874-7223. If you live in any other community, please consult with your healthcare provider to arrange for a screening mammogram.

For more information on breast cancer and screening, please visit the following websites:

www.hss.gov.nt.cawww.stha.ca/services/function_statement.php?id=10

www.breasthealthnwt.cawww.cancer.cawww.cbcf.org

October 2013www.hss.gov.nt.ca

If you would like this information in another official language, contact us at 867-920-3367.

Si vous voulez ces informations dans une autre langue officielle, téléphonez nous au 867-920-3367.

NWT Breast CancerScreening

1. Adapted from Public Health Agency of Canada Decision Aid 2009* Your healthcare provider may suggest more screening tests.

Breast cancer develops in the cells of breast tissue. Breast tissue covers an area larger than just the breast, extending up to the collarbone and from the armpit to the centre of the chest.

Women who recieve breast cancer screening have a lower risk of dying from breast cancer than women who do not receive screening. Screening is most often done by having a mammogram.

A mammogram is a specialized x-ray of the breast used to detect changes in breast tissue. Mammograms can detect changes before you are able to feel them.

Screening recommendations:Women at average risk:• Aged 50-74 years should have a screening

mammogram every 2 years• Aged 40-49 and 75+ years should discuss the

benefits and risks of mammography with their nurse or doctor.

Women at high risk:• Should have a screening mammogram every

year. Please speak with your nurse or doctor.*

You can be high risk if you have any of:• Confirmed mutations of BRCA1 or BRCA2 genes*• Previous radiation treatment to the chest area*• Family history of breast cancer in either your

mothers, sister or daughter (first degree)

Breast cancer is the most common cancer diagnosed in NWT women and the third leading cause of all cancer deaths. Screening can help prevent deaths.

• Personal or first degree family history of ovarian cancer

• Highly dense breast tissue >75%

• Personal history of breast biopsies showing Atypical Ductal Hyperplasia (ADH)

Not sure what to do? Try answering the following questions to help you decide about screening mammograms1. While they do not result in a decision, the answers can help you collect your thoughts. This is meant for women who are 40 years and older who:

• Do not have breast cancer;• Do not have any breast problems; and• Have not been told they are at high risk of breast

cancer

Step 1: Rate your risk of breast cancer and overall health.

How do you feel about your risk of breast cancer?

Very Worried A little Worried

Not Worried

How do you rate your overall health?

Good Okay Poor

Step 2: Describe what you are doing for your breast health.

Have you had a screening mammogram within the last two years?

Yes No

Do you limit alcohol to 1 drink or less each day?

Yes No

Do you have a healthy body weight?

Yes No

Do you smoke?

Yes No