American Cancer Society Surveillance Research, 2007
Risk Factors
Epidemiologic
•Early menarche
•Late menopause
•Family history
•Personal history
•Female gender
•Prior chest radiationbetween 10-30 yrs
Histologic
•Atypical lobularhyperplasia
•Atypical ductalhyperplasia
•Lobular carcinoma in situ
•?radial scar
•?papillomatosis
Relative Risk
First degree relative with breast cancer 2X
Personal history of breast cancer 4-5X
Biopsy revealing ADH, ALH 5X
Biopsy revealing LCIS 10X
Radiation for Hodgkins 20-30 yrs 7X
Radiation for Hodgkins <20 yrs 56X
BRCA 1 or 2 mutation 40-85X
Staging(TNM) & Survival
Stage
•0
•I
•IIA
•IIB
•IIIA
•IIIB
•IIIC
•IV
5-year Survival Rate
•93%
•88%
•81%
•74%
•67%
•41%
•49%
•15%
Stage Distribution and 5-year RelativeSurvival by Stage at Diagnosis2001-2007
Stage at DiagnosisStage 5- year Relative Distribution (%) Survival
Localized60 98.6
(confined to primary site)
Regional 33 83.8
(spread to regional nodes)
Distant 5 23.4
(cancer has metastasized)
Unknown 2 52.4
(unstaged)
SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD,http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission
SCREENING Mammography: WhyDoes It Work?
•Inexpensive
•Widely available
•Non-invasive
•Reduces mortality
How Do We Know If ScreeningMammography Is Efficacious
•Goal 1: detect breast cancer at a smaller size and earlier stagethan without the test (Breast Cancer Detection Demonstration Project[3])
•Goal 2: leads to a statistically significant reduction in mortality
(7 RCTs of mammography screening [4])
•Goal 3: When the screening test is introduced into the generalpopulation, the death rate declines
30% reduction in mortality from breast cancer in U.S. once screening widelyutilized
How Screening Meets These Goals:Other Evidence
•Breast cancers found by screening: mediansize 1.0-1.5 cm [5]
•Breast cancers found by clinical breastexamination (CBE) or by a woman herself:median size 2.0-2.5 cm [5]
•Node positivity:
~10% of invasive cancers < 1cm
~35% of those < 2 cm
~ 60% > 4 cm [6]
Lead Time & Selection Bias
•Cancer detection by screening will bias resultsin favor of screening regardless of whether ornot the natural history of the disease has beenaltered (lead time bias)
•Women who participate in screenings may behealthier than those who do not (selectionbias)
Randomized, controlled trials:invited group & control group
•Having these 2 groups: invited group andcontrol group-corrects for lead time andselection bias
•HIP (Health Insurance Plan of NY) Trial was thefirst in 1960s, 8 more trials have followed
•All have shown fewer breast cancer deaths inthe screened vs control group
Randomized, controlled trials:compliance and contamination
•Data from noncompliant women included (women ininvited group who die from breast cancer eventhough they were not screened by choice)
•contamination (women in control group who did notdie from breast cancer because they chose to bescreened outside the trial)
•At best only 70% of invited women participate
•Lack of complete participation combined withcontamination and non-compliance means that theRCTs underestimate the benefitof screening
What are the negatives of amammogram?
For every 1000 women screened
•80-100 called back
•45-65 of those recalled will be normal(“falsepositive”)
•20 asked to return in six months ( less than a2% chance of being cancer)
•15 will have a biopsy recommended, of which2-5 will have cancer and 10-13 will be negative(false positive)[18]
Positioning for craniocaudalview
Positioning formediolateral oblique view
Mammographic Technique: TheMLO view
•Angle used depends on angle of pectoralis muscle(usually between 45 and 60 degrees)
•Pectoralis muscle should be seen down to the levelof the nipple 90% of time
•Muscle border should be convex
•Inframammary fold (IMF) should be open
•Posterior nipple line (aka nipple axis line)-drawn fromnipple to pec used to determine adequacy of CC view
Mammographic Technique: TheCraniocaudal View
•Posterior nipple line-drawn from nipple toback of film or pectoralis (whichever comes1st) should be within 1 cm of pnl on MLO
•Routinely see pectoralis muscle ~30% of time
•Careful not to call medial insertion of thepectoralis a mass
•If anything, CC should include more of themedial tissue
Mammographic Technique
•Low Kvp (~25Kvp) provides excellent contrast
•MAS depends on thickness/density of breast
•Mammography uses Automatic ExposureControl (terminates exposure when sufficientxray photons have reached it)
•Skin, vascular, coarse or popcorn-like, large rod-like or secretory,round, lucent-centered, eggshell or rim, milk of calcium, suture,dystrophic, punctate
–Intermediate
•Amorphous, indistinct
–Highly suspicious
•Pleomorphic or granular, fine, linear or fine linear branching
•Distribution
–Grouped or clustered, linear, segmental, regional,diffuse, scattered