NICE: Guidance on familial breast cancer.

Ovarian and breast cancer patients in a pedigree chart of a family (Photo credit: Wikipedia)

Familial breast cancer occurs in people with one or more family members affected by breast, ovarian, or a related cancer such as primary peritoneal cancer. About 5% of all breast cancers can be attributed to inherited mutations in specific high risk genes such as BRCA1, BRCA2, and TP53.

This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on the classification and care of people at risk of familial breast cancer.1 The guideline updates previous NICE guidance on familial breast cancer, published in 2004 and 2006.2 3 It also provides new guidance on men and women with a newly or previously diagnosed breast cancer who have a family history of breast and ovarian cancer, as they were excluded from previous guidance.4

Full Text from NICE

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Frequency of Mammography: Age, Breast Density, and Hormone Therapy

Practice Update

JAMA Intern Med 2013 May 01;173(8)807-816, K Kerlikowske, W Zhu, RA Hubbard, B Geller, K Dittus, D Braithwaite, KJ Wernli, DL Miglioretti, ES O'Meara

TAKE-HOME MESSAGE

This large, prospective cohort study found that biennial screening mammography for most women aged 40 to 49 and 50 to 74 years, even among those with high breast density or receiving combination hormone therapy (risk factors for breast cancer), results in similar risks of presenting with advanced-stage disease as with annual screening mammography. Most women who undergo annual mammography are at high risk of false-positive results without benefit from the more frequent screening. However, a small proportion of women aged 40 to 49 with extremely dense breasts are more likely to present with advanced-stage disease if they undergo biennial vs annual screening; this benefit is counterbalanced by a higher risk of cumulative false-positive mammography results with annual screening.
Screen all women aged 50 to 74 biennially (regardless of breast density or hormone therapy use). When counseling women aged 40-49 about breast cancer screening, those with extremely high density breasts should be informed that annual mammography may minimize their risk of presenting with advanced-stage disease but the cumulative risk of false-positive results is high.

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SUMMARY

PracticeUpdate Editorial Team

Updated US guidelines recommending that women aged 50 to 74 years undergo mammography biennially, instead of every 1 to 2 years as previously recommended, do not take into account women with additional breast cancer risk factors, such as increased breast density and postmenopausal use of hormonal therapy (HT). More frequent screening may be advantageous in these women, but few studies have reported outcomes when risk factors are combined with frequency of screening mammography.
This study evaluated women aged 40 to 74 years undergoing screening mammography in a community setting to determine whether the benefits (detection of early-stage disease) and harms (false-positive result or biopsy recommendation) differed by screening frequency according to age, breast density, and postmenopausal HT use. Breast Cancer Surveillance Consortium mammography registry data from 1994 through 2008 were used to identify women with and without breast cancer who had undergone annual, biennial, or triennial screening mammography. Analyses for benefit included 11,474 women with at least two screening examinations before diagnosis with breast cancer. Most of these women were aged ≥ 50 years, and > 50% had heterogeneously dense or extremely dense breasts. Analyses for harm included 922,624 women with no previous breast cancer and no cancer within 1 year of screening. Of these women aged 40 to 49 years, 55.1% had extremely dense breasts.
The risk of presenting with advanced-stage breast cancer was similar for most women aged 40 to 49 years and 50 to 74 years screened biennially compared with those screened annually, including those women with high breast density or who were receiving combination HT. Only women aged 40 to 49 years with extremely dense breasts were at increased risk of presenting with advanced-stage rather than early-stage disease when screened biennially vs annually (adjusted odds ratio [AOR] = 1.89; 95% CI, 1.06-3.39) and of presenting with a tumor size > 20 mm (AOR = 2.39; 95% CI, 1.37-4.18). Women aged 50 to 74 years with heterogeneously dense or extremely dense breasts who were receiving combination HT had an apparent, but nonstatistically significant, increased risk of advanced-stage disease (AOR = 1.56; 95% CI, 0.88-2.80) and tumor size > 20 mm (AOR = 1.59; 95% CI, 0.97-2.61) with biennial vs annual screening.
Annual screening was associated with a high probability of a false-positive mammography result in most women, with probability decreasing as the screening interval increased. Women aged 40 to 49 years were most likely to have at least one false-positive recall after 10 years of subsequent annual mammography, with cumulative probabilities of 68.9% and 65.5% in women with heterogeneously dense or extremely dense breasts, respectively. Likewise, women aged 50 to 74 years receiving combination HT and with heterogeneously dense or extremely dense breasts had similarly high cumulative probabilities of a false-positive result with annual screening (68.1% and 65.8%, respectively). Lowest cumulative probabilities were seen in women with fatty breasts across both age groups and regardless of combination HT use (30.3%–36.3%). Cumulative probabilities of at least one false-positive biopsy recommendation after 10 years were much lower than those of a false-positive recall, although of a similar pattern.
This study found that, with the exception of women aged 40 to 49 years with extremely dense breasts, biennial screening mammography was associated with a similar risk of presenting with advanced-stage disease compared with annual screening mammography, but overall the probability of a false-positive screening result was higher.

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JAMA internal medicine

Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy

JAMA Intern Med 2013 May 01;173(8)807-816, K Kerlikowske, W Zhu, RA Hubbard, B Geller, K Dittus, D Braithwaite, KJ Wernli, DL Miglioretti, ES O'Meara

Abstract  

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Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence

heredity and cancer, breast cancer, inherited factors vs. other factors (Photo credit: Wikipedia)

 Source: https://sites.google.com/site/saludjuntos2/home

 Despite substantial increases in the number of cases of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with advanced cancer. Although it is not certain which women have been affected, the imbalance suggests that there is substantial overdiagnosis, accounting for nearly a third of all newly diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate of death from breast cancer.

Full Text PDF

Más datos sobre el cribado del cáncer de mama -> Este estudio examina las tendencias entre 1976 y 2008 en la incidencia de cáncer de mama en estadio temprano (carcinoma ductal in situ y enfermedad localizada) y la fase final del cáncer de mama (enfermedad regional ya distancia) entre las mujeres de 40 años o más. Los investigadores interpretan que el cribado, a pesar del aumento del diagnóstico precoz,  en el mejor de los casos, sólo tiene un pequeño efecto en la tasa de muerte por cáncer de mama.

N Engl J Med, 22/11/2012, "Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence".

Para reducir la mortalidad, la detección debe detectar una enfermedad potencialmente mortal en una etapa más temprana y curable. Por lo tanto, los programas eficaces de detección de cáncer aumentan la incidencia de cáncer detectado en una etapa temprana y disminuyen la incidencia de cáncer en etapas tardías. Este estudio ha utilizado los datos del Surveillance, Epidemiology, and End Results para examinar las tendencias entre 1976 y 2008 en la incidencia de cáncer de mama en estadio temprano (carcinoma ductal in situ y enfermedad localizada) y la fase final del cáncer de mama (enfermedad regional y distante) entre las mujeres de 40 años de edad o más. Resultados: La introducción de la mamografía de cribado en los Estados Unidos se ha asociado con una duplicación en el número de casos de cáncer de mama en fase inicial que se detectan cada año, de 112 a 234 casos por cada 100.000 mujeres - un incremento absoluto de 122 casos por cada 100.000 mujeres . Al mismo tiempo, el ritmo en el que las mujeres alcanzan las etapas avanzadas de cáncer disminuyó en un 8%, de 102 a 94 casos por cada 100.000 mujeres - una disminución absoluta de 8 casos por cada 100.000 mujeres-. Asumiendo una carga de enfermedad subyacente constante, sólo 8 de cada 122 cánceres adicionales diagnosticados en una etapa temprana se espera que progresen a enfermedad avanzada. Después de excluir el exceso de incidencia transitoria asociado con la terapia de reemplazo hormonal y el ajuste de las tendencias en la incidencia de cáncer de mama entre las mujeres menores de 40 años de edad, se estima que el cáncer de mama se diagnosticó en exceso (es decir, los tumores que fueron detectados en el cribado que nunca habrían dado lugar a síntomas clínicos) en 1,3 millones de mujeres estadounidenses en los últimos 30 años. Se estimó que en 2008, el cáncer de mama fue diagnosticado en exceso en más de 70.000 mujeres, lo que representó el 31% de todos los cánceres de mama diagnosticados. Los autores concluyen que a pesar de un aumento sustancial en el número de casos de cáncer de mama detectados en una etapa temprana, la mamografía sólo ha reducido marginalmente la velocidad a la que las mujeres alcanzan un cáncer avanzado. Aunque no es cierto que las mujeres han sido afectadas, el desequilibrio sugiere que hay considerable exceso de diagnóstico, lo que representa casi un tercio de todos los cánceres de mama recién diagnosticados, y que el cribado, en el mejor de los casos, sólo tiene un pequeño efecto en la tasa de muerte por cáncer de mama.

http://www.nejm.org/doi/full/10.1056/NEJMoa1206809

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Screening cancer with mammography

English: Breast cancer incidence by age in women in the United Kingdom 2006-2008. Reference: Excel chart for Figure 1.1: Breast Cancer (C50), Average Number of New Cases per Year and Age-Specific Incidence Rates, UK, 2006-2008 at Breast cancer - UK incidence statistics at Cancer Research UK. Section updated 18/07/11. (Photo credit: Wikipedia)

Age-standardised death rates from Breast cancer by country (per 100,000 inhabitants). (Photo credit: Wikipedia)

Screening with mammography uses X-ray to try to find breast cancer before a lump can be felt. The goal is to treat cancer early, when a cure is more likely. The review includes seven trials that involved 600,000 women who were randomly assigned to receive screening mammograms or not. The review found that screening for breast cancer likely reduces breast cancer mortality, but the magnitude of the effect is uncertain. Screening will also result in some women getting a cancer diagnosis even though their cancer would not have led to death or sickness. Currently, it is not possible to tell which women these are, and they are therefore likely to have breasts or lumps removed and to receive radiotherapy unnecessarily. The review estimated that screening leads to a reduction in breast cancer mortality of 15% and to 30% overdiagnosis and overtreatment. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings.
It is thus not clear whether screening does more good than harm. Women invited to screening should be fully informed of both the benefits and harms. To help ensure that the requirements for informed consent for women contemplating whether or not to attend a screening program can be met, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk.

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Guidelines for Breast Cancer

1991

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Most women with screen-detected breast cancer have not had their life saved by screening

Image via Wikipedia

By Gary Schwitzer on October 24, 2011 4:42 PM  No Comments  No TrackBacks

That's the conclusion of an article published today in the Archives of Internal Medicine. I'm on the run today, but here's the abstract: 

Background Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test "saved my life." Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute's software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death--a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).

Results We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.

Conclusions Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.

Here's the MedPage Today story on the article. 

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Breast Cancer Screening

By Graham McMahon

The latest article in our Clinical Practice series reviews current recommendations for breast-cancer screening and thesupporting evidence, including the controversy regarding mammographic screening of women in their 40s.

Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and 458,000 deaths reported in 2008.OK

Clinical Pearls

• How have the screening recommendations from the U.S. Preventive Services Task Force (USPSTF) changed in recent years?

In contrast to its 2002 guidelines, the more recent recommendations of the USPSTF, published in November 2009, support a reduction in the use of screening mammography. The two most controversial changes were the reclassification of screening for women between the ages of 40 and 49 years from a B recommendation (based on moderately strong evidence) to a C recommendation (“the decision . . . should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms”), and the recommendation that the frequency of screening be reduced from every 1 to 2 years to every 2 years.

• What is the consensus recommendation regarding mammographic screening for women between the ages of 50 and 69?

Screening mammography for women 50 to 69 years of age is universally recommended. All but one of the trials that included women in their 60s showed a significant reduction in mortality in the screened group, although this was not true for the subgroup of women in their 50s. Still, a meta-analysis revealed significant reductions in the number of deaths in both these age groups — 14% for women in their 50s and 32% for those in their 60s.

Table 1. Risk Factors for Breast Cancer.

Morning Report Questions

Q: For a 42-year-old woman with no risk factors, what are the benefits and risks of screening mammography?

A: Her chance of having invasive breast cancer over the next 8 years is about 1 in 80, and her chance of dying from it is about 1 in 400. Biennial mammographic screening will detect two out of three cancers in women her age and will reduce her risk of death from breast cancer by 15%. However, there is about a 40% chance that she will be called back for further imaging tests and a 3% chance that she will undergo biopsy, with a benign finding.

Q: What are the benefits of digital mammography?

A: The contrast between breast tumors and surrounding normal parenchyma is greater with digital mammography than with film mammography, particularly when the breast tissue is dense. In one study in which almost 50,000 asymptomatic women 40 years of age or older underwent both digital and film mammography, the two techniques were equivalent overall in sensitivity (70% and 66%, respectively) and specificity (92% for both). However, in women under the age of 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).

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