What’s Next After an Abnormal Screening Mammogram? James A. Stewart, M.D. Beth Burnside, M.D. May 19, 2004
Goals for Today • Review selected issues in breast screening • Describe the current and planned services at UW Breast Center • Discuss communication flow
Uterus† Breast Pancreas Ovary Stomach Lung & bronchus Colon & rectum 30 20 10 1990 1930 1940 1950 1960 1970 1980 Evolution of cancer death rates, females 40 Rate per 100,000 Female Population 0 Year Adapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:26.
Why Reduction in BC Mortality? • Time of diagnosis (screening) • Optimal “loco-regional” treatment • Surgery and Radiation • Adjuvant chemo and endocrine Rx • Treatment of overt systemic disease • Swiss show same curves but <1/2 the mammography use Goldhirsch et al Annals of Oncology 14:1212, 2003
Case Scenarios • First impression? • Barriers? • Research question?
28yo woman with a family history of breast cancer wants to start routine mammography: (1ST impression, barrier?, research?) • Just what is the family history? Is it suggestive of a BRCA family? • Will the radiologist do it? Is that the best test • I wish the researchers would identify people who won’t get breast cancer.
84yo woman who asks about continuing her regular mammography (1ST impression, barrier?, research?) • How long is she likely to live? • What if the radiologist finds a very small cluster of calcifications? • I need a better way of “summing” her co-morbidities to plan her care.
Comorbid Conditions Cognition / Mood Wisconsin Comorbidity Assessment Scale (WCAS) Physical Function Falls/ Mobility Medication and Polypharmacy Assessment Instrument Validation
The Future of Residents’ Education in Internal Medicine ….evidence-based medicine, and judicious use of technology will be essential skills of the future ….management of large volumes of data with an ever-changing scientific knowledge base. LG Smith, et al AJM, May 1, 2004
Test and technology oriented culture Who puts things in context and gives advice?
Computerized Health Enhancement Support System (CHESS) Breast
Breast Imaging Training:Who Will Sign Up? • Promotion and increase compliance • If > 40 mammo rate 29 67% (‘87-’98) • Reimbursement, wait times, litigation • Survey of 211 programs • Majority of residents had Negative Attitude • Malpractice exposure a leading reason Bassett, et al Radiology, June 2003
132 residents who would not choose breast imaging fellowship if offered Bassett, et al Radiology, June 2003
Breast Spectroscopy: PreChemo TE 144ms TE 35ms Maximal Slope of Increase Location of ROI Diffusion - Axial
BSE in Shanghai • Will intensive BSE instruction reduce breast cancer mortality? • n = 266,064 women in 519 factories • Accrual from 1989-91 (no mammograms) Low back pain prevention Randomize by factory BSE education with reinforcement Thomas et al, JNCI 2002;94
BSE Shanghai: Final Results (12/2000) BSE Control Breast Cancer Deaths 135 131 Number of Cancers 857 890 % Cancers Tis or T1 48.8% 44.8% Total biopsy specimens 3,620 2,395 Thomas et al, JNCI 2002; 94
Enthusiasm for Cancer Screening in the US • National telephone survey n = 500 • Finding cancer early saves lives (74%) • 66% want testing even if nothing to do • 73% would choose body CT over $1,000 in cash Schwartz LM et al, JAMA Jan 7, 2004
Screening as an Obligation Schwartz LM et al, JAMA Jan 7, 2004 41% for mammography In 80yo woman
Challenges • Where to put our resources for reducing breast cancer burden • The population is aging • Application and communication of technology • Screening strategies in general