Modern Imaging in Breast Cancer

1. Modern Imaging in Breast Cancer Dr Linda Hacking Consultant Radiologist

2. October is Breast Cancer Awareness Month • Breast cancer is commonest cancer in UK (excluding non-melanoma skin cancer) • 46,000 new cases per year • 300 men, remainder women • 80% over 50 years of age • 1 in 9 women will get it in their lifetime

3. Bad news/Good news • Incidence has increased by 50% in last 25years • 12,000 women and 70 men died from breast cancer in 2008 • 1,300 deaths in women under 50 • More than half deaths are in women over 70

4. Bad news/Good news • Since 1980s breast cancer death rates have fallen by one third • Breast cancer is no longer the commonest cause of cancer death in women • More than 8 out of 10 women survive beyond 5 years (5 out of 10 in 1970s) • Now twice as likely to survive 10 years as 40 years ago. • 2 out of 3 women survive beyond 20 years • Breast cancer death rates falling faster in UK than rest of Europe

5. Reasons for improvements in outcomes • Screening • Improved treatments (Tamoxifen etc) • Improved cancer services including imaging

7. Why are these improvements happening • Breast screening?? (also increased diagnosis rate) • Improved treatments (tamoxifen etc.) • Overall improvements in care (including imaging)

8. Breast Screening • NHS Breast Screening Programme (NHSBSP) • Began 1988-90 • Not Blackpool Victoria. • Nearest centre Lancaster (vans, WGD) • Invited for Mammograms from age 50-69 • Extended from 47-73 years from 2012 (target) • Past upper age limit, option to arrange mammogram.

9. Breast Screening • Will cause increase in incidence of cancer • Early cancers and pre-cancer (DCIS) are found that would never have led to a problem

10. For Breast Screening • One woman will be over-treated for every two lives saved • 1000 lives a year saved • Impact on population vs individual woman’s life.

11. Against breast screening • 10% of cancers are over-diagnosis and therefore over –treatment • It is impossible to estimate lives saved because of all other factors • Impact on population vs impact on individual woman’s life

12. Today we are talking about diagnosis

13. The Symptomatic Breast Clinic • Lump or thickening • Change in size or shape • Redness or rash in skin or nipple • Indrawing of nipple • Skin puckering or dimpling • Lump in armpit

14. Referral to Breast Clinic • May simply need to see senior clinician- no further –advice, no further investigations. • Triple assessment/Double assessment • See Senior Clinician (1) • Imaging (2) • Biopsy or needle test (FNA) (3)

15. Modern Imaging and Biopsy • Tests to be done at first clinic appointment for most patients • Most patients will have a benign diagnosis • Less than 1 in 10 patients attending our clinic will have a malignant diagnosis • 9 out of 10 will be benign • In new clinic, results for patients seen Monday, Tuesday available for Friday • Wednesday, within a week

16. Modern Imaging and Biopsy • Quick accurate diagnosis for the majority of patients who will have a benign diagnosis • As much information as possible about what we are dealing with in the minority if patients who have a malignant diagnosis • Treatment can then be tailored to the individual patient

17. Mammography • Symptomatic patients • Women >35 years of age • Uses x-radiation • Invented in 1960s, modern type of machine 1969 • Still not in universal use 1986 (when I started in radiology) • First unit Blackpool 1990 (Fylde Coast incl.NHS) • Blackpool Victoria Mammography unit 1999. • October 2010 Full Field Digital mammography

26. Mammography • Problems • X-radiation • Dense breasts • Young women • Men • Implants • No imaging 100% accurate

27. Field Digital Mammography • Better on all counts • Dense breast • Younger women • Less radiation

33. Ultrasound • First imaging <35, and men • To clarify lumps and cysts on mammogram • To do image guided biopsy • To look at axilla (armpit)

34. Ultrasound

35. Cyst

36. Fibroadenoma

37. Ultrasound guided biopsy

38. Ultrasound guided biopsy • Needle guided into abnormality under direct vision • Can be needle test (FNA) • Or Core biopsy • Uses local anaesthetic • Takes 5-10 minutes • “a bit like getting ears pierced” • Complications- bruising, pain

39. Ultrasound guided biopsy • Quick very accurate results • A patient specific individual plan if surgery required • Tumour grade if malignant • Hormone receptor status (Tamoxifen, herceptin) • Size and extent of mass(es) • Lymphnodes • Test done Tuesday, results Friday

40. Core Biopsy Needle

41. Ultrasound guided biopsy

42. Mammographic stereotactic biopsy • Mass seen on mammogram, not on ultrasound • Micro-calcification “chalky bits”- can be benign, can be malignant or pre-malignant (DCIS) • No lump felt • Standard core biopsy • Vacuum assisted core biopsy • Special devices

43. Mammographic stereotactic biopsy • Previously may have needed general anaesthetic surgery to remove abnormality • Now outpatient procedure under local anaesthetic • Most turn out to be benign

44. Vacuum assisted biopsy

46. Vacora vs 14G biopsy

47. Sample can be x-rayed