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Breast Cancer ScreeningWhere do we stand?
Rakhshanda Layeequr Rahman MDDirector, TTUHSC Amarillo Breast Center
of ExcellenceDivision of Surgical Oncology
How Big a Deal Is It?
• US New Breast Cancer 200,000/year• US Deaths 50,000/year
• Panhandle New Breast Cancers 900/year• Panhandle Deaths 212/year
• No. 1 Cancer in Women• No. 1 Cause of Death in Women 45 – 60 yrs
The elephant in the roomUSPSTF !!!
USPSTF Level of Certainty
USPSTF Recommendation Grades
USPSTFScreening Guidelines
USPSTFScreening Guidelines
USPSTFReactions
• Detailed ACR statement on Ill advised and dangerous USPSTF mammography recommendations
• ACR , SBI statement on Annals of Internal Medicine Poll regarding flawed USPSTF mammography recommendations
• Why the critics of screening mammography are wrong
The Real Issue• Federal healthcare legislation mandates
preventive coverage without co-pays• To have this protection category A or B
recommendation is a must form USPSTF• The only screening service that qualifies
is “ biennial screening mammography b/w 50 and 74 yrs of age”
The Aftermath• Avon Foundation survey of grant recipients in
48 states✓BCCED / BCCS program changes 25%
states✓Elimination of mammograms < 50 yrs✓Fewer mammograms for older women
Result
Higher rate on interval cancers and larger cancers in indigent population
…so what do we do?...
• Since widespread use of screening mammography, breast cancer mortality has dropped 30%• Majority of breast cancer deaths are in women who never had a mammogram or had one >2 years ago
Consider Basic FactsI
• USPSTF focused on mortality outcome
studies, therefore
Ignore improved detection technology
Pre MQSA Act
Many contain 1 view mammogram
Consider Basic FactsII
Consider Basic FactsIII Digital versus Analogue Mammography
Pisano 2005
• In USA, as of August 1, 2009:
# of mammography sites
8711
Digital units
54%
New analogue unit purchases
<5%
Consider Basic FactsIV
• USPSTF considered anxiety related to false
positive mammograms in younger women
• Anxiety related to interval / advanced
cancers in unscreened population is not
discussed
Consider Basic FactsV
• USPSTF studies have 15% mortality
reduction in favor of screening in women
aged 39-49 years
• The comparisons are made between
“invited to screen vs. not invited” and NOT
between “screened and un-screened”
Consider Basic FactsVI
• Women 40 years or older yearly mammogram
• Women younger than 40 yearly mammogram
starting 10 years younger than the youngest first
degree relative with breast cancer
The Answer - AMA
Cancers caught early with screening…… 9 out of 10 are curable (like it never happened)
Death
Stage IV
Stage III
Stage II
Stage ILife
Cancer
Situation Analysis• Cancer picked up by screening
mammogram prolongs life
• Less than 1 in 4 women > 40 years old had
mammograms in 2009
• Less than 1 in 3 doctors recommended
appropriate breast screening
Who’s Job Is It?
• Primary Care Physician or Gynecologist orders the
mammograms (no physician order needed in Texas)
• If they miss you should request