Professional Documents
Culture Documents
Cancer
Brittany Lee, HMS IV
Dr. Gillian Lieberman
Radiology clerkship
11/07 Beth Israel
Brittany Lee, HMS IV
Dr. Gillian Lieberman
Screening Criteria
The Condition
Must be important health problem.
Epidemiology and natural history of the disease should be adequately understood.
Must have a detectable risk factor, disease marker, latent period or early symptomatic
stage.
The Test
Simple, safe, precise and validated screening test.
Acceptable to the population
Treatment
The treatment/intervention for patients identified through screening must be effective
and early treatment must improve outcomes compared to late treatment.
Agreed policy on who to treat.
Screening program
RCT must demonstrate that screening reduced morbidity and mortality.
The benefit of screening must outweigh the risks/side effects from the screening.
Facilities for diagnosis and treatment should be available.
The total cost of finding a case should be economically balanced in relation to medical
expenditure as a whole.
Case-finding should be a continuous process.
HIP* New York 1963 40-64 31,000 pairs 16 years 21% 0.14%
Reductionin
Noreductionin
mortalitywith
mortalitywith
adjuvanttx
screeningalone
alone
Screening Questioned
Gotzsche and Nielsen. Cochrane Review. 2006
Screening Questioned
Gotzsche and Nielsen. Cochrane Review. 2006
Conclusion:
For every 2000 women screened over 10
years, one will have her life prolonged and 10
healthy women will be diagnosed with breast
cancer and treated unnecessarily.
Cost-effectiveness of screening
Age Cost per year of life saved
40-49 $105,000
50-69 $21,400
>65 to 75 or 80 $34,000-$88,000
Is mammography appropriate
screening for this patient?
BI-RADS 2
Brittany Lee, HMS IV
Dr. Gillian Lieberman
Fletcher.
UpToDate. 2007.
Brittany Lee, HMS IV
Dr. Gillian Lieberman
BI-RADS 4c
Brittany Lee, HMS IV
Dr. Gillian Lieberman
http://www.qcif.edu.au/industry/QldXRay.html
Brittany Lee, HMS IV
Dr. Gillian Lieberman
www.mrsc.ucsf.edu/breast/picts_of_breast_mri.htm
Brittany Lee, HMS IV
Dr. Gillian Lieberman
www.mrsc.ucsf.edu/breast/picts_of_breast_mri.htm
Brittany Lee, HMS IV
Dr. Gillian Lieberman
Conclusion
Does screening reduce breast cancer mortality?
Uncertain since although 7 RCTs show that screening reduces the
relative risk of breast cancer mortality by 15-20%, not all of these trials
were randomized well and the absolute risk reduction was only 0.05-
0.1%
References
Berry DA, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. NEJM. 2005. 353;
17: 1784-92.
Boyd NF, et al. Mammographic density and the risk and Detection of Breast Cancer. NEJM. 2007. 356; 3:
227-36.
Fletcher SW. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst. 1993.
85; 20: 1644-56.
Fletcher SW. Screening average risk women for breast cancer. 2007. UptoDate.
Glass AG, et al. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy,
screening mammography, and estrogen receptor status. J Natl Cancer Inst. 2007. 99; 15: 1152-61.
Gotzsche PC and Nielsen M. Screening for breast cancer with mammography. Cochrane Database of
Systematic Review. 2006. 4.
Humphrey LL, et al. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services
Task Force. Ann Intern Med. 2002. 137; 5 Part 1: 347-60.
Jemal A, et al. Cancer statistics from SEER, CA Cancer J Clin. 2007. 55; 1: 43-66.
Kriege M, et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or
genetic predisposition. NEJM. 2004. 35; 5:427-37.
Lehman CD, et al. MRI Evaluation of the contralateral breast in women with recently diagnosed breast
cancer. NEJM. 2007. 356; 13: 1295-1303.
Mandelblatt J, et al. The cost-effectiveness of screening mammography beyond age 65. Ann Intern Med.
2003. 139:835.
Macura KJ, et al. Patterns of Enhancement on Breast MR Images: Interpretation and Imaging Pitfalls.
Radiographics. 2006. 26:1719-34.
Pisano ED, et al. Diagnostic performance of digital vs. film mammography for breast-cancer screening.
NEJM. 2005. 353; 17: 1773-83.
Ravdin PM, et al. The decrease in breast-cancer incidence in 2003 in the United States. NEJM. 2007. 356;
16: 1670-74.
Salzmann P, et al. Cost-effectiveness of extending screening mammography guidelines to include women
40-49 years of age. Ann Intern Med. 1997. 127:955.
Saslow D, et al. American cancer society guidelines for breast screening with MRI as an adjunct to
mammography. CA Cancer J Clin. 2007. 57; 2: 75-89.
Brittany Lee, HMS IV
Dr. Gillian Lieberman
Acknowledgements
Residents:
Katie Krajewski
Anne Kim
Senthil Palaniappun
Andrew Bennett
Dr. Valerie Fein-Zachary
Dr. Gillian Lieberman
Maria Levantakis