New SBI and ACR recommendations suggest breast cancer screening should begin at age 40

09 jan 2010--The new recommendations from the Society of Breast Imaging (SBI) and the American College of Radiology (ACR) on breast cancer screening, published in the January issue of the Journal of the American College of Radiology (JACR), state that breast cancer screening should begin at age 40 and earlier in high-risk patients. The recommendations also suggest appropriate utilization of medical imaging modalities such as mammography, magnetic resonance imaging (MRI), and ultrasound for breast cancer screening.

"The significant decrease in breast cancer mortality, which amounts to nearly 30 percent since 1990, is a major medical success and is due largely to earlier detection of breast cancer through mammography screening," said Carol H. Lee, MD. "For women with the highest risk of developing breast cancer, screening technologies in addition to mammography have been adopted," said Lee.

The new recommendations released by the SBI and ACR include recommendations for imaging screening for breast cancer by imaging technique (mammography, MRI, and ultrasound) and by risk factor. The recommendations state that the average patient should begin annual breast cancer screening at age 40. High-risk patients should begin by age 30 but not before 25. "Evidence to support the recommendation for regular periodic screening mammography comes from the results of several randomized trials (RCTs) conducted in Europe and North America that included a total of nearly 500,000 women. Overall, based on a meta-analysis of the RCTs, there was a 26 percent reduction in mortality," said Lee.

"It should be remembered that mammography is the only imaging modality that has been proven to decrease mortality from breast cancer. However major efforts continue to build on this success by developing additional methods to screen for early breast cancer," she said.

"The SBI and ACR wish to remind women and their physicians that in those instances in which there is a concern that risk of developing cancer is considerably elevated from that of the general population, consultation with appropriate experts in breast cancer genetics and/or high risk management is desirable," said Lee.

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The January issue of JACR is an important resource for radiology and nuclear medicine professionals as well as students seeking clinical and educational improvement.

For more information about JACR, please visit www.jacr.org.

To receive an electronic copy of an article appearing in JACR or to set up an interview with a JACR author or another ACR member, please contact Heather Curry at 703-390-9822 or hcurry@acr-arrs.org.

Alternating mammography and MRI may be best for high-risk women

M. D. Anderson study finds improved breast cancer detection by alternating screening tests every six months

SAN ANTONIO, 13 dec 2008 - Magnetic resonance imaging (MRI) alternated with mammography at six-month intervals can detect breast cancers not identified by mammography alone, a research team from The University of Texas M. D. Anderson Cancer Center will report at the 31st at the CRTC-AACR San Antonio Breast Cancer Symposium.

MRI is known to be more sensitive in detecting breast cancers than mammography, with a 71 - 100 percent accuracy compared to a 16 - 40 percent accuracy for mammography. As a result, annual breast cancer screening for high-risk women now typically includes MRI along with mammography and a clinical breast exam.

"In the high-risk population, the recent standard of practice is to perform mammography and MRI every year," said Huong Le-Petross, M.D., assistant professor of diagnostic radiology at M. D. Anderson and the study's first author. "What we started to do at M. D. Anderson was to see if we could do mammography and then six months later do a breast MRI exam, followed six months later with a mammogram exam, and then six months after that with a breast MRI. That way the women would receive an imaging modality screening every six months."

In the pilot study, to be presented at a poster session on Dec. 13, the researchers performed a retrospective chart review of 334 women who had participated in a high-risk breast cancer-screening program at M. D. Anderson from Jan. 1997 to Dec. 2007. The women had undergone between one and four MRI screening cycles and were considered to be at high risk if they had hereditary breast and ovarian cancer syndrome, a personal history of breast cancer, a biopsy indicating atypia or lobular carcinoma in situ (LCIS), or a 20 percent or higher lifetime risk of developing breast cancer, as estimated by the Gail model.

In the all-M. D. Anderson study, 86 of the 334 high-risk women (26 percent) underwent this alternating approach. Among this group, 46 percent completed the first round of MRI screening, 28 percent completed the second round, 13 percent completed the third round, and 4 percent completed the fourth round. The other 248 women underwent prophylactic mastectomy or were started on chemoprevention agents. All study participants were given a clinical breast exam every six months. The median follow-up time was 2 years, with a range of one to four years).

The alternating MRI and mammography screening program detected nine cancers among the 86 women-five invasive ductal carcinomas, three invasive lobular carcinoma, and two ductal carcinomas in situ. Five (55 percent) of these cancers were identified by MRI but not by mammography, three (33 percent) were found by both MRI and mammography, and one (11 percent) cancer, a tumor one millimeter in size, was overlooked by both screening techniques. No cancer was detected by mammography alone.

"We found that MRI picked up the majority of cancers, while mammography picked up only three out of the nine," Le-Petross noted. With five of the eight cancers detected by MRI, the mammogram from six months earlier was either normal or suggested benign findings.

"The global picture is that MRI can pick up cancers that mammography cannot," Le-Petross said. "This would suggest that in this population it is more beneficial for the patient to have screening MRI so that we can pick up small lesions before a mammogram can detect them."

One important unanswered question is whether an alternating MRI and mammography screening program will save lives. "That is going to take a 5- to 10-year follow-up to determine," Le-Petross added. "It is an exciting question because mammography has always been the standard, and now we are challenging that gold standard examination."

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In addition to Le-Petross, other authors on the all-M. D. Anderson study include: Gabriel Hortobagyi, M.D., professor and chair of the Department of Breast Medical Oncology; Banu Arun, M.D., associate professor in the Departments of Breast Medical Oncology and Cancer Prevention and the study's senior author; Deanna Atchley, Department of Breast Medical Oncology; and Gary Whitman, MD, professor in the Department of Radiology.

Raloxifene OK'd for Breast Cancer Prevention

Mon Oct 1, 8:00 PM ET
Older women looking for a medication to help lower their risk of invasive breast cancer now have another option available to them.
The US Food and Drug Administration (FDA) has approved raloxifene (Evista) for breast cancer risk reduction in two groups of postmenopausal women: those with the bone-thinning condition osteoporosis and those at high risk for invasive breast cancer. It joins tamoxifen as just the second so-called chemoprevention drug to be approved for breast cancer.
Under the brand name Evista, raloxifene is already approved, and widely prescribed, for the prevention and treatment of osteoporosis in postmenopausal women. Researchers had previously observed that these women -- roughly half a million at present -- had lower rates of breast cancer than the general population.
Raloxifene is a type of drug known as a selective estrogen receptor modulator, or SERM. In reducing the risk of invasive breast cancer, SERMs may act by blocking estrogen receptors in the breast.
The expanded use of raloxifene -- based on positive clinical studies of approximately 37,000 postmenopausal women over a 10-year period -- "provides an important new option for women at heightened risk of breast cancer," said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research.
In its announcement, the FDA noted that raloxifene can cause serious side effects, including blood clots in the legs and death due to stroke. Other potential side effects include hot flashes, leg cramps, swelling of the legs and feet, flu-like symptoms, joint pain, and sweating.
The FDA said women with current or prior blood clots in the legs, lungs, or eyes should not take raloxifene. It should not be taken with cholestyramine, a drug used to lower cholesterol levels, or with estrogens.
It also should not be taken by women who are or may become pregnant. At present, tamoxifen remains the drug of choice for women who have not gone through menopause and have a high breast cancer risk. Raloxifene's breast cancer risk reduction effects have not been studied in younger women.
According to American Cancer Society estimates, more than 178,000 women are expected to be diagnosed with invasive breast cancer this year, accounting for more than one-fourth of all cancers in women.

Breast Cancer Prevention Measures Vary Greatly

Allison Gandey

August 17, 2007 — Genetic testing is identifying women with BRCA1 or BRCA2 mutations, but preventive options can differ so dramatically, researchers are concerned. "The benefit of genetic testing is that we can identify women at high risk of developing breast cancer and hopefully reduce that risk. Ultimately, though, women have to elect to undertake 1 of the options," lead author Prof. Kelly Metcalfe, assistant professor at the Lawrence S Bloomberg Faculty of Nursing at the University of Toronto, in Ontario, told reporters. In an article published online August 17 in Open Medicine, the group shows that many Canadian women are not taking advantage of the preventive options available.
"Our results, and those of others, suggest that there are wide variations in the uptake of preventive options among BRCA1 and BRCA2 mutation carriers," the researchers write. "The differences in uptake could be due to a number of factors, including healthcare professionals’ acceptance and recommendation of the procedures, cultural differences that influence patient preferences, and access including cost and availability."
The team observed significant differences in uptake of preventive options in women who have received genetic testing in different areas of the country. The differences cannot be explained by differing healthcare systems, because Canada has a universal system, they suggest, and all of the women in the study had similar access to healthcare.
"We were very surprised by the discrepancy in preventive measures taken across the country," Prof. Metcalfe said. "The numbers show a huge discrepancy, with women in Quebec being the least likely to elect a preventive option. This will have significant implications in terms of the numbers of cancers we see developing in this high-risk group."
In the study, 672 women were identified as carrying the genetic mutation. Follow-up questionnaires were issued after a mean of 4 years. Out of the 342 women without breast cancer, 46% had not undertaken any cancer prevention option such as mastectomy, oophorectomy, or taking tamoxifen or raloxifene. Broken down geographically, 39% of women with the genetic mutation in Ontario, 34% in Western Canada, and 62% in Quebec did not take preventive measures.
The investigators suggest that prophylactic mastectomy offers the greatest reduction in breast cancer risk (approximately 95%). And prophylactic oophorectomy performed before the age of 40 years in women with a BRCA1 or BRCA2 mutation is associated with a 50% reduction in the risk for breast cancer. They report that using tamoxifen may also reduce breast cancer by 50% in high-risk women.
"Some women prefer screening over preventive surgery or chemoprevention," they add. "The goal is to detect cancer at an early, treatable stage."
The greatest differences in uptake rates were found with prophylactic mastectomy. Women from Western Canada had the highest rate of mastectomy (46%), followed by women from Ontario (22%), and Quebec (8%). The investigators also observed pronounced differences in rates of uptake of prophylactic oophorectomy. A total of 67% of women from Western Canada and 61% of women from Ontario had undergone preventive oophorectomy. Again, fewer women from Quebec elected to have this preventive surgery, with a total of just 39%.
The differences in tamoxifen uptake may also be due to access issues. Currently, tamoxifen costs approximately $25 per month. Some women may not have drug coverage and therefore may not be able to afford this.
"The differences in surgical uptake that we observed are probably not due to differences in access across the country. Canadian women have coverage for prophylactic surgeries, including breast reconstruction, without cost," the researchers write. "This would not be the case in the United States, where differences in uptake of preventive procedures have been attributed to financial constraints." But overall, the uptake rates of various preventive modalities were similar to those reported in other countries.
Large Sample, But May Not Be Representative
Data on uptake of magnetic resonance imaging were available for 241 of the 270 women without breast cancer who had not had a prophylactic bilateral mastectomy. A total of 104 (43%) had been screened for breast cancer with MRI. Most of these women — 96% — were less than 60 years old.
In contrast, the majority of women without breast cancer had undergone mammography (96%). Most of these women (86%) began mammography screening before genetic testing; however, 14% of the women had had their first mammogram after receiving their genetic test result.
"Although ours is a relatively large sample, it may not be representative of all women who have received a positive genetic test result in Canada," the investigators note. "Canadian women may have undergone genetic testing in centers other than the ones included here, and we do not have any information on their uptake of cancer prevention options."
They add that patterns of practice have evolved since 1999, the average time at which study subjects received genetic testing. "We believe that genetic services are now better integrated with surgical care and that physician attitudes may have changed with regard to specific preventive measures. It is our intention to repeat this survey in 5 years to evaluate trends in clinical practice."
This study could not ascertain the specific reason for the discrepancies across Canada, but the investigators say future research will address this question.
The researchers report having no significant financial relationships.
Open Medicine. 2007;1:e92-e98.