Hematologist-oncologist Elham Vosoughi, MD, starts with an update on breast cancer stats, noting that incidence in the United States is increasing by 1% every year – with an even sharper rise for women under 50. She explains that earlier detection has likely played a big role in lower death rates from the disease, yet many providers have questions about how to match available screening options to individual cases. Vosoughi offers a thorough breakdown of standard and advanced techniques, including contrast-enhanced mammography, as well as guidance on personalizing recommendations according to the reasons – ranging from family history to genetic mutations to dense breast tissue – for a patient's elevated risk.
Perfect. So, um, First, let's talk about some statistics about breast cancer. So, uh, breast cancer is the most common cancer in women in the United States. Uh, it counted for 30% of all, uh, female cancer each year. Uh, the lifetime average risk of a woman getting breast cancer is 13%. But, uh, recently we have seen an increased incidence in the rate of uh breast cancer, um, uh, about 1% per year. However, this increase in the rate of, uh, breast cancer has been more pronounced in women younger than 50. Uh, we have seen it by 1.4%, uh, increase per year. And we think that it's probably, uh, multifactorial due to, um, uh, Excess weight, uh, women tend to not have children, uh, more than before or having their first kid at age 30 and older. Breast cancer is the second leading cause of cancer deaths in women. Only lung cancer kills more women than breast cancer. Uh, however, the rate of breast cancer deaths has decreased significantly, uh, since, um, from 1989 to 2022, and we think that this is, uh, mainly due to, um, uh, better detection and finding of breast cancer in early stage. Uh, increase awareness and, um, of course, better treatments that are now available for breast cancer. This plot shows, um, the. However over years, the rate of deaths from breast cancer has decreased while the rate of new cases has increased. Uh, but overall, considering all um uh stages of breast cancer, the five-year related survival is 90.2, which is great. Uh, there are some difference in, uh, different ethnicities and, um, the mortality rates from breast cancer. Uh, black women have the highest death rates from breast cancer. Um, they tend to have higher risk of triple negative breast cancer. And they also, uh, the black women also more likely to die from breast cancer than any other race or ethnic group. Uh, among white, Asian and Pacific Islander women, uh, they're more likely to be diagnosed in localized breast cancer than Black, Hispanic, and American Indian and Alaska Native women. And Asian and Pacific Islander women, uh, have, uh, the lowest, uh, death rate from breast cancer. But why screening is important? Uh, we expect that in 2025, we have about, uh, more than 300,000 new cases of invasive breast cancer to be diagnosed, about 60,000 new cases of ductal carcinoma in situ to be diagnosed, and, uh, we expect to have more than 40,000 deaths from breast cancer. So, You can see that if you, we look at the 5 years related survival uh based on the stage of the cancer, um, the localized breast cancer has the highest chance of uh survival. While survival rate in distant metastasis goes down to 20, 31%, uh, almost 32% in 5 years. So it is very important to, uh, screen and, uh, diagnose breast cancer in early stage because this is the stage that it's curable. Uh, to date, mammogram is, uh, the main and the most important, uh, modality for screening breast cancer and the only modality that so far has shown decrease in the mortality. Uh, there are some controversies about ultrasound. So, um, there are lack of evidence from randomized controlled trials, uh, in efficacy of screening ultrasound. Uh, however, we know that patients with, the women with, uh, dense breasts, um, they have, um, lower sensitivity of cancer detection with regular mammograms. And adding ultrasound to mammogram increases the sensitivity to 77.5%. Also, from studies, we know that uh combining screening ultrasound with a mammogram and um Women with dense breasts uh helps to identify additional 4.3 cancer uh per each, uh, per 1000 female that has been screened, but that increases the number of false positive and callback for biopsies. As of now, uh, routine use of ultrasound as universal supplemental screening has not been supported or recommended by NCCN panel. Um, we mainly recommend ultrasound, uh, as, um, uh, addition to diagnostic mammogram when there is a palpable mass or, uh, clinically, uh, concerning findings. How about MRI? Um, MRI has higher sensitivity compared to mammogram and ultrasound, but obviously, higher rate of false positive findings. Um, and there is, uh, some concerns about, uh, gadolinium deposits. We know that, uh, gadolinium can stay in the brain, remains in the brain, in, uh, brain of patients who undergo more than 4, contrast, um, MRI scans. Uh, as of today, uh, we are not sure about the clinical significance of, uh, this gadolinium deposition. In 2015, FDA issued a safety warning, uh, alerting that as investigation were ongoing for the Risk associated with the gadolinium deposit. In 2017, they issued an update stating that so far they, there was not um any um adverse health effects that has been identified, but usually, patients will be asked to read about it and consent to receiving gadolinium if they're opting to have annual mammogram. How about contrast, uh, enhanced mammography? This is a newer modality, uh, that uses, uh, iodine contrast, um, with mammogram. It has significantly improved the detection of early-stage breast cancer, especially in adults who have dense breasts. Uh, again, same as other modalities, it can increase the risk of recall and, um, benign breast biopsies. Uh, since it's using iodine contrast, there is a, um, risk of, uh, contrast reaction. Um, however, the, and it does have a higher radiation exposure per exam compared to standard mammography, but, uh, still, the radiation dose remains, uh, below the limits for, um, FDA. How about the age for um Screening, uh. Most of the trials has used the cutoff age of 65 to 50 years old um for stopping the screening. However, um, the observational studies has shown that we see the benefit, uh, mortality benefit of uh screening even up to age 88 to 84. Uh, right now, in the guidelines, we recommend starting screening in someone with the average risk of breast cancer at the age 40, but there is no, uh, age cutoff to stop the screening. Uh, that's usually, uh, a clinician judgment based on, um, patient's, um, Life expectancy. Uh, we expect that the mortality benefit of screening mammogram, um, uh, is often delayed by 5 to 7 years. So, uh, we, you can continue screening mammograms as long as patient's life expectancy is more than 5 to 7 years. Who considers high risk for breast cancer? Um, strong family history of breast cancer, specific genetic mutations like BRCA1, BRCA2, PALP B2, um, mutations. Uh, those who based on, um, models, um, A calculated models have a lifetime risk of more than 20%. These models are mainly um based on very comprehensive family history in first and second-degree um family members. Those who have personal history of breast cancer or high-risk breast lesion diagnosis like ADH or DCIS and history of chest radiation. So, in patients who, uh, their calculated lifetime risk of breast cancer is more than 20%, we do recommend considering um genetic counseling. Uh, annual screening mammogram should be started no later than 40 years old or 10 years prior to, um, youngest family member who was diagnosed with breast cancer. Uh, annual breast MRI, um, can be a supplement with, uh, annual screening. Um, again, and no later than 80 years old or 10 years prior to, uh, youngest family member who has been diagnosed. Uh, we can consider contrast, uh, enhanced mammography in those patients who qualify to undergo MRI but for, uh, any other reason cannot, uh, do MRI. Full breast ultrasound may be done if uh both um if contrast enhanced uh mammogram is not available or accessible. How about radiation history? So, uh, radiation to chest, uh, between age 10 to 30, and this is mainly in patients who have a history of lymphoma at young age, um, can increase the risk of breast cancer development later in life. And this risk usually goes up about 8 years after the radiation exposure. So in these patients, um, uh, we recommend uh start screening for breast cancer. Uh, begin to begin 8 years after radiation and not before age 25. Uh, since, uh, we're starting at younger age, uh, we recommend starting, um, screening mammogram with annual breast MRI. And adding the ultra uh the uh mammography at the age of 35. How about dense breast? Uh, dense breast limits the sensitivity of, uh, mammography and increases the risk of breast cancer. We know that a woman who have, uh, dense breast, um, they, um, are at the higher risk of developing breast cancer compared to, um, other women. Um, The dense breast, uh, in the combined two other risk factors increases the risk of breast cancer. But how about if the patient has a dense breast but does not admit the other criteria for increased risk category? How we circle at the screening these patients? So, for patients that have heterogeneously dense breasts, um, we recommend clinical encounter every 6 to 12 months. This includes physical exam, going over their, um, uh, Symptoms and breast exam, annual screening mammogram, and consideration of supplemental screening which includes MRI or um contrast uh enhanced mammogram. But those who have extremely dense breasts, um, uh, the guidelines recommend as long as their um insurance also um approves the guidelines recommend breast MRI, uh, to be started at age 50. Um, but can consider starting at age 40 as well and contrast enhanced mammography if they cannot go undergo MRI. Uh, how about BRCA1 and 2 positive patients. So for these patients, most of these patients undergo, uh, prophylactic, uh, bilateral mastectomy, but if a patient with a severe of BRCA1 or 2 has not gone yet under, uh, has not yet, um, underwent bilateral prophylactic mastectomy or not willing to, Uh, the screening starts from age 25, from 25 to 29, Screening includes annual breast MRIs, uh, with, uh, with and without contrast. Uh, starting age 30, uh, this will alternate with annual mammography, and age 75 and above, um, we stop MRIs and only continue with, um, annual mammography. How about breast awareness? All women are um advised to be uh familiar with their breast and uh report any changes uh to their pri primary care in terms of any new lump or any um nipple discharge or any um Skin changes. Uh, but large randomized trials for breast, uh, the, um, self-examination screening has not really showed that it will uh induce, uh, breast cancer mortality. Um, so that hasn't, uh, been in the guidelines anymore. And with this, uh, I will pause and stop my presentation and see if there is any question.
