What’s Next After an Abnormal Screening

Mammogram?

James A. Stewart, M.D.

Beth Burnside, M.D.

May 19, 2004

Goals for Today

• Review selected issues in breast screening

• Describe the current and planned services at UW Breast Center

• Discuss communication flow

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BreastPancreasOvaryStomachLung & bronchusColon & rectum

1930 1940 1950 1960 1970 1980 1990

Evolution of cancer death rates, females

Why Reduction in BC Mortality?

• Time of diagnosis (screening)

• Optimal “loco-regional” treatment– Surgery and Radiation

• Adjuvant chemo and endocrine Rx

• Treatment of overt systemic disease

• Swiss show same curves but <1/2 the mammography use

Goldhirsch et al Annals of Oncology 14:1212, 2003

Case Scenarios

1. First impression?

2. Barriers?

3. Research question?

28yo woman with a family history of breast cancer wants to start routine mammography: (1ST impression, barrier?, research?)

1. Just what is the family history? Is it suggestive of a BRCA family?

2. Will the radiologist do it? Is that the best test

3. I wish the researchers would identify people who won’t get breast cancer.

84yo woman who asks about continuing her regular mammography (1ST impression, barrier?, research?)

1. How long is she likely to live?

2. What if the radiologist finds a very small cluster of calcifications?

3. I need a better way of “summing” her co-morbidities to plan her care.

Wisconsin Comorbidity Assessment

Scale (WCAS)

Comorbid Conditions Cognition / Mood

Physical Function

Assessment Instrument Validation

Medication and Polypharmacy

Falls/ Mobility

The Future of Residents’ Education in Internal Medicine

….evidence-based medicine, and judicious use of technology will be essential skills of the future

….management of large volumes of data with an ever-changing scientific knowledge base.

LG Smith, et al AJM, May 1, 2004

Test and technologyoriented culture

Who puts things in context and gives advice?

The best communicators?

Computerized Health Enhancement Support System (CHESS) Breast

Breast Imaging Training:Who Will Sign Up?

• Promotion and increase compliance

• If > 40 mammo rate 29 67% (‘87-’98)

• Reimbursement, wait times, litigation

• Survey of 211 programs

• Majority of residents had Negative Attitude

• Malpractice exposure a leading reason

Bassett, et al Radiology, June 2003

Bassett, et al Radiology, June 2003

132 residents who would not choose breast imaging fellowship if offered

Breast Spectroscopy: PreChemo

TE 144ms TE 35ms

Location of ROIDiffusion - Axial

Maximal Slope of Increase

BSE in Shanghai

• Will intensive BSE instruction reduce breast cancer mortality?

• n = 266,064 women in 519 factories • Accrual from 1989-91 (no mammograms)

Randomize by factory

Low back pain prevention

BSE education with reinforcement

Thomas et al, JNCI 2002;94

BSE Shanghai: Final Results (12/2000)

BSE ControlBreast Cancer Deaths 135 131

Number of Cancers 857 890

% Cancers Tis or T1 48.8% 44.8%

Total biopsy specimens 3,620 2,395

Thomas et al, JNCI 2002; 94

Enthusiasm for Cancer Screening in the US

• National telephone survey n = 500

• Finding cancer early saves lives (74%)

• 66% want testing even if nothing to do

• 73% would choose body CT over $1,000 in cash

Schwartz LM et al, JAMA Jan 7, 2004

Screening as an ObligationSchwartz LM et al, JAMA Jan 7, 2004

41% for mammography In 80yo woman

Challenges

• Where to put our resources for reducing breast cancer burden

• The population is aging

• Application and communication of technology

• Screening strategies in general

UW Breast Center 1st Quarter 2004

Screening Mammogram 2619

Ultrasound 556

Stereotactic core biopsy 110