Mammography, how safe & effective in screening

&early detection of Breast cancer ?

NEED/SCREENING

• 1million new cases /yr ,cancer is a major health problem

• 18% BC

• 1in 8 US, I in 30 in India

• Advanced Breast Cancer 10-20% US, 30-60% in developing countries.

Goal

• Goal of any screening test is to use a test of sufficient sensitivity to detect a large proportion of a particular disease in population.

HOW

• BSE,BPE,MAMMOGRAPHY can detect benign ,precancers like DCIS,LCIS,PAGET’S DISEASE and early invasive cancers.

• Further evaluation of any suspicious lesion- Diagnostic Mammography ,Sonography, Elastography, MRI, PET.

RECOMMENDATIONS• ACS/ACR – Annual screening from 40• USPSTF2009, 50-74 YRS EVRY 2 YRS:

-Overdiagnosis and unnecessary treatment(10/1life saved)

- Anxiety- Slight increase in radiation induced BC- Below 35 yrs not recommended, Sonography

/MRI.- Cost of screening

ROUTINE SCREENING STILL A MATTEROF DEBATE

• COCHRANE COLLABORATIVE DATABASES 2011(US/ NORDIC)

Universal screening does more harm than good and is not reasonable.

Screening detects 3-13% BC DR in some countries with organized

screening by 2/3rd.Benefit to risk ratio-48.5/1 (safe)

Stagewise survival

0 98%

I 88%

IIA 81%

iiB 74%

IIIA 67%

iiiB 41%

IIIC 49%

IV 15%

WHAT IS MAMMOGRAPHY

• LOW ENERGY XRAY 30 Kv examines the breast & typically finds:

• Lump-( well defined/irregular)

-solid/cystic

• Macro calcifications –Ageing

• Micrcalcifications - spiculated

-clustered

-linear branching

SENSIVITY/SPECIFICITY

• SENSSITIVITY-79%,LESS IN YOUNG(Effective)

• SPECIFICITY:FALSE NEGATIVE 10-30%FALSE POSITIVE -7%(UNNECESSARY

FOLLOW UP SCREENING )

Reporting of mammography findings:

• BIRADS SCORE(BREAST IMAGING REPORTING AND DATA SYSTEM)/ACR

• 0-6=INCOMPLETE-BIOPSY PROVED

A Brief History

- 1913 Albert Salomon, German surgeon

- 1950’s - Jacob Gershon-Cohen began to advocate widespread use of X-rays for screening

- December 2005 – RSNA brings digital mammography to US

Mammography

Past & PresentSimilar equipments were & are still being used,

these can be called as old fashioned equipments

cone

Tube

Breast Stand

Standard views:

45* Medio lateral Oblique (MLO view)/

Lundgren’s view

Craniocaudal view (CC view)

RCC RMLOLCC LMLO

Left Craniocaudal

Right Craniocaudal

Right Mediolateral

Oblique

Left Mediolateral Oblique

PROCEDURE

• Breast compressed between two parallel plates ,reduces the thickness and increases sensitivity

• 2 views –CC,MLO• TALCUM POWDERS/DEODORANTS

DISCOURAGED• 1 WK AFTER MENSES• < 30 MINS

WORK UP

• SCREENING

• DIAGNOSTICMAMMOGRAPHY

• STEROTACTIC OR US GUIDED CORE BIOPSY

LATLeft Axillary Tail

LCV Left Cleavage

LFBLeft From Below

LLMOLeft Lateromedial

Oblique

LMLLet Mediolateral

LRLLeft Roll Lateral

LRMLeft Roll Medial

LLMLeft Lateromedial

CONVENTIONAL CC VIEW EKLUND CC VIEW

Mammography

In digital mammography screen-film system has been replaced by Detectors to give the digital images

Mammography

Present & future

CCD camera

Work station

Equipments look like this

ADVANTAGES

• Improved signal-to-noise ratio

• Ability to magnify, change contrast, or alter the brightness.

• Near instantaneous image acquisition

Digital Mammographic Imaging Screening Trial

(DMIST)

• Retrospective study of 49,500 asymptomatic women• Assessed accuracy of digital vs film mammograms

RESULTS:• Digital mammography significantly more accurate in pre-

and perimenopausal women under 50 with dense breasts

• Nonsignificant trend toward improved accuracy with film mammograms in women over 65 with fatty breasts

cost issues

• Digital mammography is expensive!

• Using digital technology in all women would cost >$300,000 per QALY gained

• Targeted use of digital mammography on basis of age/breast density costs ~$50,000 per QALY gained

Computer-Aided Detection

• Software program that highlights areas of concern on digital mammograms

• Uses image processing algorithms and decision threshold parameters to detect features in an image likely to be of clinical significance

• Very sensitive – detects 90% of all cancers• However, has a high rate of false positives (2-4 per study)

http://www.imagingeconomics.com/issues/articles/2005-12_04.asp

THANK YOU Stay hungry stay foolish-Steve Jobs Dr. Gopa Ghosh, M.D. Dr.O.P. Singh, M.D. FICRO