Screening Mammography in Israel

Issues and Future

Tal Arazi-Kleinman MD Wolfson Medical Center, Holon, Israel

Israel

!   A small country

!   About the size of New Jersey

!   Approx. 27,800 km2 (10,700 mi2) / 22, 000 km2

France (632760 km²) is

22.76/28.67 times as big as

Israel

(27,800 km²/22,000 km2)

!   Small size is an advantage regarding breast cancer screening

!   Enables accurate monitoring

!   Breast cancer is a reportable disease to the ministry of health (national cancer registry)

!   Mammography screening is monitored by a national breast cancer screening program since 1992

Israel - population !   8.132 million population (= to Switzerland) !   Constitutes 1/900(0.11%) of the world population

!   Diverse population §  75.2% Jewish §  20.6% Arab

§  4.2% other

!   Distinct minorities – immigrants, ultra-orthodox jews, bedouins and more

BC Incidence Female breast cancer incidence rates, 2008

•  Israel ranks 4th in the OECD in

breast cancer cases with

96.8/100,000 after Belgium, France

(99.7) and the Netherlads

•  Average OECD – 71.6/ 100,000

INBCSP

BC – Origin of birth !   In 2012 Jewish population:

73%- “Sabras” – born in Israel §  38.2% - Israeli-born to at least one parent who was

also Israeli-born

§  36% - European and American ancestry

§  14.5% - Africans ancestry

§  11.2% - Asians ancestry

BC incidence & Age

BC incidence & Age

MECC !   Middle east cancer

consortium !   4 neighboring countries

with cancer registries compared with US SEER (recently Turkey joined as well)

!   2006 NCI published a mongram with data from 1996-2001

MECC

MECC

Among Israeli Jewish women, as in American women, a larger proportion of breast cancer was diagnosed at an earlier age

!   Breast cancer in Israeli Jewish women is more prevalent and appears at a younger age than Israeli Arab women or women in the neighboring countries

!   Likely due to high prevalence of BRCA mutations

Breast Cancer Mortality

29.5

11.1

Breast Cancer Mortality

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

per

100,

000

(ASR

)

1998199920002001200220032004200520062007

Year

Jewish Arab

29.5

11.1

National Screening Program !   Established in 1992 by the Israeli Government

along with the health maintenance organizations and the Israel cancer association

!   In Israel, by law, every resident has health insurance coverage by one of 4 health maintenance organizations (HMO)

!   Mammography screening is initiated and funded by these organizations, established by law

National Screening Program !   Average population: bi-annual mammogram

between 50-75 yrs (est. 760,000 women)

!   High risk population: annual mammography between 40-75 yrs

!   56/62 mammography centers in the country participate (including 2 mobile unit) – under go quality assurance

!   >80% of mammograms performed in the country

Screening US !   Performed very commonly in Israel

!   All high risk women with dense breasts

!   Most average risk women with dense breasts

!   No clear guidelines, left to the decision of the mammographer or referring physician

!   Data not yet routinely gathered on a national basis

National Screening Program Since the program began !   4 million mammograms

!   In over 1 million women

!   72% compliance !   85.6% having repeat studies

National Screening Program In 2009 !   Screening compliance among Arab Israeli

women almost equal to Jewish Israeli

!   4,147 newly diagnosed breast cancer – 1,216 of them screen diagnosed (30%)

!   >70% of screen diagnosed cancers early stage (18.1%DCIS, 52.2% stage 1)

2008 world health statistics WHO

OECD - Mammography screening, percentage of

women aged 50- 69 screened, 2000 to 2009 (or

nearest year) France (76.7%) & Israel

(69.5%) are above the OECD average (62.2%)

!   2001 NCR issued a geographic report on breast cancer prevalence in different parts of the country

!   The peripheral regions (north and south) showed a lower prevalence

# of mammography units in the region

Mobile Unit – Reaching out !   2002: The Israel Cancer Association

purchases a mobile mammography unit reaching out to more remote areas of the country

!   Over 15,000 women a year !   Education programs are established in

these remote areas !   Recent analysis shows the gap in breast

cancer prevalence is closing between peripheral and central areas

Screening in Ultra-Orthodox !   A minority group

compromising less than 10% of the population (mostly Ashkenazi)

!   Special cultural issues make screening for breast cancer or the BRCA gene problematic

Screening in Ultra-Orthodox !   Jewish Religious Practice

§  Family and childbearing

§  Modesty and humility

§  Marriage prospect for oneself or children

§  Belief in fate and God’s will

!   Close knit community – privacy issues important

Screening in Ultra-Orthodox !   Special programs for breast cancer awareness

within the community

!   Consultation with the Rabbi (who often directs medical attention and approves procedures).

!   Ever growing awareness – in 2009 screening compliance was only 10% lower than the general population and recently similar to secular population (88%)

Screening in Ultra-Orthodox !   Recent study revealed that the rate of haredi

women diagnosed with BC was 70% lower than secular women

!   Detected at a later stage -> lower survival rates, more aggressive tumors and higher chance of cancer recurrence

!   Different life style

BRCA screening !   BRCA mutations found in 0.3% of general

population (USA and Europe) – about 1 in 350-500

!   In Ashkenazi Jews found in 2.5% - 1 in 40

!   Estimated 30,000 Ashkenazi BRCA gene carriers in Israel

!   Not clear how many non-Ashkenazi carriers exist

BRCA screening

!   Between 30-80% lifetime risk of breast cancer

!   Tend to be more aggressive and at younger ages

BRCA screening protocol !   Age 20-25: bi-annual clinical breast examination

!   Age 25-30: annual screening US, annual MRI rotating at 6 month intervals (MRI funded by the HMOs for BRCA carriers)

!   Age 40 or 10 years younger than first relative diagnosed: add annual mammography at time of screening US

!   Age 35: Bi-annual US of ovaries.

Routine Screening 32 yr old BRCA Mutation Carrier

On MR guided

biopsy a 6 mm triple

negative IDC

Summary !   Breast cancer screening in Israel is well established

and supported by the government !   Jewish Israeli women have a high incidence of

breast cancer at a relatively early age compared to the Arab population

!   Results of screening are analyzed and reported and adjustments are made to the program to specifically target less compliant groups

Thank your for your attention

Acknowledgments !  Miri Ziv – CEO of the Israel Cancer Association

!  Dr Gad Rennert – Former director of the National mammography Screening Program

!  Dr Lital Keinan-Boker–Deputy director of the National Cancer Registry

Radiology Selfie