#234 The Breast Lump, and Breast Cancer Screening with Nancy Keating MD, MPH

Master your breast cancer screening spiel, cultivate your approach to the breast mass, and empower your patients with empathetic shared decision-making (which we know you’re all already fabulous at)! On this fantastic episode, we are joined by Dr. Nancy Keating @NancyKeatingMD, policy wonk and primary care doc extraordinaire at Brigham and Women’s Hospital. This episode is rife with drama, as the ACS butts heads with the USPTF and the ACR, and you have to figure out what’s right for the patient by talking with them--almost as exciting as that moment on Grey’s when Izzie cuts the...anyway, I won’t ruin a key plot point in the most excellent medical show of all time, all in a day’s work, here at The Curbsiders. Enjoy!

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

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Credits

• Producer and Writer: Nora Taranto MD
• Show Notes: Nora Taranto MD, Isabel Valdez PA
• Infographic: Nora Taranto MD
• Cover Art: Kate Grant, MD
• Hosts: Stuart Brigham MD, FACP; Matthew Watto MD, FACP; Paul Williams MD, FACP, Nora Taranto MD
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
• Reviewer: Arielle Medford MD
• Guest: Nancy Keating MD, MPH

Sponsors Provider Solutions & Development

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VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. Note: A free VCU Health CloudCME account is required in order to seek credit.

Time Stamps

• Sponsor - Provider Solutions & Development www.psdrecruit.org/curbsiders.
• Sponsor - VCU Health Continuing Education
• 00:30 Intro & Guest Bio
• 03:27 Guest one-liner
• 05:27 Best Advice for Women in Medicine
• 07:34 Picks of the Week
• Sponsor - Provider Solutions & Development www.psdrecruit.org/curbsiders.
• 10:00 Case 1: Brenda Cantwell and Breast Lump DDx
• 13:39 Clinical Breast Exam vs Self Breast Exam
• 17:26 Practical Tips for the Clinical Breast Exam
• 21:50 Imaging to Evaluate the Breast Lump
• 26:36 Demystifying BIRADS
• 28:36 Epidemiology Potpourri
• 33:02 Breast Pain without a Mass
• 34:30 Case 2: Mammie Gram and Breast Screening
• 46:03 Average Risk vs High Risk Screening
• 47:18 Breast Risk Prediction Tools
• 48:51 Breast Density
• 53:16 Imaging Modalities
• 61:28 Shared Decision Making in Screening
• 68:04 Case 3: Ms Britta Lumpworth and When to Stop Screening Mammograms
• 74:42 Take Home Points and Outro
• Sponsor - VCU Health Continuing Education

Links*

1. Evicted: Poverty and Profit in the American City by Matthew Desmond
2. Run The List podcast
3. ACOG Practice Bulletin 179, 2017
4. Elmore et al, Ten Year Risk of False Positive Screening Mammograms and Clinical Breast Examinations, N Engl J Med, 1998.
5. Thomas, et al, Randomized trial of breast self-exam in Shanghai: final results. JNCI, 2002.
6. Semagliazov et al, Results of a prospective randomized investigation [Russia] to evaluate the significance of self-examination for the early detection of breast cancer, Vopr Onkol, 2003.
7. Fuller, M. S., Lee, C. I., & Elmore, J. G. Breast cancer screening: an evidence-based update. The Medical clinics of North America, 2015.
8. Chan et al, False-negative rate of combined mammography and ultrasound for women with palpable breast masses. Breast Cancer Res Treat, 2015.
9. ACS Recommendations for the Early Detection of Breast Cancer, 2020.
10. USPTF Breast Cancer Screening Recommendations, 2016.
11. Henderson et al, Breast Examination Techniques, 2020.
12. Kolb et al. Comparison of the performance of screening mammography, physical exam, and breast ultrasound and evaluation of factors that influence them: an analysis of 27.825 patient evaluations, Radiology, 2002.
13. Mammogram Interpretation, Chapter 2. Radiology Key.Com.
14. Flobbe et al, The Additional Diagnostic Value of Ultrasonography in the Diagnosis of Breast Cancer. Arch Intern Med, 2003.
15. ACS Understanding Mammogram Readings, 2019.
16. Bittner, Guide to mammography reports: BIRADS terminology, Am Fam Physician, 2010.
17. Seer cancer statistics review, 1975-2017. 2020.
18. Anders CK et al, Breast carcinomas arising at a young age: unique biology or a surrogate for aggressive intrinsic subtypes?. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011
19. ACS How Common is Breast Cancer?
20. SEER Lifetime Risk (%) of Dying from Cancer by Site and Race/Ethnicity: Females, Total US, 2014-2016
21. Garcia et al, Cardiovascular disease in women: clinical perspectives, Circ res, 2017.
22. Cancer Statistics Center: Breast Statistics.
23. Independent UK Panel on Breast Cancer Screening, The Benefits and harms of breast cancer screening: an independent review, Lancet, 2012.
24. CDC Breast Cancer Screening Guidelines 2020
25. ACS Breast Cancer Screening Guidelines, 2015
26. USPTF Breast Cancer Screening Recommendations, 2016.
27. ACR Breast Cancer Screening Update, 2018.
28. Canadian Task Force Breast Cancer Screening Recommendations
29. UK-NHS Breast Cancer Screening Recommendations
30. Biller-Andorno et al. Perspective: Abolishing Mammography Screening Programs? A View from the Swiss Medical Board, N Eng J Med, 2014.
31. Nelson et al, Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 US PTF Recommendation, Ann Intern Med, 2016.
32. Miller et al, Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial, BMJ, 2014.
33. Breast Cancer Risk Assessment Tool (NCI)
34. BCSC Breast Cancer Risk Assessment Tool
35. Health Decision/University of Wisconsin Decision Tool
36. Harding Center for Risk Literacy Fact Box
37. Keating et al, Breast Cancer Screening in 2018: Time for Shared Decision Making, Jama Insights, 2018.
38. ePrognosis life expectancy calculator

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Goal

Listeners will learn how to evaluate a breast lump in the primary care clinic, what the guidelines recommend for asymptomatic breast cancer screening, and how to engage a patient in shared-decision making given the data available on mammograms.

Learning objectives

After listening to this episode listeners will…

1. Triage and evaluate the Breast Lump
2. Perform breast cancer risk assessment
3. Recall the Guideline Recommendations for Breast Cancer Screening and how they vary
4. Engage patients in conversation about b...