How do you know that in the cases of the three women treated for breast cancer it would “never have caused a problem”?
Response: Overdiagnosis is a population concept. We are aware of overdiagnosis in screening trial because after many years of follow-up there is more cancers in the screened arm.

For the 50-59 pt, what can you say about the 8 woman in yellow (12 minus 3 red minus 1 green)?
Response: They live with their disease.

Please define interval breast cancer rate?
Response: Cancer that is found in between screening rounds.

Your thoughts on the discussion of screening, when the QC gov't sends out the letter for mammo starting at age 50?
Response: We need shared-decision making with transparent information. Unfortunately, this is not the case now.

Could you address the issue of screening starting at 40?
Response: 40 years old are at lower risk so lower benefit. Values and preferences are key.

Some radiologist recommend US for dense breasts.
Response: What evidence do they use? Cancer detection is not synonymous with better outcomes.

Should we automatically ask for additional imaging for a woman with 50% dense breasts?
Response: There is no evidence to support this. See USPSTF 2023.

Just a comment: In spite of the lack of evidence for u/s screening for women with dense breasts, most women I talk to choose to go ahead with screening after discussing pros and cons. This is another huge clinical burden to add on to family docs.
Response: What pros and cons can you discuss? There is no information about benefits and harms of patient-oriented outcomes of additional screening.

When you mention numbers of deaths prevented, do you mean lifetime deaths?
Response: No death prevented within the time frame - here 10 years.

The breast screening tool (1000 ps) is for average risk patients only, please confirm not to be used in higher risk patients.
Response: You can use it with moderately increased risk acknowledging the benefit is possibly a bit larger and false positive lower.

You are telling us that extra tests (US, MRI) are not indicated for breast density that is increased (>75%). Is it appropriate to increase the screening interval to Q1 year from Q2 years?
Response: To my knowledge no data supports that. We need good data and hopefully we will get some.

Speaking of overdiagnosis. Isn’t it possible that a 7 year window isn’t enough to declare a lack of mortality benefit for cancers found in an early stage?
Response: Possible. Trials that looked at a follow-up of 25 years did not see much more benefit.

Could you please give us the reference where you see that cancers don't grow or reduce the size as you mention?
Response: You can read a book by Gilbert Welch called overdiagnosis.

As a follow-up to the question on the people whose breast cancer is detected by screening but who don't fit into either life-saved or cancer which could have been left alone: Do we know if there is any difference in morbidity/life expectancy afforded by screening?
Response: We never say life-saved as no screening has been proven to impact total mortality (except sigmoidoscopy). As for morbidity, we are looking into this. For life expectancy the problem is that we have values in mean years which is difficult to translate into something meaningful to a patient as for them could be a few weeks or years. We are looking into this.

Obviously breast CA screening guidelines don’t apply to women with a history of breast CA. In a woman with breast CA but no cancer in 15+ years, how long to screen?
Response: I wouldn’t know.

Does hx of breast implants/ augmentation change screening guidelines?
Response: Not to my knowledge. If I remember well cancer can be harder to find but outcomes are similar. I didn’t look at this specific question recently though.

I heard that in USA there might be discussion of pushing the age of breast cancer screening down to 40 yo, what do you think about that?
Response: They will recommend starting at 40. What is crucial is a shared decision which I hope will happen.

Do you think that the government "PQDCS" will be more evidence-based instead? (vs sending requesition q2yrs and confuse the general population?)
Response: It would be nice if there was true shared decision with women of any age before screening.

In Ontario they recently changed to screening onset at 40.
Response: Yes and on what factual basis? I cannot find this info.

Can you comment on dense breasts and when radiologists recommend ultrasound? If my pt decides screening with mammogram and I have this report, I don’t feel comfortable medicolegally to not do an ultrasound. Why such a big shift of practice if there are no studies yet supporting this?
Response: This is a very good question. There is no evidence to support supplementary screening. I would share that with my patient.

In Ontario we have a high risk screening program (MRI and Mammogram) starting at 30 for high risk women.
Response: It is the same in many provinces.

Very interesting but the info that is passed on to the public w/r to screening is much less nuanced. Any plan for the governement/Canadian task force to share this more nuance message to the public?
Response: The Task Force is working towards better tools for patients but this would need more efforts by other parties. At Choosing Wisley we held a day for journalists in the spring. If you have other ideas please share as this is key.

Men have a 1% risk of breast cancer vs women. If a man transitions to female and developes breasts. Is the risk of breast cancer risk increased. Should they be screened?
Response: I don’t have an answer for this. Our guidelines is for individuals identified as women at birth. I doubt there is much info on this unfortunately.

Could you comment for the screening of asian communities and other ethnicities ? (from my understanding african descent and caucasian women are the most studied /discussed).
Response: We are looking to get more data on this aspect in Canadian women. Unfortunately, there is a paucity of data on if and how screening can help.

I understood that dense breasts increases one’s risk of cancer even more than having a first degree family member with history of breast cancer. Do you expect for screening guidelines to change for dense breasts?
Response: There is no evidence to my knowledge that supplemental screening changes patient-oriented outcomes See USPSTF May 2023.

Do we need to offer genetic screening tests to patients who have a stron family H/O?
Response: There are criteria for this. I don’t know them by heart.

I have a 44 year old woman (with negative family history) whose gyne recently gave her a referral for screening mammogram based on “new guidelines to start younger”. Can you please comment?
Response: If she had the information conveyed in a transparent manner (e.g. 1000 person tool) than it is fine. In my personal opinion no women should be screened without being informed on the possible benefits and harms.

In screening do we not pick up the cancer at an earlier stage? In the past 2 weeks I’ve had two women who have found lumps and axillary lymphadenopathy. I think the urologist view points for screening is that picking up earlier stages is that they can monitor and step in with progression of disease.
Response: We should share information with patient. Screening is for asymptomatic individuals so they should really know the pros and cons of screening.

The urologists are seeing more advanced disease as we may see with less screening for breast ca?
Response: These data should be published and accessible. Also we need data in absolute numbers not in proportion of cases. The proportion of advanced cases will go up will less screening. That is why we need to focus on absolute numbers.