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I know most have you have already seen this report on new breast cancer screening guidelines by now: http://www.nytimes.com/2009/11/17/health/17scre.html?scp=3&sq=breast%20cancer%20screening&st=cse

What do you think are the implications of the new screening guidelines? For providers, will this influence how you conduct screening for breast cancer? What factors need to be taken into account when determining how to screen women for breast cancer?

I'm very curious about this, as my grandmother was diagnosed with breast cancer and I'm concerned about when the appropriate time to start having screening mammograms.

Here is a video that outlines some of the various points of view on this topic: http://www.cbsnews.com/video/watch/?id=5688006n

The U.S. Preventive Services Tasks Force (USPSTF) new recommendations have certainly been the topic of heated debate. USPSTF has reversed its position on screening mammography for women in their 40s: the group no longer recommends routine screening mammography for average-risk women in this age group.

Here are the highlights of the new recommendations:

1) For women between the ages of 50 and 74 years, the USPSTF recommends mammography every two years (rather than every year).

2)The USPSTF notes that there is insufficient evidence to assess the benefit and harms of screening in women over the age of 74.

3) The USPSTF recommends against teaching breast self-exam (BSE).

Critics of the new guidelines have complained that the task force consists entirely of primary-care experts rather than oncologists. Physicians and cancer advocacy groups have criticized these recommendations, including Dr. Otis Brawley, chief medical officer for the American Cancer Society.

I am happy to see the American Cancer Society stands firm in their recommendation of annual mammograms starting at the age of 40. I truly believe we will see an increase in later stage breast cancer diagnosis if women take the USPSTF recommendation seriously. Not only could we see the initial staging for the disease change, we could also see a rise in mortality rates. Screening tests can find breast cancer early, when it's most treatable.

Every woman is different, and every cancer is unique to the person diagnosed. Like myself, women at increased risk as a result of family or personal history may need to begin screening at a younger age (even younger than 40), and may benefit from screening with breast magnetic resonance imaging (MRI) in addition to mammography. Each women should talk with their physician and derive an approach that’s right for them. Do not focus on an age if there is a justifiable cause to do otherwise.

The last recommendation of the Task Force against teaching BSE’s is another point which has not been well-received. However, a statement found at Komen.org states, “although the USPSTF’s position on breast self exams may also be perceived as controversial, there has never been clear evidence that breast self-exams reduce breast cancer mortality.” In all of my educational seminars I remind women that a breast self-exam is not a tool to look for cancer. You are simply getting to know your own body, and your changes. In the event a palpable lump is found you can address your history of BSE with your doctor to determine next steps.

 I was thrilled to see people such as Dr. Bernardine Healy,the first female to head the National Institutes of Health, say women should ignore new recommendations by the U.S. Preventive Services Task Force. Kudos for all other experts, survivors and healthcare professionals who took the same stand! Today (11/21/2009) the Wall Street Journal published an article where the USPSTF issues clarifications on the study due to intense backlash. “Diana Petitti, a professor in biomedical informatics at Arizona State University who is vice-chairwoman of the panel -- the U.S. Preventive Services Task Force -- said she felt its conclusions were misinterpreted. The task force is not against women having mammograms in their 40s," Dr. Petitti said in an interview. Instead, she said, it is in favor of women in that age range deciding on their own, after consulting with their doctors, whether to undergo regular screenings.”

I am glad to see USPSTF has taken the debate to heart and tried to offer a little more clarification, though I am sticking to my guns in support of the American Cancer Society’s firm stand.

These new so-called "guidelines" are appalling. Every woman is, indeed, different, but I have a strong suspicion that these guidelines are designed to save insurance companies money.

I had no significant family history of the disease, no BRCA 1 or BRCA 2 genes, was fit and healthy -- and I got breast cancer anyway. Medical staff cannot predict who is going to get breast cancer.

And it makes absolutely no sense to discourage breast self exams. I found my own tumor through a breast self exam. If I weren't so vigilent, I wouldn't have found it at all. 

Discouraging breast self exams dis-empowers women to be their own medical advocates. It only further instills fear of the unknown, rather than having women be in some control of their medical destiny.

It is a sexist recommendation under the guise of a health guideline and out of fake concern that women will be afraid with every dimple and lump they may find and get a biopsy -- even if the area in question is benign.

I don't see guidelines stating that men shouldn't get prostate exams because something -- benign or not -- may be found and scare men and then men would have to get a biopsy that may or may not have been needed in the first place.

I'm glad the American Cancer Society has the guts to stand its ground on this issue. Somebody has to advocate for women.

What do you all think of this article from today's New York Times re: the effects of radiation from screening in high-risk women?

http://www.nytimes.com/2009/12/01/health/research/01cancer.html?_r=1

The report of one government panel won't change policy or the recommendations of the  American Cancer Society, American College of Radiology, AAFP, or the American Society of Breast Surgeons.  It may lead to more study. 

For now  anyone with high risk (more than 20% lifetime risk) of breast cancer the age of 35 may be an appropriate age to start screening, if the breast tissue density is appropriate.  

So for now most physicians are screening by the old rules.

There are a number of real experts who have come out in favor of the new guidelines however, one of whom is Susan Love MD who is a highly respected expert in the breast cancer field.  

I am sure there will be "more to follow".  

For an excellent  discussion of both sides of this issue, there was an  NPR Science Friday podcast a couple of weeks ago that covered the debate in a very straight forward manner.  I encourage interested parties to download this and give it a listen.

Here is another article written in the WSJ today about it: http://blogs.wsj.com/health/2009/12/02/mammogram-panel-we-should-have-listened-to-docs-advice/

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Women who have been diagnosed with triple negative breast cancer (TNBC) have been especially concerned about the new guidelines, as TNBC is a highly aggressive form of cancer that affects women under 40.  So, for women at risk of TNBC, testing should start earlier than 40 rather than after 50, as the new guidelines suggest.

Who is at risk of TNBC?  We know that the BRCA mutation is linked to triple negative and that African-American women get TNBC at three times the rate of other ethnic groups (Breast Cancer Research 2009, 11:R18.).  So these groups should certainly be screened earlier. 

But the fact is that TNBC affects women who are not covered by current guidelines—women who get it in their 20s and 30s are years away from their first scheduled mammogram.  And, while there is the BRCA link, a woman can be the first in her family to discover the gene—and she can have triple negative without the gene—so she would not have been vigilant about mammograms.

And, mammograms have been less effective in finding IBC—inflammatory breast cancer—which is linked to triple negative in some women.

MRIs may be more effective for high risk women, but in conjunction with mammograms.

So, what are women supposed to do? Talk to your doctor and let your concerns be known. Be vocal and speak out through whatever forum you can find—letters to your senators and representatives and to your local paper. Connect with advocacy groups.

Most important, take care of your own health. Be aware of changes in your breasts—not just lumps, but any hardening, or variations in shape or feel. And, if you notice changes, be vigilant about getting tested. The fact is, under current guidelines, this was already a problem. So the reality remains that we are the ones most vested in our own health, and it is up to us to continue the good fight to get the care we need.

And, if you are at high risk, continue to get mammograms, but advocate for coupling them with MRIs. As I read it, the recommendations do not change that. If anything, I see the recommendations saying that highly aggressive cancers such as triple negative should get more—not less—attention.

I was disappointed to read the recommendations. We've worked hard in the US to get women comfortable with coming annually for screening mammography beginning at age 40 and doing breast self exams as well. The task force didn't factor in some significant things: 1) no member of the group was an oncology specialist or a radiologist in the field of breast cancer or any cancer actually; 2) the data was old and predated the development and implementation of digital mammography, designed specifically for women with dense breasts who are usually those in the 40-49 age group; 3) the data was based on any radiologist reading a mammogram. Studies have been done showing that if a general radiologist is reading a mammogram and a tiny cancer is in fact there it will be missed up to 41% of the time; 4) many women today are living way passed their "life expectancy" so to recommend not doing mammograms on someone when they reach 75 is insulting. It's inappropriate to determine this by a magic number and instead should be based on her health status; this actually applied to any woman. For example, if a woman was 60 and in a nursing home with dementia, congestive heart failure, diabetes and a fractured hip that won't heal, we would not be putting her in an ambulance to do a screening mammogram. However if a vibrant 81 year old who still hops on her treadmill every morning, is sharp as a tack, has no medical problems to speak of, and her PCP anticipates her continuing to enjoy life well into her 90s, then we want her to come in for her screening mammogram. (BTW, I just described my mother.)

I personally was diagnosed my first time at age 38 having a screening mammogram. i was diagnosed again at age 40 in my other breast in the same manner. 18% of women diagnosed in the US are between the ages of 40 and 49. 40% of women find their own breast cancer while doing a breast self examination. EARLY diagnosis does result in saving more lives and for that matter usually saving more breasts.

If the task force has wanted to be helpful they could have said the following recommendations: 1) reward women with eliminating co-payments for doing screening mammography annually beginning at age 40; 2) all breast imaging facilities must use digital mammography; 3) all mammograms must be read by dedicated breast imaging radiologists.

I think the reason the USPSTF's reasoning behind its recommendations are hard for the average person to understand is that they are convoluted and in doublespeak.

Basically, there's been a lot of discussion on this topic because it involves women's rights. It's taken many years for breast cancer screening information to be known about. Frankly, I have problems with this blogger's reasoning:

 "...if you imagine 1000 women in their 40's getting mammograms yearly for 10 years, the best estimates are that you will cause more than half of them to need repeat mammograms for concerning findings, and will cause nearly 200 to get breast biopsies, while only preventing 2 deaths from breast cancer."

Who did this study? How do we know this as a fact? And let's say the aforementioned was true. If someone were one of the two people kept from dying from breast cancer because of early detection of breast cancer through a mammogram, she most likely would be all for the mammogram screenings. Two deaths that would be preventable are still two deaths preventable.

Then there's this statement:

"Individual patient values and preferences heavily influence the decision. The USPSTF takes this into account by recommending against routine mammograms in the 40s, but states that a decision to screen should take consider an individual woman's values. All in all, not that unreasonable a position as far as I'm concerned."

Values? Whoa! How can one give a data value to patients?

Medicine is a science, and it's also an art, and that's what some in the medical field fail to understand. I found my own breast cancer at age 39, but my doctors helped me with decision-making based on the science AND art of medicine. I didn't match up with what numbers in studies said. And my doctors knew it.

Since then, I've talked with many women, who defiled the "breast cancer profile" but got it anyway. 

I've blogged on this issue on my Calling the Shots blog-column. It's my opinion, but at least it's not buried in doublespeak.