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What You Should Know About The New Breast Cancer Screening Guidelines

The American Cancer Society has issued newly revised guidelines on mammography and breast cancer screening. Here a woman is screened in Los Angeles in 2010. (Damian Dovarganes/AP/File)

The American Cancer Society has issued newly revised guidelines on mammography and breast cancer screening. Here a woman is screened in Los Angeles in 2010. (Damian Dovarganes/AP/File)

If you follow women’s health, there’s big news today from the American Cancer Society, which just issued newly revised (and frankly head-spinning) guidelines on mammography and breast cancer screening. Why all the fuss? Because breast cancer is the most common cancer among women worldwide; in the U.S., about 230,000 cases are expected to be diagnosed in 2015 with an estimated 40,300 deaths. And when such an influential organization changes its recommendations, it can radically shift the conversations between doctors and patients.

Here’s the crux of the news: In 2003, the ACS recommended annual mammography screening for all women starting at age 40 and continuing as long as women remain healthy. The group also recommended clinical breast exams (CBE), which is simply when your doctor examines your breasts, periodically for women in their 20s and 30s and every year for women 40 and up.

The new recommendations, published Tuesday in The Journal of the American Medical Association, change all of that, and come at a time of growing awareness about the potential downside of screening and the harms of over-diagnosis.

Here are the new guidelines from the report (my bold added):

The ACS recommends that women with an average risk of breast cancer [no family history, genetic predisposition, etc.] should undergo regular screening mammography starting at age 45 years (strong recommendation).

Women aged 45 to 54 years should be screened annually (qualified recommendation).

Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation).

Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation).

Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation).

The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

Nancy Keating, professor of health care policy at Harvard Medical School and a primary care doctor at Brigham and Women’s Hospital in Boston, co-wrote an editorial accompanying the new guidelines.

In an interview, Keating described the four most striking aspects of new recommendations:

1) the more conservative starting age for mammography (45 vs. 40 years), which brings the ACS recommendations closer to the guidelines from another important advisory group, the U.S. Preventive Services Task Force (USPSTF), which endorse biennial screening for women aged 50 to 74 years;

2) the proposal for more frequent (annual) screening intervals among women aged 45 to 54 years;

3) the recommendation against routine screening CBE, a marked deviation from prior ACS guidelines and a stronger statement than that of the USPSTF, which in 2009 concluded that the evidence was insufficient to recommend for or against CBE;

4) the recommendation to stop screening among women with a life expectancy of less than 10 years.

Keating said that for some women, the new guidelines should make things easier because both the cancer society and the federal preventative task force basically line up on guidance. The big disagreement, Keating said, is over what to do for women age 45-54.

“This exemplifies the uncertainties of evidence,” Keating said. “Two really smart groups of people looked at the evidence and came up with different conclusions.”

Specifically, the cancer society included in its analysis findings from a large, observational study of mammography. That study concluded that for premenopausal (but not postmenopausal) women, annual mammograms were associated with smaller tumors.

“Smaller tumors should be better,” Keating said, “but we don’t have long-term data from that population. So we don’t know for sure if this leads to better outcomes.”

The context of all this is a greater awareness of the harms of false positive mammograms and the the real harm of over-diagnosis, which basically is when you’re diagnosed with a cancer that would never become “clinically evident” in your lifetime except for the fact that you underwent screening. This over-diagnosis, of course, can lead to the real harm of treatment for a cancer that you may never have needed to deal with. Continue reading

Study: Most Doctors Flunk Math Of Medical Test Accuracy

mathtest

File under: “Does not inspire confidence.”

You’ve just been screened for a rare disease, one that only strikes 1 in 1,000 people. You test positive, your doctor tells you. Your heart drops into your stomach. “Is there any chance the test could be wrong?” you ask, your voice tinged with pleading.

“There’s a very small chance,” your doctor replies. “The test has a false positive rate of 5 percent. But that means there’s a 95 percent chance that you do have the disease.”

Bzzzzzzz. That’s the jarring sound of the game show buzzer that means “Wrong. Wrong. Wrong.”

A new study in the journal JAMA Internal Medicine posed just such a scenario to “24 attending physicians, 26 house officers, 10 medical students, and 1 retired physician” at a Boston‐area hospital. The hospital is not named, but all were affiliated with not-shabby medical schools: Harvard and Boston University.

And the vast majority blew the question. (Which was: “If a test to detect a disease whose prevalence is 1/1000 has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person’s symptoms or signs?”)

Close to half gave the answer “95 percent.” Not even close. The correct answer is 2 percent. (For an explanation of the math, check out Tom Siegfried’s excellent Science News post, which uses the analogy of a baseball player who flunks a drug test.)

The study — “Medicine’s Uncomfortable Relationship With Math” — replicated a similar math check done in 1978, and found little progress: 23 percent got the answer right in 2013, compared to 18 percent of a similar group in the 1978 study.

Yikes. What are patients — and doctors — to do about such medical innumeracy? I contacted the Boston-based Informed Medical Decisions Foundation, and spoke to research director Carrie Levin. Continue reading

Annual CT Scans Urged For Smokers At Risk For Lung Cancer

An influential government panel recommends that millions of smokers and ex-smokers at high-risk of developing lung cancer get annual CT scans to determine if they have early signs of the disease.

thirdhand smoke

The U.S. Preventive Services Task Force released draft recommendations that will likely be approved, experts say, paving the way for insurers to pay for such screening. Currently, most patients must pay out-of-pocket for the scans, which cost about $300-$400. The full set of recommendations was published today in the Annals of Internal Medicine. The bottom line: “Strong evidence shows that [low-dose] CT screening can reduce lung cancer and all-cause mortality.”

Lung cancer is the leading cause of cancer-related death in the United States, and “because early-stage lung cancer is associated with lower mortality than late-stage disease, early detection and treatment may be beneficial,” the report said. But such early detection and treatment has been elusive, according to experts.

In making the new recommendations, the 16-member government panel said that screening should target older patients at highest risk:

After reviewing the evidence, the Task Force determined that you can reach a reasonable balance of benefits and harms by screening people who are 55 to 80 years old and have a 30-pack-year or greater history of smoking, who are either current smokers or have quit in the past fifteen years. A “pack year” means that someone has smoked an average of one pack of cigarettes per day for a year. For example, a person reaches 30 pack years of smoking history by smoking a pack a day for 30 years or two packs a day for 15 years.

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Questioning Ovarian Cancer: Why Such A High Fatality Rate?

Photo Credit: Wikimedia Commons

Photo Credit: Wikimedia Commons

There is tragic news coming from the entertainment world today.  Pierce Brosnan announced that his daughter, Charlotte, age 41, died of ovarian cancer three days ago.  This is the same illness that took her mother’s life in 1991 when she, like her daughter, was in her early 40s.

Angelina Jolie – who underwent a preventative double mastectomy earlier this year —  lost her mother to ovarian cancer in 2007.

According to the CDC, ovarian cancer is the second most common gynecological cancer, after uterine cancer, and it’s the cause of more deaths than any other gynecological cancer.

The numbers look like this: ovarian cancer kills 15,000 women and approximately 22,000 new cases are diagnosed annually in the US.  Approximately 90% of cases occur in women over 40 and the majority of diagnoses are given to women aged 60 years or older.   According the the American Cancer society, the survival rate for patients who live for five years after they are diagnosed with ovarian cancer is 44%.

Unlike breast or cervical cancer, there is no reliable screening measure for ovarian cancer.  Once it is detected, the first line treatment option is surgery.

Earlier this year, The New York Times reported on a study that suggested the high fatality rate amongst ovarian cancer patients is attributable to widespread deficiencies in the typical treatment most women receive. The article reports that only a third of women with ovarian cancer receive “best practice” treatment, which the study says, is a complicated and intensive operation performed by a highly specialized surgeon.

Here is an excerpt from the article:

Cancer specialists around the country say the main reason for the poor care is that most women are treated by doctors and hospitals that see few cases of the disease and lack expertise in the complex surgery and chemotherapy that can prolong life.

If we could just make sure that women get to the people who are trained to take care of them, the impact would be much greater than that of any new chemotherapy drug or biological agent,” Continue reading

Lack Of Insurance A Top Predictor In Late Stage Cervical Cancer Diagnosis

Cervical Cancer awareness PSA (KWDesigns/flickr)

What’s the strongest predictor of cervical cancer at a late, more dire stage? After age, the top predictor is the lack of health insurance, according to a large national review conducted by the American Cancer Society.

The likely reason, according to researchers, is that women without insurance are less likely to be screened for cervical cancer. The new study appears online in the American Journal of Public Health.

According to the news release:

The American Cancer Society estimates that 12,170 women will be diagnosed with cervical cancer and 4,220 women will die from the disease in 2012. Although incidence and mortality from cervical cancer have declined dramatically since the introduction of the Pap test, one in three cervical cancer patients is diagnosed only after the cancer has spread to nearby organs and one in ten is diagnosed only after the disease has spread to distant organs (35% and 11% respectively). Prognosis is strongly related to stage: the 5-year relative survival rate is 91.2% for patients with localized disease, but only 57.8% for patients with regional disease and 17.0% for those with distant disease. Continue reading

Why I Love Colonoscopies (And You Should Too)

(ex_magician/flickr)

By Mary Mulkerin Donius
Guest Blogger

“Got a match? Yeah, your face and my, um, backside.”

That old insult comes to mind every time someone takes me aside to tell me they finally got a long-overdue colonoscopy or just scheduled one for a loved one. It happens all the time.

Ever since I was diagnosed and successfully completed eleven months of treatment for colorectal cancer at Massachusetts General Hospital, I feel like I’ve become a walking, talking reminder about the importance what The New York Times recently termed cancer’s “most unloved screening test.”

My face reminds friends, family members, colleagues and acquaintances to think about protecting their bottoms; it’s a role I’ve come to relish.

Just last month, a study in the New England Journal of Medicine proved what doctors have long suspected; that mortality is reduced by a whopping 53 percent in those who undergo colonoscopies and have pre-cancerous growths removed. It’s the strongest evidence yet that colonoscopies save lives. Despite the success of early detection and the steadily climbing cure rate of colorectal cancers in the past twenty years, only sixty percent of eligible adults get a colonoscopy, according to the American Cancer Society.

Okay, I’ll say it. That really bums me out.

March is Colorectal Cancer Awareness Month. With all due respect to the folks who work hard on the cause, you’d never know it. There’s no little ribbon or bracelet. It’s a tough disease to build a cute little symbol around, I’ll concede. Continue reading

Report: U.S. Cancer Screening Is Pricey, But With No Better Outcomes Than Public System

Is more screening worth the money?

A new report comparing cancer screening programs in the U.S. and the Netherlands comes up with this not-so-surprising conclusion: we screen more here — three to four times more in this case — but mortality rates are the same in both countries.

The analysis of cervical cancer screening programs, published in the Milbank Quarterly, makes the health system in the Netherlands look pretty darn rational. Not only does the publicly-run system focus on prevention, but it appears to implement its prevention plan in a way that saves money without undermining care, notably it limits cervical cancer screening to the group at highest risk, women between the ages of 30 and 60.

Here’s are some of the study details from the news release:

The team [led by by Dr. Martin L. Brown from the National Cancer Institute in the United States, alongside colleagues from the Erasmus MC University Medical Center in Rotterdam] focused on cervical cancer screening, which accounts for a small fraction of overall health care spending, but represents broader preventive health services. For comparison the authors carried out a cross-national study of cervical cancer screening intensity and mortality trends in the United States and the Netherlands.

The team used national cancer incidence and mortality data from both the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. Their results revealed that even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were similar.

Five-year coverage rates for women aged thirty to sixty-four were comparable between the countries at 80 to 90 percent. However, because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. Continue reading

Is Mammography As Much Of A Life-Saver As We Think?

The great mammography debate rages on

By Karen Weintraub
Guest Blogger

 

Where do you come down on the great mammography debate?

Are you more comfortable knowing you’ve done everything you can to prevent breast cancer? Or are you annoyed by the pushiness of screening advocates, and convinced by data suggesting that it’s often over-diagnosed and over-treated?

A study published last week in the British Medical Journal added another twist to the longstanding debate, by suggesting that better treatments – not mammography – deserve credit for the drop in breast cancer deaths since the mid-1990s.

The study looked at pairs of northern European countries or regions; one that introduced universal screening many years before the other. Sweden, for instance, began universal screening in 1986, a dozen years before neighboring Norway. Researchers found breast cancer death rates were virtually identical on either side of the border, suggesting, they said, “that screening has not played a direct part in the reductions of breast cancer mortality.”

If this is true, we should be putting more emphasis on treatment advances, and far less on getting every woman over a certain age to get a mammogram.

That’s precisely what Dr. H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, thinks should happen.

There’s no question that mammography saves lives, Welch says, but it’s not as good a screen as most people think. About 2,500 women over 50 have to be screened every year for 10 years to save one life, he wrote in a New England Journal of Medicine editorial last year. Up to 1,000 of those women will have at least one false positive, and 5 to 15 of them will be treated needlessly for breast cancer they don’t have.

“We’ve exaggerated its effect grossly. And we haven’t acknowledged – in fact we’ve largely ignored – its harm,” Welch said. (Welch qualified his statement in a follow-up email: his complaint is with using mammography to screen a broad swath of people, most of whom have no symptoms. It is an appropriate test, he said, when used to examine women with suspicious lumps or other symptoms.) Continue reading

Researchers May Have Key To Predicting Alzheimer's — But Do You Really Want To Know?

Hard questions arise on screening for incurable diseases, like Alzheimer's

By Marielle Segarra, WBUR intern

If you could find out with relative certainty that you’ll get a disease that is currently incurable would you want to know?

Relatives of people with Alzheimer’s Disease may begin asking themselves this question in light of new research that could form the basis of an accurate blood test for the disease.

A Scripps Research Institute study published in the journal Cell this month has identified two antibodies that may be markers for Alzheimer’s.

The levels of these antibodies were three times higher in the blood of those with Alzheimer’s Disease than they were in the blood of healthy participants or participants with Parkinson’s Disease.

Typically, antibodies are difficult to identify because they must be located through antigens that trigger them. But the study pioneered a new method, using synthetic molecules, rather than their antigens, to measure antibodies.

If developed further, the test could prove more accurate than any others already in use.

But how could knowing your status affect you when there is no cure? Continue reading

New Lung Screening Benefits: Vindication For A Controversial Advocate?

Dr. Claudia Henschke has been a key backer of CT scans to screen for lung cancer

The front page news in The New York Times this week that annual spiral CT scans can reduce the risk of death from lung cancer by 20 percent made me think of the Times story I read two years ago on the same topic. In that piece, the central researcher pushing the use of CT scans for screening was largely discredited because she accepted tobacco industry money to help pay for her studies.

But now, with a huge federal study showing the benefits of such screening, doesn’t it seem like much of what the researcher, Dr. Claudia Henschke, has said is turning out to be true?

Back then, not only did The Times take Dr. Henschke, now a professor of radiology at Mount Sinai School of Medicine, to task for accepting tobacco money for her research, the piece also questioned the research itself. Here’s the 2008 story, under the headline, “Cigarette Company Paid For Lung Cancer Study:

…the disclosure that Dr. Henschke’s work was in part underwritten by grants from a cigarette maker will undercut those efforts, prominent cancer researchers said. “She’s the biggest advocate for widespread spiral CT screening,” said Dr. Paul Bunn, a lung cancer expert and executive director of the International Association for the Study of Lung Cancer. “And now her research is tainted.”

Since 1999, Dr. Henschke has asserted that annual CT scans of smokers and former smokers would detect lung cancer when tumors are small enough to be cured, preventing as many as 80 percent of the 160,000 deaths a year from lung cancer, by far the biggest cause of cancer deaths in the United States.

Her 2006 study said that, after screening 31,567 people from seven countries, CT scans uncovered 484 lung cancers, 412 of them at a very early stage. Three years later, most of those patients were still alive, and she projected that 80 percent would be alive after 10 years and assumed that they would have died without the screens.

Critics question both her survival projections and her assumption that all would have died without screening. Indeed, most in the cancer establishment say that Dr. Henschke has yet to prove her case. CT scans have radiation risks and sometimes detect cancers that would not have progressed, leading to risky procedures like biopsies and lung surgery when not needed.

To settle the dispute, the National Cancer Institute started in 2002 the $200 million National Lung Screening Trial comparing death rates among 55,000 people randomly assigned to have CT scans or chest X-rays. Results are not expected until 2010. Dr. Henschke has asserted that allowing hundreds of thousands of people to die in the meantime is unethical.

Continue reading