THE MAMMOGRAM CONTROVERSYs3.amazonaws.com/myocv/ocvapps/a15471008/...American Cancer Society New...
Transcript of THE MAMMOGRAM CONTROVERSYs3.amazonaws.com/myocv/ocvapps/a15471008/...American Cancer Society New...
THE MAMMOGRAM CONTROVERSY
Reatha Williams, D.O.
• For women at average risk
• For women at higher than average risk
American Cancer Society
Updated Recommendations for Breast Cancer Screening
American Cancer Society New
Recommendations for women at average risk
• Women ages 40-44 should have the choice to start
breast cancer screening with mammograms if they wish
to do so. The risks of screening as well as the benefits
should be considered
• Women 45-54 should get mammograms every year
• Women age 55 and older should switch to
mammograms every 2 years, or have the choice to
continue yearly screening
American Cancer Society New
Recommendations for women at average risk
• Women ages 40-44 should have the choice to start
breast cancer screening with mammograms if they
wish to do so. The risks of screening as well as the
benefits should be considered
• Women 45-54 should get mammograms every year
• Women age 55 and older should switch to
mammograms every 2 years, or have the choice to
continue yearly screening
• Screening should continue as long as a woman
is in good health and is expected to live 10 more
years or longer
• All women should be familiar with the known
benefits, limitations, and potential harms
associated with breast cancer screening. They
should be familiar with how their breasts
normally look and feel and report any changes
to a health care provider right away.
Guideline's History
• 2001. Canadian Task Force-mammograms age 40, every 1-2 years
• 2003. ACS recommended screening mammograms starting at age
40 and annual CBE after age of 40
• 2002. AMA and 2006 NCCN. made similar recommendations
• 2009.USPSTF recommended that women 50-74 yrs of age are most
likely to benefit from biennial mammography screening and
evidence did not support mammography screening for women
aged 40-49.
• 2010. SBI recommended that women at average risk should begin
annual screening mammography at age. 40.
Current Guidelines Offer Conflicting Advice
• ACS, ASR, ASBS, USPSTF, NCCN, ACOG, etc all
offer different guidelines for breast cancer
screening.
• The contradictions have caused confusion
• Greater need for clarity
• Requiring physicians to adapt a more
comprehensive approach to determining risk
Current Guidelines Offer Conflicting Advice
Questions
• 1. What age should I begin screening mammograms?
• 2. How often should I be screened?
• 3. At what age should I stop?
• Guidelines advise people about what screenings they
should get and when they should get them
• Some screening tests find growths and they can be removed
before they have a chance to turn into cancer
• Other screening tests can find a cancer early when it's
easier to treat
• Guidelines also explain the limitations and risks of
screenings
• Help many people in the general public and health care
professionals, as well as policy makers and insurance
companies make important health decisions
Purpose of Guidelines
Benefits of routine screening mammography
• Earlier detection
• Cancer diagnosed at earlier stages
• Saves lives
• Less cost for treatment
• Less stress for patient and family
• Less morbidity
Risks for routine screening mammography
• False positives
• Increased procedures
• Increased cost
• Increased anxiety
• Over diagnosis
• Increased radiation
USPSTF U.S. Preventative Services Task Force
American College of Radiology
• Annual screening mammography for asymptomatic women age 40 and older
who are at average risk
• Women with a known genetic mutation with increased breast cancer risk-yearly
starting age 30
• Untested women with first-degree relative with known BRCA mutation-yearly
starting age 30
• Women with 20% or greater lifetime risk for breast cancer-yearly starting age
30, or 10 years earlier than the age at which the youngest first-degree relative
was diagnosed, whichever is later
• Women with history of chest radiation received between ages of 10 and 30-
yearly starting 8 years after the radiation therapy, but not before 25
• Women with bx-proven lobular neoplasia, ADH, DCIS, invasive breast ca, or
ovarian ca-yearly from time of diagnosis, regardless of age
American College of Radiologists
• There is no defined upper age limit at which
mammography may not be beneficial
• Screening mammography should be considered as
long as the patient is in good health and is willing
to undergo additional testing, including biopsy, if
an abnormally is detected
American Society of Breast Surgeons
Recommendations for Average Risk Women
• Discussion with her physician to consider screening
mammography at age 40-44 based on a balanced
discussion of risks and benefits
• Most studies show a decrease in breast cancer mortality
from screening starting at age 40 but in the group 40-49
there is a higher false positive rate
• Patients should discuss screening with their physician
including risk assessment to determine if they are average
risk
• Annual screening for women ages 45-54 as
indicated by the new ACS guidelines
• Biennial screening for women over the age of 75
if an estimated life expectancy is greater than 10
years
• Breast tomography may be considered for
screening because early data shows promise in
higher sensitivity and specificity rates with data
from large randomized clinical trials pending
MORATORIUM 2 YEAR
• Regarding changes to insurance coverage for
breast cancer screening, as outlined by the
USPSTF 2016 recommendations
• For private insurers, this means they will continue
to follow the task force's 2002 recommendations
• Women 40 years of age and older should undergo
screening mammograms every one to two year
• Keep the window open for more accessible
screening mammography
• If Insurance coverage for breast screening is
gone, many women may not have access to a
tool that could save their lives
Affordable Care Act
• Grading scale for private insurance coverage
• "A" or "B" by the USPSTF are covered with no copay
• Grade "C" assigned to routine screening of women ages
40-49
• Women less than 50 years of age who want to have a
mammogram may not be guaranteed coverage under the
ACA, if the 2016 USPSTF recommendations are adopted.
• The same is true for women ages 50 to 74 who prefer
annual screening
• Moving away from yearly screening in women 40
years of age and older endangers women, would
cause needless death, and would simply not be
good breast cancer screening policy
• If we look back at two of the purposes of
screening guidelines
• Some screening test find growths and they can
be removed before they have a chance to turn
into cancer
• Other screening tests can find a cancer early
when it's easier to treat
Protecting Access to Life
Saving Screening (PALS)
• Part of Consolidated Appropriations Act approved
at the end of 2015 to fund the government for one
year
• Designed to protect access to screening
mammographies for women 40-74 by posing a 2-
year moratorium on implementations of the latest
USPSTF breast cancer screening recommendations
False Positives
• USPSTF recommends biennial screening mammography for age 50-74 because women in this age range at average risk gain the most benefit from screening at this frequency
• Women 40-49 with a family history may benefit more than average-risk women from beginning screening at an earlier age
• While screening mammography in women 40-49 may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false positive results and unnecessary biopsies is larger
• Therefore the balances of benefits and harms is
likely to improve as women move from their
early to late 40's
Short Term Anxiety
• This can occur because of mammography results
with false positives
• This anxiety is short-lived and has no lasting effect
on women's health
• Short term anxiety from results and the
comparatively small numbers of mammogram false
positives do not outweigh the thousands of lives
saved each year by mammography.
• These mammograms can detect cancer
early, when it is most treatable and can be
treated less invasively
• Not only can this save lives but helps
preserve quality of lives
• False positives can cause women anxiety
but they would be more anxious if we didn't
find cancers early
Many women are afraid of their first mammogram, and
even if they have had them before, there is fear.
But there is no need to worry.
By taking a few minutes each day for a week preceding
the exam and doing the following practice exercises,
you will be totally prepared for the test, and best of all,
you can do these simple practice exercises right in
your home.
EXERCISE 1:
Open your refrigerator door, and insert one breast
between the door and the main box.
Have one of your strongest friends slam the door shut
as hard as possible and lean on the door for good
measure.
Hold that position for five seconds.
Repeat in case the first time wasn't effective.
EXERCISE 2: Visit your garage at 3 a.m.
when the temperature of the cement floor is just
perfect. Take off all your clothes and lie
comfortably on the floor sideways with one
breast wedged under the rear tire of the car.
Ask a friend to slowly back the car up until your
breast is sufficiently flattened and chilled.
Switch sides, and repeat for the other breast.
EXERCISE 3:
Freeze two metal bookends overnight. Strip to the waist.
Invite a stranger into the room. Have the stranger press
the bookends against either side of one of your breasts
and smash the bookends together as hard as he/she can.
Set an appointment with the stranger to meet next year to
do it again. You are now properly prepared!
Over Diagnosis
• All women undergoing regular screening
mammograms are at risk for the diagnosis and
treatment of noninvasive and invasive breast cancers
that would otherwise not have become a threat to their
health, or ever apparent, during their lifetime
• So beginning screening at a younger age and
screening more frequently may increase the risk for
over diagnosis and subsequent over treatment
Who Decides
• Women need a clear idea of what they're
choosing
• They shouldn't have that decision made
for them by a task force that is out of
touch
• There is no confusion among people who
understand the data
• The confusion is among people who want
to pick and choose isolated studies when
making their recommendations
• There are many criticisms of the USPSTF Study
• It relied on 30-40 year old data
• They ignored studies that show improvements in
technology over what was used 30 years ago
• We have more accurate technology now that
decreases recall rates and increases detection
3-D Mammography (Tomosynthesis)
• Able to find more invasive cancer which have the
potential to metastasize
• Up to 30% less call back rates
• Cancer detection rate in women 40-49 increased
and these cancers in younger women are usually
more aggressive and grow faster
Room for Improvement in USPSTF
• Made up of 15 members and none of which are
Radiologists or Oncologists
• These are the specialties that are experts in this area
• They are the ones who do the research, studies, and
publish the data
• Desire to eliminate the bias but this also eliminates the
knowledge by excluding the specialists who know the
field the best
• People on the task force don't fully understand the
literature on the benefits of early breast cancer screening
• Breast cancer screening is not perfect but it should be
made available to all women if they want it
“Mammography screening reduces breast cancer mortality by 15% for women aged 39–49
(RR 0.85, 95% CI 0.75–0.96); data are lacking for women 70 years and older.
Radiation exposure from mammography is low.
Adverse experiences are common and transient.
Estimates of over diagnosis vary from 1% to 10%.
Younger women have more false-positive results and additional imaging but fewer
biopsies than older women.”
• As primary care clinicians and researchers, I
hope that this lecture will facilitate greater
dialogue between women and their doctors
so they can make informed health care
decisions. I also hope that the health care
organizations will continue with additional
research addressing important evidence gaps
in the science of breast cancer screening.
Goal