United States Preventive Task Force – Recommendations for Breast Cancer Screening Creates Confusion

Since I started practicing medicine in 1976 the American Cancer Society, The American College of Radiologists, and the American College of Obstetricians and Gynecologists have all been in agreement on the necessity for breast cancer screening in adult women.  Annual breast exams by a trained examiner were recommended beginning at age 19.  Breast self-exam was taught in most hygiene classes and by educators in physicians’ offices and was felt to be an inexpensive screening test.

It made great sense that early detection saved lives. It made greater sense that individual patients who educated themselves about the normal feeling of their breasts during different phases of the menstrual cycle were more likely to detect an early change and seek medical attention.

Mammograms were recommended for women on an annual or every other year basis beginning at age 40 and then annually from age 50 and above.  There were always individual variations for women who were at high risk or who had a family history of breast cancer at a young age but, for the most part, breast cancer screening suggestions were not controversial or forever changing.

In November 2009 the United States Preventive Task Force, the same group who questioned the efficacy of yearly physical exams and chest X rays annually on cigarette smokers, issued its revised guidelines. They cited the large number of biopsies done of women between forty and fifty for what turned out to be benign fibrocystic breast disease rather than cancer. The biopsies were often the result of an abnormal breast self exam finding a new lump, an abnormal professional exam and or a spot on a mammogram which was equivocal.

Citing the cost and anxiety involved in evaluating a breast abnormality and using research studies as evidence they suggested not teaching or using breast self exam. They additionally recommended changing the initial mammogram back to age 50 unless there was agreement between the patient and physician that their individual needs justified the test.   With women living longer and breast cancer occurring frequently in the elderly, they suggested no longer performing screening mammograms after age 75.

These recommendations have led to great controversy and confusion in the profession and general public. In a recent Harris Interactive Poll 45% of the women questioned felt the USPTF pushed back the recommended age to 50 to reduce health care costs and avoid administering tests. Eleven percent of those polled thought mammograms should begin at age 20 even for women with no risk factors, while 29 percent believe mammograms should start in their 30’s.

What is clear is that confusion reigns. Consultation with your doctor using your family history, personal history of age at the start of menses, pregnancy history, smoking history and medication history will all contribute to the decision when to start breast imaging screening and how often.

I still support breast self exam and an annual exam by a trained practitioner who examines the same patient annually. As physicians and educators, we need to do a far better job of educating ourselves and the public about the reasoning behind recommended changes to health screenings.

New Suggestions for Managing High Blood Pressure in Senior Citizens

The American College of Cardiology and the American Heart Association have issued the first suggestions specifically for the treatment of high blood pressure in patients 65 and older. In the past, most research studies excluded patients 65 or older so it was difficult to extrapolate suggestions for treating younger patients to older patients.  The Hypertension in the Very Elderly (HYVET) trial changed that. It showed that when we lower the blood pressure in patients 80 years and older there is a decrease in deaths from stroke, a decrease in heart failure deaths and, decrease in death from all causes.

The consensus panel made the following suggestions:

1.  The general targeted blood pressure is less than 140/90

2.  Patients with coronary artery disease, diabetes and chronic kidney disease should aim for a BP less than 130/80 mm Hg.

3.  Lifestyle changes should be encouraged to manage milder forms of hypertension. This includes increasing exercise, reducing salt intake, controlling weight, stopping smoking and limiting alcohol to 2 drinks or less per day.  If this doesn’t work then medication treatment is indicated

The group supported the use of the “step care medication choice program” with the introduction of a thiazide diuretic as the first step in blood pressure medication usage.  They then went on to describe the appropriate usage of two medications at once, the use of beta blockers in cardiac patients and the use of calcium channel blockers.

They also supported screening patients’ urine for the presence of protein which would indicate that kidney problems need evaluation.  The group further suggested that the diagnosis of high blood pressure be made based on at least 3 blood pressure readings performed at two or more office visits.

The suggestions were not the more formal evidence based guidelines we have become accustomed to. They were a compromise agreement of a panel of experts from two organizations.  They encouraged further studies of these suggestions in the elderly so that they can accumulate the data they need to make future, firm, evidence-based guidelines.

For the average patient, nothing should change dramatically. As physicians, we will need to identify patients with elevated blood pressure and convince many of the elderly that there are significant benefits to taking medication to control their hypertension. This has been exceptionally difficult in the healthy elderly who develop hypertension in their mid to late 70’s and do not want to deal with the cost or side effect profile of taking “another pill.” Improving their lifestyle will always be the first option to control the elevated blood pressure.  However, the use of medications was strongly supported to control the pressure in those who need additional treatment.