American College of Physicians Breast Cancer Screening Guidance

The American College of Physicians released four guidance statements on detection of breast cancer in women with average risk and no symptoms of breast cancer.

  1. Doctors should discuss with their patients the pros and cons of screening with mammography for breast cancer in asymptomatic women with a modest risk of disease between ages 40- 49 years. The potential risks of screening are felt to outweigh the benefits.
  2. Clinicians should screen average risk women aged 50-74 years for breast cancer with mammography every other year.
  3. Clinicians should discontinue breast cancer screening in women aged 75 years or greater with an average risk of breast cancer and a life expectancy of 10 years or less.
  4. Clinical breast examinations SHOULD NOT be used to screen for breast cancer of average risk women of all ages.

These guidance statements DO NOT APPLY to women with a higher risk of breast cancers including those with abnormal screening results in the past, a personal history of breast cancer or a mutation in the BRCA1 or BRCA2 gene.

At the same meeting, data was presented discussing the problems with supplemental whole breast ultrasound in women with dense breasts.  The concern is that all this testing leads to invasive biopsies, over diagnosis and treatment of breast cancer in 1 in 5 patients and complications and increased cost to patients and insurers.  Like most recommendations on breast cancer, and prostate cancer in men, the results and conclusions from following these guidelines will not be apparent until 10 to 15 years from now.

Today’s adult women will either benefit from these suggestions, which have even included no longer teaching adult women how to perform breast self-exam, or they will be the unsuspecting research victims of cost containment. I question the competence of physicians in examining problematic breast disease if they are not being trained how to evaluate a breast and following that with clinical exams. In surgery we usually do not feel a clinician is competent and fully aware of the pitfalls of a procedure until the surgeon has done 200 or more. We additionally know that doing the procedure frequently results in better results than performing a procedure infrequently.

How will that apply if young physicians no longer examine breasts routinely?  How many, and how often, will they need to do an adequate exam to be able to perform when there is a real issue?  Do we actually wish to create a narrow panel of breast experts only at Centers of Excellence who actually know how to examine a breast and use the available imaging modalities safely and effectively?  It seems these ACP recommendations move in that direction.

For several years now I have been a supporter and champion of our community’s Women’s’ Center associated with Boca Raton Regional Hospital. Run by astute future thinking clinicians and researchers, and stocked with state of the art imaging equipment, it provides an option to meet with a counselor, assess your breast cancer risk and enter a screening pathway most individually suited to your personalized needs.  I will continue to support that choice.

Keep Moving for Cardiovascular Benefits

We keep extolling the benefits and virtues of regular exercise and fitness. Some research studies have documented the intensity and duration of exercise programs with cardiovascular events and mortality. Those who do more and are fitter apparently do much better which surprises few of us.

It comes down to the “which came first the chicken or egg “question?  Are people genetically able to exercise at a high level living longer and healthier because they exercise at a high intensity and duration or vice versa?

It is quite comforting to read the recent study in JAMA by Andrea LaCroix, PhD, MPH and colleagues from the University of California, San Diego that shows the benefits of even modest movement and exercise.  The study was conducted under the umbrella of the Women’s Health Initiative and put pedometers and accelerometers on women to measure activity during waking hours.  Light physical activity was defined as less than 3 metabolic equivalents (Walking one mile in about 22 minutes expends about 3 Metabolic Equivalents of Activity).  They noted that for each hour per day increment in light activity there was a 14% lower risk of Coronary Heart Disease and 8% lower risk of cardiovascular disease.

The researchers evaluated 5,861 women with a mean age of 78.5 years. Average follow-up spanned 3.5 years with study members having 570 cardiovascular disease events and 143 coronary heart disease events. The study group was diverse with there being 48.8% Caucasian women, 33.5 % Black women and 17.6% Hispanic women.

The study’s results and message was clear. Keep moving. Even modest exercise is beneficial in reducing heart attack and stroke risk.

Free Choice of Physicians & Fee for Service Medicine Ending?

The Medicare Payment Advisory Commission is a panel of financial, economic and health policy advisors created by Congress to advise CMS (Center for Medicare Services) and Congress how to pay physicians, health care providers and facilities for services rendered. According to an online article on MedPage they are close to eliminating fee for service payments for health care. CMS has encouraged alternative delivery methods for years. For the most part this has resulted in hospital and health care systems buying up and employing doctors, mid-level providers being substituted for more highly trained doctors and these alternative systems covering care only with their panel of providers and diagnostic and treatment centers.

However, publicized figures have shown these Medicare alternative products actually cost more per patient per year than traditional Medicare. This particular article claimed a 1-2% savings.

We all see the ads for Medicare Advantage plans which, in addition to no co-pay and no deductible, provide for dental care, vision care, eye care and exercise and gym memberships. Apparently 50% of the Medicare population is now enrolled in such a program.

As a 69 year old individual paying into the Medicare system for the last 55 years I see the benefits and cost savings for seniors when they are healthy. What happens however, when you become ill? Clearly the Centers of Excellence for many of the ailments seniors contract are geographically and contractually outside the narrow networks and panels these private insurance companies run and the Accountable Care Organization run plans provide.

If I do not have coverage for the Mayo Clinic or MD Anderson Cancer Center or the Cleveland Clinic or Dana Farber Cancer Center or Johns Hopkins Medical Center then have I wasted 55 years of payments? Do I really want a nurse practitioner in south Florida directing my care off a protocol list of contracted providers or do I want a clinician who sees a dozen cases of this disease per week calling the shots?

I prefer the latter but may not have a choice but to pay out of pocket if MEDPACs recommendations are accepted by CMS and Congress and become law.