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.

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Aspirin for Breast Cancer?

Aspirin (2)In an observational study published in the Journal of Clinical Oncology in 2010, Drs. Michelle Holmes and Wendy Chen of the Harvard Medical School showed that women with breast cancer who took one aspirin per week had a 50% lower chance of dying from breast cancer. They have been trying to set up a randomized blinded study of 3000 women with breast cancer to test this finding using the gold standard of research but they have been unable to raise the $10,000,000 required for a five year study. Pharmaceutical companies see no profit in aspirin and prefer to use their research money on medications that are potentially more profitable. Government agencies seem to feel the same way opting to test new cancer drugs pushed by pharmaceutical companies rather than finance an inexpensive available product.

The authors believe aspirin, if proven to be effective in randomized trials, is a less expensive alternative for women who cannot afford or cannot tolerate hormonal therapy post-surgery for five years. Great Britain, through its national health service has decided to study the effects of aspirin on four cancers, with breast cancer one of them, in a study that will not be completed until 2025. Drs. Holmes and Chen believe that with proper funding their study of women with stage 2 and 3 breast cancer, would answer the question of aspirin’s efficacy within five years.

Breast Cancer Screening DOES SAVE LIVES

Eugenio Paci, MD, of the ISPO Cancer Prevention and Research Unit in Florence, Italy working with a European breast cancer screening group, published data in the Journal of Medical Screening that clearly showed that screening mammograms save lives. The study was necessitated because of recent controversial data presented by the US Preventive Services Task Force (“USPSTF”) calling for women to wait until age 50 to begin mammograms and having them every other year rather than annually. The USPSTF recommendations were based on the belief that too many false positive tests led to too many unnecessary and expensive follow-up tests.

The European researchers found that for every 1,000 women screened from age 50 to 51, and followed to age 79, an estimated 7 to 9 lives would be saved and; an additional four cases of cancer would be diagnosed early. The screening resulted in 170 women having to have a repeat non-invasive test to rule out cancer (such as a repeat mammogram and or ultrasound of the breast) and 30 women would have to undergo an invasive test such as a biopsy.

The researchers looked at a 10 year period in Europe and expected 30 deaths per 1,000 women from breast cancer of which 19 could be prevented by screening. Their figures showed that 14 women need to be screened to diagnose one case of breast cancer and 111 to 143 need to be screened to save one life.

I will continue to recommend that patients learn how to perform a breast self exam and perform it regularly. We will begin screening our high risk patients at age 40 and others at age 50.

A thorough annual breast exam by the patient’s doctor is advised. A decision on annual mammograms versus every other year should be decided by the patient’s risk factors, family and personal health history, current examination and past mammogram findings.