Barred From Breast Screening

Under 50 … Younger women are missing out on breast screens. Source: The Sunday Telegraph

ALMOST a quarter of breast cancers diagnosed in Australia occur in females under 50, so why is the Government recommending screening for older women only?

Sitting in a drawer of a Canberra office is a report recommending significant changes to Australia’s breast-screening program.

It’s been there since last June. It says the government should lower its target age range for routine mammograms from 50 to 45, and extend it at the other end of the age range, from 69 to 75.

Such changes would have done little to help the likes of the late Jane McGrath. The wife of former fast bowler Glenn was only 31 when she was diagnosed with breast cancer. She died in 2008.

Nor would Australia’s breast-screening guidelines have done any good for the late Belinda Emmett, just 24 when she was diagnosed with the disease. Or pop princess Kylie Minogue, who was just 36.

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Australia’s breast-screening program, funded by federal, state and territory governments, targets women aged 50 to 69 for free biennial mammograms.

They are invited to their nearest clinic and receive reminders. Women aged 40 to 49 are eligible for a free scan, but few know that, despite the fact that almost a quarter of breast cancers in this country occur in women aged under 50.

Over recent months, the merits of screening women in their 40s has been the subject of much debate. In the US, women in their 40s were previously routinely screened in the hope that early detection would provide better treatment options and outcomes.

Dangerous guidelines

But in November, the US Preventive Services Taskforce dropped a bombshell: in a departure from its longstanding guidelines that women aged 40 and older be screened every one to two years, it now recommends against screening at all for women under 50. It also recommends against clinicians teaching women how to self-examine their breasts.

Just a few months earlier, the BreastScreen Australia Evaluation Advisory Committee made its own recommendations to the Australian Health Ministers’ Advisory Council.

The government has been told that Australia’s program should be expanded to target women aged 45 to 75, but that women aged 40 to 44 and older than 75 be shut out.

Rosanna Martinello, convenor of Young Breast Cancer Action Group NSW, says narrowing the age eligibility of programs cuts out more women and is particularly worrying for younger women, who tend to have more aggressive tumours and poorer prognoses.

The government has yet to respond. Experts say the tissue in pre-menopausal women’s breasts is denser than in older women, making it harder to read the mammogram and increasing the likelihood of false positive results, which can lead to more invasive investigation and anxiety.

The risk of breast cancer increases with age, but in 2006, 3083 women under 49 were diagnosed with the disease, out of a total of 12,614, according to the Australian Institute of Health and Welfare (AIHW).

Professor John Boyages, executive director of the Westmead Breast Cancer Institute in Sydney, says screening for women in their mid to late 40s is warranted.

“What I would be recommending is screening for women aged 45 to 75, because when you look at the incidence of breast cancer between 45 and 50, it’s certainly very high. Women at that age are starting to see their friends getting breast cancer and it’s very important we get them into a good [screening] program at that point.”

An economic issue

He says that despite the higher risk of false positives in the 40 to 49 age group, “In my experience, with women aged 45 to 50, it’s pretty easy to see through their breast, particularly with new digital mammogram machines.

“Ultimately, it’s an economic issue and a resource issue. We’re having trouble keeping up with our regular screening. If you include the 40 to 49  group or 45 to 50, it’s going to require a lot more machines and doctors.”

The participation rate among the target group of 50- to 69-year-olds is 56 per cent, well down on the 70 per cent the program originally aimed for.

Christine Sturrock, head of the AIHW’s cancer and screening unit, says the incidence of breast cancer in the 45 to 49 age group in 2006 was 182.3 per 100,000, compared with 349 per 100,000 among 60- to 64-year-olds, so screening is more effective in older women.

Dr Karen Luxford, general manager of the National Breast and Ovarian Cancer Centre, says women such as Jane McGrath and Belinda Emmett helped to raise awareness about breast cancer, but it is important that women understand that risk increases with age.

“I think there’s confusion in the population about that. People have started to think it’s a younger woman’s disease and, although it can affect younger women, it is indeed a disease that is prevalent in older women,” Dr Luxford says.

Dr Luxford says she supports Australia’s current screening guidelines, which target 50- to 69-year-olds.

Professor Janet Hiller, chair of public health at Adelaide University and a member of the research advisory committee of the National Breast Cancer Foundation, says there are few pros and many cons in screening younger women.

“Breast cancer is relatively uncommon in 40- to 49-year-olds. The rates are lower, and when the rates are lower and you apply a screening test, you’re more likely to get some false alarms,” she says.

“Being told you might have breast cancer and need further tests is not without hazards because having further tests can be associated with morbidity and anxiety.

“The breasts of women who are pre-menopausal are harder to read on a mammogram and overall, you need to subject many more women aged 40 to
49 to mammograms to prevent one death than you do in the 50 to 69 age group.”

BreastScreen Australia’s policy states: “Current evidence indicates the benefits of breast cancer screening for women aged 40 to 49 years are not strong enough to encourage all women in this age group to have regular breast cancer screening.”

False results

While dense breast tissue can resemble cancer in an X-ray, the policy says younger women are “more likely to have unnecessary recall for assessment, with anxiety, sometimes invasive investigations, when there was no breast cancer in the first place”.

In the US, groups such as the American Cancer Society and American College of Radiology are sticking with their guidelines advising women to have annual mammograms after the age of 40.

An Australian study published late last year found that breast cancer screening has the potential to lead to over-diagnosis and unnecessary treatment, with the researchers saying that screening can find some cancers that are so slow-growing they would never manifest in a woman’s lifetime.

Contrary to new recommendations from the US Preventive Services Taskforce advising against breast self-examination, doctors and cancer organisations in Australia still say it’s helpful, particularly for younger women who aren’t routinely screened, although they have softened their language from “breast self-examination” to “breast awareness”.

Martinello says the messages for young women are confusing and that most don’t know what being “breast aware” means.

According to the Cancer Council Australia, breast self-examination has not been shown to reduce the size or stage of tumours at diagnosis, nor the number of deaths from breast cancer.

Professor Hiller says: “You need to know what your breasts are like, but you don’t need to be obsessive about examining your breasts.”

As Jane McGrath wrote before her death in 2008: “Breast cancer doesn’t care how old you are… I was only 31 when I was first diagnosed with breast cancer. I feel very passionate about empowering women under 40 to take control of their health by conducting regular breast checks – early detection saves lives.”

Detection tools

1 Mammogram: The breast is compressed by a machine that takes a low-dose X-ray. The image is examined by at least two people under BreastScreen Australia’s program, one of them a radiologist. It can be uncomfortable.

2 Ultrasound: A scan that uses high-frequency soundwaves to produce images. It helps to distinguish between fluid-filled lumps in the breasts and solid lumps, which may be cancer. It is painless.

3 MRI: Usually used on younger women at high risk of breast cancer where a mammogram might not detect breast changes.

4 Fine needle aspiration: A thin needle is used to remove fluid or cells from a breast lesion or cyst. They are smeared onto a glass slide and sent for testing. It can hurt.

5 Core biopsy: Under local anaesthetic, a needle is inserted to take a small sample of breast tissue from the area of concern for testing. Breast may feel tender for days and there is often bruising.

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