• Gov. Jan Brewer signs Breast Density Law

    April 22, 2014

    by Loren Bonner , DOTmed News Online Editor

    breastdensitylawArizona became the fifteenth state to require physicians to inform women if they have dense breasts along with the possible risks that can be present.

    After legislation was introduced at the request of a diagnostic radiologist in Arizona, and went through the procedural votes in both chambers, Governor Jan Brewer signed SB 1225 into law late last week.
    According to JoAnn Pushkin, founder of D.E.N.S.E. NY, 50 percent of U.S. women now live in states where density notification is required.

    Connecticut was the first state to pass breast density inform legislation in 2009, followed by Texas, Virginia, California, New York, and most recently Hawaii, Maryland, Alabama, Tennessee, Nevada, Oregon, North Carolina and Pennsylvania, New Jersey and now Arizona. [Read More…]

  • Abolishing Mammography Screening Programs? A View from the Swiss Medical Board

    Nikola Biller-Andorno, M.D., Ph.D., and Peter Jüni, M.D.

    April 16, 2014DOI: 10.1056/NEJMp1401875

    In January 2013, the Swiss Medical Board, an independent health technology assessment initiative under the auspices of the Conference of Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences, was mandated to prepare a review of mammography screening. The two of us, a medical ethicist and a clinical epidemiologist, were members of the expert panel that appraised the evidence and its implications. The other members were a clinical pharmacologist, an oncologic surgeon, a nurse scientist, a lawyer, and a health economist. As we embarked on the project, we were aware of the controversies that have surrounded mammography screening for the past 10 to 15 years. When we reviewed the available evidence and contemplated its implications in detail, however, we became increasingly concerned.

    First, we noticed that the ongoing debate was based on a series of reanalyses of the same, predominantly outdated trials. The first trial started more than 50 years ago in New York City and the last trial in 1991 in the United Kingdom. None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer. Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today? [Read More…]

  • Are the Harms of Mammography Underestimated?

    April 08, 2014

    By Kristen Fischer

    More controversy has emerged surrounding mammograms ever since a new report in JAMA recommended that the test be performed based on a woman’s risk and preferences.
    Dr. Lydia Pace and Dr. Nancy Keating both of Brigham and Women’s Hospital in Boston, conducted a systematic review of data spanning 50 years. They examined about 450 studies from 1960 through the present to look for evidence on the benefits and harms of the diagnostic test.

    According to their report, annual mammograms lower mortality from breast cancer by about 19 percent, though the benefits vary based on a woman’s risk and age. Approximately 1,904 women in their 40s would have to undergo a mammogram to prevent one death, while the same would be true for 377 women in their 60s. The disease is more common as a woman ages. At 40, the risk for breast cancer in the next 10 years is 1.5 percent, but that rises to 2.3 percent by age 50, and 3.5 percent by age 60. [Read More…]

  • More Doubts About Mammograms’ Value Are Raised in Large Study

    By Melinda Beck
    Updated April 1, 2014
    Article from The Wall Street Journal

    Nearly 20% of breast cancers diagnosed by mammogram would never cause problems if left alone, according to a new report. Melinda Beck and the study’s lead author Dr. Nancy Keating join the News Hub. Photo: AP.
     

    A large study published Tuesday adds to the growing body of research concluding that screening mammograms save relatively few lives from breast cancer while discovering many cancers that wouldn’t have caused problems if left alone.

    “The more we screen for cancer, the more we find it. But we could have saved some of these women the angst of being told they have cancer,” said Nancy Keating, a researcher at Harvard Medical School and senior author of the study, which examined decades of screening data.

    Other recent studies also have found that mammograms often lead to unnecessary treatment, including a British Medical Journal study in February that followed 90,000 Canadian women over 25 years. But to date, that message hasn’t resulted in fewer mammograms or changes in treatment—largely because scientists still can’t tell which breast cancers can be safely left alone.

    “The challenge is, we can’t tell which are the aggressive cancers,” said Dr. Keating.

    Growing doubts about the benefits of mammograms prompted the U.S. Preventive Services Task Force to change its recommendations in 2009. Since then, it has urged women to get mammograms every other year starting at age 50, rather than annually at 40. The American Cancer Society and other cancer advocacy groups continue to recommend annual screenings starting at 40.

    Many health-care policies encourage more screening. Several states now require doctors to tell women if they have dense breasts, which can make mammograms less accurate, and to discuss more high-tech options. A growing number of doctors are rated—and compensated—on the percentage of their patients who are up to date on screenings. And the Affordable Care Act requires insurers to make mammograms free to women without copays or deductibles.

    About 225,000 cases of breast cancer are diagnosed in the U.S. each year, and about 40,000 people die of it, according to the American Cancer Society.

    The latest study, published in the Journal of the American Medical Association, took an especially long view of the data, examining randomized trials and observational studies on mammograms back to the 1960s to calculate the benefits and harms for women at various ages. Researchers concluded that annual mammograms reduced the overall death rate from breast cancer by about 19%. But they also discovered that about 19% of the breast cancers found when women undergo 10 years of annual mammograms are “over-diagnosed”—that is, they never would have caused problems if left alone.

    Younger women had the least benefit, researchers found. They estimate that for every 10,000 women in their 40s who undergo annual mammograms for 10 years, 190 will be diagnosed with breast cancer. But only five of those women would avoid dying of breast cancer as a result of the screening. Of the remainder, about 25 would die despite being treated, and 36 would be treated unnecessarily because the cancer wouldn’t have become life-threatening.

    For women in their 50s, 10 breast-cancerdeaths would be averted for every 10,000 women screened annually for 10 years. For women in their 60s, 42 breast-cancer deaths would be averted. But as many as 137 women in their 50s, and 194 in their 60s would be diagnosed and treated unnecessarily.

    The conclusion that some cancers are overtreated is controversial, and critics note that it is based on statistical estimates alone. Scientists can’t ethically watch to see whether some breast cancers progress and some don’t. Even precancerous changes, known as ductal carcinoma in situ, can become invasive cancers, so those are almost always treated aggressively.

    Treatment typically involves a combination of surgery, radiation, chemotherapy and hormone therapy, with side effects that can last for years.

    Still, many breast-cancer survivors say they are simply grateful that their cancer was treatable. And some experts stress that even if screening spurs some unnecessary treatments, it saves lives. “Over a decade or so, we prevent between 10,000 and 11,000 deaths,” said Richard Wender, chief cancer control officer at the American Cancer Society. “The overwhelming odds for any one women to benefit are quite low, but overall, from a population perspective, it’s one of our best tools in the war on cancer.”

    Scientists are working on ways to distinguish between breast cancers that are slow-growing and those that are fast-moving and lethal, and to better predict which women are at high risk for aggressive cancers so that screening and treatment can be more targeted.

    In the meantime, many cancer experts urge women and their doctors to weigh their individual risks and preferences.

    “There isn’t a one-size-fits-all on mammograms,” said Dr. Keating, who said she discusses all the pros and cons with her primary-care patients at Brigham and Women’s Hospital.

    “I have a lot of patients who say, ‘I’m comfortable waiting,’ ” she said.