• USPSTF new breast screening recommendations ‘would result in thousands of breast cancer deaths’: ACR

    April 21, 2015

    by Lauren Dubinsky , Staff Writer

    Breast Cancer Word Cloud ConceptThe U.S Preventive Services Task Force (USPSTF) released the draft update for its breast cancer screening recommendations on Monday — but not much has changed from the 2009 recommendations. The recommendations state that women between ages 50 and 74 should only undergo routine biennial screening and women in their 40s should discuss with their physician whether they need screening.

    On the their website, the Task Force gives screening women ages 40 to 49 a “C” recommendation and wrote, “Women who place a higher value on the potential benefit than the potential harms may choose to begin screening between the ages of 40 and 49 years.” The Task Force gave screening women ages 50 to 74 a “B” recommendation. [Read More…]

  • Psych Effects Linger After False Positive Mammograms

    March 18, 2013

    Mammograms can detect breast cancer early, and save lives. But they can also lead to false alarms that take a heavy psychological toll, a new study found.

    The Danish study of more than 1,300 women found that those who received “false positive” results on their screening mammograms reported symptoms of anxiety and depression that still lingered three years later, long after a cancer diagnosis had been ruled out. Their psychological well-being was more closely matched to that of breast cancer patients than healthy women.

    “It is comparable to a life crisis, like getting divorced or the death of a close family member,” study author Dr. John Brodersen of the University of Copenhagen’s department of public health said of mammogram false positives. “People don’t trust their body anymore; they interpret their body systems differently; they go to the doctor more frequently the search for security to know they are healthy. These women are turned from healthy people to people [at] risk, to people who are close to being sick.”

    Women who had false positives were also more likely to report disturbances in sleep and sexuality, according to the study, published today in the journal Annals of Family Medicine.

    One in eight American women will battle breast cancer in her lifetime, according to the American Cancer Society. In 2013, roughly 232,340 women will be newly diagnosed with invasive breast cancer. Nearly 40,000 women will die from the disease.

    The U.S. Preventive Services Task Force recommends biennial mammograms for women between the ages of 50 and 74. The test, an x-ray of the breast, is often the first step in diagnosing breast cancer. But it can also lead to unnecessary tests and procedures, such as biopsies and lumpectomies, not to mention stress.

    “Any abnormal finding sends a woman into a tailspin,” Lillian Shockney, a breast cancer nurse at Johns Hopkins Hospital in Baltimore, told ABCNews.com. “It’s awful. But she would rather know if she has something ominous in her breast or not.”

    A 2012 study of 100,000 women suggested the risks of mammogram false positives may even outweigh the benefits. It’s estimated that for one woman’s life to be saved, 2,000 women have to be screened, leading to 200 false positives and 10 unnecessary surgeries.

    “The default is to assume that screening must be good; catching something early must be good,” study author James Raftery, professor of health technology assessment at the University of Southampton, U.K., told ABCNews.com at the time. But “breast cancer screening was introduced because it was assumed to benefit women’s health overall. And the side effects are pretty damn serious.”

    Breast cancer screening guidelines have been a topic of ongoing of debate among researchers, with some studies supporting more frequent screening for women over 40 and others suggesting a minimal role for mammography in the reduction of breast cancer mortality overall.

    In June 2012, the American Medical Association came out in support of routine mammography for women starting at age 40, bucking the USPSTF recommendation. And in Janurary 2013, a review of Medicare data found that more then $410 million was spent on screening women 75 and older — another group for whom mammography is not recommended.

    But Americans appear to like their screening, according to a 2011 Gallup poll that found that 58 percent of responders were satisfied with the current level of screening and 31 percent wished there was more. A mere 7 percent thought there was too much.

    Brodersen hopes his study will highlight the risks of overscreening.

    “We are producing a need for health care that is unnecessary,” he said. “Please stop screening every year from age 40 to death. Trust the USPSTF recommendation.”

    Dr. Samreen Hasan contributed to this story.

  • The Benefits and Harms of Breast Cancer Screening: An Independent Review

    The Lancet, Early Online Publication, 30 October 2012

    doi:10.1016/S0140-6736(12)61611-0Cite or Link Using DOI

    The benefits and harms of breast cancer screening: an independent review

    Original Text

    Independent UK Panel on Breast Cancer Screening

    Summary

    Whether breast cancer screening does more harm than good has been debated extensively. The main questions are how large the benefit of screening is in terms of reduced breast cancer mortality and how substantial the harm is in terms of overdiagnosis, which is defined as cancers detected at screening that would not have otherwise become clinically apparent in the woman’s lifetime. An independent Panel was convened to reach conclusions about the benefits and harms of breast screening on the basis of a review of published work and oral and written evidence presented by experts in the subject. To provide estimates of the level of benefits and harms, the Panel relied mainly on findings from randomised trials of breast cancer screening that compared women invited to screening with controls not invited, but also reviewed evidence from observational studies. The Panel focused on the UK setting, where women aged 50—70 years are invited to screening every 3 years. In this Review, we provide a summary of the full report on the Panel’s findings and conclusions. In a meta-analysis of 11 randomised trials, the relative risk of breast cancer mortality for women invited to screening compared with controls was 0·80 (95% CI 0·73—0·89), which is a relative risk reduction of 20%. The Panel considered the internal biases in the trials and whether these trials, which were done a long time ago, were still relevant; they concluded that 20% was still a reasonable estimate of the relative risk reduction. The more reliable and recent observational studies generally produced larger estimates of benefit, but these studies might be biased. The best estimates of overdiagnosis are from three trials in which women in the control group were not invited to be screened at the end of the active trial period. In a meta-analysis, estimates of the excess incidence were 11% (95% CI 9—12) when expressed as a proportion of cancers diagnosed in the invited group in the long term, and 19% (15—23) when expressed as a proportion of the cancers diagnosed during the active screening period. Results from observational studies support the occurrence of overdiagnosis, but estimates of its magnitude are unreliable. The Panel concludes that screening reduces breast cancer mortality but that some overdiagnosis occurs. Since the estimates provided are from studies with many limitations and whose relevance to present-day screening programmes can be questioned, they have substantial uncertainty and should be regarded only as an approximate guide. If these figures are used directly, for every 10 000 UK women aged 50 years invited to screening for the next 20 years, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and non-invasive, would be overdiagnosed; that is one breast cancer death prevented for about every three overdiagnosed cases identified and treated. Of the roughly 307 000 women aged 50—52 years who are invited to begin screening every year, just over 1% would have an overdiagnosed cancer in the next 20 years. Evidence from a focus group organised by Cancer Research UK and attended by some members of the Panel showed that many women feel that accepting the offer of breast screening is worthwhile, which agrees with the results of previous similar studies. Information should be made available in a transparent and objective way to women invited to screening so that they can make informed decisions.

  • California Passes Breast Density Bill

    September 16, 2011
    by Brendon Nafziger, DOTmed News Associate Editor

    The California State Legislature passed a bill last Friday requiring doctors to inform women if they have dense breasts after a mammogram, making California the second state this summer and the third state so far to have passed a so-called breast density law.

    The bill, SB 791, passed the state Senate 35-1, and is now going before Gov. Jerry Brown to get signed.

    When he signs it, starting next year, Calif. radiologists will have to send women with dense breasts, as determined by an American College of Radiology-developed system, this text:

    Because your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician’s office and you should contact your physician if you have any questions or concerns about this notice.

    Texas Gov. and Republican presidential hopeful Rick Perry signed into law a similar bill, Texas Act HB 2102, or Henda’s Law, in June. And breast density legislation was also passed in Connecticut in 2009.

    New Hampshire, Massachusetts, New York and Florida all have similar legislation pending.

    The American College of Radiology Imaging Network says that around 40 percent of women getting screening mammograms have dense breasts, with younger women typically having denser breasts.

    Dense breasts are less fatty, with more connective tissue. The connective tissue appears white on a mammogram, just like the cancer, making it harder to diagnose, according to Are You Dense, an advocacy group.

    A January 2011 study by the Mayo Clinic found three-quarters of cancers in women with dense breasts are missed by mammograms.

    “When it comes to your health, ignorance is not bliss. What you don’t know can hurt you,” State Sen. Joe Simitian, a Democrat from Palo Alto who authored the bill, said in a statement.

    The idea for the bill came from by Amy Colton, a registered nurse who had breast cancer not discovered by a mammogram, and who learned she had dense breasts only after her cancer was diagnosed, according to Are You Dense. She suggested the bill in Simitian’s “There Oughta Be a Law” contest.

    However, the bill met some opposition from the California Medical Association. Writing about an earlier incarnation of the bill, SB 173, the CMA warned that it could bring legal and practical problems for Calif. doctors.

    “Because the scope of who must receive the notice is so broad, women will be ‘scared’ into thinking they need these expensive additional screenings when it isn’t at all warranted, leading to increased costs and pressures on a physician’s practice,” the group wrote in a notice on its website. “Moreover, because the grading of the condition that may/may not lead to their receipt of the prescribed notice is subjective in nature, the absence of the notice could lead to lawsuits against doctors if a patient is later diagnosed with breast cancer.”

    But the bill was backed by several other groups, including the California Nurses Association, the Breast Cancer Fund, the California Association of Health Underwriters and California NOW.

  • California Bill Aimed at Breast Cancer Worries Docs

    SACRAMENTO, Calif. (AP) — It took seven years of annual mammograms and a cancer diagnosis for Amy Colton to learn something her doctors had realized from the beginning: Her breast tissue is so dense that it could have masked tumors on earlier exams.

    “I requested a copy of the report sent from my radiologist to my primary care physician, and every single one said, ‘Patient has extremely dense breast tissue,'” the registered labor and delivery nurse said. “I was really outraged that I didn’t know this.”

    About 40 percent of women over 40 have breast tissue dense enough to mask or mimic cancers on mammograms, but many of them don’t know it. Mammogram providers in California will be required to notify those patients, and suggest that they discuss additional screenings with their doctors based on their individual risk factors, if Gov. Jerry Brown signs a bill that the Legislature passed this month. Similar laws have passed in Texas and Connecticut in the past two years but no data is available yet from either state on the effect of the legislation.

    “The notice in the bill is a two-sentence notice that gets added to a letter,” said the bill’s author, Democratic state Sen. Joe Simitian of Palo Alto. “I believe these two sentences can save thousands of lives.”

    Brown has not given his opinion about the bill, but many doctors oppose it. Researchers studying breast density, a relatively young field, said such requirements may end up causing undo anxiety in millions of women and lead to unnecessary and expensive ultrasound or MRI screenings.

    The California Medical Association, which represents 35,000 doctors, recommended a public education campaign instead of individual notifications, and said there isn’t enough evidence to support the idea the extra money spent on additional screenings will save more lives.

    Those tests could cost the state more than $1 billion, and many women wouldn’t be able to afford them, said Dr. Karen Lindfors, a professor of radiology and chief of breast imaging at the University of California, Davis Medical Center in Sacramento. She testified against the bill before a legislative committee.

    “I just don’t think that at this point we have the ability to meet the kind of demand either financially or in terms of manpower that this is going to create, and we also don’t have proof that it’s going to save lives,” she said.

    The women who would receive the notifications have more tissue than fat in their breasts. As women age, their breasts become more fatty. Fat appears black on a mammogram, making it easier to spot cancer, which shows up as white.

    Doctors agree that high breast density is an increased risk factor for cancer, but researchers say the issue needs more study to determine whether the risk is great enough to justify a higher level of screenings for women who have it.

    Pre-menopausal women are more likely to have dense tissue, regardless of whether they are at high risk for breast cancer, said Celine Vachon, an associate professor of epidemiology at the Mayo Clinic in Rochester, Minn. She said women who get the notifications required by the California bill could be frightened into seeking additional screenings, such as MRIs or ultrasounds, which can pick up false positives and cost thousands of dollars.

    “If women want their breast density information, that’s their right,” Vachon said. “However, breast density is not yet a risk factor that’s used clinically, so what women will do with this information is not clear. We need improved density measurements as well as models that do a better job of predicting women’s risk. Everyone wants density to be this silver bullet, but to date, it’s not.”

    Colton, who got the California legislation rolling by contacting Simitian’s office, said women ought to be told whether their breast density could make cancer difficult to detect.

    She said she practiced self-exams monthly, had no family history of breast cancer and thought she was among the lucky cohort of women at a low risk for breast cancer. But five surgeries, six weeks of daily radiation and 15 rounds of chemotherapy later, she is angered that she went years without being told about her dense breast tissue.

    “I don’t want anyone to think this is a rare story. There are countless women like me, and many with worse diagnoses,” she said.

    Dr. Judy Dean, a diagnostic radiologist in Santa Barbara who specializes in breast imaging, supports the effort. She said 20 of her patients have found cancers through ultrasounds after she informed them that their dense tissue might be hiding tumors in a mammogram.

    “Negative doesn’t mean negative; you could still be positive,” she said.

    All radiologists agree that a mammogram — an X-ray image of the breast — is the best way for a woman to discover whether she has dense tissue, but few agree on how to proceed with that information.

    Researchers have been experimenting with new breast imaging techniques that might provide the same answers as an MRI or ultrasound for women with a high risk for cancer, but with less expense. 3-D X-ray images known as “stereo mammograms” and molecular breast imaging are two techniques that are better than traditional mammograms at spotting cancers and cost much less than MRIs.

    Some say a notice about the hidden risks of dense tissue should be sent to all women receiving the results of their mammogram, not just those with dense tissue. That way, everyone can be armed with the available information, said California state Assemblywoman Linda Halderman, a former breast cancer surgeon.

    She said the bill would end up giving women with low breast tissue density false assurances they are not at risk for cancer.

    “We’re offering something to women that doesn’t help improve their care or shed any light on the best way to assess their risk for breast cancer,” said Halderman, a Republican from Fresno. “Unfortunately, breast density is just one of those things we don’t know about yet.”

  • Widely used CAD mammography tool fails to find invasive breast cancer, causes needless tests and stress

    Thursday, July 28, 2011 by: S. L. Baker, features writer

    Computer-aided detection (CAD) technology, which analyzes mammography images and marks suspicious areas for radiologists to review, has been widely hyped and pushed on women as a way to insure invasive breast cancer is spotted on mammograms. And it has grown into a huge industry, adding millions of dollars to the cost of healthcare.

    The problem is, CAD simply doesn’t work — at all. That’s right. Despite the fact CAD is now applied to the large majority of screening mammograms in the U.S. with annual direct Medicare costs exceeding $30 million (according to a 2010 study in the Journal of the American College of Radiology), new research by University of California at Davis (UC Davis) scientists shows the expensive technology is ineffective in finding breast tumors.

    But it does something extremely well. It causes enormous stress by greatly increasing a woman’s risk of being called back for more costly testing following a CAD analyzed mammogram.

    The new research, just published in the Journal of the National Cancer Institute, used data from the Breast Cancer Surveillance Consortium to analyze 1.6 million mammograms. Entitled “Effectiveness of Computer-Aided Detection in Community Mammography Practice,” the study specifically looked at screening mammograms performed on more than 680,000 women at 90 mammography facilities in seven U.S. states, between the years of 1998 and 2006.

    The results are being hailed as the most definitive findings to date on whether the super popular mammography tool is effective in locating cancer in the breast. The findings? CAD is a waste of time and money.

    The false-positive rate increased from 8.1 percent before CAD to 8.6 percent after CAD was installed at the medical centers in the study. What’s more, the detection rate of breast cancer and the stage and size of breast cancer tumors were similar regardless of whether or not CAD was used.

    “In real-world practice, CAD increases the chances of being unnecessarily called back for further testing because of false-positive results without clear benefits to women,” Joshua Fenton, assistant professor in the UC Davis Department of Family and Community Medicine, said in a statement to the media. “Breast cancers were detected at a similar stage and size regardless of whether or not radiologists used CAD.”

    This isn’t the first time the CAD technology has been questioned by researchers. The current study follows a previous study of the computer aided mammography tool that was published by Dr. Fenton in the New England Journal of Medicine in 2007.

    That examination of mammography screening results in 43 facilities, including seven that used CAD, found that CAD was actually linked to reduced accuracy of mammogram screenings and produced no difference in the detection rate of invasive breast cancer.

    “In the current study, we evaluated newer technology in a larger sample and
    over a longer time period,” Fenton noted in a statement to the press. “We also looked for the first time at cancer stage and cancer size, which are critical for understanding how CAD may affect long-term breast cancer outcomes, such as mortality.”

    CAD software was first approved by the Food and Drug Administration back in 1998, but its use only skyrocketed after Medicare began covering it in 2001. According to 2009 Medicare data, using CAD adds another $12 to the costs of having a mammogram (about $81 for film mammography and $130 for digital mammography), representing a 9 percent to 15 percent additional cost for CAD use.

  • TEN-YEAR RISK OF FALSE POSITIVE SCREENING MAMMOGRAMS AND CLINICAL BREAST EXAMINATIONS

    The New England Journal of Medicine
    ©Copyright, 1998, by the Massachusetts Medical Society
    VOLUME 338 A PRIL 16, 1998 NUMBER 16

    J OANN G. E LMORE , M.D., M.P.H., M ARY B. B ARTON , M.D., M.P.P., V ICTORIA M. M OCERI , P H .C., S ARAH P OLK , B.A., P HILIP J. A RENA , M.D., AND S UZANNE W. F LETCHER , M.D.

    A BSTRACT Background The cumulative risk of a false positiveresult of a breast-cancer screening test is unknown. Methods We performed a 10-year retrospective co-hort study of breast-cancer screening and diagnosticevaluations among 2400 women who were 40 to 69years old at study entry. Mammograms or clinicalbreast examinations that were interpreted as indeter-minate, aroused a suspicion of cancer, or promptedrecommendations for additional workup in women inwhom breast cancer was not diagnosed within thenext year were considered to be false positive tests. Results A total of 9762 screening mammogramsand 10,905 screening clinical breast examinationswere performed, for a median of 4 mammograms and5 clinical breast examinations per woman over the 10-year period. Of the women who were screened, 23.8percent had at least one false positive mammogram,13.4 percent had at least one false positive breast ex-amination, and 31.7 percent had at least one falsepositive result for either test. The estimated cumula-tive risk of a false positive result was 49.1 percent (95percent confidence interval, 40.3 to 64.1 percent) after10 mammograms and 22.3 percent (95 percent confi-dence interval, 19.2 to 27.5 percent) after 10 clinicalbreast examinations. The false positive tests led to870 outpatient appointments, 539 diagnostic mam-mograms, 186 ultrasound examinations, 188 biopsies,and 1 hospitalization. We estimate that among wom-en who do not have breast cancer, 18.6 percent (95percent confidence interval, 9.8 to 41.2 percent) willundergo a biopsy after 10 mammograms, and 6.2 per-cent (95 percent confidence interval, 3.7 to 11.2 per-cent) after 10 clinical breast examinations. For every$100 spent for screening, an additional $33 was spentto evaluate the false positive results.

    To read the rest of the study, click here to download the PDF.

  • Screening for Breast Cancer

    JAMA. 2005 Mar 9;293(10):1245-56.

    Screening for breast cancer.

    Elmore JG, Armstrong K, Lehman CD, Fletcher SW.

    Source

    Department of Medicine, University of Washington School of Medicine, Seattle, USA. jelmore@u.washington.edu

    Abstract

    CONTEXT:

    Breast cancer screening in community practices may be different from that in randomized controlled trials. New screening modalities are becoming available.

    OBJECTIVES:

    To review breast cancer screening, especially in the community and to examine evidence about new screening modalities.

    DATA SOURCES AND STUDY SELECTION:

    English-language articles of randomized controlled trials assessing effectiveness of breast cancer screening were reviewed, as well as meta-analyses, systematic reviews, studies of breast cancer screening in the community, and guidelines. Also, studies of newer screening modalities were assessed.

    DATA SYNTHESIS:

    All major US medical organizations recommend screening mammography for women aged 40 years and older. Screening mammography reduces breast cancer mortality by about 20% to 35% in women aged 50 to 69 years and slightly less in women aged 40 to 49 years at 14 years of follow-up. Approximately 95% of women with abnormalities on screening mammograms do not have breast cancer with variability based on such factors as age of the woman and assessment category assigned by the radiologist. Studies comparing full-field digital mammography to screen film have not shown statistically significant differences in cancer detection while the impact on recall rates (percentage of screening mammograms considered to have positive results) was unclear. One study suggested that computer-aided detection increases cancer detection rates and recall rates while a second larger study did not find any significant differences. Screening clinical breast examination detects some cancers missed by mammography, but the sensitivity reported in the community is lower (28% to 36%) than in randomized trials (about 54%). Breast self-examination has not been shown to be effective in reducing breast cancer mortality, but it does increase the number of breast biopsies performed because of false-positives. Magnetic resonance imaging and ultrasound are being studied for screening women at high risk for breast cancer but are not recommended for screening the general population. Sensitivity of magnetic resonance imaging in high-risk women has been found to be much higher than that of mammography but specificity is generally lower. Effect of the magnetic resonance imaging on breast cancer mortality is not known. A balanced discussion of possible benefits and harms of screening should be undertaken with each woman.

    CONCLUSIONS:

    In the community, mammography remains the main screening tool while the effectiveness of clinical breast examination and self-examination are less. New screening modalities are unlikely to replace mammography in the near future for screening the general population.

  • 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. [Read More…]

  • Mammograms Over 40: Surprise? Half Of Women Over Are Skipping Them

    MARILYNN MARCHIONE | 12/ 9/10 11:07 AM |

     Read More: Breast Cancer, Breast Cancer Mammogram, Breast Mammogram, Breast Screening, Mammogram Over 40, Mammogram Over 50, Mammogram Recommendations, Mammogram Test, Mammograms, Health News

    Bottom of Form

    SAN ANTONIO — Remember the uproar last year when a government task force said most women don’t need annual mammograms? It turns out that only half of women over 40 had been getting them that often to start with, even when they have insurance that covers screening.

    The information comes from a review of insurance claims that show what women actually do – not what they say in surveys.

    “We all support many things – fast food isn’t what we should eat for dinner every night – but that isn’t what we do,” said Dr. Milayna Subar of Medco Health Solutions Inc., which manages benefits for many large insurers, including some Medicare plans.

    She did the study, using records on more than 1.5 million women, and reported results Thursday at a breast cancer conference.

    The finding is disturbing, said Dr. Judy Garber of Dana-Farber Cancer Institute in Boston and president-elect of the American Association for Cancer Research, one of the conference’s sponsors. “Here’s an insured population where cost is not a barrier,” and yet many women are not getting tested. [Read More…]