Cancer Screening

Breast Cancer Screening and Mammography

by Gregory Unatin on December 26, 2012

On November 22, 2012, the New England Journal of Medicine published the results of a study examining trends in the screening of breast cancer between 1976 and 2008. The researchers found that screening has promoted a two-fold increase in the number of women diagnosed with early stage breast cancer. However, the findings also indicated the number of women diagnosed with late stage cancer has not significantly declined. Thus, the study concludes that many women, as many as 1.3 million over 30 years and 31% of women diagnosed with breast cancer in 2008 alone, were overdiagnosed. Overdiagnosis means that tumors were detected which would not have resulted in clinical symptoms during the woman’s lifetime. The article discussing the study is available to subscribers here.

The recent study would appear to support a decision by the U.S. Preventive Services Task Force (USPSTF) in December 2009 to abandon its earlier recommendation of breast cancer screening every 1 to 2 years for all women over age 40. The USPSTF now recommends clinicians recommend biennial screening for women ages 50 to 74 and “individualize decision making to begin biennial screening according to the patient’s context and values” for women between the ages of 40 and 49. The Task Force reasoned that the benefit of screening before age 50 was small compared with the potential harms of screening , such as psychological harm, unnecessary imaging and biopsies, harm associated with unnecessary treatment, exposure to radiation, and inconvenience related to false-positive findings. Like the NEJM study more recently, the Task Force cited the harm of overdiagnosis prompting women to undergo treatment and possible complications from treatment of an early form of cancer which may never become clinically apparent or cause death.

It is important to understand the USPSTF guidelines do not represent a universal consensus on breast cancer screening. On July 20, 2011, the American College of Obstetricians and Gynecologists (ACOG) recommended annual screening mammography starting at age 40. Critical to this recommendation is data showing the window of opportunity between the time very small evidence of cancer is detectable by mammogram and when that cancer becomes symptomatic is shortest for women between the ages of 40-49 (2 – 2.4 years compared with 4-4.1 years for ages 70-74). Thus, although the incidence of breast cancer in women ages 40-49 is smaller than in older women, annual mammograms improve the chances of detecting and treating cancer in women in their 40’s before the cancer spreads.

To major non-profit organizations involved in the fight against breast cancer recommend screening for women over the age of 40: the American Cancer Society and Susan G. Komen for the Cure recommend annual mammography for women over age 40. In addition, the National Cancer Institute recommends screening mammography every 1-2 years for women over age 40.

The experts do not disagree that breast cancer screening saves lives. The real debate is over screening guidelines that properly weigh the benefits against the perceived harms of early breast cancer screening. The USPSTF acknowledges the sequence by which ductal carcinoma in situ (DCIS), the most prevalent form of early breast cancer, develops into invasive cancer is unknown. And though not all cases of DCIS progress to invasive cancer, the likelihood that DCIS will develop into invasive cancer is unknown.

It should be no surprise Susan G. Komen, ACOG, the American Cancer Society and the National Cancer Institute recommend screening mammography for women after age 40. The USPSTF emphasizes the perceived harms associated with testing and treatment for women who have early forms of cancer that may never shorten their lives. In this writer’s opinion, it’s dangerous to create guidelines for cancer screening which assume women would prefer to wait as many as 10 years before they learn they have breast cancer. People consider cancer a killer who they should not gamble with. Adherence to USPSTF guidelines will allow breast cancer to smolder for years before diagnosis, with no way of knowing whether the delay will prove the difference between life and death for many women.

Recommending against screening mammography before the age of 50 is like assuming women who learn they have early or non-symptomatic breast cancer would take the bet their cancer will remain noninvasive and defer treatment. The lives of women in their 40’s with breast cancer who are not lucky enough to have a slow growing form of the disease should not be cast aside as statistically insignificant.

Risk tolerance varies from individual to individual. But the debate about screening for breast cancer begs the question: how many women would decide the benefit of the early diagnosis outweighs the risk of overdiagnosis? In a study conducted in Pittsburgh, PA, on questioning of over 1500 women between 40 and 59, 97% of women claimed a false-positive result would not deter them from continuing with regular screening and most would be willing to be recalled for non-invasive or invasive testing if it improved their chances of detecting cancer earlier. See Ganott M.A. Screening Mammography: Do Women Prefer a Higher Recall Rate Given the Possibility of Earlier Detection of Cancer? Radiology 238:3, 793-800 (March 2006). Interestingly, an article recently published in the Pittsburgh Post-Gazette discusses a recent study by the Pennsylvania Health Care Cost Containment Council and observations by a local physician and her colleagues of the increasing number of women choosing to undergo preventive mastectomies. Preventive mastectomies may represent only one end of the spectrum, but such a trend underscores how important it is for clinicians to make sure every patient has an opportunity to understand and make informed decisions about breast cancer screening.

It is extremely important that people recognize and understand the debate about screening mammography. Patients and their loved ones must stay informed about their options and the risks. Clinicians must fully inform their patients about the potential harms and benefits of screening before age 50 and at 1 or 2 year intervals. People trust their doctors to use their professional judgment and recommend the best care for a given condition. However, with the varied data and recommendations for breast cancer screening so dependent on the perceived physical and psychological harms of overdiagnosis, it is impossible to exclude the patient and their family from the equation. The true harm associated with screening mammography is measured on a personal level.

From a different perspective, Dr. Andrew Kaunitz offers a concise statement summarizing the recent NEJM study and how clinician could best address the uncertainty regarding which breast cancers will progress to advanced disease – http://www.medscape.com/viewarticle/775209.

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NEJM MAKES NO SENSE OF NEW CERVICAL CANCER SCREENING GUIDELINES

by Jerry Meyers on December 13, 2011

In the December 8th issue of the New England Journal of Medicine in the Perspective section, there appears an article, “Making Sense of the New Cervical Cancer Screening Guidelines,” by Dr. S. Feldman.  Dr. Feldman concedes that Pap smear sensitivity is poor, “roughly 50 to 60% [false negative].  She does not in her article explain the relatively poor sensitivity of the test but we can learn easily from other literature that a major contribution to the poor sensitivity of the test relates to improperly identified or interpreted smears.

 

While it is true that multiplying the frequency of smears increases the likelihood in spite of negligent readings that a cervical abnormality will be discovered while the disease is pre-invasive.  There is no study randomized and prospective which proves that.  Someone has simply picked out of a hat a frequency that they think is greater than needed and a frequency that is somehow lesser than needed and it comes to kind of a consensus that after age 21 every three years is frequent enough.

 

Cervical cancer is a very aggressive disease particularly in women who acquire the disease in their 30’s and 40’s.  No intelligent woman knowing she possessed a cervical abnormality would decide to wait three years to do something about it.  Where therefore does the pressure come from to reduce the frequency of looking?  Most women considered healthy to have their gynecologist see them annually and Pap smears are done at this annual exam.  Pap smears are relatively inexpensive.  Of course, even something that is inexpensive becomes expensive when you multiply it by 100,000,000.

 

On the other hand, if a lab is getting $25.00 to $30.00 for every Pap smear it screens and requires the cytotechnologists (not doctors)  who read the slides to read as many as 100 a day, one can see readily where the money is going.

 

I recently questioned during a deposition a cytotechnologist who had screened a slide with obvious severe abnormalities on it which she had in fact marked with screening dots.  She doesn’t know why she put the slide back in the box but she did.  She was having difficult times in her personal life which she had shared with her supervisors and others at the organization that was requiring her to perform as many as 96 screenings a day in spite of her obvious distraction.

 

While 4,000 to 5,000 women are needlessly dying of cervical cancer in the United States every year, cost efficiency is truly in the mind of the beholder.

 

In her article Dr. Feldman goes on to assert that HPV testing done with Pap smears, though recommended by the American Cancer Society every three years, is not recommended by anyone else including the United States Preventative Services Task Force.

 

It is well-know that women who are HPV positive are at much higher risk of developing cervical cancer in women who do not have this characteristic.  It is also well recognized that any sexual encounter with a new person, particularly if it is unprotected sex could result in the transmission of HPV.  Therefore, the fact that a person in a committed relationship is negative for ten years doesn’t mean that they are going to be negative for the next ten.

 

I keep on writing about this even though few hear what I have to say.  It is simply that I am tired of watching my clients die of cervical cancer that was preventable if a person had been allowed to spend more than eight minutes reviewing their slide or were willing to endure the further expense of subjecting the slide to HPV testing.  I wonder which committee of government or the prestigious professional organizations that direct these policies think they are in a position to decide what a woman’s life is worth.  Perhaps if they watched more women die of cervical cancer as has been my unfortunate experience, they would find that testing every year rather than every three and adding HPV testing is cost efficient.

 

What do you think?

 

Jerry I. Meyers

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Incidentaloma can make healthy people ill-especially if ignored!

July 23, 2010

Kevin Pho M.D. has written that a screening test incidentaloma can make healthy people ill.  This is a theme that appears too frequently in the medical literature. When I previously addressed this issue in a prior article it did not then occur to me that the argument might be used to impair patients receiving recommended screening. [...]

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