06 May 2010

Mammograms detect few breast cancers in women younger than age 40 and often lead to more tests and unwarranted anxiety because of false positives, according to a study published Monday in the Journal of the National Cancer Institute, Reuters reports.

For the study, radiologist Bonnie Yankaskas of the University of North Carolina-Chapel Hill and colleagues analyzed the medical records of 117,000 women ages 18 through 39 who received their first mammogram in 1995. After one year, no tumors were identified in women younger than age 25. In addition, 12.7 per 1,000 women ages 35 to 39 required additional tests after their mammograms detected a lesion, though very few had cancer, Reuters reports.

“In a theoretical population of 10,000 women aged 35 to 39 years, 1,266 women who are screened will receive further workup, with 16 cancers detected and 1,250 women receiving a false-positive result,” the study found. The study added that before a woman receives a mammogram, “[h]arms need to be considered, including radiation exposure because such exposure is more harmful in young women, the anxiety associated with false-positive findings on the initial examination, and costs associated with additional imaging.”

In an accompanying editorial, Ned Calonge of the Colorado Department of Public Health and Environment suggested that women younger than age 40 do not receive mammograms unless they detect a lump in their breast (Fox, Reuters, 5/3).

The age at which women should begin routine breast cancer screenings is a subject of debate among experts, the AP/Miami Herald reports (AP/Miami Herald, 5/3). In November 2009, the U.S. Preventive Services Task Force issued guidelines suggesting that most women should begin routine mammograms to screen for breast cancer at age 50, not age 40 as previously recommended. In setting the new guidelines, the experts weighed the benefits of early screening against the risks, including the chance that a mammogram could result in a false positive, prompting unnecessary treatments and stress (Women’s Health Policy Report, 11/17/2009).

In January, the American College of Radiology and the Society of Breast Imaging issued guidelines recommending that women with an average risk of breast cancer begin regular mammograms at age 40 and that women with an elevated risk begin screenings at age 30 (Women’s Health Policy Report, 1/5).

Reprinted with kind permission from http://www.nationalpartnership.org. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

© 2010 The Advisory Board Company. All rights reserved.

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04 May 2010

Screening mammograms in women under age 40 result in high rates of callbacks and additional imaging tests but low rates of cancer detection, according to a study published online May 3 in the Journal of the National Cancer Institute.

Many studies have assessed mammography in women over age 40 years, but little is known about its usefulness in younger women. Although screening mammograms are not generally recommended under age 40, about 29% of women between 30 and 40 report having had one.

To determine the accuracy and outcomes of mammograms in younger women, Bonnie C. Yankaskas, Ph..D., from the University of North Carolina at Chapel Hill, and colleagues, pooled data from six mammography registries around the country. Their study included 117,738 women who had their first mammogram between the ages of 18 and 39. The researchers followed the women for a year to determine the accuracy of the tests and their cancer detection rates. They analyzed data for both screening mammograms and diagnostic mammograms, which were performed because a woman had a warning sign or symptom, such as a lump.

No cancers were detected in women 25. Among the 73,335 women aged 35-39, the researchers found that screening mammograms had poor accuracy (sensitivity, specificity, and positive predictive value) and high rates of recall for additional tests. The cancer detection rate in this group was 1.6 cancers per 1,000 women.

For diagnostic mammograms, accuracy was better and the detection rate was 14.3 cancers per 1,000 women aged 35-39.

The authors conclude that in a theoretical population of 10,000 women having a screening mammogram between ages 35 and 39, 1,266 would be called back for further testing, 16 cancers would be detected, and therefore 1,250 women would have false positives.

In this population, they write, “our findings support a need for serious discussion about the appropriateness of mammography in women without the presence of symptoms.”

In an editorial, Ned Calonge, M.D., of the Colorado Department of Public Health and Environment, notes that this “landmark descriptive study should inform women and physicians and guide research efforts” on early detection in younger women. He emphasizes that even women in the study with a family history of breast cancer had the same detection and false positive rates as women without a known family history. This calls into question he says, the recommendation of some health groups that women with a family history start screening early.

He concludes that “the study by Yankaskas et al. is a powerful reminder that we must continue to strive for better tests and better treatments…..Furthermore, we should not be satisfied with better detection rates alone. We need evidence that early detection of these cancers translates to improvements in important health outcomes.”

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Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional. For more information, please read our terms and conditions.

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 Under pressure from doctors, some women’s groups and imaging equipment makers, lawmakers are likely to require coverage for more mammograms in health reform legislation than is currently recommended by the U.S. Preventive Services Task Force, the Wall Street Journal reports.

According to the Journal, many doctors’ and patients’ groups in recent years have formed alliances — such as sponsorships, joint events and endorsements — with companies that make mammography equipment. The groups and their corporate partners “swung into action” in November 2009 after USPSTF issued new guidelines suggesting that routine mammograms were not necessary for women in their 40s who have normal cancer risk, the Journal reports. USPSTF said the risks associated with annual mammograms — such as false positives, unnecessary treatment and low-level radiation exposure — could outweigh the benefits for many women in their 40s. The panel recommended that women ages 50 through 74 receive mammograms biennially.

The new recommendations “sowed unease and confusion,” including among major medical societies that disagree with USPSTF, the Journal reports. Advocacy groups stepped up lobbying, and their supporters “swamped lawmakers with angry calls and e-mails” urging them to guarantee access to mammograms under health reform legislation, the Journal reports.

The House in December 2009 voted 426-0 for a nonbinding resolution — named for Rep. Debbie Wasserman Schultz (D-Fla.), a breast cancer survivor — saying that insurers should not use the USPSTF recommendations to deny coverage for routine mammograms. The Senate adopted a similar amendment by Sen. Barbara Mikulski (D-Md.) to its health reform bill (HR 3590). Congressional aides say that a version of the amendment is likely to be in the final bill.

Meanwhile, a few women’s health groups that receive little or no corporate financing are standing behind the USPSTF guidelines. Fran Visco, founder of the National Breast Cancer Coalition, said, “The guidelines were always going to create a firestorm because they threaten some groups’ existence.” Adriane Fugh-Berman, a professor at the Georgetown University School of Medicine, said, “You have to ask if there’s a conflict of interest, because breast cancer advocacy has become big business.”

Sen. Chuck Grassley (R-Iowa) last month sent letters to 33 major not-for-profit groups requesting that they disclose their industry funding. The American Cancer Society said that it had received less than $1 million from screening device makers over the past five years, a sum that its spokesperson said is small compared with its more than $1 billion in annual revenue. The money does not influence ACS’ recommendations, the spokesperson added. Nancy Brinker — co-founder of Susan G. Komen for the Cure, which has received money through partnerships with GE — said the organization has always pushed for early detection (Mundy, Wall Street Journal, 1/12).

Reprinted with kind permission from http://www.nationalpartnership.org. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

© 2009 The Advisory Board Company. All rights reserved.

Here’s a quote from the article:

“Several years ago, the U.S. Preventive Services Task Force (PSTF) issued an updated set of recommendations about mammogram screenings, suggesting which and how often women should get them. Since the last time the group issued its recommendations in 2002, new study data emerged that has led to a few changes. Its new guidelines, suggesting that women over 40 only need a mammogram every two years, has led to a firestorm of criticism from professional and advocacy groups as well as politicians.”

To read this complete article click here.

The two techniques look at different things. Thermography looks at abnormal blood vessel formation, which is an early event in the life of a cancer. Mammography looks at masses (1 centimeter or larger) and calcification patterns, which are later developments.

Each has reliability in the recent literature of around 88 percent to 96 percent. Each misses tumors picked up by the other (perhaps as many as 10 percent). Mammography cannot visualize tiny tumors with new vessels, which show up on thermography. Conversely, tumors large enough to show up on mammography don’t always have thermographically abnormal vessels.

So, each technique is weak where the other is strong. The techniques are complementary. It is not a case of either one or the other.

One of the reasons for moving the starting age to 50 for mammograms was the vast number of negative breast biopsies for calcifications. I suspect, in my personal experience, I did 20 benign biopsies for calcification for every cancer we picked up. That is way too many, but abnormal calcifications are pretty common — and frequently benign.

Personally, I think the most prudent course for a woman to take is to get a baseline mammogram somewhere between the age of 40 and 50 (unless she has a high-risk family history, in which case earlier is better) to be reasonably sure larger lumps are not seen, and get a baseline thermography to look for early blood-vessel formation.

If both are negative, then follow with annual thermography looking for new vessel formation, with mammography every few years to look for solid lumps. Less frequent mammography means less radiation and mechanical pressure.

That regimen allows a woman to take advantage of the strengths of each technique without undue risks from radiation or unnecessary biopsy and, it seems to me, to maximize cost-benefit considerations.

— Robin A. Bernhoft, M.D., practices medical toxicology in Ojai.

Click here to read complete article at Cancer Decisions website.

Click here to view the article.

Women Have A Safe Alternative to Mammograms to Maintain Annual Screenings

For immediate release from the American College of Clinical Thermology.

 Women of all ages received good news with the recent revision of the government recommendations for screening mammography.  The US Department of Health and Human Services released their findings and recommendations that screening mammography should now be started at age 50 and performed bi-annually. Up until now, screening was recommended on an annual basis at age 40; this new recommendation has created renewed controversy as doctors have concerns about reducing the number of mammograms that would be clinically justified and indicated..  It takes years for most cancers to develop to the stage that they can be detected with mammogram or ultrasound (dense enough for location and biopsy) so Breast Thermography or Digital Infrared Thermal Imaging (DITI) is ideally placed as an alternative screening tool to identify changes over time in the ‘early’ development stages, before there is more advanced pathology that can be detected with other tests. If changes for the better are to be made, then the recent recommendations of the Preventative Services Task Force will establish the foundation of a more affective screening program which should integrate other types of safe testing.  Of the various testing options Breast Thermography or Digital Infrared Thermal Imaging (DITI) offers the most promise for screening the younger age group women.  

To understand the arguments and issues involved with the new recommendations, we need to understand the difference between ‘screening mammography’ and ‘diagnostic mammography’:

‘Screening’ mammography has been performed annually on healthy women from the ages of 40 to 70 and is aimed at identifying suspicious findings, which justify further investigation. ‘Diagnostic’ mammography is performed on patients who have one or more risk factors, clinical symptoms, or most commonly a palpable lump. There is little argument about mammography’s role as the ‘gold standard’ for

evaluating suspicious symptoms but the question was, can we still justify subjecting women without symptoms to ‘screening’ mammography ?  The answer was NO.

The federal department of health and human services  task force says that “the modest benefit of screening mammograms must be weighed against the harms… which are nearly cut in half when mammograms are performed every other year  but the benefits remain the same”. It needs to be pointed out that the recommendations of the task force are not intended for women at increased risk for breast cancer who should continue to be referred for diagnostic mammography by their doctors when appropriate, and on a case by case basis. It is interesting to note that The United States is currently the only country that routinely screens women below age 50 and extends its screening practice by taking two or more mammograms per breast annually in women over age 50. This contrasts with the more restrained European practice of a single view every two to three years. The evidence concludes that while there is a justifiable role for mammography to play in a breast cancer screening program that role is very different from the one currently in place.

For over 20 years Breast Thermography is being used increasingly  by women throughout the US, and it has been rapidly gaining acceptance by doctors as an additional tool in the early diagnosis of breast disease. FDA registered since 1984, Thermography is an adjunctive diagnosic test being offered by hundreds of clinics in all states. A list of certified thermography clinics can be found at the The American College of Clinical Thermology website at :   http://www.thermologyonline.org/Breast/breast_thermography_clinics.htm. Thermography is 100% safe, has no radiation, does not touch the breast, and only takes a couple of minutes. A positive or suspicious thermal study will indicate medical necessity for a mammogram, ultrasound or other tests. The thermal findings will increase the sensitivity and specificity of most other tests by targeting an area of the breast showing dysfunction and providing decision making information in women that would not have otherwise been tested.

Early detection is aimed at prevention and if early changes are detected then we have an opportunity to intervene and change the outcome. The earlier an abnormality is detected the better the treatment options will be, resulting in a better outcome. There are no contraindications for DITI, it is totally non-invasive, no radiation of any type, and no contact with the body so it can ‘do no harm’. DITI is positioned as the ideal screening test for women of all ages but particularly for the 30 to 50 age group. The best possible plan is to use every appropriate test adjunctively to get the highest detection rates without generating additional or unnecessary invasive testing. It would be unfortunate for a patient to forgo a necessary mammogram that was justified, and any decision should be made between the patient and her doctors based on individual history, symptoms and test results.

The principle of informed consent in medicine is ignored if women are not informed of the evidence relating to any risks of a test and if women more readily consent to annual mammograms because they have been given ‘misinformation’ this is as bad as obtaining consent by deliberately blocking valid information. Women are entitled to know the full range of responsible opinion about the benefits, the risks, and the many uncertainties of mammography.

The government task force are to be applauded for presenting the evidence for women and their doctors to be able to make better informed decisions about breast screening.

As reported, the scientific and medical evidence indicates that:

No ‘screening’ mammography is justified for women under the age of 50.

A baseline screening mammogram may be justified at age 50 and bi-annually thereafter.

Accountability and responsibility should be considered in regard to all radiation exposure and the accumulative biological effects.

Reducing ionizing radiation exposure from all other sources whenever possible should be practiced.

Up-to-Date and accurate information must be given to patients for informed consent.

Other non invasive tests should be promoted as part of a breast screening program.

Thermography, Ultrasound and MRI should be further explored, adapted and integrated.