Is Personalizing Mammogram Screening the Way to Go?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

I read the LA Times article by Shari Roan, Study urges more individual mammogram guidelines, with interest.  As Roan notes, guidelines to date have mainly focused on a woman’s age and not her other risks factors.

The American Cancer Society recommends that healthy women undergo screening mammograms every one to two years beginning at age 40 regardless of risk factors. In 2009, the U.S. Preventive Services Task Force recommended a different schedule which urged the inclusion of an individual’s personal risks:  screening for women ages 40 to 49 should be based on individual risk factors and women ages 50 to 74 should be screened every two years.

Monday, a paper was published in the Annals of Internal Medicine (full reference below) which argues for a more personalized approach to screening mammograms.

The study by Dr. Steven R. Cummings, senior author and senior researcher at the California Pacific Medical Center Research Institute, and colleagues was based on a computer model comparing the lifetime costs and health benefits for women who got mammograms every year, every two years, every three to four years or never.

The researchers concluded that “Annual mammography was not cost-effective for any group, regardless of age or breast density.”

They also note that “Mammography is expensive if the disutility of false-positive mammography results and the costs of detecting nonprogressive and nonlethal invasive cancer are considered.”

I find it interesting that the major limitation of the paper noted by it’s authors is that the results are not applicable to carriers of BRCA1 or BRCA2 mutations.   This is a group of women who has a major risk factor for developing breast cancer, yet “personalization” of screening mammograms might not work for them.  Why not?  Might not personalization for this group involve more frequent rather than fewer mammograms?

I personally like the idea of individualizing the screening schedule, rather than one-size fits all.  It is why I have embraced the U.S. Preventive Services Task Force recommendations. 

Related posts:
New Breast Cancer Screening Guidelines (November 17, 2009)
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision (December 15, 2010)

REFERENCES

1.  Personalizing Mammography by Breast Density and Other Risk Factors for Breast Cancer: Analysis of Health Benefits and Cost-Effectiveness; John T. Schousboe, Karla Kerlikowske, Andrew Loh, and Steven R. Cummings; Ann Intern Med July 5, 2011 155:10-20

2.  To Screen or Not to Screen Women in Their 40s for Breast Cancer: Is Personalized Risk-Based Screening the Answer? (Editorial); Jeanne S. Mandelblatt, Natasha Stout, and Amy Trentham-Dietz; Ann Intern Med July 5, 2011 155:58-60

USPSTF Breast Screening Guidelines Pushback

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

The question continues as to when breast screening should begin.  The current pushback comes from radiologists Dr. Mark Helvie of the University of Michigan Health System and colleague Dr. Edward Hendrick of the University of Colorado.

The two researchers have published an article (full reference below) in the February issue of the American Journal of Roentgenology questioning the U.S. advisory panel’s breast cancer screening guidelines and suggesting the panel ignored scientific evidence that more frequent mammograms save lives.

For the article, the two conducted a review of the risk models used by the U.S. Preventive Services Task Force (USPSTF) to issue controversial breast screening guidelines in 2009.  They used Cancer Intervention and Surveillance Modeling Network modeling to compare lives saved by different screening scenarios and the summary of evidence prepared for the USPSTF to estimate the frequency of harms of screening mammography by age.

As a reminder, the USPSTF 2009 breast screening guidelines recommend:

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.  (Grade: B recommendation)
• The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.  (Grade: C recommendation)
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (Grade: I Statement)
• The USPSTF recommends against teaching breast self-examination (BSE). (Grade: D recommendation)
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.  (Grade: I Statement)
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. (Grade: I Statement)

 

Helvie and Hendrick analysis found that having annual mammograms from age 40 saved 64,889 more lives with the current 65% compliance rate.

They found that getting a yearly mammogram from age 40 cut a woman’s risk of fatal breast cancer by 71% versus the 23% reduction for women who followed the USPSTF recommendations.

The two researchers state, “The potential harms of a screening examination in women 40–49 years old, on average, consist of the risk of a recall for diagnostic workup every 12 years, a negative biopsy every 149 years, a missed breast cancer every 1,000 years, and a fatal radiation-induced breast cancer every 76,000–97,000 years.”

The two researchers feel the advantages of yearly mammograms starting at age 40 years outweighs the potential harms of screening.

I think perhaps they should read Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision

……..So, going back to the 10,000 women we are screening, of 9,900 who do NOT have cancer (remember that only 100 can have a true cancer), 10%, or 990 individuals, will still be diagnosed as having cancer. So, tallying up all of the positive mammograms, we are now faced with 1,070 women diagnosed with breast cancer. But of course, of these women only 80 actually have the cancer, so what's the deal?  ……….

 

Related posts:
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)

Source

Hendrick, R. Edward, Helvie, Mark A.; United States Preventive Services Task Force Screening Mammography Recommendations: Science Ignored; Am. J. Roentgenol. 2011 196: W112-116

New Breast Cancer Screening Guidelines

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Yesterday,  the U.S. Preventive Services Task Force’s announced it’s new recommendations for Screening for Breast Cancer (November 2009).  The uproar has been loud and mostly against. 
The summary of the USPSTF’s recommendations:

• Recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
• Recommends biennial screening mammography for women aged 50 to 74 years.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
• Recommends against teaching breast self-examination (BSE).
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

If you recall some of the recent discussions regarding over-diagnosis  of breast cancers and the resulting harm done by the increased radiation, biopsies, and surgeries then it is easier to understand the task forces conclusions.  There has been an estimated 52% over-diagnosis of breast cancer in a populations of women who are offered organized mammography screening.  That amounts to one in three breast cancers being over diagnosed.

My personal feeling is that anyone with a family history of breast cancer should begin getting mammograms at 10 years earlier than the age when their mother was diagnosed with breast cancer.  There will always be “outliers” like the 10 year girl diagnosed with breast cancer. 

I do not agree with not teaching breast self-examination.  I think every woman/man should be familiar with their bodies.

Here are links to some of the responses to the USPSTF’s recommendations.  Some of the comments are as enlightening as the stories.

• Response of The American College of Obstetricians and Gynecologists to New Breast Cancer Screening Recommendations from the U.S. Preventive Services Task Force, November 16, 2009
• M. D. Anderson Maintains Mammogram Recommendations, November 16, 2009
• Will patients accept the new, evidence-based, breast cancer screening guidelines? by KevinMD, November 17, 2009
• Does number needed to treat help with rational decision-making? by Marya Zilberberg, November 17, 2009
• Panel Puts Off Mammography until Age 50; MedPageToday, November 16, 2009
• Mammography Screening: Are the New Guidelines Rationing by Dr Susan Love, November 16, 2009
• USA TODAY Forum: Breast cancer survivors sound off on new mammogram advice, moderated by @LizSzabo
• Susan G. Komen for the Cure® Recommends No Impediments to Breast Cancer Screening, November 16, 2009
• Breast Self-Examinations: What’s Wrong With Them? by Shirley S. Wang; Wall Street Journal Blog; November 16, 2009
• Breast-Screening Advice Is Upended by Shirley S. Wang, Wall Street Journal, November 17, 2009

Mammograms

 Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

Last October, I wrote this post on Mammograms.  I am reposting it today.

First, please, refer to my post on breast self-exam. It is important to do your monthly self-exam. It is important to do it properly. Also, check out this article on breast changes during your lifetime that are not cancer from the National Cancer Institute.
Mammography is a low-dose x-ray system to examine breasts. A mammography exam, commonly known as a mammogram, is used to aid in the diagnosis of breast diseases in women. Mammograms are used for both screening and diagnosis. (normal, credit)
Screening Mammogram
Mammography can show changes in the breast up to two years before a patient or physician can feel them. Cure rates are much higher when the breast cancer can be found at this stage. Current guidelines from the U.S. Department of Health and Human Services (HHS), the American Cancer Society (ACS), the American Medical Association (AMA) and the American College of Radiology (ACR) recommend screening mammography every year for women, beginning at age 40.
The National Cancer Institute (NCI) adds that women who have had breast cancer and those who are at increased risk due to a genetic history of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and about the frequency of screening.
Diagnostic Mammogram
Diagnostic mammography is used to evaluate a patient with abnormal clinical findings—such as a breast lump or lumps—that have been found by her or her doctor. Diagnostic mammography may also be done after an abnormal screening mammography in order to determine the cause of the area of concern on the screening exam.
Important Things to Know and Do Prior to Mammogram
Before scheduling a mammogram, discuss any new findings or problems in your breasts with your doctor. At the time of the mammogram, inform the radiologist (or the techs) of any prior surgeries, hormone use, and family or personal history of breast cancer. Try not to schedule your mammogram for the week before your period if your breasts are usually tender during this time. The best time for a mammogram is one week following your period. Always inform your doctor or x-ray technologist if there is any possibility that you are pregnant.

• Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots.
  
• If possible, obtain prior mammograms and make them available to the radiologist at the time of the current exam. Or try to use the same facility each year so they will already have prior mammograms.
  
• Ask when your results will be available; do not assume the results are normal if you do not hear from your doctor or the mammography facility. Make sure you state who should get a copy of your mammogram results--family doctor, general surgeon, oncologist, plastic surgeon, etc.
  

What a Mammogram Can Show
The radiologist will look at your x-rays for breast changes that do not look normal. The doctor will look for differences between your breasts. He or she will compare your past mammograms with your most recent one to check for changes. The doctor will also look for lumps and calcifications.

• Lumps (or "mass")--The size, shape, and edges of a lump sometimes can give doctors more information about whether or not it is cancer. A growth that is benign often looks smooth and round with a clear, defined edge. On the other hand, breast cancer often has a jagged outline and an irregular shape. (benign lump, photo credit)
  
• Calcifications--A calcification is a deposit of the mineral calcium in the breast tissue. Calcifications appear as small white spots on a mammogram. There are two types:
  

1. Macrocalcifications are large calcium deposits often caused by aging. These are usually not cancer.
2. Microcalcifications are tiny specks of calcium that may be found in an area of rapidly dividing cells. If they are found grouped together in a certain way, it may be a sign of cancer. (photo credit)

Depending on how many calcium specks you have, how big they are, and what they look like, your doctor may suggest that you--1) have a different type of mammogram that allows the radiologist to have a closer look at the area, 2) have another screening mammogram, usually within 6 months, or 3) have a biopsy done.
Mammograms are not perfect, but are currently the best method to find breast changes. If your mammogram shows a change in your breast, sometimes other tests will be needed to better understand it. These follow-up tests include ultrasound or more mammograms views. The only way to find out if an abnormal result is cancer is to do a biopsy. It is important to know that most abnormal findings are not cancer.
References

• Mammography--RadiologyInfo
• Mammograms--National Cancer Institute
• Mammograms in Women under 50--TBTAM
• MRI Urged for High Breast Cancer Risk--WebMD