Friday, February 5, 2016

What are the new breast cancer screening guidelines?


More is not always better

New breast cancer screening guidelines released by the U.S. Preventive Services Task Force are designed to balance mammography's benefits, that is, catching cancer early when it is easiest to treat, with its potential harms.
A new set of breast screening guidelines released beginning of 2016 from the U.S. Preventive Services Task Force. As with the guidelines released by the American Cancer Society October 2016, the Task Force guidelines are designed to balance mammography’s benefits (catching cancer early, when it is more treatable) with its potential harms: unnecessary biopsies, false positives that can freak women out, and over-diagnosis — leading to over-treating women who don’t actually have a deadly or dangerous form of the cancer.

For women overwhelmed with recommendations regarding their breast health, there’s good news: the two sets of guidelines — both of them geared towards average-risk women with no symptoms — have more in common in their latest iteration than ever. In a nutshell, both the Task Force and the ACS are leaning towards a “less is more” philosophy with regard to mammography, with the Task Force opting for a little less screening than the ACS. 

Here’s a quick breakdown of the Task Force’s finalized guidelines:

* Women 50 to 74 years old should get mammograms every other year (the ACS suggests yearly exams for woman ages 45-54 and exams every other year after that).
* If women want to start getting mammograms every other year at age 40, they are welcome to do so. The ACS’s guidelines are cool with that, too, although they recommend mammograms every year for younger women. Again, both organizations acknowledge the importance of individual choice.
* There’s not enough evidence to know if mammograms after age 75 are more beneficial or more harmful overall. (The ACS suggests women continue to get mammograms as long as their health is good and they have a life expectancy of 10 years or longer.)
* There’s also not enough evidence to make a recommendation for the use of 3D tomosynthesis instead of regular 2D mammography for breast screening, or to make a recommendation about using additional screening like ultrasound, MRI, 3D tomosynthesis, etc., for women with dense breasts. The ACS didn’t make any recommendations regarding 3D tomosynthesis or additional breast screening for dense breasts.

In 2009, the Task Force first recommended that mammograms start at age 50 rather than 40, spurring a heated national debate and prompting Congress to pass legislation ensuring mammograms would still be covered by insurance if women got them starting at age 40.

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'Tailored screening'

Dr. Janie Lee, director of breast imaging at Seattle Cancer Care Alliance, said the new Task Force guidelines are similar to the 2009 version, but take a more “nuanced” view of individual women’s decisions, emphasizing the need for a more “tailored breast cancer screening based on risk and patient values.” 

“This update brings the recent recommendations of the [Task Force] and of the American Cancer Society closer together than they were in 2009,” she said. “It’s a tremendous step forward to recognize that the best screening option may be different from one woman to another. It reflects a shift away from a ‘one size fits all’ approach.”

Lee said the new guidelines confirm that regular screening with mammography saves lives and also recognize that a woman’s values will influence what is the best decision for her. In 2009, the emphasis was on the greater benefit for women in their 50s and 60s, she said, compared to women in their 40s.

“Now the [Task Force] also recognizes that when women are making decisions about when to start screening, the women who focus most on receiving the benefits of screening will choose to start earlier, perhaps in their 40s, or to screen annually after they begin screening,” she said.

Generally speaking, breast cancers in premenopausal women tend to be more aggressive and faster growing, while those found in older women, past menopause, are slower-growing.  So women, particularly those in their 40s and early 50s, have to weigh for themselves what’s most important to them. Screen early and often and there’s a better chance they’ll catch a cancer early (the benefit); unfortunately, they’ll also bump up their chance of false-positive biopsies and overtreatment (the harm).

Dr. Julie Gralow, a clinical researcher with Fred Hutchinson Cancer Research Center and breast cancer oncologist at SCCA, the Hutch’s treatment arm, emphasized that both sets of guidelines are designed for average-risk women.

“They’re irrelevant for people with a strong family history of cancer, who’ve already had breast cancer, who’ve had biopsies that show something that could lead to breast cancer or who’ve had radiation to treat something like lymphoma,” she said.

Gralow, as well as SCCA, follows the American Cancer Society’s approach of annual mammograms from age 45 to 54 with screening every other year after that.

Dr. Christoph Lee, an SCCA radiologist and public health researcher with the Hutchinson Institute for Cancer Outcomes Research, said the new approach taken by the two sets of guidelines stems from a better understanding of both the benefits and harms of mammography.

“Everyone agrees that screening mammography saves lives but what’s becoming more and more apparent is that for a minority of women, screening mammography also causes some harm,” he said, citing false positives, biopsies, overtreatment and increased radiation exposure from additional and unnecessary mammography.

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Another reason 'less is more'

And according to a new modeling study published in January 2016 in the journal Annals of Internal Medicine by Lee and others, too many mammograms could put certain women at a slightly elevated risk for breast cancer.

Researchers from SCCA, the University of California Davis School of Medicine, the Group Health Research Institute in Seattle and other institutions, used simulation models for breast cancer risk from radiation exposure to estimate how many women could get radiation-induced breast cancer from a variety of screening approaches — including mammography.

So, what is the bottom line?

Digital mammograms posed a very small risk for most women, and the benefits of screening still outweigh the risks. Screening annually starting at age 40 — as past guidelines had recommended — prevents 968 breast cancer deaths for every 100,000 women and is projected to induce 16 deaths from radiation-induced cancer, their model found. Starting regular screening mammograms every other year at age 50, as the new Task Force guidelines recommend, would drop the risk for those extra cancers fivefold.

Lee said it all had to do with the amount of radiation the women received.

“Think about it logically,” he said. “If you start having mammograms later or you screen less often, you’re exposed to less radiation so there’s less radiation-induced cancer.”

The risk of radiation-induced breast cancer was also slightly higher for women with larger breasts and those with breast implants. While most women get four images taken per mammogram, women with larger breasts may require more to cover the entire area.

Although the research team didn’t explicitly set up a modeling scenario for women with breast implants, Lee said these women receive “double the amount of projections and views during mammograms as the average woman” so were also at potential risk.

However, he also emphasized the overall safety of the screening procedure.

“Mammography is a very safe technology,” he said. “We’re well under the limit set by the government for maximum threshold for radiation exposure even with additional views. This should not be a large concern for women.”

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Change in your breast? Get it checked out!

Although safe, the experts agreed that mammography was imperfect.

“It’s the best tool we have but it’s far from perfect,” said Gralow. “We do need better screening methods and we also need to figure out how to diagnose the aggressive breast cancers where it does matter and back off the quiet ones [such as some ductal carcinomas in situ, a noninvasive form of breast cancer] where it’s never going to be a problem.”

Gralow and Drs. Christoph and Janie Lee also stressed how crucial it was for women to discuss the various screening options with their health care providers. Equally important: being breast-aware.

“No one knows your breasts and your body better than yourself,” said Gralow. “So if you find anything worrisome — a lump, a thickening of the skin, a spot where the skin looks a little puckered, anything weird in the armpit or the nipple — get it checked out right away. That is one way to get early detection of breast cancer. Mammography isn’t the only way.”

Breasts Self-Check

Adult women of all ages are encouraged to perform breast self-exams at least once a month. Johns Hopkins Medical center states, “Forty percent of diagnosed breast cancers are detected by women who feel a lump, so establishing a regular breast self-exam is very important.”

While mammograms can help you to detect cancer before you can feel a lump, breast self-exams help you to be familiar with how your breasts look and feel so you can alert your healthcare professional if there are any changes.

How Should A Breast Self-Exam Be Performed?

1) In the Shower
Using the pads of your fingers, move around your entire breast in a circular pattern moving from the outside to the center, checking the entire breast and armpit area. Check both breasts each month feeling for any lump, thickening, or hardened knot. Notice any changes and get lumps evaluated by your healthcare provider.

2) In Front of a Mirror
Visually inspect your breasts with your arms at your sides. Next, raise your arms high overhead.

Look for any changes in the contour, any swelling, or dimpling of the skin, or changes in the nipples. Next, rest your palms on your hips and press firmly to flex your chest muscles. Left and right breasts will not exactly match—few women's breasts do, so look for any dimpling, puckering, or changes, particularly on one side.

3) Lying Down
When lying down, the breast tissue spreads out evenly along the chest wall. Place a pillow under your right shoulder and your right arm behind your head. Using your left hand, move the pads of your fingers around your right breast gently in small circular motions covering the entire breast area and armpit.

Use light, medium, and firm pressure. Squeeze the nipple; check for discharge and lumps. Repeat these steps for your left breast.

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What Should I Do If I Find a Lump?

See your health care provider if you discover any new breast changes. Conditions that should be checked by a doctor include:
* An area that is distinctly different from any other area on either breast.
* A lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle.
* A change in the size, shape, or contour of the breast.
* A mass or lump, which may feel as small as a pea.
* A marble-like area under the skin.
* A change in the feel or appearance of the skin on the breast or nipple (dimpled, puckered, scaly, or inflamed).
* Bloody or clear fluid discharge from the nipples.
* Redness of the skin on the breast or nipple.

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