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.
'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.
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.”
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.
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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