On breast cancer screening. Guest post by Dr. Elaine Schattner
Mammography screening. Should you? Or shouldn’t you?
A few weeks ago, I received a letter in the mail from the clinic where I get my mammography. Rather than the expected ‘all is fine,’ the clinic was requesting that I call to schedule another screening due to abnormal findings. Not only was this not the way that I wanted to receive news that something might be wrong, but, I opened the letter at 4 pm on a Friday afternoon, giving me little time to get over the initial shock and then get on the phone to see if I could learn a bit more before the clinic closed for the weekend.
Mammography screening has been in the news quite a bit over the past year, with lines being drawn between experts who say that screening doesn’t save lives and women who want their mammograms regardless of the facts. I happen to fall on the latter side of the aisle and while I suffered a lot of anxiety before I had a second screening, not knowing would have been even worse. (FYI – it turned out fine.)
Recently, my friend Dr. Elaine Schattner, a trained oncologist, hematologist, educator and journalist, wrote about a new review that I believe that every woman should read before deciding whether or not to have a mammogram. It puts some of the controversy into perspective and also provides a much more balanced viewpoint on the risk-benefit ratio. And rather than reinvent the wheel, I asked Elaine if I could re-run the post on Flashfree. Please share it far and wide; it’s important.
With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography.
The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem:
Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)
On screening:
The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained….
She breaks down the data for mammography by age groups:
For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There’s a consensus that screening isn’t appropriate for women with serious coexisting illnesses and a life expectancy of less than 5–10 years.
For those between the ages of 40–49, Warner challenges the revised 2009 USPSTF recommendationson several counts. She critiques those authors’ weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers:
…However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained.”
What I like about Warner’s analysis, besides its extreme attention to details in the data, is that she’s not afraid to, at least implicitly, assign value to a procedure that impacts a young person’s life expectancy relative to that of an older person.
She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).
The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.
In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history):
…Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There’s about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding.…
In my opinion (ES) this is key – that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.
About the author…Dr. Elaine Schattner is a trained oncologist, hematologist, educator and journalist who writes about medicine. Her views on health care are informed by her experiences as a patient with scoliosis since childhood and other conditions including breast cancer. Elaine is a Clinical Associate Professor of Medicine at Weill Cornell Medical College in New York City where she teaches part-time. Her blog, Medical Lessons, is geared towards dissecting and providing commentary on how healthcare news is comunicated in order to foster learning and help bridge the gap between patients and doctors.
Cancer…it’s still personal
Two years ago, I wrote a post about breast cancer and the fact that it was personal. Very personal. I want to share a portion of that post today and also add a few thoughts. The reason? It’s personal. Again.
Location: Department Store dressing room stall. Circa: late 1960s, early 1970s.
The characters: Me and my mom.
Scene: She is covering herself as she removes her shirt. I notice the scars. Lots of scars….to the side of one breast. I meet her eyes and she meets mine. Then I learn what the term ‘ breast cancer’ means.
My mother was diagnosed with breast cancer when she was 30. Thirty. Even today, less than half of women under the age of 40 are likely to develop breast cancer and the majority of cases are diagnosed after the age of 50. So, imagine the shock. What’s more, imagine the time. 1960… when breast cancer awareness wasn’t at the fore and people didn’t discuss it, when breasts and surrounding muscle were literally hacked off rather than carefully removing the tumor with clean margins, when many men left their wives after they became disfigured.
My dad didn’t leave. And my brother learned about it through a ‘friend’ in school who was teasing him.
I’ve spoken to my mother about her cancer, about the fear of it returning, and about how she feels about not being able to wear sleeveless tops or strengthen/firm those muscles even though she has exercised regularly her entire life. How she felt when my brother came home from school and asked her about it. How she feels now when a friend is diagnosed with cancer. Her answer is always pretty much the same.
But cancer can return. And even though this time it’s not in her breast, it looks like she’s may go down that road…again. And my heart is breaking. Because the fear in the tone of her voice says more than any words can.
She is afraid.
I don’t blame her. I would be afraid too.
Only this time? She’s 80, not 30 and although she’s tough as nails and very, very active, cancer has an insidious nature, sometimes too insidious. And even though in my heart of hearts I believe that she will be fine, I still feel awful about it.
In the past two years, I’ve had two friends who’ve been diagnosed with breast cancer, not for the first but second time. Recently, another close friend developed a very rare form of cancer and despite its severity, emerged in one piece and better than ever. Others in my life are four-, five-time survivors. Hell, even my dad has had bladder cancer since the early 90s. People survive. People move on with their lives. And yet sometimes, we lose people that we love.
Although it may be too early for a Mother’s Day post, it’s never too late to let someone know how you feel about them.
So Mom?
Thank you. The relationship has been a difficult one for most of our lives, threatened by personality and character and actions and words. Often, this road has not been an easy one. But you brought me into this life and I want you to know that despite all, the forks we’ve taken to get to this place have converged and our road is paved with mutual love and respect. I. Love. You. That is all.
And the cancer, I am not certain of the outcome this time. But I am certain of one thing: a mother’s love, and my mother’s love, is one of the most important gifts.
This one’s close to the bone. It’s close to my heart. It’s personal.
Read MoreEstrogen: Worth the risk?
Any regular reader of this blog knows that I am not a fan of hormone replacement therapy (HRT) nor the health risks associated with it. Nevertheless, although I espouse alternative strategies for dealing with menopause, I do feel that sharing news about HRT is important; accurate information leads to informed and shared decisionmaking.
So, do they (i.e. hormones) or don’t they (cause harm)? Undoubtedly, important variables come into play, including current age, how close to menopause hormones are started, current health status, whether or not a woman has had a hysterectomy, smoking history, etc. Also important is whether estrogen is used alone or in combination with progesterone. And yet despite these factors, many medical organizations continue to recommend that HRT be used for the shortest time period possible if at all.
Still, researchers continue to delve into data from the now infamous Women’s Health Initiative Study to tease out the bad, ugly and even the good.
This week, they are reporting on over 7,600 women who had taken estrogen alone for approximately 6 years, had had prior hysterectomies and were followed for an average of 10 years after the trial ended. If you recall, there has been some controversy as to whether or not estrogen alone is safer than combined HRT and actually lowers the risk for breast cancer in particular, which is why these data are particularly intriguing.
The researchers report that age at the time that hormone therapy (in this case, estrogen alone) is started is important. In fact, women who started estrogen therapy in their 50s, an increased risk for stroke and embolism, which appeared while taking estrogen, actually disappeared in the years that followed. Unfortunately, so did protection against hip fracture. Moreover, earlier reports of a decline in breast cancer risk were upheld despite body mass indices. However, the researchers say that this finding in particular, runs contrary to the preponderance of evidence from the majority of observational studies which show that estrogen use increases the risk of breast cancer, especially in lean women and after a long time period of use.
In an accompanying editorial, also in JAMA, the authors point out that more than 80% of women who took estrogen as directed only used it for an average of 3.5 years. Their point is that the results don’t directly address the “balance of risk and benefits associated with longer term estrogen use.” They also point to a larger review of data that show duration is an important factor when it comes to breast cancer risk, especially among lean women. Additionally, they say that tamoxifen, which actually antagonizes estrogen, has been shown to reduce breast cancer by 50%, which has led the International Agency for Research on Cancer to “conclude that unopposed estrogen therapy and combination HRT are carcinogenic.”
Are you confused yet?
Both set of researchers say that the decision to use estrogen or not is one that should be made between a woman and her doctor. Don’t forget: study findings continue to contradict. They add that while “there may still be a role for short-term use of unopposed estrogen for treating some women with menopausal symptoms, this role may be vanishing as existing and emerging data continue to be better understood in terms” of patients.
My thoughts? Err on the side of caution. Always.
Read MoreWednesday Bubble: Holy Hot Flash Menopause Woman!
Bet you never thought you’d hear holy and hot flash in the same sentence! However, it appears that menopausal hot flashes, those bothersome, sweat inducing, embarassment producing, change of clothing inducing symptoms might actually deliver something better than a whole lotta dread. And so, dear readers, after the bad breast cancer news that I delivered on Monday, I’m happy to report some good!
You mean I WANT hot flashes? Well not exactly. But there sure is a interesting paradigm hidden somewhere in the diminishing returns of estrogen, that is, severe, wake you in the middle of the night or interrupt your meeting hot flashes might actually reduce risk for invasive breast cancer.
As we know all too well, menopausal symptoms often occur as estrogen and progesterone levels fluctuate and the ovaries cease to function reproductively. However, utilizing data culled from a study whose original intent was to evaluate the link between hormone therapy and risks of different types of breast cancer, researchers have actually uncovered some positivity! In this study, women between the ages of 50 and 74 were randomly selected based on confirmed invasive breast cancer and then matched by age to healthy women. All were interviewed about their reproductive history, menstruation/menopause history, use of hormones, BMI, medical history, family history of cancer and use of alcohol. They were also asked specifically about their experience with menopausal symptoms, including hot flashes, night sweats, vaginal dryness, bladder issues, irregular menstruation, depression, anxiety, emotional distress and insomnia and requested to rate them based on their frequency and severity.
Interesting enough, women who reported menopausal symptoms had a 40% to 60% lower risk of the type of invasive breast cancer that starts in the milk ducts (i.e., invasive ductal carcinoma or IDC) and invasive breast cancer that starts in the glands at the end of the milk ducts (i.e. invasive lobular carcinoma or ILC). Moreover, reduced risk for these cancers as well as the mixed ductal/lobular type was especially pronounced among women who experienced hot flashes with perspiration or whose hot flashes woke them up compared to women who had hot flashes without perspiration or others symptoms with awakening during the night.
The researchers say that they believe that menopausal symptoms may be markers for hormonal changes that precipitate breast cancer. In other words, pronounced the changes in reproductive hormones may actually be related to breast cancer risk. Less clear are the direct connections between individual symptoms and risk. However, they noted that the relationship between symptoms and risk did not change when hormone use, age when menopause began or BMI were factored into the equation.
Clearly, this is only one study so no firm conclusions can be drawn, at least not yet. But with all the bad news about hormone therapy and breast cancer risk, it’s heartening to learn that the hormones that are wreaking havoc on our lives may actually be protecting us from harm.
Holy hot flash indeed!
Read MoreHormone replacement therapy…timing is everything, right?
Hormone replacement therapy (HRT) continues to be a hot topic in the menopausal world. And no wonder! Because the deeper we dive into the controversies, the more information we seem to learn about its dangers.
If you search for hormone replacement or HRT on this blog, you’ll find that the dialogue has nothing but consistent. And while naysayers may try to accuse me of a personal vendetta against hormones, it’s actually not the case. I started Flashfree for several reasons, the most important being that I wanted to provide enough information about menopause and aging and treatment strategies to enable women to think on their feet, consider the facts and have intelligent dialogues with their peers and practitioners before making any decisions that could affect their health and wellbeing as they grow older. Moreover, although I am a strong proponent of alternative strategies to combat the unpleasantries of dwindling hormones, I still believe strongly in the benefits of certain Western approaches to treating illness. However, I also a strong believer in integrative strategies that combine the best of our knowledge in an individualized fashion; my mantra is ‘treat the individual, not the masses.’ Hence, when I read about the history of the menopause in general and HRT in particular, what I see is disease mongering at its finest, examples of fear and loathing and mostly, a disrespect of women. And I care too much about women’s health to remain silent.
Last Friday, several of my colleagues sent me a link to the following study:
“Breast cancer risk in relation to the interval between menopause and starting hormone therapy.”
This newly-published study in the Journal of the National Cancer Institute is one of the largest to date since the findings of the now infamous Women’s Health Initiative (WHI) study linking Preempro to breast cancer. In it, investigators used observational information culled from over a million postmenopausal women in the United Kingdom to determine how type and timing of hormone therapy might influence the risk of developing breast cancer.
A bit of context is necessary for those of you who are unfamiliar with the major criticisms of WHI, namely that that the women studied were not representative of the normal menopausal population, were older, started hormone therapy later in life (i.e. >5 years from when menopause started) when their risks for disease were greater, and that the type of hormone replacement, namely the progestin component, were not taken into consideration. WHI was also criticized for not focusing on the small percentage of women in the study who took estrogen-only and were not at greater risk for breast cancer. (If you want to read more about that particular issue, check out the write up on data presented at this past year’s San Antonio Breast Cancer Conference.)
In the UK study, the average age of participants was 56.6, considerably younger than the study population in WHI. More than half (55%) of participants reported having used hormones at some point and 35% were current users, and the rest, had never used hormone therapy. Study participants were matched by socioeconomic status, childbirth information, BMI, physical activity, alcohol consumption and smoking to insure that these factors did not influence the study findings.
Overall, 15,759 breast cancers developed and were diagnosed approximately a year and a half after the last point of contact:
- Despite contentions by some experts that starting combination hormonal therapy within 5 years of menopause is safe, women between the ages of 50 and 50 who began HRT less than 5 years after menopause had the highest rates per year of breast cancer — .61% per year — that twice that of women who had never used hormones (.31%).
- Current users of estrogen also demonstrated increased breast cancer rates (.43%) who started hormones within or less than 5 years after menopause started.
- The risk of developing breast cancer was roughly 1.5 times higher among women on combination hormone therapy who started within 5 years than women who started 5 year or more from menopause.
- The risk of developing breast cancer among past users of hormonal therapy tended to decline over time after use of hormones stopped, and within 14 years, were almost equivalent to never users.
Mind you, the study is not without fault and may be criticized on the basis of the fact that it relied on observational information rather than randomized controlled results. In other words, data were collected and then analyzed based on what they inferred. The research might also be questioned due to the fact that information about use of hormones was reported over a year before cancer was diagnosed, thereby possibly leading to mischaracterization of hormone users/non users and estimates of the risk for developing breast cancer. Nevertheless, the researchers say that taking these factors into account, breast cancer risk among hormone users regardless of type, would have increased by a factor of at least 1.2.
The key take-away message from this new study is that it’s may be impossible to define the safest parameter for using hormone therapy. For certain women, HRT may never be safe. For others who are willing to risk life-threatening conditions for fewer hot flashes, HRT may be worth the gamble. As always, ask the hard questions.
Timing is everything, right? Maybe not when it comes to hormone replacement.
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