Monday, October 18, 2010

October serves as a reminder to schedule your breast cancer screening

October began turning pink for breast cancer awareness more than 25 years ago. A lot has changed in that time. October is now not only about awareness of this disease. It is about raising money to find/fund a cure or in the words of Dr. Susan Love, not to find a cure but to find the causes so that we can prevent breast cancer in the first place. October is also for reminding women to schedule their breast cancer screening because early detection saves lives. We are all in favor of the reminder to women to schedule their breast screening. But what kind of screening? There is increasing confusion about when women should begin screening and what type of screening they should have.

Part of the confusion comes from the change in screening mammography recommendations from the United States Preventive Services Task Force (USPSTF) in November 2009. The USPSTF no longer recommends regular screening mammograms for average-risk women between the ages of forty and forty-nine. Much of the confusion over these new guidelines stems from an assumption that they advise against mammography in all average-risk women in their forties, which is not the case. Rather, the USPSTF urges women who have risk factors for breast cancer, including a first-degree relative with breast cancer or a personal history of abnormal breast changes, to continue to work with their doctors and do appropriate mammography screening, even in their forties.

The mammography controversy is not a new one, despite the headlines of the past year touting it as such.  If you are interested in a detailed and thorough review of the research and the politics behind mammography screening recommendations check out Understanding the Mammography Controversy: Science, Politics, and Breast Cancer Screening by Madelon L. Finkle. Nonetheless, various groups including the American College of Radiology, the American Cancer Society, and Susan G. Komen for the Cure still recommend that women in their forties have annual screening mammograms to check for breast cancer.  The American College of Radiology points to a recent Swedish study that find the death rate in women ages 40 to 49 is reduced by one-third by use of screening mammography.

Another part of the confusion comes from the plethora of other breast screening modalities available, which range from the well established to the experimental to the unproven. We devoted an entire chapter of Positive Results: Making the Best Decisions When You're at High Risk for Breast or Ovarian Cancer to all of the various breast cancer screening techniques and the scientific studies that support or do not support their efficacy in either high-risk or average-risk women.  Specifically, we discuss:
  • Mammography (both film and digital)
  • MRI
  • Ultrasound
  • Digital Breast Tomosynthesis
  • Breast CT
  • Cone Beam Breast Computed Tomography
  • Automated 3D Breast Ultrasound
  • PET/PEM scans
  • Molecular Breast Imaging (MBI)
  • Breast Specific Gamma Imaging (BSGI)
  • Elastography
  • Ductal Lavage
  • Halo Breast Pap
  • Thermography
We discussed PEM and BSGI again in a recent post in light of a new study on the increased risk for future breast cancers caused by the radiation exposure of these new techniques.

Despite the controversy about when to begin mammography, it remains the mainstay of breast cancer screening because it is an inexpensive, effective tool for detecting early-stage breast cancer.  Is it perfect?  No.  It can miss some cancers, especially in young high-risk women, which is why adding MRI to the screening protocol is recommended for high-risk women.  Just a reminder, Dr. Gordon's breast screening recommendations for high-risk women are:
  • Breast surveillance beginning at age twenty-five or ten years earlier than the youngest breast cancer in family (but no earlier than age twenty).
  • Baseline digital mammogram at first surveillance to assess breast density and for MRI comparison.
  • Annual MRI.
  • Additional mammograms under age thirty-five if determined to be clinically useful.  Annual mammograms (in addition to annual MRI on an alternating six-month schedule) beginning no later than age 35.
  • Clinical breast exams every four months.
  • If high-risk surveillance is recommended due to moderate to high childhood radiation exposure (such as for childhood cancer treatment) surveillance should begin either at age twenty-five or eight years after the end of treatment, whichever is later.
Wednesday:  The controversy over thermography.

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