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HEALTH UPDATE

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
World Health Organization


Breast Cancer Screening

By Kimberly Siu, MD, MPH

Guyana Journal, March 2010



On November 16, 2009, the United States Preventive Services Task Force (USPSTF) announced that it was no longer recommending routine screening for breast cancer by mammography for women between the ages of 40-49. This is different from the Task Force's previous statement in 2002 that recommended screening mammography every 1-2 years for women ages 40 years and over. The Task Force does recommend mammography for women ages 51-74 years, but feels that current evidence is not sufficient to determine if it is of benefit to screen women over the age of 75. In addition, the Task Force recommends against teaching the breast self-examination.

What does this new recommendation mean for women in their 40s?

It means that if you are a woman in your 40s you should discuss your risk of breast cancer with your doctor. Both you and your doctor should determine if mammography is right for you based on your family history, general health, and personal values.

Why does the Task Force recommend against routine screening for breast cancer in women in their 40s?

After reviewing the evidence, the USPSTF concluded that the net benefit is small to screen for breast cancer with mammography in women between 40-49 years old. Women in their 40s are less likely to have breast cancer and more likely to have a test that is falsely positive (this means that the test shows you to have breast cancer when you really do not have it). However, as a woman gets older, the balance of benefits and harms improves. This is why the USPSTF recommends routine screening mammography for women between 50-74 years.

What harm comes from having “extra” mammograms?

An abnormal mammogram cannot prove that there is cancer. Tests that are falsely positive usually require a follow-up test called a biopsy to confirm the diagnosis of cancer. This means taking a piece of tissue from the breast which can cause discomfort and anxiety to the patient. Sometimes the biopsy can also detect cancers that are not dangerous and would never have caused problems, but the person may still be given treatment. It has been estimated that every breast cancer detected requires 5 biopsies for women in their 40s compared to 3 for women in their 50s and 2 for women in their 60s.

Why does the Task Force not want women to perform a breast self-exam?

The Task Force did not tell women to stop examining their breasts. However, the Task Force does not recommend that doctors teach women how to do the breast exam because studies have shown that this instruction is not effective.

Who is on the USPSTF and are they paid by the government to be on this Task Force?

The USPSTF is mostly made up of primary care physicians. They come from a variety of specialties: 4 family physicians, 4 general internists, 2 obstetrician/gynecologists, 2 pediatricians, 2 nurse practitioners, 1 preventive medicine physician and 1 PhD researcher. None of the Task Force members are federal employees. The Task Force is an independent panel of experts that receives only administrative support from a small federal agency called the Agency for Healthcare Research and Quality (AHRQ). Task Force members are nominated through an open process announced in the Federal Register, an official government publication. Nominations are accepted by anyone, including self-nominations. Members are selected based on their expertise in prevention, evidence-based medicine, and primary care.

Who is at higher risk for breast cancer?

The BRCA1 and BRCA2 genes are human genes that have been linked to hereditary (passed from parent to child) breast cancer. Those at highest risk have a known BRCA1 or BRCA2 gene mutation, have a first-degree relative (mother, father, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, or had radiation treatment to the chest when they were between the ages of 10 and 30 years. Women with a moderate risk for breast cancer have breasts that are dense or unevenly dense when seen by mammograms, a personal history of breast cancer, or certain conditions of the breast such as ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH).

What should you expect when you have a mammogram?

A mammogram is an x-ray of your breast. For a mammogram, you will undress above the waist and will be given a wrap to wear. A specialist will be there to give you instruction and to position your breasts for the mammogram. Most specialists are women. You and the specialist are the only people in the room during the mammogram. In order to have a high-quality mammogram picture, it is necessary to slightly flatten the breast. A specialist places the breast on the mammogram machine's lower plate, which is made of metal. The upper plate is made of plastic and is lowered to flatten/compress the breast for a few seconds while the picture is taken. The actual breast compression only lasts a few seconds and you will feel some discomfort when your breasts are flattened. For some women compression can be painful. Try not to schedule a mammogram just before or during your period when your breasts are likely to be tender or more sensitive.

You should receive your results in 5 working days. However, mammogram facilities are only required to send your results to you within 30 days. You should contact your doctor if you do not know your result after one week.

For more information about the USPSTF recommendations, please visit their website: http://www.ahrq.gov/clinic/uspstfix.htm#Recommendations

For additional information, you may also visit the American College of Preventive Medicine's website and the American Cancer Society's Website:
http://acpm.org/Response-MammographyRecs.htm
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?sitearea



Dr. Siu is a Board-certified preventive medicine specialist in Raritan, NJ.
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