Important Breast Cancer Update

When the US Preventive Services Task Force (USPSTF) recently issued updated recommendations for less frequent breast cancer screening than has been previously used for many women, it sparked an immediate controversy.

The debate focused mainly on two of the USPSTF's recommendations-that there is insufficient evidence to support routine mammography for women ages 40 to 49 with an average risk for breast cancer...and that women ages 50 to 74 with an average risk should undergo screening mammography only every two years (biennial). For women age 75 and older, the USPSTF concluded that there was insufficient evidence to advise for or against breast cancer screening.

*To read a summary of the USPSTF's new recommendations (including a clarification of the task force's intent), go to the Web site of the Agency for Health Care Research and Quality, www.abry.gouy clinic/Uspsfuspsbrca.htm.

Many doctors disagreed with the new recommendations, claiming that reducing the frequency of mammography would increase deaths from the disease.

How can women make the best choices for themselves?

Here are some important details that weren't widely reported in the press and what you need to know about breast cancer tests besides mammography…

Why The Controversy?

The USPSTF is an independent panel of doctors and scientists that bases its recommendations on an analysis of the benefits and harms associated with preventive services such as screening for the early detection of various diseases.

In reviewing the evidence for breast cancer screening, the USPSTF analyzed several studies and mathematical simulations of women undergoing regular mammography screening. The task force found that while most of the studies did show a greater benefit with annual versus biennial mammography-as many as one-third of cancers would be missed with biennial versus annual screening—the harms, including false positive test results, inconvenience, anxiety and unnecessary biopsies of noncancerous abnormalities, were judged to outweigh the benefits.

Doctors who object to the USPSTF's recommendations argue that although the majority of women will experience a false-positive test result for breast cancer at some point in their lives (resulting in a follow-up mammogram, ultrasound or, less often, a biopsy), the risk is worth the potential benefit of detecting a malignancy earlier. That's why the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists and several other groups believe that the guidelines that existed prior to the USPSTF's updated recommendations should continue to be followed.

For most women, this means that yearly mammography should begin at age 40 and continue as long as the woman is in good health. Women of any age who are at increased risk for breast cancer (due to such risk factors as a family or personal history of the disease) should talk to their doctors about the appropriate age and frequency for screening.

**To read the ACS's guidelines for breast cancer screening, go to the ACS Web site, www.cancer.org

How can medical experts interpret the data so differently?

The ACS, in particular, analyzed the same data reviewed by the USPSTF but also looked at supplemental data because some of the trials examined by the USPSTF screened women with procedures that are no longer used today, such as single-view mammography. The more recent data studied by the ACS found that when women in their 40s were screened annually with high-quality mammography, there were two to three times fewer breast cancer deaths than what the USPSTF estimated.

Other Important Tests

What you should know about other tools that can be used in addition to mammograms to help detect breast malignancies-and the ACS's position on each…

• Magnetic resonance imaging (MRD uses a magnet and computer technology to create highly detailed images of the breast without exposing the patient to radiation.
  

Women at high risk for breast cancer-such as those who have a known BRCA1 or BRCA2 gene mutation...a first-degree relative (mother, sister or daughter) with a BRCA1 or BRCA2 gene mutation...or a history of radiation treatments to the chest for childhood cancer-should get an annual MRI plus mammography.

Women who are at moderately increased risk—a personal or family history of breast cancer or other breast conditions, such as extremely dense breasts-should talk with their doctors about the benefits and risks of adding MRI screening to their yearly mammography.

• Ultrasound produces an image by bouncing nonradiation-producing, ultra-high frequency sound waves off of breast tissue.
  

Ultrasound is mainly used in women with unusually dense breast tissue to help determine whether a questionable image on a mammogram is a noncancerous, liquid-filled cyst or a solid mass that might be a cancerous tumor.

• Breast self-exam (BSE) involves a woman inspecting her own breasts for changes, such as hard lumps or thickening. Most women do not perform frequent BSEs, or they use poor technique (such as failing to inspect the entire breast).

Since BSE has not been found to reduce deaths due to breast cancer, women should consider this an optional technique. (For advice on the proper way to perform a BSE, go to www.cancer.org and type "breast self-exam" in the search field.)

Women should always be attentive to the look (color, size and shape) and feel of their breasts while changing clothes or showering and report any changes to their physicians right away.

• Digital mammography uses a computer so the image can be sharpened for greater clarity.
  

Digital mammography has been shown to be equal to not better than-film mammography in detecting cancers in most women. For premenopausal women and women with dense breasts, however, digital mammography appears to provide more accurate results. And it may be able to reduce the rate of false-positives.

The latest statistics indicate that more than half the breast-imaging facilities in the US now have digital technology. For postmenopausal women, either technology is acceptable.

Will My Breasts Hurt If I Have Cancer?

It would be good if pain were the first sign of breast cancer, because that would help us catch it earlier. However, malignant breast lumps usually are painless in the early stages. Rarely, a woman reports a tugging or pulling sensation in a breast and then a biopsy reveals cancer-but we seldom do biopsies based on breast pain. Usually the pain has some benign cause, such as cyclical hormonal changes, pulled ligaments or tenderness related to fibrocystic lumpiness. Discomfort that occurs in both breasts or at the same time every month is highly unlikely to signal cancer.

Cystic pain prevention: Try taking evening primrose oil capsules at 1,500 milligrams (mg) twice daily and consider giving up caffeine.

Better Mammograms

When scheduling a mammogram, ask if the imaging center's accreditation is current. The federal Mammography Quality Standards Act (MQSA) passed in 1992 requires imaging centers that provide mammograms to have their equipment inspected annually to ensure that it meets the act's stringent criteria. Faulty mammography equipment can produce inaccurate test results.

Synthetic Hormone Replacement Warning

Almost three in every 100 women taking A synthetic hormone replacement therapy (HRT) whose breasts became tender during the first year of the therapy developed breast cancer, say researchers at University of California at Los Angeles, who analyzed data on more than 16,000 women who took estrogen-plus progestin as part of the Women's Health Initiative study. If you are on synthetic HRT, speak to a holistic physician about switching to a bioidentical hormone, especially if you experience breast tenderness.