October 29, 2013 — When women skip a mammography screening exam — even for just one year — their risk of late-stage cancer increases, according to a new study published in the November issue of the American Journal of Roentgenology.
These findings conflict with the revised 2009 mammography screening guidelines from the U.S. Preventive Services Task Force (USPSTF), which state that women should start screening mammography at age 50, rather than 40, and continue thereafter biennially through age 74, the authors wrote.
Missed mammograms represent missed opportunities for earlier breast cancer diagnosis, according to lead author Dr. Adedayo Onitilo, from Marshfield Clinic Weston Center in Weston, WI, and colleagues.
“As a practicing oncologist, I see a lot of women who have never had mammography, and up to about 20% of them are younger than 45,” Onitilo told AuntMinnie.com. “When they finally present for their first mammogram, they often have more-advanced disease.”
For the study, Onitilo and colleagues parsed patient characteristics associated with missed mammograms and examined the association between the missed tests and breast cancer stage at diagnosis. They identified 1,428 women with breast cancer diagnosed between January 2002 and December 2008 (53 were eventually excluded, leaving 1,368 for analysis).
The researchers collected demographic and other information including the following:
- Number of medical encounters during the study period
- Insurance status
- Medical and family history
- Any mammograms within five years of breast cancer diagnosis
- Other cancer diagnoses
- Residence location
- Reasons for not undergoing mammography
Using mapping software, the team also estimated patients’ travel time from their residence to the nearest mammography screening clinic (AJR, November 2013, Vol. 201:5, pp. 1057-1063).
Regardless of age, the women in the study cohort who had regular mammograms were more likely to have early-stage breast cancer at diagnosis, compared with those who did not undergo mammography, Onitilo’s group found.
The difference between women who had undergone mammography screening and those who had not increased incrementally with each additional year: Those with no mammograms in the five years before breast cancer diagnosis had an 18% increase in late-stage disease at diagnosis. Put another way, more than 50% of the women included in the study with late-stage breast cancer missed five out of five annual mammograms before their disease was found.
Even one skipped year makes a difference, according to Onitilo and colleagues.
“Our results are in direct contradiction to the USPSTF guidelines,” they wrote. “We found that even one year makes a significant difference in diagnosis of early- versus late-stage breast cancer. Women without a mammogram in the one year before a breast cancer diagnosis had a 12% increase in the risk of diagnosis of late-stage breast cancer compared with those who underwent annual mammography. This percentage difference was consistent in women older and younger than 50 years.”
Why did women skip mammograms? The most common factors included not having a family history of breast cancer, fewer medical encounters of any kind, and increased travel time from home to the mammography center. (In fact, they found that each additional minute of travel time decreased the odds of a woman undergoing at least one mammographic examination in the five years before her cancer diagnosis.)
Primary care physicians can play a crucial role in encouraging women to get regular breast cancer screening — and creative scheduling can help, too, the authors noted.
“[Patients] who must travel a greater distance for healthcare services, including mammography, may benefit from additional counseling or the opportunity to schedule screening mammography for the same day as an annual physical examination to avoid making multiple trips to the clinic,” they wrote. “In addition, the annual physical should be used to emphasize the importance of annual mammography to women with no comorbid conditions, because this may be their only contact with the healthcare system throughout the year.”
The complexity of factors that contribute to a woman skipping regular breast cancer screening exams suggests that guidelines such as the USPSTF’s are not nuanced enough, according to Onitilo.
Incidence of advanced breast cancer among
younger women on the rise
The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased over the last three decades, according to a study released Tuesday. The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009. Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.
For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.
“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital. Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why. The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller. The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease. Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found. Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said. It is important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.
Dr. J. Leonard Lichtenfeld , deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real. “We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”
Physical Activity Can Reduce Your Risk For Breast Cancer
Physical activity, even including walking, can substantially reduce a woman’s risk of developing breast cancer, encouraging new science shows, in part, it seems, by changing how her body deals with estrogen.
Evidence has been accumulating for some time that exercise reduces the risk of many types of cancer, including breast malignancies. But the physiological mechanisms involved have not been well characterized, nor have scientists known what kinds and amounts of exercise provide the surest protection.
Which makes the results of two recently published studies of considerable interest to women and those of the remaining gender who love us.
In the newest and largest of these studies, published online last week in Cancer Epidemiology, Biomarkers & Prevention, researchers with the Epidemiology Research Program at the American Cancer Society began by turning to a huge trove of data maintained by the cancer society. The database includes detailed health and medical information from more than 73,600 postmenopausal women, age 50 to 73, who enrolled in the study in the early 1990s. For almost two decades, they completed follow-up questionnaires every two years.
The questionnaires asked, among other things, for detailed descriptions of how the women spent their leisure time and in particular whether and how they exercised. About 9 percent reported never exercising. A few said that they exercised vigorously and often, typically by running, swimming or playing singles tennis.
But most walked, usually at a pleasant pace of about 3 miles per hour. About half of the group reported that such strolling was their only form of exercise.
Over the course of the study, 4,760 of the women enrolled developed breast cancer.
When the researchers cross-tabulated exercise regimens and medical records, they found that those women who walked at least seven hours per week, usually distributed as an hour a day, had 14 percent less risk of developing breast cancer than those who walked for fewer than three hours per week, a significant reduction in risk.
Meanwhile, those few women who were the most active, sweating vigorously for up to 10 hours each week, realized an even greater benefit, with 25 percent less risk of developing breast cancer than those women who exercised the least.
These risk reductions held true, the researchers determined, whether or not the women were overweight and whether or not they were using hormone replacement therapy.
“We think these results are very encouraging,” said Alpa V. Patel, a senior epidemiologist with the American Cancer Society and senior author of the study. “Walking is an easy, inexpensive type of exercise. Almost everyone can do it. And for this population of postmenopausal women, it provided a very significant reduction in the risk of breast cancer.”
Another intriguing study that looked at younger women, published in May in Cancer Epidemiology, Biomarkers & Prevention, helps to elucidate how exercise may reduce breast cancer risk. For this experiment, scientists from the School of Public Health at the University of Minnesota divided several hundred sedentary, premenopausal women into two groups. One group remained sedentary, while the other began a moderate aerobic exercise program that continued five times a week for 16 weeks.
At the start and end of the four months, the researchers collected urine and tested it for levels of estrogen and various estrogen metabolites, the substances that are formed when estrogen is broken down by the body. Past studies have found that a particular ratio of these metabolites in a woman’s urine indicates a heightened risk of breast cancer during her lifetime.
In this study, those volunteers who remained sedentary showed no changes in the ratios of their estrogen metabolites after four months.
But among the group that began exercising, the levels of one of the metabolites fell and another rose, shifting the ratio in ways that are believed to indicate less chance of breast cancer. The women also lost body fat and gained muscle.
This finding, although derived from younger women, has implications for women of any age. As Dr. Patel pointed out, postmenopausal women produce estrogen, although in much smaller doses and primarily from fat cells and not the ovaries.
Exercise, by altering the ratio of estrogen metabolites and also reducing total body fat, may change the internal makeup of a woman’s body and make it harder for breast cancer to take hold.
But, of course, exercise, is not a panacea. Some of the women in Dr. Patel’s study who dutifully walked every day developed breast cancer. Many who rarely if ever exercised did not.
“There is still a very great deal that we don’t know” about how cancer of any kind starts or why it doesn’t, Dr. Patel said.
“But physical activity, and especially walking, are so simple and so accessible to most women,” she continued. “And statistically, they do seem to reduce breast cancer risk. So why not?”
New technology may change approach to breast cancer screenings
April 12, 2013
New findings reported in the American Journal of Medicine this month seek to shed some light on the best way to screen for breast cancer. Although mammography is considered the gold standard of breast cancer screening and has proved time and time again to reduce breast cancer mortality, new studies point out that it may not be the best answer for every woman.
Authors of the report argue for a more individualized approach to breast cancer screening. The paradigm shift includes new technologies to give patients a more personalized option based on certain factors like age, breast density, genetics and other risk factors.
“Mammography is not a perfect screening test,” lead author Dr. Jennifer Drukteinis of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, “There are sub-populations of women for whom mammography is less than ideal, such as women with dense breasts. There has also been significant controversy over the ideal age and interval to screen women by mammography. It is time to move beyond that argument and examine ways we can improve the breast cancer screening paradigm.”
In response to some of the limitations of mammography, new technologies for breast cancer screening have been developed, including low-dose mammography, contrast-enhanced mammography, tomosynthesis, automated whole breast ultrasound, molecular imaging, and magnetic resonance imaging, all of which are discussed in the report.
“We chose to outline the major emerging technologies that are commercially available in breast cancer screening, as well as those not yet available that have shown promise in studies to improve the sensitivity and specificity of breast cancer screening,” said Drukteinis.
Not only did the report relay a vision for the future, but it was also intended to educate clinicians about emerging technologies in breast cancer screening that patients may inquire about, according to Drukteinis.
Tomosynthesis, for example, a popular FDA approved technology that produces 3-D “slices” of an entire breast tissue volume, can eliminate the pitfalls of overlapping tissue, and has the potential to lower recall rates on screening mammography and reduce false negative examinations due to dense breast tissue. However, radiation exposure is a concern, as is decreased sensitivity for detection of microcalcifications, according to the report.
“The development of a personalized, individual patient-centered approach to breast cancer screening mirrors the evolution of similar strategies in other aspects of medicine,” wrote Dr. Robert Stern, a radiologist affiliated with the University of Arizona College of Medicine, in an accompanying editorial. He cites the intricacies of each modality and one critical point that should be considered with such an approach: The need for a much closer working relationship between breast imagers and clinicians to make sure each woman undergoes breast cancer screening tailored to her.
What to Know About Getting a Mammogram
A new tool that finds 3 times as many cancers as mammorgaphy….
Where you have your mammogram, and who reads it, matters ….
From time to time we receive inquiries from women asking how they should choose where to go for their mammogram, and if it really matters. From our prospective of working with over 30 facilities and interacting with dozens more for the past twelve years – yes it does matter! Here are a few tips to help your search:
The most basic requirement is whether a facility is accredited under the MQSA (Mammography Quality Standards Act). The accrediting body for most states is the ACR (American College of Radiology), which has a list of requirements and tests that facilities must comply with in order for the centers to achieve accreditation. They look at things such as equipment and film quality, radiation dose, credentials of the mammography technologists and of the radiology doctors who interpret the films, quality of reporting and follow-up, etc. Inspectors visit centers at regular intervals for “site visits.”
The ACR has a convenient webpage for you to search http://www.acr.org/map_fac for facilities close to your home.
When you see the results of your search on the ACR site, look for this badge next to the names of the breast centers on your list:
This symbol means that the center has been quilifed as a “Breast Imaging Center of Excellence.” It’s worth your while to go to one of these centers if it’s practical for you, depending on where you live and how far you are willing to travel. It can make your life easier down the line because if you ever need to have additional testing or a stereotactic biopsy, these centers can handle it and won’t need to send you somewhere else.
It matters who reads your mammogram. If your study is read by a radiology doctor (radiologist) who practices general radiology or another radiology subspecialty and only reads a few mammograms per week, you are probably not receiving the best care. If possible you should have your study read by someone who’s specialty is breast imaging.
A well-done study published several years ago proves and quantifies this point. The researchers found that specialty-trained breast radiologists find significantly more cancers, and at earlier stages, than the general radiologists.
So how do you make sure the most qualified radiologist will read your mammogram?
•When you make your mammogram appointment, hopefully at a Breast Imaging Center of Excellence, ask if the center has radiologists who have completed fellowships in breast imaging, OR who read breast imaging studies at least 50% of their work hours.
•When you go for your appointment, confirm with the technologist (the person who runs the machine and takes the pictures) that the doctor you requested will be personally handed your examination .
•When you receive the report that informs you of your results, confirm that the correct doctor performed the reading.
All mammograms are not created equal. We urge you to do your homework. Where you have your mammogram, and who reads it, matters.
New York Times reports that “Surgery Used Too Often For Breast Biopsies”
Links to web sites that contain helpful information about stereotactic breast biopsy and breast cancer:
The American Cancer Society
The National Breast Cancer Foundation Inc.
The Suzan G. Komen for the Cure Foundation
Devicor Medical Products – Makers of the Mammotome biopsy device