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Screening mammography guidelines controversy continues.

The US Preventive Services Task Force (USPSTF) issued a new and updated draft of guidelines for breast cancer screening in April 2015. These guidelines are similar to the previous one from 2009 that received widespread criticism from the American Cancer Society (ACS), the American College of Radiology, the American College of Obstetricians and Gynecologists (ACOG), and the Susan Komen Foundation. ACOG went so far as to advise patients and physicians to ignore the USPSTF. A provision was even signed into law that was meant to prevent the 2009 USPSTF recommendation from going into effect. Once again, these updated guidelines from the task force recommends that average-risk women have screening mammograms every other year beginning at age 50 years and ending at age 74. They gave a "B" rating for mammography every 2 years for women ages 50 to 74 and "C" rating for mammography for women ages 40 to 49, which is similar to the 2009 document. They found insufficient evidence on the benefits and harms of continuing mammography in women age 75 years or older. They also state that the decision to start screening mammography before age 50 should be individualized; women who value the potential benefits of breast cancer detection more than they do the potential harms of false positives and overdiagnosis may choose to start screening at any time after age 40. The USPSTF also concludes that "some women in their 40s will benefit from mammography, while others will be harmed." Harm includes exposure to radiation from multiple tests, the stress of overdiagnosis, and unnecessary biopsies

One of the current main concerns with the USPSTF recommendations is that a "C" rating will lead to mammography no longer being covered without consumer cost-sharing for women 40-49 (about 17 million annually), and impacts coverage for women 50 and older who request and/or require annual rather than biennial screening mammograms. An additional concern from advocates for annual screening mammography starting at age 40 is that these USPSTF recommendations will cause women under 50 to delay paying attention to their breast health and may not understand that they are at low vs. higher risk... this lack of information may not bode well for these younger women who are at risk for breast cancer (based on family history, genetics, obesity and alcohol intake) and for African-American women who are diagnosed with aggressive forms of the disease at younger ages than Caucasian women.

Some very new information in the 2015 document is related to additional imaging. Currently, 22 states have now passed laws requiring physicians to notify women whose breasts appear "dense" on mammography that other imaging tests such as ultrasound, MRI, and tomosynthesis are available, and in some cases requiring insurers to pay for these additional screening tests. Approximately half of women being screened have dense breasts and it is more difficult for a mammogram to detect suspicious lesions. These women also can have up to twice the risk of average woman of developing breast cancer. The intent of these breast density screening laws is to alert women to the limitation of mammography and encourage them to speak with their doctors about additional imaging.

The task force systematically reviewed the evidence to support adjunctive imaging for breast cancer in women with dense breasts. They found that not only was there no widely accepted standard for breast density, but that measurements changed over time: up to 1 in 5 women with "dense" breasts on one screening mammogram were reclassified into a "non-dense" category on the next examination. Although ultrasound and MRI found additional cancers, they also led to more false-positive results and biopsies. Most important, no studies examined the effect of additional screenings on breast cancer recurrence rates or deaths. The task force concluded that there was insufficient evidence to decide whether the harms of adjunctive imaging are greater than the potential benefits. The practice of recommending additional imaging beyond a mammogram, for dense breasts, is not routinely practiced by physicians, despite the fact that the patients get a letter from the radiology center reporting their dense breast status and encouraging them to speak with their physicians about additional imaging. As I mentioned in the NAC and breast density section above, ACOG does not recommend additional testing for mammographically dense breasts.

ACOG, ACS, Komen Foundation, and American College of Radiologists (ACR) urge that women decide on a screening program in consultation with their physicians --not bad advice, of course. However, I would urge all readers to see my previous column on the screening mammography controversy in 2010 and 2011, to have a deeper understanding of the benefits and risks.

I will continue to do the following with each patient:

1. Subjectively assess her risk for breast cancer; if low risk, then discuss the "four camps" for screening mammography:

a. ACOG, ACS, Komen, ACR: yearly starting at 40

b. USPSTF: every other year starting at 50 and until 74

c. Several European countries: every 3 years

d. Sweden and select others: not at all.

2. If not low risk: then discuss and likely recommend yearly starting at age 40.

3. A breast lump on exam or nipple discharge: evaluate with needed testing.

4. If moderate or severe dense breasts: discuss potential benefit of screening ultrasound.

5. Consider tomosynthesis and MRI on individual basis, in discussion with radiologists, and breast cancer surgeon.

by Tori Hudson, ND and

Guest coauthor Michelle Cameron, ND

womanstime@aol.com

Dr. Tori Hudson graduated from the National College of Naturopathic Medicine (NCNM) in 1984 and has served the college in many capacities over the last 28 years. She is currently a clinical professor at NCNM and Bastyr University; has been in practice for over 30 years; and is the medical director of the clinic A Woman's Time in Portland, Oregon, and director of research and development for Vitanica, a supplement company for women. She is also a nationally recognized author, speaker, educator, researcher, and clinician.
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Title Annotation:Women's Health Update
Author:Hudson, Tori
Publication:Townsend Letter
Date:Aug 1, 2015
Words:986
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