RxPG News : Mammography

Should all women in 40s be routinely screened for breast cancer?

Thu, 05 Apr 2007 11:51:27 PST

( from http://www.rxpgnews.com ) Should all women in their 40s be routinely screened for breast cancer? Not necessarily, according to the American College of Physicians. In a new set of guidelines for clinicians of 40-something patients, the group recommends that mammography screening decisions be made on a case-by-case basis. It advises clinicians to discuss the benefits and harms of screening with the patient, as well as each woman's individual cancer risk and preference about screening.

The organization based its recommendations, which will be published in the April 3 issue of Annals of Internal Medicine, on a rigorous review of evidence showing there is variation in the benefits and harms associated with mammography among women in their 40s. The American College of Physicians is the leading professional organization for internal medicine specialists, with a membership of 120,000.

"There are important benefits to screening mammography, but we believe the decision to be screened should be based on an informed conversation between a patient and her physician," said health policy expert Douglas K. Owens, MD, MS, a researcher with the Veterans Affairs Palo Alto Health Care System and a professor of medicine at the Stanford University School of Medicine, who chaired the committee that developed the guidelines. "In our view, the evidence doesn't support a blanket recommendation for women in this age group."

Breast cancer is the second-leading cause of cancer related death among women in the United States; according to the American Cancer Society, 25 percent of all diagnosed cases are among women younger than age 50. Among these younger women, the risk of breast cancer varies greatly - from less than 1 percent for a 40-year-old woman with no risk factors to 6 percent for a 49-year-old woman with multiple risk factors, which include family history of breast cancer, older age at the birth of her first child and younger age at the onset of menstruation.

Physicians and medical groups have for years debated the merits of screening mammography for women in their 40s. While it is well-established that mammography reduces mortality from breast cancer in 50- to 70-year-old women - and that women in this age-group should be routinely screened - the evidence isn't as clear-cut for younger women.

Five years ago, the U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention, examined data from numerous clinical trials and estimated that screening mammography every one or two years in women in their 40s resulted in a 15 percent decrease in breast cancer mortality after 14 years of follow-up. But a separate Canadian study published in the same issue of the journal found that women in this age-group received no benefit from mammography.

Past analyses have also made note of the potential harms of screening, including radiation exposure, procedure-associated pain, false-positive results, over-diagnosis and potentially unnecessary treatment.

Based in part on the conflicting evidence, medical groups have differing screening recommendations for women under age 50. The U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists both recommend screening mammography every one to two years for women in their 40s, while the 2006 American Cancer Society guideline recommends yearly mammograms starting at age 40.

Because of the ongoing controversy, the American College of Physicians' Clinical Efficacy Assessment Subcommittee decided to take its own look at the evidence related to screening in women in their 40s. After their review, the group concluded that screening mammography for women in this age group likely provides a modest reduction in breast cancer mortality, but - as with any screening intervention - it also comes with the risk of potential harms.

In the new guidelines, the organization emphasizes the importance of using a woman's concerns about breast cancer and screening to help guide decision-making about mammography. Women's thoughts about mammography or their risks of developing breast cancer will likely vary greatly, the group notes, but it expects the potential reduction in breast cancer mortality associated with screening to outweigh other considerations for many women.

"We still think many women will choose to get mammography, and we're supportive of that," said Owens. "The most important thing is that women be well-informed about the decision they're making."

Computerized reminders boost mammography screening rates

Thu, 05 Apr 2007 11:46:15 PST

( from http://www.rxpgnews.com ) Findings of a new Mayo Clinic study published this week in Archives of Internal Medicine show that a computerized mail and phone reminder program can significantly increase the percentage of patients receiving preventive health services and improve the value of health care.

"National evidence-based guidelines say every woman over age 40 should have a yearly mammogram, but only about 65 percent of women nationally have had one in the last two years," explains Rajeev Chaudhry, M.B.B.S., the Mayo Clinic physician who led the study. "In this study we showed we can increase that percentage through a team approach, and we're applying the findings to other chronic disease and preventive services, too."

The researchers divided a population of 6,675 women aged 40â75 into two nearly equal groups: one to get mailings and, if necessary, a phone call to remind them to schedule a mammogram; and a control group that did not receive reminders. Among the reminded group, 64.3 percent had their yearly mammogram, compared to 55.3 percent in the control group. As the program has expanded following the study period, compliance with yearly mammograms has now grown to over 72 percent, with 86 percent having had one within the previous two years.

Dr. Chaudhry said a redesign of the primary care practice to enable appointment secretaries to schedule preventive services was a key to the program's success.

"In the old way, a woman had to remember that it was time for her yearly mammogram and call her physician's appointment secretary, who then got the doctor's approval for the test," he explains. "Then the secretary had to get back in touch with the woman to schedule the mammogram. That made the process more complicated, time-consuming and expensive than it needs to be, with several places where missed communication could mean the test didn't get done. With our new electronic tool and our related practice changes, one appointment secretary can now schedule mammography for over 10,000 women. When women get the reminder notice, it means they are preapproved, so the mammography can be scheduled with the first phone call without having to consult the physician."

"Not everyone needs to see a doctor every year, but they still should get the appropriate preventive care and screenings," explains Robert Stroebel, M.D., chair, Division of Primary Care Internal Medicine at Mayo Clinic and the study's senior author. "We were pleasantly surprised at how much we could increase mammography percentages through this new system. As we get more women screened, we're also going to find cancers earlier, when we're more likely to be able to treat them successfully. The goal is to improve the value of heath care, providing higher quality at lower cost by having all members of the health care team working at their highest potential," Dr. Stroebel says. "We already have expanded this reminder method to Pap smears and diabetes care, and will be adding other preventive services this year."

"This kind of practice happens in other fields," says co-author Rosa Cabanela. "Dentist practices, for example, typically call or mail patients to remind them to make an appointment. Health care has been behind many other industries in using technology to optimize service and efficiency. It's time to catch up."

Dr. Chaudhry says the study has important implications in designing better care delivery systems. "With baby boomers getting older and having more chronic conditions, it's estimated that a primary care physician may have to spend up to six hours a day managing the preventive services and chronic disease tests for his or her patient population," he says. "By using information technology and a team approach to manage chronic and preventive care, we can free physicians to focus on the individualized needs of their patients."

Recent declines in breast cancer mortality most significant in women under 70

Tue, 03 Apr 2007 03:03:33 PST

( from http://www.rxpgnews.com ) A new study shows that recent declines in breast cancer mortality rates have been most significant among women with estrogen receptor (ER)-positive tumors and women younger than 70. The results of the study are being published online April 2 in the Journal of Clinical Oncology (JCO).

Approximately 75% of breast cancers are ER-positive. The average age of breast cancer diagnosis is 62.

Between 1990 and 2003, breast cancer mortality rates declined by 24%. This is the first study to examine which patients have experienced the greatest declines in mortality. In 1989, the mortality rate for breast cancer peaked at 33 out of 100,000 women per year. By 2003, the mortality rate had dropped to 25 out of 100,000 women per year.

Although breast cancer mortality has declined for all groups of patients, declines were greatest for women under 70 and women whose tumors were ER-positive. The researchers found that among women under 70, mortality from breast cancer declined 38% for those with ER-positive tumors vs. 19% for those with ER-negative tumors. Among women 70 or older, mortality declined 14% for those with ER-positive tumors vs. no decline for those with ER-negative tumors.

'These trends in breast cancer mortality since 1990 are likely attributable to at least two important factors: the use of tamoxifen after surgery, which substantially reduces the risk of recurrence in ER-positive tumors only; and widespread use of screening mammography, which is more likely to detect the slow-growing tumors that tend to be ER-positive,' said Ismail Jatoi, MD, PhD, Director of the Breast Cancer Center in the Department of Surgery at the National Naval Medical Center, and the study's lead author.

This study did not explore the reasons why breast cancer mortality rates declined less for older women. However, previous studies have suggested that older women are less likely to receive adjuvant therapy for breast cancer. Because older women are under-represented in clinical trials, their optimal treatment has not been well established.

The researchers point to the importance of further reducing mortality rates among women over 70 and women with ER-negative tumors. The authors argue that recruiting more older women into clinical trials could lead to better treatments and outcomes for this age group. In addition, while a number of breast cancer drugs have recently been introduced that are likely to benefit women with ER-negative tumors, any impact they would have on mortality was not seen during this study period. For example, adjuvant use of Herceptin (trastuzumab) was approved in November 2006 for HER-2+ breast cancer (many ER-negative breast cancers are HER2+).

Investigators at the National Cancer Institute (NCI) and the National Naval Medical Center looked at 234,828 cases of invasive female breast cancer diagnosed between 1990 and 2003. The study analyzed data from the Surveillance Epidemiology and End Results (SEER) cancer registry, an NCI-sponsored, population-based database that compiles detailed cancer statistics.

Study shows higher mortality rates in African and African American women with breast cancer

Wed, 21 Feb 2007 07:49:07 PST

( from http://www.rxpgnews.com ) African and African American women are more likely to die of breast cancer than their white counterparts because they tend to get the disease before the menopause, suggests new research from the University of East Anglia and the Childrenï¿½s Hospital Boston in collaboration with researchers in the US and Italy.

A racial disparity in mortality rates from breast cancer in the US first appeared in the 1970s coinciding with the introduction of mammography. The new research, published in The International Journal of Surgery, posits that the reason for this is not reduced access to medical care, but because surgery in pre-menopausal women could encourage growth of the cancer.

The average age of breast cancer diagnosis in African American women is 46, compared with 57 for European Americans.

A previous study by one of the articleï¿½s authors, Dr Isaac Gukas, of the University of East Angliaï¿½s School of Medicine, Health Policy and Practice, identified a mean age of 43 for diagnosis of breast cancer in Nigerian women compared with a mean age of 64 in the United Kingdom. Over 70% of the Nigerian cases were aged below 50, compared to less than 20% of cases in the UK.

Further research published in 2005 suggested that those who underwent surgery for the disease before the menopause were more likely to relapse.

"Surgery to remove a primary tumour induces the formation of new blood vessels ï¿½known as angiogenesis. In pre-menopausal women who have high levels of oestrogen and other hormones, this may encourage the growth of the tumour," said Dr Gukas.

"Early detection, through mammography, is more effective in post-menopausal women, and more white women are diagnosed after the menopause. This could explain the disparity in mortality."

Dr Gukasï¿½s experience as a clinician treating breast cancer in Africa led him to form the hypothesis that surgery-induced angiogenesis might explain the very high early mortality and generally poor outcome of patients in that part of the world.

He also noted that African patients presented with the disease in their early 40s, although no one has yet identified why black women get the disease earlier.

"We do not intend to oversimplify this subject, but it seems clear that at least part of the phenomenon of widening mortality along racial lines could be attributed to surgery leading to accelerated tumour growth in pre-menopausal women," said Dr Gukas.

"We have the data from epidemiology. Now we need further research to confirm these observations before we explore any necessary changes in practice."

The hypothesis, if proven, has implications for all women with breast cancer, especially pre-menopausal women ?including the 20% of women in the UK who get breast cancer before the age of 50.

"We do not have enough evidence to alter treatment at present and younger women should not be deterred from having surgery. But, if further studies confirm our hypothesis, we may need to give them appropriate chemotherapy, including angiogenesis inhibitors, beforehand to ensure the best outcome," added Dr Gukas.

New approaches in breast cancer management may lead to exciting new nonsurgical tools

Mon, 12 Feb 2007 03:21:29 PST

( from http://www.rxpgnews.com )

Current research in the fields of radiology, drug therapeutics, and vaccine development has great potential to change breast cancer management.

Aggressive research currently underway brings hope of dramatic advances in breast cancer management, according to a new review. Published in the March 15, 2007 issue of CANCER a peer-reviewed journal of the American Cancer Society, the review reveals that new approaches in breast cancer imaging, investigations into the timing of chemotherapy, and research on breast cancer vaccines may lead to exciting new nonsurgical tools for the physician treating breast cancer patients. These new tools may significantly alter current screening and treatment paradigms used by surgical oncologists, as well improving the care of patients.

Our understanding of breast cancer has changed since Dr. William Halsted started performing radical mastectomies in the 1880s. Advances in genetics, immunology, and cell biology have demonstrated that breast cancer is not a single disease, but a complex family of diseases that requires fine-tuning of treatment at the level of the each individual patient. The current multidisciplinary approach to breast cancer treatmentï¿½surgery, radiotherapy, chemotherapy, hormonal therapy, targeted therapyï¿½will continue to evolve as our knowledge of the disease grows.

S. Eva Singletary, M.D., F.A.C.S, a surgeon from the University of Texas M. D. Anderson Cancer Center in Houston, discusses the latest research in breast cancer screening and management in this new review. "As we progress into the 21st century," she writes, "new treatment schema and devices outside of the surgical arena may significantly alter" current practices.

She finds that current research in the fields of radiology, drug therapeutics, and vaccine development has great potential to change breast cancer management. In radiology, 3-dimensional digital mammography, color doppler ultrasonography, and other more sophisticated technologies, such as magnetic resonance imaging (MRI), are being refined to more accurately identify the size and location of tumors, and to distinguish between benign and malignant lesions. The use of nanotechnology may provide safer imaging that capitalizes on our growing knowledge of specific genes associated with cancer.

In the area of systemic therapy, the timing of drug treatments is being altered to maximize cell death, "short-circuit" tumor growth, and minimize toxicity to the patient. Though early in development, vaccines that stimulate the patient's own immune system to attack developing tumors are being tested in animals with encouraging results. Preliminary clinical trials in breast cancer patients have also shown promising immune responses, although much remains to be done in this complex, but promising, area of research.

"During the lifetime of most surgeons practicing today," Dr. Singletary writes, "we have seen breast cancer management evolve dramatically from a paradigm centered on radical surgery to one that involves the synergistic combination of multidisciplinary approaches." She concludes, "It will be important for surgeons to stay aware of all developments that may improve the care of their patients, and to be true surgical oncologists rather than merely surgical technicians."

Technology can't replace doctors' judgment in reading mammograms

Mon, 04 Dec 2006 15:05:05 PST

( from http://www.rxpgnews.com ) Radiologists should not become too dependent on the use of computer-assisted detection (CAD) technology when reading screening mammograms because the doctors can see lesions that CAD sometimes misses. This is according to a study conducted at Group Health Cooperative, a Seattle based health care system. The research appears in the December issue of the American Journal of Roentgenology.

"Our study shows that radiologists must continue to rely on their own judgment when determining whether lesions seen on mammograms require further testing," said Stephen Taplin, MD, MPH, who led the research at Group Health before joining the National Cancer Institute as a senior scientist.

CAD uses computer software to identify and mark areas of concern on mammograms. Radiologists typically review the CAD-marked images after they interpret the original film.

While early CAD evaluations showed it improved cancer detection, more recent studies have raised questions about CAD's performance. For example, while it is believed that CAD alerts radiologists to potential areas of concern, experts have wondered whether CAD too frequently marks normal areas rather than only identifying problem areas that the radiologist should have detected.

To answer these questions, the researchers at Group Health designed a study using a sample from more than 56,000 screening mammograms taken between 1996 and 1998. By identifying cases of breast cancer diagnosed within two years after the mammograms were taken, they created a total set of 441 mammograms from three different groups. Included were mammograms from women who:

1) remained cancer-free two years after their mammograms
2) developed breast cancer within one year, or
3) developed breast cancer within 13 months to two years.

The sample was then used to test the performance of 19 radiologists, each of whom read 341 mammograms with and without CAD. The researchers then compared the results of the two approaches for each mammogram.

This is the first study of CAD using a random sample of cases from a screened population rather than using selected cases of visible cancers. In this way, it more closely resembles the way that radiologists use CAD in real practice.

The study showed that CAD assistance increased radiologists' ability to determine that a woman without cancer was, in fact, cancer free—a quality known as mammographic "specificity." Overall specificity increased from 72 percent without CAD to 75 percent with CAD. This 3 percent difference means that CAD allows 30 women in every thousand women screened to avoid further evaluation.

CAD assistance did not affect the radiologists' overall ability to spot cancer where it was present—a quality known as mammographic "sensitivity." The doctors performed equally well with and without CAD.

However, CAD does not mark all visible abnormalities. And when the researchers analyzed the radiologists' performance on mammograms with lesions that CAD did not catch, they found that the doctors were less likely to recommend further evaluation when they were using CAD than when they were not using CAD.

"This means that the radiologists may have been deferring to CAD and believing its interpretation rather than their own interpretation," said Taplin. "This is something the originators of the technology say radiologists should not do. This study shows that it is hard to ignore the technology, and it raises the question of whether there is a potential for CAD to do harm."

Taplin and his co-authors recommend training for radiologists that focuses on characteristics that CAD may miss, namely "masses, asymmetries, and architectural distortions" visible on the mammograms. They also note that research into these visible, unmarked lesions may offer the best chance to improve CAD-assisted mammography.

The researchers also found that breast density—a measure of the amount of fat tissue in the breast—did not affect CAD's performance