Internal Medicine Blog
Cervical Cancer Screening
The History of Mammogram Recommendation
The latest recommendations not recommending mammograms for women in their 40's isn't new.
Get a Mammogram. No Don’t. Repeat.
By GINA KOLATA
Published: November 21, 2009
The current dispute over mammograms gives many people who’ve been around since the 1980s a sense of déjà vu. Like archeologists arguing endlessly over the same set of bones, cancer specialists, it can seem, have been arguing endlessly over pretty much the same set of data.
The problem is that the screening test is not very helpful in preventing breast cancer deaths. Current estimates are that it reduces the death rate by 15 percent. If it were completely effective it would reduce the death rate by 100 percent. And screening has some downsides. It leads to false positives and unnecessary biopsies.
But more important, and only recently recognized, it leads to overdiagnosis — the test is finding cancers that grow so slowly that if they were left alone they would never be noticed or cause any problem in a woman’s lifetime. Since the harmless cancers look the same as deadly cancers, they are treated as if they are potentially lethal, with surgery, chemotherapy and radiation.
So the arguments continue to rage over risks and benefits, and over how strongly to recommend mammograms, and for whom, just as they have for decades:
1963 Health Insurance Plan of New York, or HIP, begins first mammography trial.
1971 HIP reports that mammography reduces breast cancer deaths by 30 percent.
1977-83 Four randomized trials are begun in Europe; eventually, they find that mammography cuts the breast cancer death rate by up to 30 percent. But two in Canada find no benefit for women in their 40s, and find a breast examination equally effective for women over 50.
1979 A National Institutes of Health conference recommends annual screening for women 50 and older. It supports screening for women in their 40s only if they have had cancer or a family history of it.
1980s After sharp debate, the National Cancer Institute recommends routine screening for women in their 40s.
1989 Eleven health care organizations recommend an initial baseline mammogram for women age 35 to 39, and mammograms every one to two years for women over 40.
1992 The American Cancer Society drops its recommendation for baseline mammography for women 35 to 39.
1993 Citing growing evidence from randomized trials, the National Cancer Institute drops its recommendation for screening in the 40s.
1997 A National Institutes of Health conference concludes that there is not enough evidence to recommend routine screening for women in their 40s. But the Senate votes to encourage an institute advisory board to reject that conclusion, and the institute recommends beginning mammography in the 40s and continuing every one to two years.
1997 The American Cancer Society recommends annual mammography for all women over 40, and clinical breast exams close to or, preferably, just before the annual mammogram.
2001 A Danish study questions the findings of earlier trials and suggests that mammography’s value may have been overstated.
2002 After reviewing the research, an independent panel at the National Cancer Institute decides it can no longer make a recommendation on whether women should be screened. The institute concludes that the new analysis did not refute evidence that mammography is effective, and stands by its earlier recommendation: women 40 and older should have routine screening.
2007 Guidelines issued by the American College of Physicians acknowledge that regular mammograms for women in their 40s can reduce the risk of dying from breast cancer by a modest amount. But a very high percentage will get false positive results that lead to unnecessary biopsies, increased costs and risks of injury. The college recommends that women in their 40s and their doctors periodically evaluate their risk to guide screening decisions.
2008 A Norwegian study in the Archives of Internal Medicine suggests that some invasive breast cancers may go away without treatment, raising the possibility that some cancers detected by mammograms may “spontaneously regress.
November 2009 New guidelines published in The Annals of Internal Medicine recommend that most women start regular breast cancer screening at age 50, not 40, and that women age 50 to 74 should have mammograms less frequently — every two years, rather than every year. Doctors should also stop teaching women to examine their breasts on a regular basis, according to the guidelines issued by an independent panel of experts in prevention and primary care appointed by the federal Department of Health and Human Services.
No More Mammograms For Women Under 50
New information recommends against routine mammograms for women under 50.
Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement
Description: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population.
Methods: The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals.
Recommendations: The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation)
The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement)
The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation)
The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement)
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.
It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.
The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.
Summary of Recommendations and Evidence
The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. This is a C recommendation.
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. This is a B recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. This is an I statement.
The USPSTF recommends against teaching breast self-examination (BSE). This is a D recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. This is an I statement.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. This is an I statement.
Healthy Living is the Best Revenge
Healthy Living is the Best Revenge
A study published in the August 10/24th issue of the Archives of Internal Medicine supports that healthy living reduces disease. Over 23,000 people aged 35-65 were studied for an average of 7.8 years. Participants who never smoked, were not obese (BMI<30), performed at least 3.5 hours of physical activity per week and followed a healthy diet had a strong impact on preventing chronic diseases. Participants with all 4 factors at base line had a 78% lower risk of developing a chronic disease including diabetes, heart attack, stroke and cancer than participants without a healthy factor.
Study Reveals Way to Make Medical Abortions Safer
A study published in the July 9th issue of the New England Journal of Medicine reveals a way to make medical abortions (not surgical) safer. The data comes from Planned Parenthood Centers throughout the country. By switching medication administration from the vagina to the mouth the rate of infections after medical abortions declined 73%. Subsequent addition of routine antibiotics further reduced the rate of infections by 76%. Women seeking medical abortions should insist on only oral medications and a prescription for antibiotics or testing for sexually transmitted diseases to reduce their risk of infection.More Articles...
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