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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.
Say No to Tanning Salons
Tanning Salons and Skin Cancer
A recent article in the Lancet details how dangerous tanning salons are, estimating a 75% increase in melanoma, the deadliest form of skin cancer in people who use tanning salons regularly.
The Lancet Oncology, Volume 10, Issue 9, Page 835, September 2009
The Lancet Oncology
On July 6, 2009, the British Association of Dermatologists (BAD) reported a disturbing lack of customer screening and generally unsafe equipment use in a survey of 332 tanning salons in Northern Ireland, prompting even the UK sunbed industry to agree that “there may be a case” for better standards. A few weeks after this announcement, on July 29, the International Agency for Research on Cancer (IARC) raised the classification of ultraviolet-emitting tanning devices from “probably carcinogenic to humans” to “carcinogenic to humans”—the highest risk category—based on evidence of a substantially higher risk of cutaneous melanoma in those who regularly used sunbeds. IARC's assessment leaves no doubt about the carcinogenic potential of sunbeds, and with the reported lax operating procedures of tanning salons, is it not time to ban this practice altogether?The UK government has been uncharacteristically reticent to involve itself in the regulation of the tanning industry, especially considering sunbeds have long been assumed to have a role in skin cancer. Nevertheless, some local authorities have followed the advice of health activists and prohibited tanning beds in leisure centres, but the sunbed industry itself is only under voluntary regulation. Any individual, seemingly without qualifications or experience, can set up a tanning salon and there are no regulatory restrictions on the type of equipment that can be purchased. In fact, around 25% of the salons surveyed by BAD had sunbeds with radiation levels intended for medical use only, and most did not know what level of ultraviolet radiation their beds emitted. The Department of Health publishes guidance for salon owners, but with only half of the facilities in the BAD survey checking their customers' age, any advice clearly is not being followed.The Department of Health is considering banning children under 18 years of age from using sunbeds in England—following Scotland's lead—but this is far short of what is needed to protect public health. The incidence of skin cancer is increasing worldwide, and the number of melanoma cases in the UK is around four times that seen 30 years ago. A quantitative association between sunbed use and skin cancer is difficult to prove, not least because of confounding by sun exposure and under-reporting of tanning habits. But what is certain is that sunbed use is increasing and that available tanning devices are more powerful than even a decade ago. A ban on sunbeds for under-18s recognises that burns early in life are particularly dangerous and that young people might not understand or might ignore the risks; but these concerns are equally applicable to adults. IARC's meta-analysis found a 75% increase in the risk of cutaneous melanoma when people began tanning regularly before the age of 30 years.So is there any benefit from tanning? The inclusion of sunbeds in gyms and health facilities, and the public misconception about possible benefits of tanning hinder an appropriate understanding of the risks. Some proponents suggest that vitamin D deficiency from sun avoidance is an issue, especially for those living in northern climates, and that this deficiency can be treated with “safe” tanning. But this claim is irresponsible: vitamin D can be easily and more safely acquired in the diet. A further misconception is that previous exposure to sunlight, via a sunbed, provides protection against sunburn from intensive vacational exposure. This is not true since overexposure during tanning is likely, with individuals being less likely to take preventive measures. Of note, guidelines for skin-cancer prevention recommend avoidance of direct exposure to mid-day sun as a first priority—regardless of skin type—with sunscreen only a secondary preventive measure. A practice whereby a source of intense ultraviolet radiation is brought within 6 inches of a person's skin must therefore be questioned.Most of the 100 000 new cases of skin cancer diagnosed in the UK each year are preventable, so why attempt expensive industry regulation and ineffective consumer education programmes? Sunbeds for cosmetic tanning clearly increase the risk of skin melanoma, and probably the risk of ocular melanoma; they should be banned for all ages. WHO, the British Medical Association, and Cancer Research UK already advise against sunbed use completely. In the name of skin-deep beauty, a beast has been unleashed—in face of the recognised health risks, the industry's continued existence can in no way be justified.
Staying Fit During the Holiday Season
Like it or not— here come the holidays. Sticking to your exercise program can be extremely challenging during this time. It is so easy to miss a workout when you are busy with family, friends, and festivities. Although we have several weeks before the holidays begin, now is the time to plan! If you are prepared with some strategies you can avoid gaining weight and stick to your workouts.
*Plan ahead:
The most difficult part of an exercise program is not the exercising itself, but the planning. Planning ahead of time to fit exercise into your day will help you to be successful and compliant. Acknowledge that the holiday season will probably affect your exercise routine. This way you can calmly make adjustments when necessary. During this time of year consider removing something from your schedule instead of trying to squeeze exercise in. For example, instead of an office party or a manicure, plan for a 30 minute workout. Set out your exercise clothes ahead of time so you don’t have to get them together at the last minute. Put exercise on your “to do” list most days of the week. Whether or not you already have well-established exercise habits, be sure to make exercise a priority in your daily life.
*Be realistic:
Keep in mind that most people eat more than usual during the holidays. However you don’t have to indulge everyday. Minimizing when you indulge and sticking with your exercise regimen can help to keep you in check. Be flexible when your days get busy by mixing up your routine. If you have obligations that will interfere with your regular schedule, try to wake up an hour earlier to do a quick 20-30 minute workout. Also, keep in mind that you don’t have to over do it with hour long exercise sessions. Exercising for 20-30 minutes with an elevated heart rate (swimming, jogging, kickboxing) most days of the week should keep your metabolism humming.
*Get help from a professional:
Give yourself a gift this holiday season and hire a personal trainer. A trainer will have the expertise to guide you through the most effective workouts while keeping you motivated. Many trainers have reasonable package deals and holiday specials. Just make sure that your trainer has a respected certification such as ACE, ACSM, or NASM to name a few.
*Try something new:
Instead of blowing off your workout—try something new. There are many ways to get into shape. Kickboxing, team sports, swimming and power yoga are all great ways to burn calories. You can try walking briskly during half of your lunch break as well. You may be surprised at how good it makes you feel. If the weather is bad and you cannot get out—try an exercise video. Exercise videos can be very effective and can be done in the privacy of your own home or office.
Keep a Journal:
Keeping an exercise journal can help you to stay motivated and organized. You are more likely stick to your workouts if you make daily journal entries and follow through with them. You can set goals for yourself each day or once a week. When you accomplish your goals, it will motivate you to continue and progress with your fitness plan and may even reduce your desire to over-indulge.
Keep in mind that during the busy holiday season nobody is perfect. There are going to be temptations and erratic schedules for everyone. If you exercise most days and indulge in moderation, you will do great! This way you will be able to enjoy yourself while staying healthy.—and that’s what the holiday season is all about.
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