I hope this week’s headlines and editorials don’t add to the blurriness of the public’s perception of cancer screening – that people might begin to think it’s a bad thing all around. The details matter…
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A seemingly slight adjustment in a statistic, for teaching purposes, can significantly change a test’s calculated value.… See more A Closer Look at the Details on Mammography, in Between the Lines With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography. The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem: Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1) On screening: The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the See more NEJM Publishes New Review on Breast Cancer Screening This week I’ve come across a few articles and varied blog posts on screening mammography. The impetus for rehashing the topic is a new set of guidelines issued by the American College of Obstetricians and Gynecologists. That group of women’s health providers now advises that most women get annual mammograms starting at age 40. Why every year? I have no idea. To the best of my knowledge, there are no data to support that annual mammograms are cost-effective or life-saving for women in any age bracket at normal risk for BC. Pertinent also, is a recent paper* in the Annals of Internal Medicine supporting a personalized approach to BC screening and mammography for women over the age of 40, and an editorial* to go with it. “Talk to your doctor,” is the point for patients. (Women’s breasts are not all the same.) “Talk with your patient,” is the point for See more Mammography Update! A worrisome report on breast cancer trends in the U.S. appeared on-line today, ahead of print in an AACR journal, Cancer Epidemiology, Biomarkers & Prevention. The analysis, based on the NCI’s SEER data from 2000 — 2007, shows that the incidence of breast cancer in the U.S. is no longer declining. (A drop after 2002 in BC incidence is generally attributed to an abrupt reduction in HRT around that time.) Since 2003 the overall BC rate has been steady overall, with a few exceptions: The incidence of BC in non-Hispanic white women ages 60–69 rose by 4.8% in this period. “It remains to be seen if this trend will continue,” according to the study authors. Among white women ages 40–49 rates of estrogen receptor (ER) positive (ER+) breast cancer significantly increased by an average of 2.7% per year during this period. In contrast, the rate of ER– breast tumors decreased, See more Breast Cancer Rate in the U.S. is No Longer Declining There’s a new study out on mammography with important implications for breast cancer screening. The main result is that when radiologists review more mammograms per year, the rate of false positives declines. The stated purpose of the research,* published in the journal Radiology, was to see how radiologists’ interpretive volume – essentially the number of mammograms read per year – affects their performance in breast cancer screening. The investigators collected data from six registries participating in the NCI’s Breast Cancer Surveillance Consortium, involving 120 radiologists who interpreted 783,965 screening mammograms from 2002 to 2006. So it was a big study, at least in terms of the number of images and outcomes assessed. First — and before reaching any conclusions — the variance among seasoned radiologists’ everyday experience reading mammograms is striking. From the paper: …We studied 120 radiologists with a median age of 54 years (range, 37–74 years); most worked See more Radiologists’ Experience Matters in Mammography Outcomes On Friday the New York Times reported that surgeons are performing far too many open breast biopsies to evaluate abnormal mammogram results. A new American Journal of Surgery article analyzed data for 172,342 outpatient breast biopsies in the state of Florida. The main finding is that between 2003 and 2008, surgeons performed open biopsies in an operating room – as opposed to less invasive, safer biopsies with needles — in 30 percent of women with abnormal breast images. I was truly surprised by this should-be outdated statistic, which further tips the mammography math equation in favor or screening. See more New Numbers Should Factor Into the Mammography Equation As Sue, a woman who’s had breast cancer told me last month: “You don’t want a radiologist who’s just looked at someone’s broken foot examining your mammogram.” She’s right. Expertise can make a huge difference in clinical outcomes. See more Five Ways to Improve the Quality and Success of Breast Cancer Screening by Mammography Maybe, one good application of Telemedicine would be in the sharing of digital mammography images, so that any woman’s breast films could be checked by a radiologist who works at a cancer imaging center and specializes in breast imaging.…there’s every reason to think that the incidence of false positives in screening mammograms is going down and will drop further… See more Why It’s So Hard to Assess False Positives, and How We Might Reduce Them If physicians’ potential profit motives cloud the mammography debate, as the authors contend, that doesn’t mean that mammography is ineffective. Rather it signifies that doctors and scientists should analyze data and make clinical decisions in the absence of financial or other conflicts of interest. See more It’s Not About the Money But consider — if the expert panel’s numbers are off just a bit, by as little as one or two more lives saved per 1904 women screened, the insurers could make a profit! By my calculation, if one additional woman at a cost of, say, $1 million, is saved among the screening group, the provider might break even. And if three women in the group are saved by the procedure, the decision gets easier… Now, imagine the technology has advanced, ever so slightly, that another four or five women are saved among the screening lot. How could anyone, even with a profit motive, elect not to screen those 2000 women? See more Getting the Math on Mammograms |
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