October is breast cancer awareness month

October is breast cancer awareness month. I would like to send hugs out to all of the breast cancer survivors including my dear friend Nancy (8 year survivor-yay!), And to all of the family and friends of those who were not so fortunate as to survive breast cancer. I am so sorry for your loss!

There is a lot of conflicting information regarding breast cancer screening. Currently I am following the lead of the American College of OB/GYN (ACOG), and still screening for breast cancer (with mammography and clinical breast exams) every 1-2 years starting at age 40.

I will include the new breast cancer screening guidelines from the US Preventative Services Task Force (USPSTF), and the official statement from ACOG regarding the new recommendations by the USPSTF. Please also read the article from the National Cancer Institute on breast cancer prevention.

Thanks,

~Lisa



NEW BREAST CANCER SCREENING GUIDELINES FROM THE USPSTF


November 16, 2009 ( UPDATED November 17, 2009 ) — The US Preventive Services Task Force (USPSTF) has issued new breast cancer screening guidelines, which are published in the November 17 issue of the Annals of Internal Medicine. The task force now recommends against routine mammography screening for women before age 50 years and suggests that screening end at age 74 years.

The new USPSTF recommendations are in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society and the American College of Radiology, which have both criticized the new document. Several agencies and organizations, such as the Seattle Cancer Care Alliance, have said they will continue to follow the American Cancer Society guidelines. However, according to an article in the New York Times, advocacy groups like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network "welcomed the new guidelines."

Updated USPSTF Breast Cancer Screening Guidelines

The new USPSTF guidelines, which update those they issued in 2002, also recommend changing the screening interval from 1 year to 2 years and suggest that women aged 40 to 49 years who are at high risk for breast cancer consult with their clinician concerning the optimal time to begin regular, biennial screening mammography.

"Mammography, as well as physical examination of the breasts, can detect presymptomatic breast cancer," write Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues from the USPSTF. "Because of its demonstrated effectiveness in randomized, controlled trials of screening, film mammography is the standard for detecting breast cancer; in 2002, the USPSTF found convincing evidence of its adequate sensitivity and specificity."

Because of insufficient evidence to determine the benefits and harms of screening mammography in women older than 75 years, the updated guidelines recommend stopping screening at age 74 years.

Because the USPSTF found adequate evidence that teaching self-examination is not associated with a decrease in breast cancer mortality rates, the task force recommends against teaching breast self-examination (BSE).

Current evidence is now insufficient to evaluate additional benefits and harms of clinical breast examination (CBE) for women aged at least 40 years. This recommendation is a change from the 2002 statement, which endorsed mammography screening, with or without CBE, annually or biennially for women 40 years or older.

Film mammography is associated with decreased breast cancer mortality rates, particularly in women aged 50 to 74 years, based on evidence to date. Women aged 60 to 69 years appear to have the greatest benefit, whereas evidence of benefit associated with film mammography is lacking for women aged at least 75 years.

Current evidence is insufficient to determine additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) as screening modalities for breast cancer vs film mammography. Therefore, the USPSTF did not recommend one form of mammography vs another.

The evidence base for the updated guidelines was a systematic review of published evidence of the efficacy of the 5 screening modalities in lowering breast cancer mortality rates. These include film mammography, CBE, BSE, digital mammography, and MRI.

Other evidence reviewed by the USPSTF included 2 studies commissioned by the task force. These were a systematic evidence review targeting 6 questions concerning the benefits and harms of screening and a decision analysis using population modeling techniques to determine anticipated health costs and outcome benefits of screening every year vs every 2 years, and of starting and ending mammography screening at various ages.

Specific Recommendations

Specific recommendations of the USPSTF, and the accompanying strength of recommendations, were as follows:

•The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. Based on patient context, including patient values concerning specific benefits and harms, individual decisions should be made regarding starting regular, biennial screening mammography before age 50 years (grade C recommendation).
•Women aged 50 to 74 years should undergo biennial screening mammography (grade B recommendation).
•Current evidence is insufficient to determine additional benefits and harms of screening mammography in women 75 years or older (I statement).
•In women 40 years or older, current evidence is insufficient to determine the additional benefits and harms of CBE beyond screening mammography (I statement).
•The USPSTF recommends against clinicians teaching women the technique of BSE (grade D recommendation).
•Current evidence is insufficient to determine additional benefits and harms of either digital mammography or MRI vs film mammography as screening modalities for breast cancer (I statement).
Evidence-Based Findings

The accompanying updated evidence review on breast cancer screening looked at published studies identified from a search of Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through the fourth quarter of 2008, MEDLINE January 2001 to December 2008, and bibliographies of identified articles. Also reviewed were Web of Science searches and Breast Cancer Surveillance Consortium for screening mammography data.

"Mammography screening reduces breast cancer mortality for women aged 39 to 69 years; data are insufficient for older women," write Heidi D. Nelson, MD, MPH, from Oregon Health & Science University in Portland, and colleagues. "False-positive mammography results and additional imaging are common. No benefit has been shown for CBE or BSE."

Inclusion criteria for studies were randomized controlled trials with breast cancer mortality outcomes for screening effectiveness and studies of varying designs and multiple data sources regarding harms. The reviewers found that for women aged 39 to 49 years, mammography screening was associated with a 15% decrease in breast cancer mortality rates (relative risk, 0.85; 95% credible interval, 0.75 - 0.96; 8 trials). However, data are lacking for women 70 years or older.

Radiation exposure from mammography is low, and adverse experiences are common but transient and do not alter screening practices. The estimated rate of overdiagnosis from screening ranges from 1% to 10%. Compared with older women, younger women have more false-positive mammography results and additional imaging but fewer biopsies. Trials of CBE are ongoing. In trials of BSE, benign biopsy results increased, and there were no decreases in mortality rates.

Study Limitations

Limitations of this review include lack of studies in older women, lack of digital mammography studies, and lack of MRI studies.

"We can improve primary and secondary breast cancer prevention effectiveness by implementing risk assessment in primary care and mammography facilities and providing tailored recommendations for prevention based on individual risk," Karla Kerlikowske, MD, from San Francisco Veterans Affairs Medical Center in San Francisco, California, writes in an accompanying editorial.

"Health professionals will need education about how to communicate breast cancer risk to women, potential benefits and harms of prevention interventions, and how to assist women in understanding which factors might influence their choice to have an intervention or not. Women should have the opportunity to make informed choices about primary and secondary breast cancer prevention on the basis of their risk for disease and the potential benefits and harms of prevention interventions."

The guidelines were supported in part by a National Cancer Institute–funded Breast Cancer Surveillance Consortium cooperative agreement and National Cancer Institute–funded University of California, San Francisco, Breast Cancer Specialized Programs of Research Excellence.

The updated evidence review was supported by grants from the Oregon Evidence–based Practice Center under contract to the Agency for Healthcare Research and Quality, the Veterans Administration Women's Health Fellowship, and the Oregon Health & Science University Department of Surgery in conjunction with the Human Investigators Program.

The USPSTF is an independent, voluntary body supported by the Agency for Healthcare Research and Quality. Recommendations made by the USPSTF are independent of the US government and should not be construed as an official position of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

The review authors, task force, and editorialist have disclosed no relevant financial relationships.

Ann Intern Med. 2009;151:716-726, 727-737, 750-752.

[CLOSE WINDOW]Authors and DisclosuresJournalistLaurie Barclay, MDFreelance writer and reviewer, MedscapeCME

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.



ACOG STATEMENT

ACOG Statement on Revised US Preventive Services Task Force Recommendations
On Breast Cancer Screening


Washington, DC -- In response to today's US Preventive Services Task Force (USPSTF) statement that recommends against routine mammography screening for women in their 40s and recommends screening only once every two years for women ages 50 to 74, The American College of Obstetricians and Gynecologists (ACOG) maintains its current advice that women in their 40s continue mammography screening every one to two years and women age 50 or older continue annual screening. The USPSTF revised recommendations are published in the November 17, 2009, issue of Annals of Internal Medicine. (Read more.)

As the organization representing the nation's ob-gyns who provide health care exclusively for women, ACOG welcomes these new review data on breast cancer screening. However, the implications of the USPSTF's recommendations for both women and physicians are not insignificant and require that ACOG evaluate both the data and the USPSTF's interpretations in greater detail. All women, along with their physicians, should individually assess the benefits and as well as the risks of mammography screening.

The USPSTF also recommends against clinicians teaching women how to perform breast self-exams (BSE). At this time, ACOG's position is that ob-gyns should continue to counsel women that BSE has the potential to detect palpable breast cancer and can be performed.

ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.




NATIONAL CANCER INSTITUTE ARTICLE


General Information About Breast Cancer and Breast Cancer Prevention



What is prevention?


Cancer prevention is action taken to lower the chance of getting cancer. By preventing cancer, the number of new cases of cancer in a group or population is lowered. Hopefully, this will lower the number of deaths caused by cancer.

To prevent new cancers from starting, scientists look at risk factors and protective factors. Anything that increases your chance of developing cancer is called a cancer risk factor; anything that decreases your chance of developing cancer is called a cancer protective factor.

Some risk factors for cancer can be avoided, but many cannot. For example, both smoking and inheriting certain genes are risk factors for some types of cancer, but only smoking can be avoided. Regular exercise and a healthy diet may be protective factors for some types of cancer. Avoiding risk factors and increasing protective factors may lower your risk but it does not mean that you will not get cancer.

Different ways to prevent cancer are being studied, including:

Changing lifestyle or eating habits.
Avoiding things known to cause cancer.
Taking medicines to treat a precancerous condition or to keep cancer from starting.

General Information About Breast Cancer

Key Points for This Section

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

Breast cancer is the second most common type of cancer in American women.

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.

Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels lead to organs called lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter lymph and store white blood cells that help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

Women in the United States get breast cancer more than any other type of cancer except skin cancer. The number of new cases of breast cancer decreased from 1999 to 2006. Breast cancer is second to lung cancer as a cause of cancer death in American women. However, deaths from breast cancer have decreased a little bit every year for the past several years. Breast cancer also occurs in men, but the number of new cases is small.

Breast Cancer Prevention

Key Points for This Section

Avoiding risk factors and increasing protective factors may help prevent cancer.
The following risk factors may increase the risk of breast cancer:
Estrogen (endogenous)
Hormone replacement therapy/Hormone therapy
Exposure to Radiation
Obesity
Alcohol
Inherited Risk
The following protective factors may decrease the risk of breast cancer:
Exercise
Estrogen (decreased exposure)
Selective estrogen receptor modulators
Aromatase inhibitors
Prophylactic mastectomy
Prophylactic oophorectomy
Fenretinide
The following have been proven not to be risk factors for breast cancer or their effects on breast cancer risk are not known:
Abortion
Oral Contraceptives
Environment
Diet
Active and passive cigarette smoking
Statins
Cancer prevention clinical trials are used to study ways to prevent cancer.
New ways to prevent breast cancer are being studied in clinical trials.

Avoiding risk factors and increasing protective factors may help prevent cancer.

Avoiding cancer risk factors such as smoking, being overweight, and lack of exercise may help prevent certain cancers. Increasing protective factors such as quitting smoking, eating a healthy diet, and exercising may also help prevent some cancers. Talk to your doctor or other health care professional about how you might lower your risk of cancer.

NCI's Breast Cancer Risk Assessment Tool uses a woman's risk factors to estimate her risk for breast cancer during the next five years and up to age 90. This online tool is meant to be used by a health care provider. For more information on breast cancer risk, see Estimating Breast Cancer Risk: Questions and Answers or call 1-800-4-CANCER.

The following risk factors may increase the risk of breast cancer:

Estrogen (endogenous)

Endogenous estrogen is a hormone made by the body. It helps the body develop and maintain female sex characteristics. Being exposed to estrogen over a long time may increase the risk of breast cancer. Estrogen levels are highest during the years a woman is menstruating. A woman's exposure to estrogen is increased in the following ways:

Early menstruation: Beginning to have menstrual periods at age 11 or younger increases the number of years the breast tissue is exposed to estrogen.
Late menopause: The more years a woman menstruates, the longer her breast tissue is exposed to estrogen.
Late pregnancy or never being pregnant: Because estrogen levels are lower during pregnancy, breast tissue is exposed to more estrogen in women who become pregnant for the first time after age 35 or who never become pregnant.
Hormone replacement therapy/Hormone therapy

Hormones that are made outside the body, in a laboratory, are called exogenous hormones. Estrogen, progestin, or both may be given to replace the estrogen no longer produced by the ovaries in postmenopausal women or women who have had their ovaries removed. This is called hormone replacement therapy (HRT) or hormone therapy (HT) and may be given in one of the following ways:

Combination HRT/HT is estrogen combined with progesterone or progestin. This type of HRT/HT increases the risk of developing breast cancer. Studies show that when women stop taking estrogen combined with progesterone, the risk of getting breast cancer decreases.
Estrogen-only therapy may be given to women who have had a hysterectomy. It is not known if this type of HRT/HT affects the risk of breast cancer. In women who have a uterus, estrogen-only therapy increases the risk of uterine cancer.
Exposure to Radiation

Radiation therapy to the chest for the treatment of cancers increases the risk of breast cancer, starting 10 years after treatment and lasting for a lifetime. The risk of developing breast cancer depends on the dose of radiation and the age at which it is given. The risk is highest if radiation treatment was used during puberty. For example, radiation therapy used to treat Hodgkin disease by age 16, especially radiation to the chest and neck, increases the risk of breast cancer.

Radiation therapy to treat cancer in one breast does not appear to increase the risk of developing cancer in the other breast.

For women who are at risk of breast cancer due to inherited changes in the BRCA1 and BRCA2 genes, exposure to radiation, such as that from chest x-rays, may further increase the risk of breast cancer, especially in women who were x-rayed before 20 years of age.

Obesity

Obesity increases the risk of breast cancer in postmenopausal women who have not used hormone replacement therapy.

Alcohol

Drinking alcohol increases the risk of breast cancer. The level of risk rises as the amount of alcohol consumed rises.

Inherited Risk

Women who have inherited certain changes in the BRCA1 and BRCA2 genes have a higher risk of breast cancer, and the breast cancer may develop at a younger age.

The following protective factors may decrease the risk of breast cancer:

Exercise

Exercising four or more hours a week may decrease hormone levels and help lower breast cancer risk. The effect of exercise on breast cancer risk may be greatest in premenopausal women of normal or low weight. Care should be taken to exercise safely, because exercise carries the risk of injury to bones and muscles.

Estrogen (decreased exposure)

Decreasing the length of time a woman's breast tissue is exposed to estrogen may help prevent breast cancer. Exposure to estrogen is reduced in the following ways:

Pregnancy: Estrogen levels are lower during pregnancy. The risk of breast cancer appears to be lower if a woman has her first full-term pregnancy before she is 20 years old.
Breast-feeding: Estrogen levels may remain lower while a woman is breast-feeding.
Ovarian ablation: The amount of estrogen made by the body can be greatly reduced by removing one or both ovaries, which make estrogen. Also, drugs may be taken to lower the amount of estrogen made by the ovaries.
Late menstruation: Beginning to have menstrual periods at age 14 or older decreases the number of years the breast tissue is exposed to estrogen.
Early menopause: The fewer years a woman menstruates, the shorter the time her breast tissue is exposed to estrogen.
Selective estrogen receptor modulators

Selective estrogen receptor modulators (SERMs) are drugs that act like estrogen on some tissues in the body, but block the effect of estrogen on other tissues. Tamoxifen is a SERM that belongs to the family of drugs called antiestrogens. Antiestrogens block the effects of the hormone estrogen in the body. Tamoxifen lowers the risk of breast cancer in women who are at high risk for the disease. This effect lasts for several years after drug treatment is stopped.

Taking tamoxifen increases the risk of developing other serious conditions, including endometrial cancer, stroke, cataracts, and blood clots, especially in the lungs and legs. The risk of developing these conditions increases with age. Women younger than 50 years who have a high risk of breast cancer may benefit the most from taking tamoxifen. Talk with your doctor about the risks and benefits of taking this drug.

Raloxifene is another SERM that helps prevent breast cancer. In postmenopausal women with osteoporosis (decreased bone density), raloxifene lowers the risk of breast cancer for women at both high risk and low risk of developing the disease. It is not known if raloxifene would have the same effect in women who do not have osteoporosis. Like tamoxifen, raloxifene may increase the risk of blood clots, especially in the lungs and legs, but does not appear to increase the risk of endometrial cancer.

Other SERMs are being studied in clinical trials.

Aromatase inhibitors

Aromatase inhibitors lower the risk of new breast cancers in postmenopausal women with a history of breast cancer. In postmenopausal women, taking aromatase inhibitors decreases the amount of estrogen made by the body. Before menopause, estrogen is made by the ovaries and other tissues in a woman's body, including the brain, fat tissue, and skin. After menopause, the ovaries stop making estrogen, but the other tissues do not. Aromatase inhibitors block the action of an enzyme called aromatase, which is used to make all of the body's estrogen. Possible harms from taking aromatase inhibitors include osteoporosis and effects on brain function (such as talking, learning, and memory).

Prophylactic mastectomy

Some women who have a high risk of breast cancer may choose to have a prophylactic mastectomy (the removal of both breasts when there are no signs of cancer). The risk of breast cancer is lowered in these women. However, it is very important to have a cancer risk assessment and counseling about all options for possible prevention before making this decision. In some women, prophylactic mastectomy may cause anxiety, depression, and concerns about body image.

Prophylactic oophorectomy

Some women who have a high risk of breast cancer may choose to have a prophylactic oophorectomy (the removal of both ovaries when there are no signs of cancer). This decreases the amount of estrogen made by the body and lowers the risk of breast cancer. However, it is very important to have a cancer risk assessment and counseling before making this decision. The sudden drop in estrogen levels may cause the onset of symptoms of menopause, including hot flashes, trouble sleeping, anxiety, and depression. Long-term effects include decreased sex drive, vaginal dryness, and decreased bone density. These symptoms vary greatly among women.

Fenretinide

Fenretinide is a type of vitamin A called a retinoid. When given to premenopausal women who have a history of breast cancer, fenretinide may lower the risk of forming a new breast cancer. Taken over time, fenretinide may cause night blindness and skin disorders. Women must avoid pregnancy while taking this drug because it could harm a developing fetus.

The following have been proven not to be risk factors for breast cancer or their effects on breast cancer risk are not known:

Abortion

There does not appear to be a link between abortion and breast cancer.

Oral Contraceptives

Taking oral contraceptives ("the pill") may slightly increase the risk of breast cancer in current users. This risk decreases over time. The most commonly used oral contraceptive contains estrogen.

Progestin-only contraceptives that are injected or implanted do not appear to increase the risk of breast cancer.

Environment

Studies have not proven that being exposed to certain substances in the environment (such as chemicals, metals, dust, and pollution) increases the risk of breast cancer.

Diet

Diet is being studied as a risk factor for breast cancer. It is not proven that a diet low in fat or high in fruits and vegetables will prevent breast cancer. For more information on diet and health, see the Fruits and Veggies website.

Active and passive cigarette smoking

It has not been proven that either active cigarette smoking or passive smoking (inhaling secondhand smoke) increases the risk of developing breast cancer.

Statins

Studies have not found that taking statins (cholesterol -lowering drugs) affects the risk of breast cancer.

Cancer prevention clinical trials are used to study ways to prevent cancer.

Cancer prevention clinical trials are used to study ways to lower the risk of developing certain types of cancer. Some cancer prevention trials are conducted with healthy people who have not had cancer but who have an increased risk for cancer. Other prevention trials are conducted with people who have had cancer and are trying to prevent another cancer of the same type or to lower their chance of developing a new type of cancer. Other trials are done with healthy volunteers who are not known to have any risk factors for cancer.

The purpose of some cancer prevention clinical trials is to find out whether actions people take can prevent cancer. These may include exercising more or quitting smoking or taking certain medicines, vitamins, minerals, or food supplements.

New ways to prevent breast cancer are being studied in clinical trials.

Clinical trials are taking place in many parts of the country. Information about clinical trials can be found in the Clinical Trials section of the NCI Web site. Check NCI's PDQ Cancer Clinical Trials Registry for breast cancer prevention trials that are now accepting patients.

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Changes to This Summary (03/12/2010)


The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Changes were made to this summary to match those made to the health professional version.

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If you have questions or comments about this summary, please send them to Cancer.gov through the Web site’s Contact Form. We can respond only to email messages written in English.

About PDQ


PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ contains cancer information summaries.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

The PDQ cancer information summaries are developed by cancer experts and reviewed regularly.

Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.

PDQ also contains information on clinical trials.

A clinical trial is a study to answer a scientific question, such as whether a certain drug or nutrient can prevent cancer. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients and those who are at risk for cancer. During prevention clinical trials, information is collected about the effects of a new prevention method and how well it works. If a clinical trial shows that a new method is better than one currently being used, the new method may become "standard." People who are at high risk for a certain type of cancer may want to think about taking part in a clinical trial.

Listings of clinical trials are included in PDQ and are available online at NCI's Web site. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).