Would the new mammogram guidelines have caught my breast cancer?

November 22, 2011 07:20 by Dr. Marla Shapiro

This week, in the Canadian Medical Association Journal, are newly published breast cancer screening guidelines from the Canadian Task Force on Preventive Health Care updating the last set from 2001. It is sure to cause an uproar as a first look at the guidelines will have women feeling a certain sense of hopelessness in options for breast cancer screening.

The guidelines breaks down the recommendations by age groups, which does make sense as age is one of the greatest risk for breast cancer. To put things into perspective: of the newly diagnosed cases of breast cancer 80% happen in women over the age of 50 and 28% happen in women over the age of 70.

The authors remind readers that overall, we have to balance outcomes of screening, which include the context of harm in over-diagnosis, over treatment and false positive results that lead to anxiety. These guidelines are also aimed at the average risk woman, which means those with no previous breast cancer, no history of the disease in a first degree relative, no known mutations or previous exposure to chest wall radiation.

The key recommendations include:

No routine mammography for women aged 40-49 because the risk of cancer is low in this group while the risk of false–positive results and over diagnosis and over treatment is higher
Routine screening with mammography every two to three years for women aged 50-69
Routine screening with mammography every two to three years for women aged 70-74
No screening of average-risk women using MRI
No routine clinical breast exams or breast self-exam to screen for breast cancer

These guidelines are based on evidence from randomized clinical trials. The authors estimate the risks versus the benefits by age. Here are what the authors state:

Screening 2,108 women aged 40-49 years once every 2 to 3 years for about 11 years would prevent 1 single death from breast cancer. But it would also result in about 690 women having a false-positive mammogram, and 75 women having an unnecessary biopsy.
Screening 721 women aged 50 to 69 every 2 to 3 years for about 11 years would prevent one death from breast cancer, but would result in 204 false-positive mammogram and 26 women having an unnecessary biopsy.

Both of these are looking at the NNS or "number needed to screen", and so are focused on the number to prevent one death. If we look at it differently, what happens per 10,000 women screened we would get:

Screening 10,000 women aged 40-49 every 2 to 3 yrs for 11 yrs would prevent 4.8 deaths from breast cancer, would cause 3,270 false positives and 360 unnecessary biopsies.
Screening 10,000 women aged 50-69/every 2 to 3 yrs for 11 yrs would prevent 13.9 deaths from breast cancer, would cause 2,820 false positives, and 370 unnecessary biopsies.

We do note that mammography is associated with significant reductions in relative risk of death from breast cancer and these absolute benefits are greater in the 50-69 than in the younger age group who have more false positives. However, when we look at the information provided on the effect of screening with mammography on the relative risk of death from breast cancer by age group and interval, in fact, we see the greater benefit in younger women when screened more frequently albeit at the greater cost of false positives.

When it comes to MRI, no screening is recommended for average risk women. And perhaps even more confusing for women is the advice that neither self exam or routine clinical breast exams is recommended to screen for breast cancer.

The authors put a lot of emphasis on the importance for women to be given the appropriate counselling information to help them make a decision on the balance of acceptance of false positives versus earlier detection. The benefit in survival we are seeing is being attributed to better adjuvant therapies in breast cancer treatment.

The concern I have as a clinician is the actual process of how and who is giving this counselling. There are many sources of information for women, as my colleague Dr. Bryant points out. For many women, if the decision-making process gets too onerous or difficult, many women may make a decision from what they perceive to be a reliable source and those sources may, in my opinion, not be all that reliable.

As a physician and woman, I come at this from two blended perspectives.

I usually do not editorialize in my blogs and seek to provide the information in an understandable context, but for many women these guidelines will be confusing and upsetting. As a woman who was in my 40s, average risk, without family history or a positive gene, a mammography diagnosed me with invasive breast cancer that one done within a 2-year period had missed. Am I to believe that had I waited until I personally noted a difference in my breasts -- even though the advice is not to do routine self breast exams -- I would have done as well?

It is true that my earlier mammograms had resulted in biopsies with negative results, which these guidelines would call "false positives." But that, for me, was tolerable. The guidelines say that for many women that outcome in waiting for the negative biopsy and its results is unacceptable. That is where the counselling piece comes in. I do believe that my mammogram detected my disease at a stage well before I personally could have noted it and I will never know had I waited what the outcome would be.

The bottom line for me is that these are guidelines and as such, are a tool and review of the evidence that looks at populations of women and screening outcomes. In my office, I sit with an individual woman and together we will have to look at the evidence and decide what is right for her as an individual in making the decision as to how to screen, when to screen and how often to screen.

WATCH: My mammogram chat on Canada AM

New drug for advanced HER2+ breast cancer approved in Canada Coffee, alcohol and cancer: To drink or not to drink?Stopping HRT decreases breast cancer risk: The evidence grows

Comments

November 22. 2011 08:15

Dr. Shapiro, THANK YOU for everything you have done for practical breast cancer awareness! Your book was the only book that made sense to me when struggling with my own cancer diagnosis and your appreance today was refreshing to say the least! Your comments regarding only a woman knowing her own body best made me think back to how I felt ignored and then bullied by the medical profession here in little Moncton, NB -- for a year before my cancer was found, my GP kept dismissing my concerns about a new lump in my right breast -- I was too young to have IT (41) and there was no history of it in my family. "It's just a cyst" he said over and over.

My journey, as they call it, became unusual and rare indeed. At 42, I had my breasts augmented for my self alone, my husband decided he needed out of our marriage, and I began rebuilding my life finding myself for the first time, then WHAM -- my plastic surgeon listened about the lump and after an MRI and an unnecessarily painful core biopsy, I was diagnosed with oat cell of the breast. VERY rare as my tumour did not originate from any other part of my body. My oncologist said I was one of ten women "in the world" to have this, however, on more research of my own (I used to be a legal editor so my research was not just WebMD LOL), and with the help of the Canadian Cancer Society, I found a valid medical study that had "dozens" of women in Japan with this presentation. The Breast Cancer Society was less than no help -- all they seemed to want from me was pink, pink, pink! As an aside, how do they justify asking $45 from a single mother with no job going through this hell to walk in their walk?? Sorry, but I do not support the Breast Cancer Society using their millions to launch 6 pink buses to "raise awareness" -- pink is everywhere (from toilet paper to bumper stickers) -- I think there cannot be a woman in Canada who is unaware at this point!

I do not want to bore you with the details of my treatment. I had two tumors and two positive lymph nodes by the time they figured out what to do with me. Suffice it to say I am now being examined for metatases to my femur (I find out tomorrow). No two women are the same. My best friend had a similar story but if it hadn't been for her insisting the doctors listen to her, and as she did not accept she was too young for a mammogram, she would be dead by now.

I thank you again for being so frank and advising common sense for each of us. Now if the doctors would listen. I actually had a cancer surgeon say to me that in Ontario, he became used to patients being very curious and involved in their treatment -- he said the Maritimes seem to engender a "yes doctor" attitude and when they come up against people like me or my friend, they are taken aback. There is very much the attitude of "shut up and do what I say -- I'm God -- I mean a specialist".
Kim Aiken
Riverview, New Brunswick

Kim Aiken

November 22. 2011 09:51

I don't understand why you think women would feel "hopeless" in the face of these guidelines. These seem quite sensible to me and are similar to guidelines that have been in place in other parts of the world. I allowed myself to be pressured into a mammogram before the age of 50 because my FP really wanted it. He has also recommended yearly ones now that I'm 50 and I have pushed back based on the UK guidelines. I'm happy that the Canadian guidelines now support my preferences.

I'm terribly sorry that you turned out to be an early breast cancer victim. There are also those who get breast cancer in their 20s, and yet no one advocates for routine screening at that age. There will always be outliers. Worrying about that is what leads people to pay for things like full body MRIs without indication. You could say that the only normal person is one who hasn't been examined by enough specialists yet. We could all be screened for many things, but taking a look at the risk/benefit ratio is important.

I think one of the challenges for clinicians who have had personal health crises is to not bring that experience into the office. I have certainly known other doctors who scared patients into thinking something was wrong, based on a recent experience the doctor had had either with themselves or with another patient. It's human, but it's not very helpful.

I think we all need to make an effort to get to know our bodies, take the precautions that seems sensible to us, and recognize that sometimes bad things happen and no one could have done anything about it ahead of time.

Rean Cross

November 22. 2011 14:12

I am a mammography technologist and was made aware of this article by a patient today. I realized after hearing what she said and then reading the article that there are some misunderstandings.

My patient understood that when it was stated that screening mammogrpahy in the different age groups would prevent a certain number of deaths due to breast cancer that the mammogram CAUSED the breast cancer. What it means is that the mammogram is going to discover a cancer, not cause it, and therefore the patient can get the appropiate care early.

To me, having the training that I do, I didn't find any of the recommendations appalling, until I reached the last one. "No routine clinical breast exams or breast self-exams to screen for breast cancer". I think that what needs to be understood is that clinical and self breast exams should not be used alone for diagnosis. They are very important and helpful in discovering any changes that may be the result of a disease process in the breast.

It is a part of my job to ensure that my patients are informed. Every patient's situation is different (from breast composition to family history) and that we need to remember that these are GUIDELINES!!! A younger woman may have less chance of developing breast cancer, but if there are symptoms or cause for concern, she does need to receive the proper diagnostic tests to comfirm or disprove any suspicions.

There are many facts and myths about mammography that the general public has misconceptions about. What I suggest to women (or anyone regarding any health care concerns) is to ask questions!! We are here to help and want to help you to understand!

Tiffany Bester

November 22. 2011 14:47

Thank you CTV and Dr. Shapiro for this very enlightening episode on Mammograms. During the weekend, I attended the Christmas Show at the Careport Centre in Hamilton. One of the booths set up was Thermography Clinic of Niagara Region. Laurie-Ann Whitnall , CTM owns a clinic in Welland. She provides Pain Free, NON Evasive Breast Screening to her patients.

Early detection is important, but prevention is the key! The advantage of an early assessment of risk factors could be life-saving. Breast Thermography is one of the best early warning systems available today. THERMOGRAPHY is a non-invasive, radiation-free monitoring of breast health.

Breast Thermography is a breakthrough imaging procedure where infrared images of the breast are analyzed and rated to determine the risk of developing breast cancer. Thermography is non-invasive, safe and painless – no radiation or compression is used.

The infrared imaging process allows you to see the range and amount of heat or thermal energy emitted from the body. Structural tests, such as mammograms and ultrasound rely on finding physical lesions (anatomy), while breast thermography detects asymmetrical blood vessel circulation (physiology) within the breast.

Thermography is based on the premise that before the growth of abnormal cells is possible, a constant blood supply must be circulated to the growth area. Thermography measures the heat generated by the microcirculation of blood in the breast during this process.

What we don't understand and many women at the show were also wondering is why this is not a covered service by OHIP??? Mammograms however frequent or infrequent will only capture something that is structural not vascular. Isn't early detection the key to the success of any Cancer survivor??? Why are we worried about the frequency or infrequency of a mammogram, why are we not worried about what we can do before Cancer exists or at least what can we do befor it is full blown?

A state-of-the-art FDA approved infrared imaging camera measures skin temperature and transmits this information to a computer which converts these radiometric measurements into images. These thermographic findings are evaluated based on 32 standard thermological signs and quantification criteria as set forth and accepted standards of clinical thermology. Temperature measurements will differ in various parts of the body, but in a normal healthy individual, the temperature changes should be relatively symmetrical. Once the images are acquired in a controlled setting they are sent for processing to our board certified clinical Thermologists for analysis and interpretation. Your written report is then returned to your imaging center in a few days and presented back to you with an explanation and follow up recommendations. Studies show that when breast thermography is used as part of a multimodal approach (clinical examination + thermography + mammography), 95% of early stage cancers will be detected.

Take a look at the false/negative statistics:

Mammography

Structural test: can pinpoint the location of suspicious area
Compresses the breast
X-ray radiation produces an image; the area of concern must have greater density to stand out against regular tissue
Can detect tumors in mainly slow growing stage or pre-invasive stage
Cannot detect fast growing tumors in the pre-invasive stage
The use of hormones decreases sensitivity
Large, dense and fibrocystic breasts are difficult to read
The upper portions of the breast including the tail of the breast and the Axillary region cannot be visualized
Can detect tumors 1-2 years earlier than physical examination
Average Specificity 75% (25% false-positive) 9 out of 10 biopsies initiated by mammography are negative
Average Sensitivity 80% with 20% of cancers missed in women over age 50 in women under age 50 Sensitivity is 60% or 40% of cancers missed

Ultrasound

Structural test, can pinpoint the location of suspicious area
Uses sound waves with moderate contact
High frequency sound waves are bounced off the breast tissue and collected as an echo to produce an image
Able to detect some tumors missed by mammography
No data available on detecting pre-invasive tumors
May be affected by the hormonal influence due to the menstrual cycle, (i.e. cystic changes)
All areas of the breast and Axillary region can be analyzed
Good for distinguishing between solid and fluid masses, helpful in investigating an area of concern due to mammography, thermography or physical examination findings
Average Specificity 66% (34% false positive)
Average Sensitivity 83% (17% of cancers missed)

Thermography

Functional testing, able to detect physiological changes, cannot pinpoint the exact location of suspicious area
No radiation, non-invasive, no risk, can be used as often as necessary to observe the effectiveness of treatment over time
Uses infrared detectors to detect heat and increased vascularity that may be related to angiogenesis
Can detect physiological changes many years prior to any other method of screening
Very sensitive to fast growing aggressive tumors
Hormonal activity in the breast will affect thermographic imaging but not to the point of abnormality
All breast shapes, conditions and areas are within the scope of imaging
Earliest warning system with breast tissue and physiological changes that usually precedes tumor formation years prior to its occurrence
Average Specificity 90% (10% false positive)
Average Sensitivity 90% (10% cancers missed) most of these are slow growing tumors with low metabolic rate in the area with a high rate of survival

It goes without saying that prevention is key as early detection means you already have it. However, with the options out there today, I am completely baffled by where we as a society spend our time and money.

Check out the Thermography Clinic Niagara website. There are clinics all over Ontario. At least someone like Laurie-Ann Whitnall is willing to get the word out and educate many of us with that fear. We do not want to wait until a lump is detected, or until we reach the age of 40 or 50. These services should not have to depend on OHIP coverage...Cancer does not restrict age, sex or how much money you have, it comes in many forms and without criteria.

It is important that we LOBBY to have this incredible service covered! CTV, please do an additional episode on Thermography. There are many women out there wanting this service. Almost everyone I spoke to at the show had 1 or more friends and family with Cancer. Let's start talking about other options for detection.

Josie Ainsworth

November 23. 2011 22:31

Is Thermography only available in Ontario? Does Manitoba offer this screening procedure? If not where is all the money going that is raised for breast cancer awareness??? Should this not be offered as a free service through Cancer Care?

cindy edmonds

November 25. 2011 08:27

apparently, some of the background to these guidelines, as reported in the popular press, has been omitted.

for example, the mantra that "earlier detection saves lives" may no longer be entirely true.

we can detect very small tumours that it may be unnecessary and inappropriate to treat, resulting in either over-treatment or unnecessary stress for the patient. and even if the doses are small, any and all unnecessary radiation used in the screening carries some risk.

without any improvement in the ability to treat, or in the outcomes, just being able to watch the development of the disease from an earlier stage provides no benefit to the patient, but is a burden to the healthcare system overall.

the biggest question that these new guidelines raise is, should we believe everything we believe?

tom

November 25. 2011 10:00

Hi Cindy,
There are Thermography Clinics everywhere...and more and more of them are starting to appear. Women love the fact that they can be screened, pain free and it provides them with early detection.

go to the website www.thermographyclinicniagara.ca

they have all the locations in Canada.

Josie

Josie Ainsworth

Add comment

Name*
E-mail*
Country Country flag

Captcha*

b i u quote

Comment
Preview

Notify me when new comments are added

Website

Would the new mammogram guidelines have caught my breast cancer?

Related posts

Comments

Add comment

Recent Posts

CTV's Avis Favaro on Twitter

Search

Category list

Tag cloud

Would the new mammogram guidelines have caught my breast cancer?

Related posts

Comments

Add comment

Recent Posts

CTV's Avis Favaro on Twitter

Search