More Clarity, Not Confusion, Needed in Breast Cancer Screening Recommendations
October is breast cancer awareness month. This year an expected 231,840 cases of invasive breast cancer will be diagnosed in women, along with 62,290 cases of non-invasive, or in-situ, breast cancer. About 1 in 8 women will develop invasive breast cancer. More than 40,000 women will die from breast cancer this year. Early detection is vital. Unfortunately, recent American Cancer Society (ACS) changes to recommended guidelines for mammography are fraught with controversy and are adding to confusion for patients and the public.
New guidelines controversy
The ACS guidelines state that for women at average risk:
Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered.
Women age 45 to 54 should get mammograms every year.
Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening.
Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
The physical breast exams done by either a health professional or by yourself for breast cancer screening is no longer recommended.
As a pathologist, I see breast cancer too often. Research has shown that early detection saves lives. In a landmark study, Dutch researchers have found that detecting breast cancer at an early stage saves lives, even in this era of targeted therapies, new chemotherapy options and more conservative surgery. The findings have been widely publicized in the press.
What is already known
It is known that survival is correlated with tumor size and number of positive lymph nodes, i.e. increasing size and number of nodes leads to decreased survival. However, only rare studies looking at more recent data (patients after 2004) exist.
Since 2004, chemotherapy regimens have improved, leading to increases in survival rates.
It is unknown how stage (tumor size and number of positive lymph nodes) at breast cancer detection, impacts survival in modern times.
What this study finds
The current study examined almost 174,000 Dutch women between 1999 and 2012. They found a 91% 5 year survival rate for the 1999-2005 cohort, whereas those from 2006-2012 had a 96% 5 year survival rate.
They found that both tumor size and nodal status still have a major influence on overall mortality.
This is independent of age, tumor biology, more conservative surgery and newer chemotherapy regimens.
Thus, early stage at detection saves lives. Surgery is imperative, with more conservative approaches resulting in more favorable outcomes.
This study will give critics of mammogram guidelines a renewed argument in favor of yearly screening. Currently the US Preventive Services Task Force (USPSTF) recommends screening women aged 50-74 years every other year. The decision to start regular, biennial screening mammography before the age of 50 years should be a individualized, taking patient context into account, including the patient's values regarding specific benefits and harms in a shared decision making process with one’s physician. The USPSTF states there is insufficient evidence to offer screening mammograms to women 75 and older. From the study, it is clear that yearly screening does save lives.
The study also gives reassurance that conservative surgery is as good as mastectomy. The findings prove that consistent high quality care makes a difference. The 5 year breast cancer survival rate in the Netherlands is 96%, while that of small tumors is 100%. Currently the US 5 year breast cancer survival rate is 90%. Clearly, much can be learned from our Dutch colleagues.
More cancers in young women
I am increasingly diagnosing more breast cancers in women in their 30s and early 40s, the groups that would be missed by adhering to the new guidelines. Our group also does humanitarian work for Partners in Health reading cases of breast cancer from Haiti. In such third world countries where cancer screening is not universally available, cancer hits hard. The cases from Haiti are often in young women and at a far advanced stage, something we don’t see here because of the life saving efforts of routine mammography.
The costs of screening far outweigh those of expensive treatment for advanced cancers. Research has shown that women who receive routine screening have cancers detected sooner, are less likely to need aggressive treatment and are more likely to be cured.
Shared decision making key
As a pathologist and critical member of cancer care teams, I urge women to understand that there is no “one size fits all” approach to diagnosing and treating all types of cancer, particularly breast cancer.
All women can and should communicate with their primary care physicians and assess their personal levels of breast cancer risks based on a variety of components that include family and health history as well as genetic factors such as BRCA1 and BRCA2 genetic mutations. Pathologists help care teams identify these risks and are the specialized doctors that help radiologists, oncologists and other physicians resolve mammography findings when biopsies are required.
So rather than be alarmed, be informed. Communicate with your physician. Ask about your personal risks based on your health and history. Understand lifestyle factors that may contribute to your risks and take the steps you need to stay healthy.
To learn more about the vital role of the pathologist, visit cap.org. And when a biopsy is required, the College of American Pathologists also provides a helpful resource to understand the details behind your biopsy and pathology report to help make informed decisions about your health.
Get the facts about your health. Get a copy of your pathology report. Understand it and ask questions. Discover the other member of your care team, the pathologist.
Stay tuned to Path Report during the month of October for continuing stories on breast cancer. What you need to know and how pathologists are working to make patients healthy.