TO
WELCOME
TO CONTENTS |
Breast self-examination - a good idea or not? A Pap Smear for the Breast? mammography reporting regulations and list of centres mammography risks and benefits breast cancer mortality in Australia HRT and breast cancer Bone mass and risk of breast cancer among postmenopausal women For a demonstration of cautions when reading a study abstract about the effect of continuous progestin on breast tissue see http://www.oxford.net/~tishy/breastconthrt.html |
Jan 4, 2003 Excerpt from http://bmj.com/cgi/content/full/326/7379/1 BMJ 2003;326:1-2 ( 4 January ) Editorials:
A large well conducted randomised controlled trial from Shanghai shows conclusively that teaching women how to examine their breasts does not lead to a reduction in mortality due to breast cancer compared with no screening at all.1 The findings should bring to an end more than decade of controversy and confusion in the United Kingdom concerning the efficacy and effectiveness of self examination of the breast. Sept 11 2002: An editorial on Medscape (free registration required) offers commentary on the ongoing mammography controversy. I think it well worth reading, as are the two articles linked in the extract below. From the Editor
April 9, 2002: An article
in The New York Times, uses the announcement of a failed screening test
for neuroblastoma to illustrate the uncertainties of screening for cancer
in general and in particular. It can be read at http://www.nytimes.com/2002/04/09/science/09CANC.html?pagewanted=1
(free registration required)
For years, it was a medical truism that the earlier cancer could be detected, the better. Most cancers would inevitably worsen if left untreated, the theory went. Spontaneous remissions were so rare as to be almost unheard of. Yet another salvo in the mammography controversy appeared in the Mch 15, 02 issue of The Lancet at www.thelancet.com Free registration is required to access the full text, which includes the claim that "The recent criticism against the Swedish randomised controlled trials is misleading and scientifically unfounded."Benefits of screening mammography Some research has doubted the benefit of screening mammography. But new data now show that there may be a modest benefit for women aged 55 years or over........ they found a significant 21% reduction in breast cancer mortality for women given screening mammography. But the benefit was less apparent in women aged 50-54 years.......The latest round in the screening mammography controversy was triggered by a letter published in the Lancet. To access it, go to www.thelancet.com (free registration is required)and search on "screening mammography". Extract
from Lancet Volume 359, Number 9304 02 February 2002
Sir--Reviews of randomised screening trials done earlier than that undertaken by Ole Olsen and Peter Gøtzsche (Oct 20, p 1340)1 have supported the practice of screening for breast cancer with mammography, particularly for women older than 50 years;2,3 Olsen and Gøtzsche challenge this view. Unfortunately, they provided one version of their review to The Cochrane Library4 and another (which is not an approved Cochrane review) to The Lancet.1 These two reviews, although similar, differ in some important features that may lead to confusion. This was widely reported and commented upon in the general press, including the following decided anti-mammography press release Wednesday February 6,
4:08 pm Eastern Time Press Release SOURCE: Cancer Prevention Coalition
CHICAGO, Feb. 6 /PRNewswire/ -- The following was released by Samuel S.. Epstein, M.D., Chairman of the Cancer Prevention Coalition and Professor Emeritus of Environmental and Occupational Medicine, University of Illinois School of Public Health, Chicago: Recent confirmation by Danish researchers of longstanding evidence on the ineffectiveness of screening mammography has been greeted by extensive nationwide headlines. Entirely missing from this coverage, however, has been any reference to the [following] well-documented dangers of mammography.The New York Times went beyond the current report to consider if and how the present dilemma might be resolved http://www.nytimes.com/2002/02/05/health/womenshealth/05MAMM.html February 5, 2002 Putting Mammograms to
the Test
In what is considered the gold standard of scientific evidence gathering, a randomized controlled clinical trial, some people are having the potentially lifesaving screening tests, and some are not. An independent monitoring committee is standing by to see if the cancer death rate in one group exceeds that in the other. At that point, the study will end. But when it comes to mammograms, even Dr. Kramer gives up...... Oct 21, 2001 extract
from an editorial which can be found through www.thelancet.com/search
and entering the title below as the search term
The editorial includes further references and explanation of the Cochrane reviews"There is no reliable evidence that screening for breast cancer reduces mortality." This conclusion, published in The Lancet this week, confirms previous controversial analysis from researchers in Denmark. Peter Gøtzsche and Ole Olsen from the Nordic Cochrane Center, Copenhagen, did a second analysis of data from a previous study. Reporting the results in a fast-tracked Research letter, they also confirm, with additional data available on thelancet.com, their earlier finding that screening leads to more aggressive treatment, increasing the number of mastectomies by about 20% and the number of mastectomies and tumorectomies by about 30% Extracts only from other commentaries: http://www.nature.com/nsu/011025/011025-5.html <snip> "There is an urgency for the data to be re-analysed correctly," says breast-cancer clinician Serge Rozenberg of the Free University of Brussels in Belgium, and for women to be informed of existing doubts over the efficacy of screening. "This is about millions of women," he says; not acting on this study is "unacceptable". http://www.bmj.com/cgi/content/full/323/7319/956(British
Medical Journal)
The difficulty of getting scientists to reach a consensus on their interpretations of trial data was illustrated last week when two reviewers for the Cochrane Breast Cancer Group published their own review of mammography screening trials after editors from the group had disagreed with some of their conclusions. <snip>http://www.abc.net.au/science/news/stories/s394891.htm(Australian public radio) Debate over evidence for breast screening Monday, 22 October 2001 A dispute over breast cancer screening has brought into the spotlight international power plays over the interpretation of medical evidence. June 25, 01 An article in the Canadian Medical Association Journal made the surprise recommendationthat routinely teaching BSE to women beteen 40 and 70 should be abandoned as part of a periodic health examination. http://www.cma.ca/cmaj/vol-164/issue-13/1837.asp Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case-control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results.Recommendations: Women aged 40-49 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation).In the same issue, another article athttp://www.cma.ca/cmaj/vol-164/issue-13/1851.asp argues that the recommendation is premature. It says in part: .....In summary, we agree with the task force that there is still not much evidence BSE helps and that there is more evidence it can harm. Is it time, therefore, to tell patients that BSE should not be practised? In making this decision, we must consider the effect of eliminating a widely practised procedure. For over 30 years many women have grown to accept BSE as a screening tool for breast cancer. They have become comfortable with examining their breasts and have gained a sense of control over their health care. How will women react to a sudden reversal in medical advice about BSE? How will it affect their reaction to medical advice about other screening methods for breast cancer? <snip>Note: The practice of BSE is by no means universal. For instance the official UK site at http://www.cancerscreening.nhs.uk/breastscreen/breastawareness.html#routine says in part: The Department of Health's policy on breast awareness, which has strong support from the nursing and medical professions, encourages women to check their breasts for what is normal for them but does not recommend routine self examination to a set technique. Copied with permission from the Breast Cancer Information Site (BCIS) at http://trfn.clpgh.org/bcis/GeneralInfo/bse.html Breast Self-Exam (BSE)
WhyWhen to Do a Breast Self-ExamHow to Do Breast Self-Exam
You should also check your breasts in a mirror looking for any change in size or contour, dimpling of the skin or spontaneous nipple discharge. |
For a good description of
benign conditions which cause breast lumps see http://www.sjbnet.com/breastproblems.htm
This site also covers reasons for 'abnormal mammograms, complete with ilustrative images. |
A
Pap Smear for the Breast? As the result of many years of research by
Dr.
Susan Love MD and colleagues, there is finally a new approach -ductal
lavage - to the breast.
http://www.susanlovemd.com/lavage_frames.html has a good illustrated description of the procedure. There is also a list of doctors who are [Mch 2001] performing the procedure.(Extract below) Ductal lavage is a washing procedure that can identify cancerous and precancerous cells in the milk ducts of the breast. The procedure has been dubbed "Pap smear for the breast" because, like the test for cervical cancer, it is a nonsurgical approach to identifying abnormal cells, potentially making it possible to find them when they are just thinking about becoming cancer. |
Extracts
from http://www.fda.gov/bbs/topics/NEWS/NEW00679.html
MAMMOGRAM LAW TAKES EFFECT APRIL 28, 1999 The Food and Drug Administration is further strengthening the nation's standards for mammography centers by requiring that all women who have mammograms must be directly notified in writing about their results. Although many mammography facilities already provide this service, the FDA rule ensures that written notification occurs promptly, in easy-to-understand language, and that it is provided by every mammography facility in the United States. Facilities performing mammograms will continue to report results directly to the patient's physician. But they will now provide patients with a separate, easy-to-understand summary report within 30 days. Self-referred patients with no designated healthcare provider will receive both the simplified report and the one doctors normally receive. If the results are suspicious or suggest cancer, they must be communicated to the patient as soon as possible, ordinarily within five working days. If the results are unclear or incomplete, the FDA recommends that facilities communicate this to patients as soon as possible to avoid delays in follow up care. The exact language of the report and the system for reporting are left up to the facility. The final regulations also
require mammography facilities to transfer original, as opposed to copies
of, mammograms to a patient's
Under MQSA, all mammography facilities in the United States must now meet certain stringent standards for equipment, personnel and image quality, be accredited by an FDA-approved accreditation body, be MQSA-certified, and be inspected annually. Today virtually all 10,000 facilities have fully met standards and are certified to perform mammography. The names and locations of certified mammography facilities are available by calling the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237), or on FDA's Website at www.fda.gov/cdrh/faclist.html. |
From
the Canadian Family Physician "critical appraisal" series
http://www.cfpc.ca/CFP/1999/cfpjan99critical.htm#False-positive results False-positive results in breast cancer screening Michael F. Evans, MD, CCFP Elmore JG, Barton MB, Moceri VM, Polk S, Arena PJ, Fletcher SW. Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med 1998;338(16):1089-96. Research question
• Estimated cumulative risk of having at least one false-positive result during the 10-year period was 49.1%. For those older than 50 the rate was 47.3%.
• This translates to telling our female patients older than 50 that their
risk of requiring unnecessary interventions (eg, biopsies) is almost one
in two if they have
• Cumulative risk of false-positive results was similar for both mammography and CBE. After five screening mammograms the risk was 30.3%; after 10, 56.2%. These rates dropped to 23.8% and 47.3%, respectively, for those older than 50. After five CBEs the risk was 20.8%; after 10, 34.1%. This dropped to 11.1% and 18.7%, respectively, for omen older than 50. • From a natural history point of view, it was interesting to note that cancer was diagnosed in 88 of the 2400 women over the 10 years of the study and that the cancers were picked up by screening mammogram in 58, by CBE in seven, and by patient concern in 23.
• These data need to be assessed in light of your local breast screening
strategy and diagnostic practices.
http://mammography.ucsf.edu/inform/index.cfm This is an easily read site which provides information in point form about the important basics of mammography and its relationship to breast cancer. It is unusual in that it is not wholly positive. Potential Benefits &
Risks of Mammograms
Research Study: This Website is also part of a scientific study being conducted at the University of California, San Francisco. Researchers at the university have developed the information on this site and would like your help evaluating whether the information provided about mammograms helps women make the personal decision whether to have or not have a mammogram. Here’s how to
participate: First read the 17 questions and answers in the section "Potential
Benefits and Risks of Mammograms." Then complete and submit the questionnaire
that follows. The questionnaire includes 20 questions about your impressions
of the information you have just read. Personal comments are appreciated
and can be included after reading the section "Potential Benefits and Risks
of Mammograms" or after completion of the questionnaire.
Effect of Estrogen and Estrogen-Progestin Replacement Regimens on Mammographic Breast Parenchymal Density By Ingemar Persson, Erik Thurfjell, and Lars Holmberg Purpose:Hormone
replacement therapy (HRT) may increase the mammographic density with a
possible reduction in the sensitivity or specificity. If so, the benefit
of mammographic screening in women using HRT could be compromised. We evaluated
the hypothesis that HRT regimens have differential effects on the mammographic
density depending on treatment regimens or on age.
J Clin Oncol 15:3201-3207
October 97
Risk-Based Recommendations for Mammographic Screening for Women inTheir Forties By M. Gail and B. Rimer We assumed that regular mammographic screening is justified for a 50-year-old woman, even one with no risk factors, and that a younger woman with an expected 1-year breast cancer incidence rate as great or greater than that of a 50-year-old woman with no risk factors would benefit sufficiently to justify regular screening. Results: Two methods, the exact-age procedure (EAP)and the grouped-age procedure (GAP), were developed. The less precise GAP only requires following a flow diagram. The proportion of white women recommended for screening by the EAP ranges from 10% for 40-year-old women to 95% for 49-year-old women, and the corresponding percentages for black women are 16% and 95%. The assumptions that underlie the guidelines are discussed critically. J Clin Oncol 16:3105-3114.
|
http://www.mja.com.au/public/issues/jan5/smith/smith.html
Extract
from:
Breast cancer mortality trends in Australia:
1921 to 1994
Abstract
|
June
19, 01 A further study (in the Journal
of the National Cancer Institute) confirms
that high bone density has a down side
http://jnci.oupjournals.org/cgi/content/abstract/93/12/930 Bone Mass and Breast Cancer Risk in Older Women: Differences by Stage at Diagnosis Conclusions: Elderly women with high BMD have an increased risk of breast cancer, especially advanced cancer, compared with women with low BMDTake a look at http://www.webcom.com/mjljweb/jrnlclb/vol2/a45.html for Bone mass and the risk of breast cancer among postmenopausal women Authors: Zhang Y, Kiel D, Kreger B, Cupples L, Ellison R, Dorgan J, Schatzkin A, et al. Source: New England Journal of Medicine. 336:611-7. February 27, 1997. Institutions: Boston University; Harvard University; the Framingham Study. Financial support: National Institutes of Health; Boston University School of Medicine. SummaryBackgroundThe role of estrogen in the promotion of breast cancer is difficult to quantitate. Isolated measurement of serum estrogens may not reflect long-term exposure. Studies linking estrogen replacement therapy to breast cancer are subject to bias, since most of them have been case-control studies. Bone density in women is related, in part, to estrogen exposure. Thus, if long-term estrogen exposure increases bone density and also increases the risk of breast cancer, there should be a positive correlation between bone density and the incidence of breast cancer. This study was designed to look at this issue, using data from the Framingham study. "Comparing age-specific
quartiles of bone density 1 through 4 (increasing bone density), there
were 12 women with breast cancer in quartile 1, 17 in quartile 2,
18 in quartile 3 and 44 in quartile 4."
An abstract of a related study is at http://www4.ncbi.nlm.nih.gov/htbin-post/Entrez/query?form=6&db=m&uid=97047874&Dopt=r JAMA 1996 Nov 6;276(17):1404-1408 Bone mineral density and risk of breast cancer in older women: the study of osteoporotic fractures. Study of Osteoporotic Fractures Research Group. Cauley JA, Lucas FL, Kuller LH, Vogt MT, Browner WS, Cummings SR Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA 15261, USA. "Women with BMD above
the 25th percentile were at 2.0 to 2.5 times increased risk of breast cancer
compared with women below the 25th percentile. Results were consistent
across all BMD sites."
http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_277/no_19/letter1.htm#le6821
The title of the page is JAMA Letters - May 21, 1997
skipping partway down the page to this: To the Editor.--In their Editorial, Dr Insogna and coauthors[1] misquote the report of the Study of Osteoporotic Fractures.[2] In doing so, they appear to miss their main point. In their report, Cauley et al state: "Our findings suggest that the risk of breast cancer associated with hormone replacement therapy may have been underestimated by previous investigators [emphasis added] because osteoporosis is a primary indication for its use." Cauley et al do not purport to show direct evidence that HRT is associated with breast cancer but do show that bone mineral density is correlated with breast cancer risk. A direct corollary of this is that patients with low bone mineral density (ie, with osteoporosis) have a lower risk of breast cancer than patients with normal bone mineral density. Thus, if users of HRT are more likely to have osteoporosis than nonusers, yet users are found to have the same breast cancer risk as nonusers, it follows that HRT must have increased the low breast cancer risk of osteoporotic users to achieve the same level of risk as the nonosteoporotic nonusers. |