Article Outlines Dilemma of Benefits and Harms of Mammography

A review article published in this week’s Journal of the American Medical Association (JAMA) suggests that the benefits of screening using mammography are often overestimated, while harms are underestimated. It calls for more guidance for patients and their doctors on how best to individualize breast cancer screening. The review was done by researchers at Harvard Medical School’s Department of Health Care Policy and Brigham and Women’s Hospital, who say they hope their review will help physicians understand the complex data and encourage the development and use of tools for customizing the information shared with their patients.

We asked Chief Cancer Control Officer Richard C. Wender, M.D. for a comment.

“Screening mammography along with improved treatments and increased awareness has played a key role in a 34 percent drop in breast cancer mortality in the past two decades. And while regular mammography beginning at 40 years is an integral part of avoiding premature death from breast cancer, it is true that a lot of women need to be screened to benefit a relatively small number of women, particularly for women in their 40’s. It is important that women are aware of the kind of information in this article, such as how many breast cancer deaths are averted at different ages, and the risks of false positives and more follow up tests, to help women make personalized screening decisions.

Richard C. Wender, M.D.

“As the authors themselves report, research is still needed to get a better understanding of what these numbers are for individual women, so we can more accurately portray each woman’s risk. The authors also note that research is needed to explore the long-term effects of decision aids for screening decisions, especially since women with more information may actually be less likely to engage in screening.

“Better information to guide individual screening decisions is helpful, but what another important part of this is improving the quality of breast cancer screening for women of all ages. Better tests would offer an important opportunity to improve the number needed to screen reflected in this report. New tests and strategies are needed, and some are being tested now.

“We are entering an era of personalized medicine, based not just on someone’s DNA, but also based on a man or woman’s personal values. Women who value the opportunity to prevent a premature cancer death are willing to accept a high rate of abnormal mammograms, recalls, and biopsies to avoid a breast cancer death.  Some women may place greater value on avoiding recalls, biopsies, and treatment of conditions like DCIS that do not always progress to cancer. These women may opt to delay starting mammography or even to not be screened at all. Learning to discuss risk and personal values poses a new challenge and will require new tools.”

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What to Make of New Study on Mammography

News today about a Canadian study on mammography has renewed the debate over the test’s effectiveness and prompted plenty of questions to us at the American Cancer Society. The new report, appearing on bmj.com is actually updated data from a study that’s been ongoing for many years. It finds that screening does not reduce deaths from breast cancer, but can lead to many cancers being found that would have caused no problems during the patients’ lifetime.

We asked Richard C. Wender, M.D., American Cancer Society chief of cancer control, for some thoughts about the new work.

“First and foremost, this study by itself is not enough to cause a change in our recommendations for annual screening using mammography for women starting at age 40.

“The Canadian study has been included in the American Cancer Society’s guideline reviews for many years. This long-term data will be included again as our Guidelines Committee reviews the evidence for their next update, expected later this year.

“Although this 25 year update didn’t add much new information, the overall findings are important. But they are at odds with several other trials on mammography. Even the U.S. Preventive Services Task Force, a group that has been somewhat skeptical of mammography, agrees that screening reduces the relative risk of breast cancer death by about 15 percent in women ages 40 to 59.

“Finally, death rates from breast cancer have dropped more than 30 percent from their peak thanks to a combination of better treatments, heightened awareness, and early detection. The fact is mammography is not as effective as some people say, and not as ineffective as others say. Women need the truth about its benefits and its limitations. Exaggerating either one helps no one.

“We continue to believe women should get an annual mammogram starting at age 40,  and that it is very important that they receive quality care, a part of the discussion that has been largely lost in the debate.”

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Report Says HPV Vaccination Should Be a Top Priority

A report today from the President’s Cancer Panel calls achieving widespread human papillomavirus (HPV) vaccination one of the most important opportunities for cancer prevention. The Panel’s report, Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer, issues an urgent call for energizing efforts to reach the HPV vaccines’ potential to save lives and prevent cancers and HPV-related conditions in men and women.

Nearly all sexually-active men and women get HPV at some point in their lives. This is true even for people who only have sex with one person in their lifetime. HPV is linked to multiple cancers and other diseases. The report examines underuse of HPV vaccines, identifies key barriers to increasing vaccine uptake, and provides actionable recommendations for overcoming these obstacles.

Debbie Saslow, PhD, leads the American Cancer Society’s efforts in HPV and cervical cancer, including the Society’s screening and vaccination guidelines, so we asked her about the report, and why this potentially lifesaving vaccination has not taken off.

Debbie Saslow, PhD

Debbie Saslow, PhD

“This is a comprehensive report that makes the case for an urgent call to action. We now have two safe and effective vaccines, but they are not reaching their potential to prevent cancer in the United States and around the world.

“Centers for Disease Control and Prevention (CDC ) Director Dr. Tom Frieden recently named slow uptake of HPV vaccination as one of the top five health threats for 2014. Experts now know improving HPV vaccination rates for girls and boys will lead to decreases not only of cervical cancer but also other genital cancers, anal cancer, and probably some oral cancers, as well as other health conditions in both males and females.  Increased vaccination can also reduce racial and socioeconomic disparities in cervical cancer.

“HPV vaccines have been recommended for girls in the United States for several years. The American Cancer Society has recommended their use since 2007. They protect against human papillomavirus (HPV), the virus that causes most cases of cervical cancer, and one of the vaccines also protects against nearly all cases of genital warts.

“But uptake of HPV vaccination has been slow in this country; only about one in three girls has received all three doses of the vaccine, as recommended.

“So why aren’t parents vaccinating their daughters? A recent survey showed the five most common reasons are that parents:

  • Did not think the vaccine was needed or necessary;
  • said their child was not sexually active;
  • had concerns about vaccine safety or side effects;
  • lacked knowledge about the vaccine or HPV and/or;
  • did not receive a recommendation from the child’s health care provider

“One recent study found that more than four out of five girls who have not received that vaccine had a health care visit where they received a vaccine against a different illness. These are major missed opportunities. If those girls had also received HPV vaccine, vaccination rates could have exceeded 92%.

“This report represents an opportunity to do better. We need to educate parents about the vaccine, why it’s needed, the importance of vaccinating before the onset of sexual activity, and its excellent safety record. We also need to educate health care providers, to reiterate these messages and help increase the number of girls being vaccinated.

“Even with low vaccination rates, HPV infections targeted by the vaccines have dropped by more than half in the United States since the introduction of the vaccine. That’s a remarkable and lifesaving improvement, but we can and must do more. It is not often that we have an opportunity to prevent cancer, or in this case multiple cancers, with a single tool. Concerted efforts are needed so this opportunity is not lost.”

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50 Years After a Public Health Victory, Can We Do It Again?

January 11, 2014 marks 50 years since the release of the Surgeon General’s Report on smoking and health. In a just published commentary, Otis W. Brawley says the report’s conclusions “are arguably the most important and far-reaching in the history of public health and are, perhaps, the classic example of science driving public policy.”

Otis Brawley

Otis W. Brawley, MD, Chief Medical Officer, American Cancer Society

The report led to rapid, dramatic drops in smoking, whose impact can be seen today. In fact, less smoking may be the most important factor in drops in cancer mortality since the early 90’s. Decreases in lung cancer deaths attributed to smoking are credited with 40 percent of the overall drop in cancer mortality in men.

Public health experts today look back with envy at the remarkable impact of this single report. As Brawley writes, “Given the numerous medical controversies today, it is of value to explore why this process was so successful and why so many were willing to accept this pronouncement as truth.”

Brawley then tells the winding tale of how methodology developed to study infectious disease was first applied to chronic disease; how the creation of case control studies and cohorts came along just in time to cut off a widening epidemic caused by tobacco use; and how public health groups, scientists, and a single question at a press conference converged to bring public attention to “the tobacco problem,” and led directly to Surgeon General Luther L. Terry’s efforts to put together a panel of “outstanding experts who would assess the available knowledge in the area of smoking and health and make appropriate recommendations.”

It is a fascinating retelling of the history that led to that momentous January day 50 years ago, when Dr. Luther Terry and others released a report that “forever changed the course of public health.” And it may prompt us to ask ourselves: what would it take to be that successful again, and is it achievable in our lifetimes?

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New Guideline Aims to Make Chemotherapy Effective for All Patients

Are obese patients being shorted needed doses of chemotherapy? That question made the rounds last week when news reports highlighted treatment guidelines adopted by the American Association for Cancer Research (ASCO). The guidelines were first proposed in 2012.

We asked Len Lichtenfeld, M.D., deputy chief medical officer and author of Dr. Len’s Cancer Blog to give us some perspective on the new recommendations, and whether they might help make sure all patients get adequate treatment.

“The question of appropriate chemotherapy dosing for overweight and obese patients treated for cancer is in fact not a new problem. It has been with us literally for decades, when it was first recognized that underdosing patients with chemotherapy may have accounted for inferior results seen in actual oncology practice compared with clinical trials.

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

“The issue has remained an active question for many years, especially today as doctors treat an increasing number of overweight and obese patients with cancer. The resulting large doses of chemotherapy given to these patients understandably raise concerns among oncologists that they may cause unnecessary harm to their patients.

“This guideline puts that concern to rest, with the exceptions for patients who have other serious medical conditions that may prohibit full doses of chemotherapy. And the guideline does not put aside the clinical judgment of the physician which is an important part of any treatment decision.

“As the authors note, the increasing incidence of obesity—including morbid obesity—in the United States is going to make this question even more relevant in the future. The authors of the guideline make clear that for most cancer chemotherapy drugs getting the dose ‘right’—which is based on carefully designed and executed clinical trials which follow treatment impact carefully—is absolutely necessary if patients are going to get the intended benefits from the chemotherapy drugs they receive.”

Our web site at cancer. org includes a comprehensive section on chemotherapy. For any questions not answered there, please remember our cancer information specialists are available any time, day or night, at 800.227.2345 to help.

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Expert Panel Backs Lung Cancer Screening Using CT Scans

The U.S. Preventive Services Task Force (USPSTF), an independent panel of non-Federal experts that conducts scientific evidence reviews of preventive health care services for the U.S. government,  is posting its draft recommendations for lung cancer screening using low-dose computed tomography (LDCT). The recommendations, which are not final but instead posted for comment by experts and the general public, give annual screening in those at high risk for lung cancer (based on age and smoking history) a “Grade B” recommendation, indicating high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial.

We asked Otis W. Brawley, M.D., chief medical officer, for his thoughts on these new draft recommendations.

“This update to the USPSTF’s 2004 lung cancer screening recommendation has been long anticipated, and adds to a growing consensus that using low dose spiral CT to screen high risk individuals, based on age and smoking history, should be considered.

“Within the screening profession, the Task Force reviews are viewed as the most exhaustive and rigorous with very high standards for grading the quality of studies under review. Most importantly the Task Force takes into account the quality of each study considered. That’s important because some studies are better than others, and some study results are not as reliable as others.

Otis Brawley

Otis W. Brawley, MD, Chief Medical Officer, American Cancer Society

“This draft recommendation recognizes that low-dose spiral CT almost certainly saves lives when done on individuals at high risk for lung cancer, based on age and smoking history. It also recognizes that there are harms associated with spiral CT lung cancer screening. It says screening is reasonable for healthy people who have at least a 30 pack-year history of smoking, who are between 55 and 79, and who have smoked within the past 15 years. It also says that health professionals should be cautious about recommending screening to patients at the upper end of this age range who have other significant health issues.

“The draft recommendation is very consistent with the recommendation from other organizations, including the American Cancer Society. A little more than a year ago the Society and several other professional organizations recommended that people at high risk for lung cancer, based on their age and smoking history (age 55 or over and greater than 30 pack-year smoking history) consider the documented benefits and risks of screening and make an informed decision. These criteria are essentially the same as those that were used as study eligibility criteria for the U.S. National Lung Screening Trial (NLST), which was run by the National Cancer Institute and supported by the American Cancer Society, which helped recruit participants whose contribution gave us critical evidence about using this new tool.

“One notable difference between the USPSTF draft recommendation and the ACS guidelines is the high emphasis the ACS places on informed decision making about the benefits and harms associated with screening for lung cancer; in particular, the high likelihood of false positive test results on the initial screening test that will require additional follow-up. In contrast, the USPSTF endorses shared decision making only for eligible individuals who have significant health issues. It’s important to remember that this is a draft recommendation, and that and other aspects of the recommendation could change in the final version.

“The USPSTF gives lung screening using low dose spiral CT a “B” recommendation. Under the Affordable Care Act (ACA), new private health insurance plans and Medicaid plans for newly eligible enrollees must cover screenings that receive an “A” or “B” rating with no deductibles or co-pays . Most health insurance companies have delayed offering coverage for lung cancer screening pending the outcome of the USPSTF review.

“The new recommendation is likely to result in increased demand and promotion for lung cancer screening in the U.S. It is critically important that programs and policies are put into place to insure that best practices are put into place to insure that screening for lung cancer achieves the greatest potential benefit with the fewest harms.”

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Low dose aspirin: More evidence it can protect against colon cancer

A study appearing in the most recent Annals of Internal Medicine concludes that low- dose aspirin used every other day may reduce the risk of colorectal cancer in healthy women.

The report comes from a large study of nearly 40,000 women enrolled in the Women’s Health Study, a landmark trial that started in about in 1994, when researchers randomly assigned women aged 45 years or older to take either 100 mg of aspirin or placebo every other day for a period of about 10 years.

After the first ten years of the study, rates of colorectal cancer were the same in women who had taken aspirin and those who had taken placebo, leading some to conclude that the dose was too low to prevent colorectal cancer.  Women taking aspirin did, however,  have increased rates of gastrointestinal bleeding and peptic ulcers.  Now, however,  participants have been followed for a total of 18 years, including 8 years after aspirin use was stopped The new report shows that during the last 8 years of the study, the rate of colorectal cancer was about 40% lower in women who had originally been randomly assigned to take aspirin.

We asked Eric J. Jacobs, PhD, who himself has studied the association between aspirin use and cancer risk, for his reaction to the new study. 

“Studies conducted over about the last 20 years have provided convincing evidence that aspirin use lowers risk of developing colorectal cancer. Combined analyses of smaller trials of daily aspirin use published in the Lancet in 2010 suggested that regular use of even low-dose aspirin, such as the 81 mg aspirin tablet commonly used for heart disease prevention, lowers risk of colorectal cancer but only after a delay of several years.

Eric M. Jacobs. Ph.D.

Eric  J. Jacobs. Ph.D.

“The new results from the Women’s Health Study provide important evidence confirming that low-dose aspirin use does indeed lower risk of colorectal cancer, but that this benefit does not kick in until about 10 years after the start of regular use.

“It is important to remember that aspirin is a real drug with real side effects, including sometimes causing serious, even occasionally fatal, stomach bleeding, even at low doses.

“Aspirin use is recommended for most people who have had a heart attack, and has some benefits for colorectal cancer as well, but at this point the American Cancer Society does not recommend that people use aspirin specifically to prevent cancer.

“People who are uncertain about whether they should be using aspirin should talk to their health care provider who knows their personal medical history and can help weigh their individual risks and benefits.”

But unlike many cancers, colorectal cancer is largely preventable, thanks to screening. It usually takes 10 to 15 years for polyps to develop into colorectal cancer.  Most polyps can be found and removed before they have the chance to turn into cancer. Even if a polyp has already turned into cancer, finding it early, when it is highly curable, can save lives, which is why the American Cancer Society recommends colorectal cancer screening for all women and men 50 or older.

For more information, see “Can colorectal cancer be prevented?” on cancer.org.

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