Medicare Considering Coverage for HPV Test for Cervical Cancer Screening

The Centers for Medicare and Medicaid (CMS) has started the process to consider covering cervical cancer screening using a combination of HPV and Pap tests, called “co-testing.” The American Cancer Society recommends co-testing as the preferred method of cervical cancer screening for women ages 30 to 65. (Women ages 21 to 29 should not get the HPV test with the Pap test, because HPV is so common in younger women that it’s not helpful to test for it. They should have a Pap test every 3 years [at ages 21, 24, and 27] to test for cervical cancer.)

Debbie Saslow, Ph.D., director, breast and gynecologic cancer for the American Cancer Society, welcomed the development from CMS.

“We are pleased that CMS is considering covering the HPV test, which is an important preventive service.  The American Cancer Society along with 25 other organizations have guidelines that are virtually identical to those from the United States Preventive Services Task Force (USPSTF), recommending “co-testing.” The one difference between the recommendations is that the Society and all of the other groups recommend HPV/Pap “co-testing” as the “preferred” strategy whereas USPSTF recommends either co-testing or Pap alone without designating one as preferred to the other.

Debbie Saslow, PhD

Debbie Saslow, PhD

“Based on our evidence review, we and the other organizations conclude that HPV testing (co-testing) has greater health benefits and fewer harms to women as long as screening is not performed too frequently. While the American Cancer Society did not consider cost or cost-effectiveness as part of our guideline process, we are aware that cost-effectiveness data supports co-testing.

“Together with our advocacy affiliate, the American Cancer Society Cancer Action Network (ACS CAN), we are reviewing the details of CMS proposal and considering whether to file comments, which are due by December 25th.”

Medicare currently covers a screening pelvic examination and Pap test for all female beneficiaries at 12 or 24 month intervals, based on specific risk factors. CMS does not currently include HPV testing in its coverage.

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Medicare Proposes Covering CT Screening for Lung Cancer

Medicare has released its proposed decision on lung cancer screening using low dose computed tomography (LDCT), saying the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, using the technology to screen once per year.

CMS proposed the benefit under Medicare as long all of the following criteria are met:

  • Age 55-74 years;
  • No signs or symptoms of lung disease;
  • Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
  • Current smoker or one who has quit smoking within the last 15 years.

In addition, patients undergoing screening with LDCT would  have a “lung cancer screening counseling and shared decision-making visit” from their health care provider.

The CMS coverage decision will also require that centers meet defined standards in order to be eligible to receive CMS payment for screening. Centers will be responsible for establishing a patient registry that documents risk factors and the results of screening, as well as inclusion of tobacco cessation services.

Richard C. Wender, M.D.

Richard C. Wender, M.D.

Richard C. Wender, M.D., the American Cancer Society’s Chief Cancer Control Officer, had this to say about the news:

“The American Cancer Society is pleased that the Centers for Medicare and Medicaid Services (CMS) today issued a proposed decision providing coverage for lung cancer screening for appropriate high risk Medicare beneficiaries nationwide. Although CMS will evaluate additional comments before issuing a final rule and actually offer coverage under Medicare, this decision likely means that thousands of Medicare beneficiaries will have access to this important and potentially life saving service. This would place Medicare policy in line with current guidelines and the recommendations of many interested advocacy and professional organizations, including the Society.

“The American Cancer Society joined with several professional societies, including the American College of Radiology, the American Thoracic Society, and the American College of Chest Physicians to promote a quality framework that helped shape the CMS decision.

“We will now focus our efforts on helping the nation build capacity to deliver high quality screening in as many centers as possible so that high quality lung cancer screening is available to everyone who meets screening criteria. We are committed to serving as the convening organization for this capacity building work. The cooperation of many organizations to commit to and promote a quality framework signals a broad national commitment to delivering only high quality screening to the patients who are most likely to benefit.

“We join many others who share the hope that this decision will mean that many lives will be saved from a premature death related to lung cancer, and that many others will receive the information and help they may need to discontinue smoking and other forms of tobacco consumption.”

You can read more about lung cancer early detection, including the American Cancer Society’s Guidelines, on our web site.

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Dr. Gordon Klatt, 1942-2014

Dr. Gordon Klatt, Founder of Relay For Life

Gordon “Gordy” Klatt, M.D., founder of the American Cancer Society’s Relay For Life event passed away August 3, 2014, at the age of 71 from heart failure after battling stomach cancer.

Gordy was one-of-a-kind. He helped shape an idea that started off as one man running and walking a track, and turned it into a global phenomenon for saving lives in every corner of the world.

The Klatt family has asked that memorial donations be made to the Gordy Klatt Pay-If Research Endowment Fund, which supports cancer research.

You can read a tribute from Dr. Len Lichtenfeld on his blog.

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“Ultraviolet Bad:” The Surgeon General Issues a Call to Action to Prevent Skin Cancer

Due to technical difficulties, today’s dispatch from Dr. Len’s Cancer Blog is being posted to the ACS Pressroom Blog

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

“Ultraviolet bad.”

That was the core message that came out of the introduction this morning of the Surgeon General’s Call to Action to Prevent Skin Cancer at a meeting held at the National Press Club in Washington DC.

There were some other messages that now raise skin cancer awareness and prevention high on the public health awareness list, such as the fact that over 5 million people every year have a diagnosis of skin cancer (and many have more than one skin cancer), and that we are spending over $8 billion dollars treating the disease. But most important is the fact that this is one of the most preventable cancers, and if current trends are any indication we are not getting the job done when it comes to decreasing the number of skin cancers and saving lives.

Acting Surgeon General Boris Lushniak

Acting Surgeon General Boris Lushniak

Acting Surgeon General Boris Lushniak, MD and Assistant Secretary of Health Howard Koh, MD were masterful presenting the evidence contained in the report, and American Cancer Society Cancer Action Network volunteer Stacey Escalante—who herself is a melanoma survivor and media personality from Las Vegas—made the story personal.

And it is personal. It is particularly personal for me as a skin cancer survivor, and it is personal for millions of people throughout this nation and throughout the world. The real question remains, however, given the fact that skin cancer is so common and has impacted so many, why aren’t we doing more to prevent it? Hopefully this report will bring that conversation to a new level and lead to more and better public health interventions.

The reality is that in years past we didn’t know what we could do to reduce the threat of skin cancer. That wasn’t always the case. People like me who grew up decades ago didn’t know about the risk of sun exposure, tans and sunburns. We didn’t use sunscreens because we didn’t have them. We thought tan was a sign of health, not a sign of damage as was repeated several times today during the presentations. We simply didn’t know.

Now we know.

We know what to do to prevent many (not all) skin cancers and skin aging. We know to avoid the sun at peak times of the day. We know to wear wide brimmed hats and use UV certified protective sun glasses. We know to use plenty of sunscreen that is broad spectrum (limiting the absorption of the harmful ultraviolet A and B rays from the sun). We know to reapply sunscreen again and again when swimming and/or sweating. We know to wear sun protective fabrics and seek the shade when outdoors.  We know tanning beds are bad for us (but their use is everywhere, especially by young white women. By the way, they have been linked to 245,000 basal cell cancers, 168,000 squamous cell cancers and 6000 melanomas every year in the United States according to the report). We know that we can get vitamin D safely from supplements instead of overexposure to the sun. And every year 1/3 of American adults get a sunburn which especially in childhood is a leading risk factor for skin cancer, including melanoma (last year even the self-confessing Surgeon General readily admitted he got a sunburn, noting that bad things happen even to people who know better).

Yes, we know what to do but we still really don’t do what we know.

We can do better. We need to develop messaging that resonates with people. We need laws that restrict youth access to tanning beds (lots of progress has been made on that front, but we have a ways to go). We need to see more people engaging in sun safe behaviors, even while engaging in healthy outdoor (and enjoyable) activities.

We need to read and take to heart and mind the goals of the Surgeon General’s report and move forward with a coordinated, nationwide public health action plan that makes the lessons real and makes them actionable. Among the goals:

  1. Increase opportunities for sun protection in outdoor settings
  2. Provide individuals with the information they need to make informed, healthy choices about UV exposure
  3.  Promote policies that advance the national goal of preventing skin cancer
  4.  Reduce harms from indoor tanning
  5. Strengthen research, surveillance, monitoring and evaluation related to skin cancer prevention.

Maybe there is some evidence of hope: This past weekend while at a beach in south Georgia we saw lots of people outside in the sun enjoying themselves. On one day, I counted about three out of four families were actually under what I call “meaningful shade” such as a large canopy tent. It was a lot different than what I have seen before, so maybe we are making some progress after all. But I want (need?) to believe we can do even more to embrace sun safe behaviors.

So the Surgeon General has laid out the call to action. But as he noted to the audience and to me personally after the session it is up to us to translate that information into effective education and interventions.

As he pointed out, years ago the message went out “Tobacco bad.” Today, the message is “Ultraviolet bad.” We need to make certain that people understand what that means, and that all of us together do something about it. 5 million people getting a largely preventable and sometimes disfiguring and even fatal cancer every year in the United States is simply not something that we need to endure any longer.

We know what to do. Now is the time to make it happen.

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Bras and Breast Cancer: A Theory that Lacks Support

You may be seeing reports around the web or in your email charging that the American Cancer Society and other groups are involved in a “cover-up” of a connection between wearing a bra and breast cancer. The claim that bras cause breast cancer is not new, and there’s no credible evidence to suggest a link. Nonetheless, a 2002 survey by American Cancer Society researchers showed six percent of respondents agreed that ‘‘Under-wire bras can cause breast cancer.” Another 31 percent were not sure.

So why do people believe it? The theory got a boost from a 1995 book by a husband and wife team of medical anthropologists. The pair noted that among indigenous groups who had not adopted Western lifestyles, breast cancer was rare, while cultures where the Western way of life had been embraced had breast cancer rates comparable to those in the developed world. The culprit, they concluded, was the bra.

The authors tested their hypothesis by surveying women in the U.S., but they did so without the careful controls done to make sure this kind of study is accurate. They then analyzed the results without adjusting for the factors we know can increase the risk of breast cancer risk (more on those later). They concluded that frequent ⁄ prolonged bra use impedes the elimination of toxins via the lymphatic system, and causes breast cancer. They published their findings not in a peer-reviewed journal, but in a book. Meanwhile, no other, credible studies have shown that bras increase the risk.

The emails and posts also point to a 1991 Harvard study, claiming that it showed there was a higher rate of breast cancer in women who wore bras. That’s true, but the authors of that study suggest this finding was  due to larger breast size of bra-wearers. In fact, their study did find among women who wore bras, larger cup size was associated with increased risk of breast cancer. Most experts think the culprit here isn’t bras, but having more breast tissue, which is correlated not only with increased risk of breast cancer but also with overweight or obesity, which itself causes metabolic changes that increase breast cancer risk.

Because of the attention this book generated,  ACS scientists Ted Gansler, M.D. and Ahemdin Jemal, Ph.D. conducted a small study in 2009 published in the Breast Cancer Journal (subscription required) to explore the biological mechanism behind the carcinogenic bra hypothesis. They looked at survivors of shoulder or upper extremity melanoma. Many patients with this cancer have their underarm lymph nodes removed surgically, which substantially impedes lymphatic drainage from the breast. If lymphatic obstruction caused breast cancer, one would expect those who got the surgery to have higher rates of breast cancer. Their analysis found no increase in breast cancer among those who had surgery to remove the lymph nodes. The authors caution that their study was preliminary, but concluded the “results do not support the hypothesis of lymphatic disruption being a breast cancer risk factor.”

So what’s wrong with telling people bras are a risk? We think it’s very important that women learn about the things we know can reduce their risk of this disease and focus on making changes that can really make a difference. That’s why our website includes evidence-based information on breast cancer risk factors (and risk factors for all other types of cancer), and why we recently published a review of breast cancer risk factors in our journal CA: A Cancer Journal for Clinicians. It pointed out that “acting on information that we already have could prevent thousands of [breast cancer] cases each year.”

The report was authored by Graham Colditz, M.D., a world-recognized expert in cancer prevention. It says among the most important ways to prevent breast cancer: avoiding weight gain as an adult, being physically active, limiting alcohol, and eating a healthy diet, high in fruits, vegetables, and whole grains.

Those may not be as intriguing  as a conspiracy to promote lingerie, but women deserve honest evidence, not scare stories.

For another, pretty humorous take on all this, see “Bad Chart Thursday: Bra Cancer” by Melanie Mallon at Skepchick.

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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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