Monday, November 23, 2009

New Mammography Guidelines

This is a special report in response to the U.S. Preventive Services Task Force regarding the Screening for Breast Cancer. You can read this report directly at: http://www.ahrq.gov/clinic/USpstf/uspsbrca.htm

U.S. Preventive Services Task Force Key Recommendations were:

- Recommend against routine screening mammography in women aged 40 to 49 years.

- Recommends screening mammography every 2 years for women between the ages of 50 and 74

- Concludes that the current evidence is insufficient to assess the benefits and harms of clinical breast examinations by physicians and other health providers

- Recommends against clinicians teaching women how to perform breast self-examination.





You may find yourself torn between confusion, anger and concern as you try to do what is best. I have heard most react negatively to these guidelines. My reaction to points 1 & 2 concerning mammogram guidelines has been strongly in favor of them. I am still undecided on points 3 and 4 regarding clinical breast exams and self exams.







Why I Support the USPSTF Mammogram Recommendations:





  1. Less x-ray exposure. These guidelines are an improvement because they result in ionizing radiation with more caution and result in less risk. The task force states that “Radiation exposure (from radiologic tests), although a minor concern, is also a consideration." I suspect they are understating how much radiation factored into their conclusions.



The U.S. has been the only country in the world to recommend premenopausal routine mammographic screening. The guidelines for screening mammograms starting at age 40 were based on optimistic assumptions on their safety. It turns out that the ionizing radiation used in mammography is 2-5 times as damaging to the tissue as x-rays used in chest x-rays. This increased biologic effect of mammographic x-rays had not been factored into safety estimates (see Radiation Research 162, 120–127 (2004) and International Journal Radiation Biology (2002, vol. 78, no. 12, 1065-1067).



This new understanding would make each mammogram more comparable to 14-35 chest x-rays. The International Journal of Radiation Biology article calculated the risk to benefit using this new understanding of the radiation used in mammography. This new calculation results in concluding that mammograms should be started later. They suggested starting screens at age 47 at the earliest and starting annual mammograms at around age 60 instead of 50. Note that these ages would be much higher if, instead of 2x, the upper end of the estimate is used (5x). Those who understand the radiation effects are more cautious in recommending mammography.





  1. More realistic estimates of benefit. These guidelines help to shatter the myth that mammography dramatically changes the course of breast cancer. The conclusions in which mammography is stated to make the most differences focus on the assumption that there is little downside to screening. The downsides include:
Unnecessary studies including surgery needed to prove that there is no cancer
- Unnecessary treatment. For example, excessive screening may result in treating DCIS which may have never caused disease. Ductal Carcinoma in Situ is commonly diagnosed via mammography but often does not actually develop into what most people would think of as cancer – it stays fairly dormant. No one actually knows when this should be treated. Overtreatment exposes women to harm and perhaps no benefit
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The Psychological Stress of the ordeal can cause disease
-
Possibly spreading the cancer through unnecessary biopsies. This is a theoretical concern which is hard to quantify



You may be surprised that in some studies the benefits may not even exceed the risks. One well done Swedish trial concluded that “Screening for breast cancer with mammography is unjustified” Why there was more harm than benefit. To read the actual article published in The Lancet go to the following:


You can see the full text free as well; just sign up with a username and password

This is The Lancet, January 8, 2000 Volume 355, Issue 9198, Pages 129 – 134



The Cochrane Collaboration is an international, independent non-profit group which is often cited as one of the best medical reviewing organizations. They concluded that while mammography has benefit it also causes harm and stated: “It is thus not clear whether screening does more good than harm.”The 2001 Cochrane Review of Breast Mammography http://www.cochrane.org/reviews/en/ab001877.html

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3. These guidelines will hopefully encourage women to focus on using natural ways to prevent cancer – an area which is ignored in October: Vitamin D, Iodine/Iodide, Progesterone, Cruciferous Vegetables and avoiding plastics, pesticides, hair dyes and underwire bras. I will cover more on these later

4. These guidelines may result in more widespread use and clinical studies involving breast thermography and breast ultrasound. These hold the promise of lower false positives and no radiation.



Recommendations:



These are my thoughts but obviously we are dealing with way too many unknowns to be dogmatic. We do not know the natural progression of DCIS, we do not know the exact risk of radiation nor do we have all the studies we would like to see on thermography, ultrasound and prevention strategies. We do have a lot of studies on these topics but I would like to see more. For more information on thermography see my January 09 post.



In order to settle this in your mind and make an informed decision, you will want to do your own research. Ask Questions. Factor in your risk factors for breast cancer – the above guidelines were for routine screening – not high risk individuals. Overall, Think Prevention and Safe Screening for early disease. More restraint with mammography and greater use of thermal imaging and ultrasound make more sense.



What I see points to much more success on the Prevention Side: Vitamin D (around 1000 iu for every 25 lbs is a general guideline but check your 25-Hydroxy-Vitamin D levels), Iodoral 1 a day helps insure adequate iodine intake (see www.PhysiciansPreference.com, Eat Your Veggies and if you are not getting at least 5 servings of fruit and vegetables daily I highly recommend increasing your intake – especially the cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, kale, cabbage, and bok choy. Fruit & Vegetable capsules are an excellent way you can conveniently supplement your intake by taking 2 fruit and 2 cruciferous vegetable containing vegetable capsules a day. You can order a well researched fruit & vegetable capsule through www.naturalwellnesschoices.com. Progesterone capsules and cream are available to our wellness center guests. Over the counter Progesterone cream is also available at www.physicianpreference.com and off course avoid heating food in plastic and avoid cosmetics that are petrochemical based (most are) and hair dyes.






The text contained herein does not constitute medical advice. Natural Wellness Choices & Dr, Ellsworth advise you to consult your own physician before acting on any recommendations contained in this email or blog posting