In the cancer world, there are only two screening tests that have really been proven to reduce mortality:  mammogram for breast cancer and the Pap smear for cervical cancer.  Tests like PSA (prostate specific antigen) for prostate cancer, chest x-ray for lung cancer, and stool blood test or colonoscopy for colorectal cancer, may be well known, but they actually have not passed the “acid” proof of usefulness in cancer screening, meaning that they have not been shown to reduce cancer death.

However, although mammogram is the best screening test for breast cancer, it can miss one out of six breast cancer cases.  That one missed cancer is typically found on physical exam; that’s why it’s very important to get an annual check-up with your doctor.  Therefore, there certainly is room for improvement in early breast cancer detection.  A novel test for diagnosing breast cancer would potentially have a significant impact on this very prevalent disease, particularly if this test is simple, inexpensive and non-invasive.

How to not miss breast cancer – Guidelines for physicians who take care of women and important information also for all women.

  1. American Cancer Society Guidelines for Breast Cancer Screening:  caonline.amcancersoc.org/cgi/reprint/53/3/141
  2. California Department of Public Health Breast Diagnostic Algorithms:  qap.sdsu.edu/resources/tools/index.html
  3. Centers for Disease Control and Prevention Follow –up of Abnormal Clinical and Imaging Findings of the Breast:  www.medscape.com/editorial/public/breastcancer-cdc

 

 

Dr. Mai Brooks MD advises women to continue screening for breast cancer

What to do about new controversy about mammogram

The controversy about screening mammogram rages on.  Last week, the Canadian National Breast Screening Study published its conclusion that “annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination.”  Some people may interpret this result as women don’t need mammogram anymore.  On the other hand, we have new laws recommending more tests beyond screening mammogram for people with dense breasts.  Breast density is determined by the radiologist.  So you don’t know your breast density until you have a mammogram.  The majority of women aged 40-59 have dense breasts.

So what should a woman do?  First, please realize that screening for breast cancer is NOT controversial.  It is the method of screening that generates debate.  For normal risk women without symptoms, annual breast examination by a health care professional is strongly recommended.  If a woman feels something in her breast, she should seek medical help as soon as possible – this is not controversial.

The US BCDDP (Breast Cancer Detection Demonstration Project), the largest study of mammography and clinical breast exam, demonstrated that screening decreases breast cancer mortality.  The evidence to justify mammography for population-based screening is derived from both randomized and several non-randomized clinical trials.  The largest randomized controlled trial was conducted in Sweden, and shows a 31% reduction in breast cancer mortality in women invited to screening mammogram.   The US PSTF (Preventive Services Task Force) agrees that among women between 39 and 49 years of age, screening mammography results in a 15% reduction in the risk of death from breast cancer.  For women aged 50 to 59 years, the risk reduction is 14%.

Yes, it is true that sometimes screening mammogram can pick up some findings, which lead to biopsies, that turn out to be benign or just pre-cancer.  Yes, this would cause anxiety, discomfort, and would cost some healthcare money.  This is because we have no perfect test that can tell with absolute 100% accuracy in each person which mammogram finding is cancer and which is not.  Screening mammogram can also find tiny cancers (over-diagnosis), that then get treated with surgery, maybe even radiation and anti-estrogen pills (over-treatment).  This is because we have no perfect test that can tell with absolute 100% accuracy in each person which tiny cancer will kill without treatment, and which would be fine left alone.  But the bottom line is that despite these imperfections, screening mammogram can find cancer at earlier stage than physical examination alone.  In general, early small cancer needs less aggressive treatment than bigger cancer.  Think lumpectomy instead of mastectomy, no chemotherapy instead of chemo.  Each woman needs to decide for herself whether she wants to do everything possible to find breast cancer earlier, rather than later, over the inconvenience of “over-diagnosis” and the possible side effects of “over-treatment”.

 

 

Dr. Mai Brooks MD advises women with dense breasts to see their physician

California law requires that women are told if they have dense breasts

Breasts are made up of a mixture of fibroglandular tissue and fat.  Your breasts are considered dense if they have a lot of fibroglandular material but not much fat.  Young women’s breasts tend to have more fibroglandular tissue, whereas older breasts have more fat.  Thus, density usually decreases with age.  Breast density is determined by the radiologist.  There are four categories of mammographic density.  10% of American women have almost entirely fatty breasts (level 1), and 10% have extremely dense breasts (level 4).  The rest falls in level 2 (scattered areas of fibroglandular density) or level 3 (heterogeneously dense).

In April 2013, California law SB 1538 took effect.  This law mandates that the radiologist informs women when their breasts have levels 3 or 4 density.  The wording may include:  “Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer.

So what is a woman to do with this information?  Dr. Brooks recommends that you should go see a physician.  Why?  There are at least 3 good reasons.  First, you should have a professional breast exam, because sometimes cancer can ONLY be found by feeling a lump on exam, i.e. not seen on any kind of radiological imaging.  A proper exam also includes surrounding lymph nodes, as well as any other part of the body with symptoms.

Second, it may not be appropriate to act on reflex and just get more tests, such as ultrasound, MRI, etc.  After all, mammogram is the only breast screening modality proven to decrease breast cancer mortality, based on multiple randomized and non-randomized clinical trials.  Using these rigorous criteria, ultrasound and MRI are considered not effective in breast cancer screening.  Thus, it is questionable if ordering more imaging does any good.  Furthermore, a screening ultrasound or MRI will definitely sometimes show findings that lead to unnecessary biopsies, i.e. false positives.  So there is potential harm.  More often than not, insurance will not pay for these extra tests, and the patient may not realize this until the bill arrives.

Third, you should be thoroughly evaluated for breast cancer risk.  Patients with level 4 dense breasts have a slightly higher chance of developing breast cancer, compared with women in level 1.  However, having dense breasts alone does not place a woman into a high-risk group, not even a moderate-risk group.  Therefore, no special preventive therapy is prescribed for this condition.  It is important for you to tell your physician your complete medical history as well as your family history, so that your overall breast cancer risk can be determined.

After the physician’s exam and cancer risk determination, then it would be proper to decide on further action, such as ultrasound or MRI or genetic testing.  Remember that any test in medicine has risks and benefits, and the time to think about the pro’s and con’s is BEFORE embarking on more imaging procedures. of women have extremely dense breasts. At the other extreme, 10% have almost entirely fatty breasts (not dense at all). The rest of American women are somewhere in between.

Dense breasts can make it more difficult for the radiologist to spot cancer on mammograms. Studies have shown that ultrasound or MRI may help find breast cancers that can’t be seen on a mammogram in dense breasts. However, both ultrasound and MRI show more findings that are not cancer, which can result in additional testing and unnecessary biopsies. Also, the cost of ultrasound and MRI may not be covered by insurance.
If you have dense breasts, you should talk to your doctor. Together, you can decide if you should get any additional test(s).

 

 

Cancer Screening

One out of four deaths in the US is due to cancer.  In 2013, approximately 580,350 Americans die of cancer.  If cancer is found early, confined to the organ only, then survival is in general excellent.  Later stage cancer is defined as regional (involving lymph nodes or neighboring tissues) and/or distant (involving distant lymph nodes or distant organs) disease.  Mortality worsens as the stage increases.  Screening means doing a test when the patient has no symptoms, i.e. no pain, no mass, no nothing.  Cancer discovered during screening tends to be early and curable.  If you wait until you have symptoms, then the test is no longer screening, it is called “diagnostic”, meaning it is done to figure out the cause of your symptom.

Breast cancer:

For normal-risk women, the recommendations are as follows:  1) Yearly mammogram starting at age 40.  The age at which screening stops should be individualized by considering the potential risks and benefits of screening in the context of overall health status and longevity; and 2) Clinical breast exam every 3 years for women in their 20’s and 30’s, and every year for women 40 and older.

In women at high risk for developing breast cancer, screening may also involve diagnostic mammogram (as well with contrast enhancement or with 3D), breast ultrasound, breast MRI (magnetic resonance imaging), and genetic testing.

Cervical cancer:

Normal-risk women should have:  1)  Pap smear to start at age 21

2)  < 30 years of age:  every 2 years

3)  > 30 years of age:  every 3 years

4)  Stop screening at age 65-70, after 3 normal tests during the last 10 years

Screening is more frequent for high risk women.

Colorectal cancer:

Screening of patients with normal risk begins at age 50.  In general, physicians recommend doing ONE of the below:

1)  Colonoscopy every 10 years,

2)  Flexible sigmoidoscopy every 5 years,

3)  Double-contrast barium enema every 5 years, or

4)  CT with contrast (virtual colonoscopy) every 5 years

Screening for high-risk patients can be much more frequent and/or start earlier.

Prostate cancer:

Prostate cancer screening has become controversial lately.  This is because in some cases, this malignancy does not affect life expectancy.  Another major consideration is the significant side effects that accompany treatments for prostate cancer, such as incontinence and impotence.   The recommendation used to be blood test for the PSA (prostate specific antigen) tumor marker, either with or without a digital rectal exam, starting at age 50.  Now, men with average risk should be counseled starting at age 50 whether to do the above test or not.  Each man should ask himself what he is willing to do if the screening test comes back abnormal.  If the answer is “nothing”, then it is not worth doing any test.

 

 

Breast cancer gene test price drops significantly in 2014

Genetic testing more affordable

BRCA gene is currently the most well known breast cancer (and ovarian cancer) gene.  Women with a BRCA1 and/or BRCA2 gene mutation are up to eight times more likely to develop breast malignancy than women without.  In other words, the lifetime risk for getting breast cancer is up to 85%.  If and when cancer happens, it tends to be more aggressive.  This is the gene problem that actress Angelina Jolie was tested for and found to have a significant mutation.  Last year, she went public with this information and shared the news that she had a double mastectomy to prevent breast cancer.

This BRCA gene test is expensive.  For years, a company named Myriad owns the patent on these two genes, and tests can cost up to $4,000.  The big news from June 2013 is that the United States Supreme Court has ruled that this patent is no longer valid.  Very soon, other companies have started to offer the BRCA gene test.  Ambry Genetics offers a similar test for about $2,200.  Quest Diagnostics charges about $2,500.  Dr. Mai Brooks predicts that this year 2014, competition will continue to drive the price down dramatically.  The cost of the BRCA gene test may be as low as $1,000 or even lower, in the hundreds of dollar range.  There probably will be more companies joining in the testing pool.  Patients will have more choices, and can shop around.

However, this does not mean that everybody should rush out to get this test.   Genetic testing is not indicated in most patients, because the chance of having a BRCA mutation in the general population is very low.  Currently, the criteria for testing include:

  1. Early onset breast cancer (diagnosed before age 45)
  2. Multiple foci of breast cancer, or triple-negative breast cancer, or Ashkenazi (Eastern European) Jewish heritage
    3. A significant family history of breast cancer
    4.  Male breast cancer
    5.  A personal or family history of ovarian cancer
    7.  A previously identified BRCA1 or BRCA2 mutation in the family

Usually, insurance would cover the cost of testing if the person meets one or more of the above criteria.  Please keep in mind that the majority of people getting this test have a normal result.  So if you don’t have one of these criteria, it is extremely likely that you do not have this gene mutation.  Angelina Jolie was tested, because her mother had ovarian cancer and died at a young age from this disease

 

 

Cancer in the USA – what to expect in 2014

One out of four deaths in the US is due to cancer.  In 2014, approximately 585,720 Americans will die of cancer.  The following tables summarize the distribution of the top ten types of invasive cancer among men and women.  Please note that this number does not include the early in situ carcinomas from any organ (except the bladder).  Excluded from this table are 62,570 breast carcinomas in situ, 63,770 melanomas in situ, and millions of unreported cases of squamous cell and basal cell skin cancers (http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full).

 

Cancer in women:

New cases Ranking by % Deaths Death by %
breast 232,670 1 (29%) 40,000 2 (15%)
lung 108,210 2 (13%) 72,330 1 (26%)
colorectal 65,000 3 (8%) 24,040 3 (9%)
uterus 52,630 4 (6%) 8,590 7 (3%)
thyroid 47,790 5 (6%)
Lymphoma* 32,530 6 (4%) 8,520 8 (3%)
melanoma 32,210 7 (4%)
kidney 24,780 8 (3%)
pancreas 22,890 9 (3%) 19,420 4 (7%)
leukemia 22,800 10 (3%) 10,050 6 (4%)
ovary 14,270 5 (5%)
liver 7,130 9 (3%)
brain 6,230 10 (2%)
All organs 810,320 275,710

* non-Hodgkin

 

Cancer in men:

New cases Ranking by % Deaths Death by %
prostate 233,000 1 (27%) 29,480 2 (10%)
lung 116,000 2 (14%) 86,930 1 (28%)
colorectal 71,830 3 (8%) 26,270 3 (8%)
bladder 56,390 4 (5%) 11,170 8 (4%)
melanoma 43,890 5 (5%)
kidney 39,140 6 (5%) 8,900 10 (3%)
Lymphoma* 38,270 7 (4%) 10,470 9 (3%)
oropharynx 30,220 8 (4%)
leukemia 30,100 9 (4%) 14,040 6 (5%)
liver 24,600 10 (3%) 15,870 5 (5%)
pancreas 20,170 4 (7%)
esophagus 12,450 7 (4%)
All organs 855,220 310,010

* non-Hodgkin

 

As shown above, the #1 cancer killer in both men and women is lung cancer.  As lung cancer is predominantly caused by cigarettes, smoking cessation can significantly decrease this type of mortality.  Breast cancer is the most common (and #2 killer) in women, as is prostate cancer in men.  Colorectal cancer ranks #3 in both new case incidence and death rate for both genders.  Since there are good screening tools for breast, prostate and colorectal cancers, these death rates can also be reduced if more of these cases are detected earlier at curable stages.

 

 

 

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