The Breast Debate
December 8, 2016
Sonnenalp Breast Center maintains support for annual screenings beginning at 40
Breast screening saves lives — we all know it. The question is when to start and how long to screen.
The American Cancer Society (ACS) recently changed its long-standing guidelines for breast diagnostics, now advising women to begin a screening program at age 45 — five years later than the previous recommendation. Additionally, the ACS is suggesting that primary care physicians and patients collaborate to decide, based on personal and family history, when they feel screening should begin.
The experts at Sonnenalp Breast Center and Shaw Regional Cancer Center believe a tailored approach to screening will eventually become the new norm; however, at this point, there isn't adequate information to make an informed decision about who is at average risk and should wait to begin screening, and who is at higher risk and should start screening at age 40.
“Our primary responsibility at Sonnenalp is our patients,” says Dr. Ugale. “We maintain our commitment to provide the best care and expertise to guide our patients in the pursuit of breast health.”
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Who qualifies as average risk?
The ACS is vague about this category and is currently reviewing the factors that would indicate which patients are at an average risk.
"If you are above average risk, you should begin screening at age 40, no question," says Dr. Monique Fox, a certified breast radiologist at Sonnenalp.
Higher risk is defined by significant family history, a diagnosis of benign proliferative breast disease and/or dense breast tissue. If any of these criteria are met, yearly screening is recommended.
One flaw in this categorization is that in order to know if you have dense breasts, you first need a baseline mammogram. This is determined solely by mammography and not by a clinical breast exam. "Based on this alone, it is wise to recommend a baseline mammogram at age 40," says Dr. Fox.
According to current data, screening every year has decreased the mortality from breast cancer in all age groups by 40 percent when beginning screening at age 40. So why change the recommendations?
The national data show that only 6 percent of breast cancer is found in women ages 40-45. This means that the percentage is low enough in this age group to warrant discussion with the patient on whether or not she wants to be screened and accept the perceived harms of screening. "The media emphasizes unnecessary callbacks and biopsies, but in fact, the average number of times a patient will get called back from screening in this age group is once every 12 years," explains Dr. Fox. "The average number of times a patient will undergo a false positive biopsy is 1 in 149 years. These numbers are extremely low, and the numbers at Sonnenalp Breast Center are even lower because of our advanced technology."
In Eagle County, the percentage of cancers detected in women age 40-45 is 11 percent, almost double the national average. "This significant number of cancers found warrants screening," says Dr. Janice Ugale, a breast radiologist and the medical director at Sonnenalp.
Why things are different locally
So why are the national numbers different than those at the Sonnenalp? One reason is that the data collected by the ACS is more than two years old.
"At the Sonnenalp, we are seeing a trend of younger women being diagnosed with breast cancer," explains Dr. Ugale. "A second reason is that we use 3D imaging, also known as Tomosynthesis." With this technology, the average number of times a woman will get called back is 1 in every 14 years, 15 percent lower than the national average.
"Our cancer detection rate is 40 percent higher than the national average using 3D imaging," says Dr. Ugale. "We are 6 percent more successful in finding stage 1 cancers, which are the smallest detected cancers and do not have lymph node involvement, resulting in the best chance for cure. This is entirely due to 3D technology and annual screening. Finding early breast cancers by using 3D mammography is the goal of a good screening. We are doing it right at Sonnenalp. 3D technology screening breast ultrasound, also used at the Shaw Breast Center in Frisco, is used to increase our cancer detection rate."
The second push by the ACS and United States Preventive Services Task Force, USPSTF, is to change to screening recommendations for women over age 50 to every other year. At age 50, or around the time of menopause, the rate of hormone-responsive cancers increases, and these tumors tend to be slower growing. Unfortunately for this group of women, there isn't a way to know who will get these slower-growing tumors versus the faster-growing ones. Important to note is that the incidence of breast cancer is the highest after age 50. Therefore, experts at Shaw conclude this group benefits from annual screening to detect cancer early. There is simply no good reason to wait to treat a type of cancer that is easily detected.
The Shaw Cancer Center Cancer Committee unanimously recommends annual screening for all women beginning at age 40, and encourages women to continue screening as long as they choose to be proactive concerning their breast health. They are joined by Strategic Radiology (SR), a consortium of large radiology practices across the country, in their opposition to the new guidelines, and physician organizations like the American Congress of Obstetricians, the American College of Radiology and the Society for Breast Imaging confirm the long-held recommendation to begin screening at 40 and annually thereafter. SR is concerned that the USPSTF recommendations could result in millions of women losing insurance coverage for their annual mammograms, forcing them to pay out of pocket or avoid the exam. They say that scenario negatively impacts underserved populations most. "In addition, it impacts the minority population, which is at an increased risk for developing breast cancer," says Matthew Gromet, MD, a board certified radiologist and member of SR.
Both the US House and Senate have passed the Protect Access to Lifesaving Screenings (PALS) Act, a legislation preventing the USPSTF breast cancer screening recommendations from being implemented for two years. SR explains this two-year "time out" will allow for concerns to be addressed, while ensuring women's continued access to lifesaving mammograms.
If you are above average risk, you should begin screening at age 40, no question. – Dr. Monique Fox
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