Mammography: Sometimes science tells us what we don't want to hear
Posted by on December 12, 2011 - 6:08am

While mammograms certainly play an important role in the early detection of breast cancer (and women have responded to this selling point), when weighed against other issues related to quality of life, this benefit  becomes the question of debate among the scientific community.  While researchers have ways to measure quality of life via quality-adjusted life years (QALYS), how do women measure quality of life?  Some recent research done in the UK has caught my attention that found:    after 10 years of mammograms, a woman may get more harm than good from the screening.    When false positive diagnoses and unnecessary surgeries were taken into account, the quality-adjusted life years (QALYs) gained were significantly reduced, James Raftery, PhD, of the University of Southampton, and colleagues reported online in the British Medical Journal.

"Inclusion of the harms from false-positive results and unnecessary surgery reduced the benefits of screening by about half, with negative net QALYs in the early years after the introduction of screening," they wrote.   In 1986, the Forrest report led to breast screening in the U.K., suggesting it would reduce the death rate from breast cancer by almost a third, and with few harms and at low cost.  Since then, a number of harms associated with screening have been acknowledged, particularly false positives and overdiagnosis of cancers that would never have caused symptoms. Also, a recent Cochrane review noted that mortality reductions may be smaller than initially expected, the researchers said.

They looked at data from eight trials involving 100,000 women from the U.K., ages 50 and up, who had breast screening and found that taking the effects of those harms into account reduced the estimate of net cumulative QALYs gained after 20 years by more than half, from 3,301 to 1,536.  And when they changed the reduction in mortality from that suggested by the Forrest study to that suggested by the recent Cochrane review, the net QALYs after twenty years fell even more. .

So how does this finding relate to the everyday woman who, responsibility, has her annual mammogram and feels good about it?    Who finds a small cancer before it is felt?   How do these feelings weigh against the possibility of going through a biopsy (and finding it negative--to her relief).      On the negative side, what if having ten mammograms over the years actually creates a cancer?   These ideas and concepts are hard to understand for the layperson.

Means of reducing the harms from screening might include less frequent screens, particularly for younger women, the researchers said.  Maybe they are right.   Another solution is finding 100% safe ways to detect breast cancer at an early stage.

It is refreshing that Raftery and colleagues recognized this dilemma and wrote that more research is needed on the extent of unnecessary treatment and its impact on quality of life.  Maybe women are not that upset about these procedures vs. missing a cancer.     Further study should also focus on identifying patients who stand to benefit most from surgery, they added.

"From a public perspective, the meaning and implications of overdiagnosis and overtreatment need to be much better explained and communicated to any woman considering screening," they concluded.

So, reader, what do YOU think?

More preventive health tests should be covered for women
Posted by on July 25, 2011 - 2:10pm

A new report from the Institute of Medicine (IOM) recommends that eight preventive health services for women be added to the services that health plans will cover at no cost to patients under the Patient Protection and Affordable Care Act of 2010 (ACA).  The ACA requires plans to cover the services listed in the U.S. Department of Health and Human Services' (HHS) comprehensive list of preventive services.  At the agency's request, an IOM committee identified critical gaps in preventive services for women as well as measures that will further ensure women's health and well-being.

The recommendations are based on a review of existing guidelines and an assessment of the evidence on the effectiveness of different preventive services.  The committee identified diseases and conditions that are more common or more serious in women than in men or for which women experience different outcomes or benefit from different interventions.  The report suggests the following additional services:

·                     screening for gestational diabetes
·                     human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
·                     counseling on sexually transmitted infections
·                     counseling and screening for HIV
·                     contraceptive methods and counseling to prevent unintended pregnancies
·                     lactation counseling and equipment to promote breast-feeding
·                     screening and counseling to detect and prevent interpersonal and domestic violence
·                     yearly well-woman preventive care visits to obtain recommended preventive services

"This report provides a road map for improving the health and well-being of women," said committee chair Linda Rosenstock, dean, School of Public Health, University of California, Los Angeles.  "The eight services we identified are necessary to support women's optimal health and well-being.  Each recommendation stands on a foundation of evidence supporting its effectiveness."

Deaths from cervical cancer could be reduced by adding DNA testing for HPV, the virus that can cause this form of cancer, to the Pap smears that are part of the current guidelines for women's preventive services, the report concludes.  Cervical cancer can be prevented through vaccination, screening, and treatment of precancerous lesions and HPV testing increases the chances of identifying women at risk.

Although lactation counseling is already part of the HHS guidelines, the report recommends comprehensive support that includes coverage of breast pump rental fees as well as counseling by trained providers to help women initiate and continue breast-feeding.  Evidence links breast-feeding to lower risk for breast and ovarian cancers; it also reduces children's risk for sudden infant death syndrome, asthma, gastrointestinal infections, respiratory diseases, leukemia, ear infections, obesity, and Type 2 diabetes.

HHS should consider screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.  The United States has the highest rates of gestational diabetes in the world; it complicates as many as 10 percent of U.S. pregnancies each year.  Women with gestational diabetes face a 7.5-fold increased risk for the development of Type 2 diabetes after delivery and are more likely to have infants that require delivery by cesarean section and have health problems after birth.

To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity.  Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy.  Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.

HHS's guidelines on preventive health services for women will need to be updated routinely in light of new science.  As part of this process, HHS should establish a commission to recommend which services health plans should cover, the report says.  The commission should be separate from the groups that assess evidence of health services' effectiveness, and it should consider cost-effectiveness analyses, evidence reviews, and other information to make coverage recommendations.

The report addresses concerns that the current guidelines on preventive services contain gaps when it comes to women's needs.  Women suffer disproportionate rates of chronic disease and disability from some conditions.  Because they need to use more preventive care than men on average due to reproductive and gender-specific conditions, they face higher out-of-pocket costs, the report notes.

The study was sponsored by the U.S. Department of Health and Human Services.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.

 

 

Women with Disabilities and Breast Screening
Posted by on October 14, 2010 - 3:17pm

Breast Cancer is a major health concern for all women, including women with disabilities. About 30% of women aged 40 years or older have a disability.  In the US in 2008, 76.2% of women aged 40 or older reported having a mammogram in the past two years, while women with a disability have a lower reported mammography rate than women without a disability.  The Center for Disease Control and Prevention (CDC) has prepared a fact sheet that includes tips for women with disabilities to help them eliminate difficulties they may encounter while undergoing screening.    To view the CDC article, click HERE.

October is Breast Cancer Awareness Month----it's a good time for ALL women to be sure they have appropriate screenings.  For the men who read this blog, make sure the women in your lives take care of themselves and find time to be screened.  Remember, too, that about 1% of breast cancer cases  (nearly 2,000 per year) are found in men so if you have an unusual growth or swelling in the chest area, have it checked out!  They sometimes do mammograms on men, too!