Page 4 - Breast Cancer
P. 4
8 SUNDAY, OCTOBER 18, 2015 THE MORNING CALL
BREAST CANCER AWARENESS MONTH
A screening ‘conundrum’
Array of state laws surges ahead of doctors on breast density, mammography
By Judy Peres of fibrous or glandular (as TETRA IMAGES since 2009. Some just say breast tomosynthesis, or
opposed to fatty) tissue. It’s women with dense breasts 3-D mammography.
Tribune Newspapers an especially common About half of all women undergoing mammograms have should be told they might
problem for women in their dense breasts, considered a risk factor for breast cancer. benefit from additional A computer simulation
As lawmakers around 40s, who are more likely to screening tests. published in the journal
the country rush to enact have dense breasts and in and Data System. ing at UCSF, and other Radiology in March found
legislation requiring pro- whom mammography is They found a high rate of radiologists believe the Some, like Connecticut, that adding tomosynthesis
viders to notify women if notoriously inaccurate. more serious problem of require doctors to offer to biennial mammography
their screening mammo- interval cancers (more than mammographic density is ultrasound or MRI. Unlike would avert 0.5 deaths and
grams find dense breast Researchers have been 1 case per 1,000 mam- its ability to mask cancers, most states, Connecticut 405 false-positive results
tissue, doctors remain at a struggling for 40 years to mograms) in women with not its effect on breast also mandates that insur- per 1,000 women. The
loss, unsure how to counsel understand why women extremely dense breasts if cancer risk. ance cover the additional additional cost per quality-
such women. with dense breasts have a they also had a five-year screening. adjusted life year saved was
higher risk of developing breast cancer risk of 1.67 Sickles said the in- $53,893 with tomosynthe-
Dr. Leonard Berlin, pro- breast cancer, but progress percent or greater, and in creased risk has been exag- According to Are You sis, compared with
fessor of radiology at Rush has been slow. women with hetero- gerated by some research- Dense, Delaware, Louisi- $325,000 using ultrasound
University and the Univer- geneously dense breasts if ers, who compared women ana, Michigan and North in the Sprague study.
sity of Illinois at Chicago, “At this point, we can’t they had a five-year risk of with the densest breasts Dakota passed laws this
called the array of state tell a woman with high 2.5 percent or higher. That with those with the fattiest year. The other states are Dr. Daniel Kopans of
laws “a real conundrum. No density what she can do to added up to 24 percent of breasts. If, instead, women Alabama, Arizona, Califor- Harvard, who invented
one knows exactly what to reduce her risk,” said Rulla those with dense breasts. with dense breasts are nia, Delaware, Hawaii, tomosynthesis, said his test
do with them.” Tamimi, a researcher at compared with average Maryland, Massachusetts, is not meant to be a supple-
Harvard Medical School. Kerlikowske pointed out women, the difference is Missouri, Minnesota, Ne- ment to regular mammog-
According to the advo- “All you do is increase her that the women in her not so great. Even those vada, New Jersey, New raphy. Rather, he said, “it
cacy group Are You Dense, anxiety.” high-risk group were at risk with extremely dense York, North Carolina, Ohio, will completely replace 2-D
24 states have laws mandat- not only of missed cancers breasts are only 2.1 times Oregon, Pennsylvania, mammography, just as
ing the reporting of mam- Recently, a study by Dr. but of advanced cancers. “If more likely to develop Rhode Island, Tennessee, digital mammography has
mographic density, which Karla Kerlikowske and you’re going to do supple- breast cancer, a risk equiva- Texas and Virginia. replaced screen-film mam-
increases a woman’s risk of others at the University of mental screening,” she said, lent to having a mother or mography.
getting breast cancer and California at San Francisco “you should target the 24 sister with the disease. “Those laws happened
can hide small cancers. found that not all women percent who are really at before we were ready,” “(It’s) actually a much
Similar legislation is pend- with dense breasts are at high risk.” There is great variability Tamimi said. “We don’t better mammogram, since
ing at the federal level. The increased risk — only those in the array of state laws on have clear guidelines or it finds many more early
organization has pushed for with additional risk factors. Dr. Edward Sickles, breast density enacted recommendations for these cancers while having fewer
such state and federal legis- former chief of breast imag- women or their physicians. recalls,” Kopans said.
lation. Kerlikowske’s team There’s still so much we
looked at interval cancers, don’t know.” Like other experts, Ko-
Some state laws require or breast cancers that are pans stressed that mam-
that women be informed diagnosed within a year of a Radiology studies have mography is the only
about the availability of normal mammogram. shown that supplemental screening test that has been
supplemental screening Interval cancers can be imaging with ultrasound shown in randomized
tests, such as ultrasound especially aggressive, so can detect some cancers clinical trials, the gold
and magnetic resonance additional screening tests missed by mammography standard of medical evi-
imaging. Although both likely would be most bene- in women with dense dence, to reduce breast
ultrasound and MRI have ficial in women at high risk breasts. However, a study cancer mortality.
been shown to detect can- for such cancers. published this year by Brian
cers missed by mammo- Sprague of the University of But even his “much
grams, myriad questions The team analyzed more Vermont Cancer Center better mammogram” won’t
remain, among them: Does than 800,000 mammo- concluded that supple- detect every cancer. “Some
such additional testing grams from 365,426 wom- mental ultrasonography for cancers that are palpable do
prevent deaths from breast en. They calculated each these women has little not show up on mam-
cancer? At what cost? Will woman’s five-year risk of impact on outcome but mograms,” he said. “All
insurance cover it? developing breast cancer dramatically increases costs women should be vigilant.
using the Breast Cancer and harms, including false If they feel something new,
The problem is wide- Surveillance Consortium alarms. even if it is soon after a
spread, because up to half risk model (https:// (normal) mammogram,
of all women undergoing tools.bcsc-scc.org/ Sprague’s team looked at they should bring it to their
routine mammograms have BC5yearRisk), which ultrasonography because doctor’s attention.”
breasts classified as “ex- factors in age, first-degree it’s widely available and Judy Peres is a freelance
tremely” or “hetero- relatives with breast cancer, relatively inexpensive. reporter.
geneously” dense, meaning biopsy history, race or eth- Potential alternatives in-
they have a high proportion nicity, and density on the clude MRI and digital
Breast Imaging Reporting
Old age’s
silver lining
Ditching the health screenings
DIGITAL VISION
By Judy Peres people do — that it can be The potential benefit — suffer its side effects?” she for something. We need to attack or stroke) is uncon-
hard to give up,” said Dr. preventing death from the asked, noting that older ask: How much risk? And scionable,” because the
Tribune Newspapers Lisa Schwartz of the Dart- disease — can be elusive, patients are more sensitive what’s the something? Will potential benefit does not
mouth Institute for Health especially if the cancer is to medications and more reducing that particular outweigh the risk of serious
Feeling sorry for yourself Policy and Clinical Practice growing slowly. likely to suffer ill effects. risk matter in the overall adverse events.
because you can no longer in Lebanon, N.H. scheme?”
do all the things you used to Dr. Ranit Mishori, pro- There are no age limits And if you’re not going to
do? Because your joints are The chance of being fessor of family medicine at on blood pressure screen- A Pap test indicates the treat it, there is no reason to
creaky and your strength diagnosed with cancer goes Georgetown University in ing. And taking someone’s risk of developing cervical test for it.
and stamina seem to be up as you age, but compet- Washington, notes that the blood pressure is quick and cancer. But, Hadler said,
dribbling out along with ing risks, such as heart upper age limits on screen- noninvasive. “Everybody “we won’t do anything The same goes for
your memory? attacks and strokes, are ing tests are “population- gets a blood pressure read- meaningful with a Pap screening for Type 2 diabe-
increasing faster. based.” She prefers to have ing,” Mishori said. “And if smear in an older woman — tes, the kind that develops
Take heart in the fact a discussion with each it’s high, we have a con- it won’t change the date later in life. According to
that growing old comes “So you don’t have to patient based on individual versation. Do you want to you die.” Hadler, oral drugs that
with a silver lining of sorts: worry so much about (can- wishes and health status. be treated? If you’re 50, it lower blood sugar, though
You can cross a bunch of cer) screening because could make a huge differ- On the subject of high popular, have never been
things off your health- you’re more likely to die of “When the patient is frail ence. If you’re 85, the rami- blood pressure, he said: “It shown to improve longev-
related to-do list, including something else,” said her or has other serious ill- fications are different. We will increase the likelihood ity; decrease the incidence
routine screening tests for husband and colleague, Dr. nesses, it makes sense not can be more permissive in of heart attack and stroke, of stroke, heart attack or
cancer and other health Steven Woloshin. “That’s a to screen for diabetes or older individuals in terms but by how much? And is it loss of limbs; or prevent
issues. hard conversation for doc- breast or colon cancer,” she of blood pressure and blood a function of something kidney failure or blindness.
tors and patients to have.” said. “But if you have a sugar limits.” else, like my age? The an- But they are associated
According to the U.S. robust, active 75-year-old swer is yes — age is a bigger with occasionally serious
Preventive Services Task Schwartz and Woloshin, who plays tennis and you When a patient is out- risk factor. The older you adverse events.
Force, average-risk folks professors of medicine at think they have another 10, side the recommended age are, the sooner you will
can stop getting mam- the Dartmouth Institute, 15, even 20 years ahead of range for a screening test, die.” The task force recom-
mograms for breast cancer have written extensively them, the question of Mishori said, “we have a mends screening for Type 2
and colonoscopies for about communicating whether they should be conversation about risks Hadler conceded that he diabetes only in people
colon cancer around 75. medical risk. screened becomes differ- and benefits. More often would “rather not have a with high blood pressure.
And, after 65, most women ent.” than not, the patients opt stroke in the last years of But it’s because hyperten-
can forget about Pap tests Telling a patient she not to screen. But occasion- my life, and I can reduce sion is more dangerous in
for cervical cancer. (The doesn’t have enough time She also takes into ac- ally someone wants to have that risk a little bit if I nor- diabetics, Hadler said; “it’s
task force does not recom- left to reap the potential count the nature of the test. a few more years of tests.” malize my blood pressure.” not to treat the diabetes.”
mend prostate cancer benefit of a screening test Climbing onto an exam For most of the elderly, he
screening for men of any isn’t always perceived as table for a Pap test might be Dr. Nortin Hadler, said, that little bit can be Here’s one more thing
age; but the American good news. The related hard for a patient with emeritus professor of medi- accomplished with the you can stop worrying
Urological Association, message, that a competing mobility issues. The benefit cine at the University of gentlest of drugs — often about: your BMI. Being
which suggests that men risk is more likely to get her, of the test is unlikely to North Carolina at Chapel just a low-dose water pill — overweight or even moder-
over 55 discuss screening likewise might be hard to outweigh the discomfort. Hill and author of “Re- whereas “getting it truly ately obese will not take
with their doctors, sets an swallow. So Schwartz and thinking Aging,” sees even normal through aggressive time off your allotted life-
age limit of 69.) Woloshin might instead But even cholesterol less value in screening tests. means could make you span, Hadler said (although
talk about the balance of screening, which involves sicker, because all drugs being underweight or mor-
While some people may benefits and harms. only a blood draw, is prob- “Everybody knows their have side effects.” bidly obese will).
find this liberating, howev- ably unnecessary after a numbers,” he said. “They
er, others are troubled by it. The harms of cancer certain age. “At 70 or 80, take their blood pressure, As to cholesterol, Hadler And those extra 10
screening, including com- will the benefit of the test cholesterol, BMI (body said, “treating high choles- pounds might plump out
“Some people are so plications of a biopsy and be such that you want the mass index), A1C (blood terol in older well people some of your wrinkles.
indoctrinated about screen- side effects of treatment if patient to have to take a pill sugar). All these numbers (that is, people who have Judy Peres is a freelance
ing — we’re taught that’s cancer is found, are “front- every day and potentially speak to an element of risk not already had a heart reporter.
what socially responsible loaded,” Woloshin said.
BREAST CANCER AWARENESS MONTH
A screening ‘conundrum’
Array of state laws surges ahead of doctors on breast density, mammography
By Judy Peres of fibrous or glandular (as TETRA IMAGES since 2009. Some just say breast tomosynthesis, or
opposed to fatty) tissue. It’s women with dense breasts 3-D mammography.
Tribune Newspapers an especially common About half of all women undergoing mammograms have should be told they might
problem for women in their dense breasts, considered a risk factor for breast cancer. benefit from additional A computer simulation
As lawmakers around 40s, who are more likely to screening tests. published in the journal
the country rush to enact have dense breasts and in and Data System. ing at UCSF, and other Radiology in March found
legislation requiring pro- whom mammography is They found a high rate of radiologists believe the Some, like Connecticut, that adding tomosynthesis
viders to notify women if notoriously inaccurate. more serious problem of require doctors to offer to biennial mammography
their screening mammo- interval cancers (more than mammographic density is ultrasound or MRI. Unlike would avert 0.5 deaths and
grams find dense breast Researchers have been 1 case per 1,000 mam- its ability to mask cancers, most states, Connecticut 405 false-positive results
tissue, doctors remain at a struggling for 40 years to mograms) in women with not its effect on breast also mandates that insur- per 1,000 women. The
loss, unsure how to counsel understand why women extremely dense breasts if cancer risk. ance cover the additional additional cost per quality-
such women. with dense breasts have a they also had a five-year screening. adjusted life year saved was
higher risk of developing breast cancer risk of 1.67 Sickles said the in- $53,893 with tomosynthe-
Dr. Leonard Berlin, pro- breast cancer, but progress percent or greater, and in creased risk has been exag- According to Are You sis, compared with
fessor of radiology at Rush has been slow. women with hetero- gerated by some research- Dense, Delaware, Louisi- $325,000 using ultrasound
University and the Univer- geneously dense breasts if ers, who compared women ana, Michigan and North in the Sprague study.
sity of Illinois at Chicago, “At this point, we can’t they had a five-year risk of with the densest breasts Dakota passed laws this
called the array of state tell a woman with high 2.5 percent or higher. That with those with the fattiest year. The other states are Dr. Daniel Kopans of
laws “a real conundrum. No density what she can do to added up to 24 percent of breasts. If, instead, women Alabama, Arizona, Califor- Harvard, who invented
one knows exactly what to reduce her risk,” said Rulla those with dense breasts. with dense breasts are nia, Delaware, Hawaii, tomosynthesis, said his test
do with them.” Tamimi, a researcher at compared with average Maryland, Massachusetts, is not meant to be a supple-
Harvard Medical School. Kerlikowske pointed out women, the difference is Missouri, Minnesota, Ne- ment to regular mammog-
According to the advo- “All you do is increase her that the women in her not so great. Even those vada, New Jersey, New raphy. Rather, he said, “it
cacy group Are You Dense, anxiety.” high-risk group were at risk with extremely dense York, North Carolina, Ohio, will completely replace 2-D
24 states have laws mandat- not only of missed cancers breasts are only 2.1 times Oregon, Pennsylvania, mammography, just as
ing the reporting of mam- Recently, a study by Dr. but of advanced cancers. “If more likely to develop Rhode Island, Tennessee, digital mammography has
mographic density, which Karla Kerlikowske and you’re going to do supple- breast cancer, a risk equiva- Texas and Virginia. replaced screen-film mam-
increases a woman’s risk of others at the University of mental screening,” she said, lent to having a mother or mography.
getting breast cancer and California at San Francisco “you should target the 24 sister with the disease. “Those laws happened
can hide small cancers. found that not all women percent who are really at before we were ready,” “(It’s) actually a much
Similar legislation is pend- with dense breasts are at high risk.” There is great variability Tamimi said. “We don’t better mammogram, since
ing at the federal level. The increased risk — only those in the array of state laws on have clear guidelines or it finds many more early
organization has pushed for with additional risk factors. Dr. Edward Sickles, breast density enacted recommendations for these cancers while having fewer
such state and federal legis- former chief of breast imag- women or their physicians. recalls,” Kopans said.
lation. Kerlikowske’s team There’s still so much we
looked at interval cancers, don’t know.” Like other experts, Ko-
Some state laws require or breast cancers that are pans stressed that mam-
that women be informed diagnosed within a year of a Radiology studies have mography is the only
about the availability of normal mammogram. shown that supplemental screening test that has been
supplemental screening Interval cancers can be imaging with ultrasound shown in randomized
tests, such as ultrasound especially aggressive, so can detect some cancers clinical trials, the gold
and magnetic resonance additional screening tests missed by mammography standard of medical evi-
imaging. Although both likely would be most bene- in women with dense dence, to reduce breast
ultrasound and MRI have ficial in women at high risk breasts. However, a study cancer mortality.
been shown to detect can- for such cancers. published this year by Brian
cers missed by mammo- Sprague of the University of But even his “much
grams, myriad questions The team analyzed more Vermont Cancer Center better mammogram” won’t
remain, among them: Does than 800,000 mammo- concluded that supple- detect every cancer. “Some
such additional testing grams from 365,426 wom- mental ultrasonography for cancers that are palpable do
prevent deaths from breast en. They calculated each these women has little not show up on mam-
cancer? At what cost? Will woman’s five-year risk of impact on outcome but mograms,” he said. “All
insurance cover it? developing breast cancer dramatically increases costs women should be vigilant.
using the Breast Cancer and harms, including false If they feel something new,
The problem is wide- Surveillance Consortium alarms. even if it is soon after a
spread, because up to half risk model (https:// (normal) mammogram,
of all women undergoing tools.bcsc-scc.org/ Sprague’s team looked at they should bring it to their
routine mammograms have BC5yearRisk), which ultrasonography because doctor’s attention.”
breasts classified as “ex- factors in age, first-degree it’s widely available and Judy Peres is a freelance
tremely” or “hetero- relatives with breast cancer, relatively inexpensive. reporter.
geneously” dense, meaning biopsy history, race or eth- Potential alternatives in-
they have a high proportion nicity, and density on the clude MRI and digital
Breast Imaging Reporting
Old age’s
silver lining
Ditching the health screenings
DIGITAL VISION
By Judy Peres people do — that it can be The potential benefit — suffer its side effects?” she for something. We need to attack or stroke) is uncon-
hard to give up,” said Dr. preventing death from the asked, noting that older ask: How much risk? And scionable,” because the
Tribune Newspapers Lisa Schwartz of the Dart- disease — can be elusive, patients are more sensitive what’s the something? Will potential benefit does not
mouth Institute for Health especially if the cancer is to medications and more reducing that particular outweigh the risk of serious
Feeling sorry for yourself Policy and Clinical Practice growing slowly. likely to suffer ill effects. risk matter in the overall adverse events.
because you can no longer in Lebanon, N.H. scheme?”
do all the things you used to Dr. Ranit Mishori, pro- There are no age limits And if you’re not going to
do? Because your joints are The chance of being fessor of family medicine at on blood pressure screen- A Pap test indicates the treat it, there is no reason to
creaky and your strength diagnosed with cancer goes Georgetown University in ing. And taking someone’s risk of developing cervical test for it.
and stamina seem to be up as you age, but compet- Washington, notes that the blood pressure is quick and cancer. But, Hadler said,
dribbling out along with ing risks, such as heart upper age limits on screen- noninvasive. “Everybody “we won’t do anything The same goes for
your memory? attacks and strokes, are ing tests are “population- gets a blood pressure read- meaningful with a Pap screening for Type 2 diabe-
increasing faster. based.” She prefers to have ing,” Mishori said. “And if smear in an older woman — tes, the kind that develops
Take heart in the fact a discussion with each it’s high, we have a con- it won’t change the date later in life. According to
that growing old comes “So you don’t have to patient based on individual versation. Do you want to you die.” Hadler, oral drugs that
with a silver lining of sorts: worry so much about (can- wishes and health status. be treated? If you’re 50, it lower blood sugar, though
You can cross a bunch of cer) screening because could make a huge differ- On the subject of high popular, have never been
things off your health- you’re more likely to die of “When the patient is frail ence. If you’re 85, the rami- blood pressure, he said: “It shown to improve longev-
related to-do list, including something else,” said her or has other serious ill- fications are different. We will increase the likelihood ity; decrease the incidence
routine screening tests for husband and colleague, Dr. nesses, it makes sense not can be more permissive in of heart attack and stroke, of stroke, heart attack or
cancer and other health Steven Woloshin. “That’s a to screen for diabetes or older individuals in terms but by how much? And is it loss of limbs; or prevent
issues. hard conversation for doc- breast or colon cancer,” she of blood pressure and blood a function of something kidney failure or blindness.
tors and patients to have.” said. “But if you have a sugar limits.” else, like my age? The an- But they are associated
According to the U.S. robust, active 75-year-old swer is yes — age is a bigger with occasionally serious
Preventive Services Task Schwartz and Woloshin, who plays tennis and you When a patient is out- risk factor. The older you adverse events.
Force, average-risk folks professors of medicine at think they have another 10, side the recommended age are, the sooner you will
can stop getting mam- the Dartmouth Institute, 15, even 20 years ahead of range for a screening test, die.” The task force recom-
mograms for breast cancer have written extensively them, the question of Mishori said, “we have a mends screening for Type 2
and colonoscopies for about communicating whether they should be conversation about risks Hadler conceded that he diabetes only in people
colon cancer around 75. medical risk. screened becomes differ- and benefits. More often would “rather not have a with high blood pressure.
And, after 65, most women ent.” than not, the patients opt stroke in the last years of But it’s because hyperten-
can forget about Pap tests Telling a patient she not to screen. But occasion- my life, and I can reduce sion is more dangerous in
for cervical cancer. (The doesn’t have enough time She also takes into ac- ally someone wants to have that risk a little bit if I nor- diabetics, Hadler said; “it’s
task force does not recom- left to reap the potential count the nature of the test. a few more years of tests.” malize my blood pressure.” not to treat the diabetes.”
mend prostate cancer benefit of a screening test Climbing onto an exam For most of the elderly, he
screening for men of any isn’t always perceived as table for a Pap test might be Dr. Nortin Hadler, said, that little bit can be Here’s one more thing
age; but the American good news. The related hard for a patient with emeritus professor of medi- accomplished with the you can stop worrying
Urological Association, message, that a competing mobility issues. The benefit cine at the University of gentlest of drugs — often about: your BMI. Being
which suggests that men risk is more likely to get her, of the test is unlikely to North Carolina at Chapel just a low-dose water pill — overweight or even moder-
over 55 discuss screening likewise might be hard to outweigh the discomfort. Hill and author of “Re- whereas “getting it truly ately obese will not take
with their doctors, sets an swallow. So Schwartz and thinking Aging,” sees even normal through aggressive time off your allotted life-
age limit of 69.) Woloshin might instead But even cholesterol less value in screening tests. means could make you span, Hadler said (although
talk about the balance of screening, which involves sicker, because all drugs being underweight or mor-
While some people may benefits and harms. only a blood draw, is prob- “Everybody knows their have side effects.” bidly obese will).
find this liberating, howev- ably unnecessary after a numbers,” he said. “They
er, others are troubled by it. The harms of cancer certain age. “At 70 or 80, take their blood pressure, As to cholesterol, Hadler And those extra 10
screening, including com- will the benefit of the test cholesterol, BMI (body said, “treating high choles- pounds might plump out
“Some people are so plications of a biopsy and be such that you want the mass index), A1C (blood terol in older well people some of your wrinkles.
indoctrinated about screen- side effects of treatment if patient to have to take a pill sugar). All these numbers (that is, people who have Judy Peres is a freelance
ing — we’re taught that’s cancer is found, are “front- every day and potentially speak to an element of risk not already had a heart reporter.
what socially responsible loaded,” Woloshin said.
