Category: News

March 15, 2021 – Radiomics features on dynamic contrast-enhanced MRI (DCE-MRI) exams can enable noninvasive predictions of the risk of breast cancer recurrence, according to research from Memorial-Sloan Kettering Cancer Center (MSKCC) in New York City.

The researchers developed a radiomics model that yielded a high degree of correlation with the Oncotype DX genomic cancer recurrence risk scores, according to Dr. Carolina Rossi Saccarelli. She presented the findings during a presentation at ECR 2021.

“Our preliminary results indicate that radiomics analysis allows a non-invasive identification of high-risk patients — the ones who will really benefit from chemotherapy — with a high sensitivity,” Saccarelli said.

The researchers sought in their study to correlate breast MRI radiomics features and Oncotype DX recurrence scores in patients with early-stage invasive breast cancer.

“Although effective, genetic analysis such as Oncotype DX is invasive and expensive, which has motivated the investigation of imaging analysis to determine radiomics features [that] could replace invasive procedures in the future,” Saccarelli said.

Their retrospective study included breast cancer patients with luminal subtype (ER-positive/HER2-negative), axillary node-negative, early-stage breast cancers. All subjects in the study had an available Oncotype DX recurrence score and had received a pretreatment multiparametric breast MRI exam between November 2016 and September 2018. Patients were excluded if the MRI was deemed to have insufficient image quality for radiomics analysis, she said.

The MRI radiomics signatures were extracted from 3D segmentations of tumors captured on the first postcontrast T1 sequence.

The researchers used the following Oncotype DX recommendations for stratification and analysis:

• Low risk of recurrence (considered to have little to no benefit from chemotherapy): < 50 years old and an Oncotype DX score of < 26, or ≤ 50 years old with an Oncotype DX score of < 16
• Intermediate risk of recurrence (chemotherapy may be offered): ≤ 50 years old with Oncotype DX score ranging from 16-25
• High risk of recurrence (should be considered candidates for chemotherapy): Oncotype DX score > 26

Of the 175 tumors in the study, 87 were categorized as low risk, 67 were intermediate risk, and 21 were high risk based on the Oncotype DX recommendations. The radiomics analysis initially produced 101 parameters, but the researchers achieved better results after combining the low-risk and intermediate-risk tumors together into one category and comparing those 154 tumors with the 21 high-risk tumors. The researchers then found 11 parameters that showed significant differences between the two groups.

Logistic regression analysis was used to determine the five most important radiomics features to be included in the final radiomics model. In testing, the final radiomics model yielded the following performance in correlating with the Oncotype DX scores:

• Sensitivity: 96.8%
• Specificity: 76%
• Positive predictive value: 80.5%
• Negative predictive value: 95.5%
• Accuracy: 86.5%
• Area under the curve: 0.87

Saccarelli noted that the researchers are now validating the results of this initial work in an ongoing study with larger patient numbers.

March 2, 2021 — Skipping even one screening mammogram can increase a woman’s risk of dying from breast cancer, according to a March 2 study involving more than half a million Swedish women. Conversely, more regular screening greatly reduces risk.

The study was led by mammography heavyweights Dr. László Tabár, a radiologist and oncologist from Falun Central Hospital in Falun, Sweden, and Stephen Duffy, a professor of cancer screening at Queen Mary University of London. The research team analyzed data from more than half a million women eligible for mammography screening in nine Swedish counties between 1992 and 2016.

The group found that women who attended two regularly scheduled mammography appointments before a cancer diagnosis had a 49% lower risk of breast cancer mortality and a 50% lower risk of breast cancer death within 10 years of diagnosis (Radiology, March 2, 2021).

“While we suspected that regular participation would confer a reduction greater than that with irregular participation, I think it is fair to say that we were slightly surprised by the size of the effect,” Duffy said. “The findings support the hypothesis that regular attendance reduces the opportunity for the cancer to grow before it is detected.”

Scientific literature has indicated that women with symptomatic breast cancers who have recently participated in screening have a survival advantage over women who have not. This is due in large part to the advantage of finding invasive cancers earlier, especially poorly differentiated tumors when they are smaller and have less node positivity.

The question is how much benefit does screening mammography confer? Does it matter whether women attend every appointment, or can they skip a few? That’s what Duffy, Tabár, and colleagues set to find out.

The team sorted 549,091 women into the following four groups based on how frequently they kept their mammography appointments:

• Serial participants, who participated in the two most recent scheduled screening exams prior to cancer diagnosis
• Intermittent participants, who attended the last screening exam but not the penultimate one
• Lapsed participants, who attended the penultimate screening only
• Serial nonparticipants, who skipped both screening mammogram appointments

Serial participants had the highest mortality reduction at 49%, but women in the intermittent group had a mortality reduction of 33%, while lapsed participants had a mortality reduction of 28%. See the full results in the table below:

Impact of screening mammography attendance on breast cancer mortality
	Serial participants	Intermittent participants	Lapsed participants	Nonparticipants
Breast cancer mortality reduction	49%	33%	28%	None
Incidence rate reduction of breast cancers fatal within 10 years	50%	36%	25%	None

“Our current study shows a greater mortality benefit for those attending two successive screening examinations than for those who attended only one examination,” the researchers wrote. “[R]egular participation in screening mammography is necessary to optimize the reduction in risk of dying from breast cancer.”

The research team plans to keep studying mammography data to develop a more comprehensive picture of screening benefits, including for cancers that develop in between screening exams, known as interval cancers.

“We are planning further prognostic research into the mechanism of this effect,” Duffy said. “For example, we plan to investigate whether and — if so — to what extent regular attendance improves the prognosis of interval cancers as well as screen-detected cancers. Estimation of this by time since last screen may have implications for policy on screening frequency.”

February 10, 2021 — The death rate for women under 40 with breast cancer in the U.S. used to be waning, but it is now poised to rise, along with an increased incidence in distant-stage breast cancer, according to a new study in Radiology.

According to the study, between 2010 and 2017, the mortality rate for women between the ages of 20 and 39 increased by 0.5% per year. That’s not a statistically significant result. But it represents a reverse from significant declines in mortality reported in prior years. A statistically significant, rapid increase in distant-stage cancer in younger women helps explain the trend, researchers said.

“To our knowledge, our analysis is the first to point out that the longstanding trend of decreasing breast cancer mortality rates in women younger than 40 years has ended,” wrote R. Edward Hendrick, PhD, professor of radiology at the University of Colorado, and colleagues.

In a statement from the RSNA, Hendrick said that the data suggested the mortality rate in women under the age of 40 was likely to significantly increase in a matter of a few years. The authors prescribed focused research to explore causes and implications for the trends reported.

The study was conducted with the goal of understanding mortality and incidence rates for various age subgroups to complement what is known about the U.S. population overall. Breast cancer mortality decreased by 40% from 1989-2017, the authors noted.

“This steady decrease in breast cancer mortality rates has been attributed to increased rates of screening mammography use starting in the early to middle 1980s and improved treatment,” Hendrick et al wrote.

The study involved an analysis of breast cancer mortality and incidence data from the National Cancer Institute (NCI)’s Surveillance Epidemiology and End Results (SEER) program. Results were compared for age groups over time.

“Our analysis was novel in that it analyzed the full range of available breast cancer incidence and mortality data and provided analysis on women by age decade rather than collectively across multiple age decades,” Hendrick and colleagues wrote.

Researchers noted significant declines per year in breast cancer mortality for all age groups studied between 1989 and 2010. Then the picture started to change. From 2010-2017, mortality decreased significantly for age groups over 40 years (down by from 1.2% to 2.2% per year) — but not under 40 (see table). From age 20-29, the increase was 2.8% and from 30-39 it was 0.3%, both nonsignificant. In an analysis of rates by race, researchers noted that the nonsignificant increase in mortality was driven by an increase among white women, whereas rates for Black, Asian, and Native American women continued to decline from 2010-2017.

The data show a rise in incidence of breast cancer and a rapid rise per year in the incidence rate of distant-stage disease, which likely drove the nonsignificant increase in mortality, though more research is needed to elucidate causes.

“In women aged 20-39 years at diagnosis, distant-stage breast cancer incidence rates have increased by more than 4% per year since 2000, and since 2010 are comparable to mortality rates in this age cohort,” the authors wrote. “In contrast, distant-stage breast cancer rates have risen by 1.2% per year or less in women aged 40-69 years and remain well below mortality rates in this age cohort.”

Breast cancer mortality in U.S., 2009/2010-2017
Age group	Annual percent change	P-value
20-39	0.46%	0.59
40-69	-2.07%	< 0.001
70-79	-1.22%	< 0.001

It’s also noteworthy that the drop in mortality for those aged 70-79 was lower than what had been reported the prior 15 years.

“Among women aged at least 40 years, women aged 70-79 years have had the steepest increase in distant-stage breast cancer rates, at 1.85% per year,” Hendrick and colleagues wrote. “This may be contributing to the slower decline in mortality rates in this cohort.”

The authors noted that U.S. Preventive Services Task Force (USPSTF) screening mammography guidelines in 2009 recommended against screening women ages 40-49, and it did not endorse screening for women over the age of 74.

“Although these changes do not appear to have had a pronounced effect on women aged 40-69 years, women older than 65 years have shown significant declines in mammography use, with women aged at least 75 years having the largest decline in use,” Hendrick et al wrote.

February 5, 2021 — Breast cancer in women has surpassed lung cancer as the most commonly diagnosed type of cancer worldwide, according to a new report published February 4 in CA: A Cancer Journal for Clinicians.

The numbers highlight the importance of early detection, researchers said.

The report, called “Global Cancer Statistics 2020,” was written by the American Cancer Society (ACS) and the International Agency for Research on Cancer (IARC) and used data from the latter’s Global Cancer Observatory (GLOBOCAN). The organizations found that there were 19.3 million new cancer cases in 2020; of these, 2.3 million (11.7%) were female breast cancer.

The incident rate of cancer is tied to socioeconomic factors, noted a team led by Hyuna Sung, PhD, principal scientist at the ACS, with women in “transitioning” countries (i.e., those shifting from a centrally planned economy to a free market structure) experiencing increases in incidence compared with their already-transitioned counterparts.

“Overall, the burden of cancer incidence and mortality is rapidly growing worldwide; this reflects both aging and growth of the population as well as changes in the prevalence and distribution of the main risk factors for cancer, several of which are associated with socioeconomic development,” Sung’s group wrote.

Female breast cancer has now exceeded lung cancer as the leading cause of global cancer incidence in 2020, and it is the fifth leading cause of cancer mortality around the world, the report authors found. Breast cancer ranks first for incidence in 159 out of the 185 countries included in the report.

Top 10 cancer sites of new cases worldwide, 2020
Cancer site	Percentage of total new cases
Female breast	11.7%
Lung	11.4%
Prostate	7.3%
Nonmelanoma of skin	6.2%
Colon	6%
Stomach	5.6%
Liver	4.7%
Rectum	3.8%
Cervix uteri	3.1%
Esophagus	3.1%

Breast cancer rates are increasing in countries where its incidence has tended to be low — such as those in South America, Africa, and Asia — but also high-income Asian countries (Japan and South Korea), the investigators wrote.

“Dramatic changes in lifestyle, sociocultural, and built environments brought about by growing economies and an increase in the proportion of women in the industrial workforce have had an impact on the prevalence of breast cancer risk factors — the postponement of childbearing and having fewer children, greater levels of excess body weight and physical inactivity — and have resulted in a convergence toward the risk factor profile of western countries and narrowing international gaps in breast cancer morbidity,” the group noted.

Common killer

Cancer is the primary cause of death around the world, with one in five people developing the disease in their lifetime, according to the authors. The report found that lung cancer remains the leading cause of cancer death, with 1.8 million deaths per year (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers.

But the death rate from breast cancer among women in transitioning countries is higher compared with their peers in developed countries — despite the fact that the incidence rate among women in transitioning countries is much lower compared with their free-market counterparts.

2020 breast cancer death and incidence rates worldwide, “transitioning” versus “transitioned” countries
Measure	Transitioning countries	Transitioned countries	Percent difference
Breast cancer death rates per 100,000 women	15	12.8	17%
Breast cancer incidence rates per 100,000 women	29.7	55.9	88%

Why the higher death rates? Perhaps because women in transitioning countries present with more advanced disease, Sung and colleagues said in the ACS statement.

“As the poor outcome in these countries is largely attributable to a late-stage presentation, efforts to promote early detection, followed by timely and appropriate treatment, are urgently needed through the implementation of evidence-based and resource-stratified guidelines,” they said.

Cancer incidence will likely get worse over the next two decades, Sung’s team warned. The report estimates 28.4 million new cancer cases worldwide in 2040, up 47% from 2020, and transitioning countries will experience a higher relative increase (64% to 95%) compared with their already-transitioned counterparts (32% to 56%).

Cancer prevention efforts must increase if the disease is to be contained, the team concluded.

“The growing rate of incidence could overwhelm healthcare systems, if left uncontrolled,” it said in the ACS statement. “Efforts to build a sustainable infrastructure for the dissemination of proven cancer prevention measures and the provision of cancer care in transitioning countries are critical for global cancer control.”

January 29, 2021 — The COVID-19 pandemic has demonstrated the tragic consequences that result from ignoring science, evidence, and the analysis and advice of experts while being guided by inexpert advice.

The history of the U.S. Preventive Services Task Force (USPSTF) on breast screening is another case in point, in which decisions on mammography guidelines have been based on flawed analyses of scientific data.

When the USPSTF last week opened a new review of breast screening guidelines, it created the opportunity to revisit the group’s flawed decision in 2009 to not recommend breast screening for women in their 40s. However, a number of factors need to be addressed for the 2021 review to present a fair and impartial review of the science and evidence in favor of breast screening.

A brief history of USPSTF and breast screening

In 2005, the USPSTF supported annual screening for all women ages 40 and over.¹ Then in 2009, the USPSTF dropped support for screening women ages 40-49, instead advising them to consult with their physician whether to be screened. It urged women ages 50-74 to be screened every two years.²

In 2016, the USPSTF advised that women ages 50-74 be screened every two years,³ despite the fact that the task force admitted that the most lives are saved by screening beginning at the age of 40 — “the USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women aged 40 to 74 years.”⁴

These decisions came in spite of facts demonstrating the proven effectiveness of breast screening. Randomized controlled trials (RCTs) of breast cancer screening proved that screening and early detection of breast cancer reduces deaths for women ages 40-74 (the ages of the women who participated in the trials).⁵ Confusion had been created in 1993 by the inappropriate use of subgroup analysis⁶ to claim no benefit for women ages 40-49, but this was later refuted with longer follow-up⁷ (the 1993 claims had ignored the fact that an immediate benefit is not expected from a screening program).

There is clear benefit for breast screening in women ages 40-74. Although it has been suggested that these randomized controlled trials are old, they provide the fundamental proof that early detection reduces deaths.

Because of “noncompliance” and “contamination,” the RCTs have underestimated the benefit of early detection of breast cancer. Therefore, the results of these trials should be viewed as the lower level of the likely benefit of mammography.

The USPSTF should be aware that the Edinburgh Trial is no longer cited with the RCTs because of an apparent imbalance in the socioeconomic factors of participants.

Another RCT, the Canadian National Breast Screening Studies (CNBSS), should also have been dropped from guidelines analyses years ago. Not only are their results major outliers among the RCTs, but numerous critical analyses over the years have challenged their validity.

The CNBSS trials were compromised by poor-quality mammography,^8,9 and their data compromised by the fact that they violated the fundamental requirements of RCTs by having a nonblinded allocation process.^10,11 This resulted in a statistically significant excess of women with advanced cancers being assigned to the screening arm of CNBSS1.^12,13

It has been claimed that the CNBSS trials showed a major, 22% rate of “overdiagnosis,” when, in fact, data from the trial show that there was only a 4% difference in cancers diagnosed between the two study arms.¹⁴ The CNBSS results are compromised and unreliable and should not factor into the USPSTF review.¹⁵

Numerous observational studies have validated the benefit of screening women starting at the age of 40 in the general population with reductions in deaths of 40% or more.^{16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33}

In a review of the incidence of death among more than 500,000 women in Sweden, the researchers found some benefit from improvements in therapy, but those who participated in mammography screening had a 41% reduction in their risk of dying of breast cancer within 10 years compared with those who had not participated in screening.³⁴

In addition, there are no data that show that any of the parameters of screening change abruptly at age 50 or any other age.³⁵ The RCTs proved mortality reduction for women ages 40-74. The threshold for initiating screening at the age of 50 is completely arbitrary, with NO scientific support. Grouping of data and averaging has falsely suggested a legitimate threshold when the data show that none exists. The only reason to use the age of 50 as a threshold is based on individual and scientifically unsupportable biases by analysts.

In fact, all major groups — including the USPSTF — agree that the most lives are saved by annual screening starting at the age of 40.

What’s more, studies have shown that there are more years of life lost to breast cancer among women ages 40-49 than for women ages 50-59.³⁶

The risk of developing cancer due to radiation delivered to the breast from mammography (there is little exposure to any other susceptible organs) drops rapidly with increasing age, such that by the age of 40 the risk is unmeasurable and may be nonexistent. Even the extrapolated risk is below the smallest amount of benefit from screening.^37,38

Statistical models from the U.S. National Cancer Institute and Cancer Intervention and Surveillance Modeling Network all predict that the most lives are saved by annual screening starting at the age of 40.³⁹

Despite specious arguments to the contrary, breast screening has been shown to reduce the rate of advanced cancers (see references)^{40,41,42,43,44,45,46,47,48,49,50,51} that has been used as a surrogate for death since these are incurable cancers.

In the Harvard Hospitals, 71% of deaths from breast cancer were among the 20% of women who were not participating in screening despite having access to modern therapies.⁵¹ Spencer et al had similar results.⁵²

Mammography and all-cause mortality

Critics of mammography claim that the RCTs of breast screening did not show a reduction in “all-cause mortality” — but this is a specious argument.⁵³

All-cause mortality is an appropriate metric in treatment trials where everyone has breast cancer and most of the deaths will be due to breast cancer. You want to be certain that the treatment is not causing an unforeseen risk. In radiation therapy trials, for example, analysis of all-cause mortality revealed the unexpected risk that radiation therapy damaged the coronary arteries.

In screening trials, however, most deaths will be due to other causes, since breast cancer only accounts for 3% of deaths each year from “all causes.” If you reduce breast cancer deaths by 30%, then this will reduce “all-cause mortality” by 1%. It would take a 2.5 million-woman trial to prove that a major decrease in breast cancer deaths significantly reduces all-cause mortality.

It would be more appropriate to look at all-cause mortality among women with breast cancer in the RCTs, and this does show that screening reduces the rate of all-cause mortality.⁵⁴

The CISNET models show that as many as 100,000 women now in their 30s will die by waiting until the age of 50 and being screened every two years whose lives could be saved by annual screening starting at 40.⁵⁵ Among just the women who are 40 today, if they wait until 50 to be screened every two years as many as 13,770 will die whose lives could be saved by annual screening beginning at the age of 40.⁵⁶

Overdiagnosis

What about overdiagnosis — the claim that breast screening discovers cancers that would never present a health risk to a woman during her lifetime? This is another criticism that is frequently levied against breast screening.

The claim of massive overdiagnosis has been manufactured by “guessing” that the incidence of breast cancer was not steadily increasing as screening was being introduced. Since no one has ever seen a mammographically detected invasive breast cancer disappear on its own (the few “miracles” have all been clinically evident), and Arleo et al showed that none of almost 250 invasive cancers that were untreated did not regress or disappear,⁵⁷ then waiting until age 50 and screening every two years will not reduce “overdiagnosis,” if it even exists, because the cancers will still be there.

Delaying screening will reduce recalls from screening (inappropriately called “false positives”) for a few extra pictures or an ultrasound. The recall rate is approximately 10% (which is, approximately, the same recall rate as cervical cancer screening using Pap tests) and a very small chance of having an imaging-guided needle biopsy using local anesthesia with a fairly high yield of cancer. Approximately 2%-4% of women screened will be advised to have an imaging-guided needle biopsy, and 20%-40% of these lesions will prove to be malignant.

There is no question that recalls make all of us anxious, and recalls from screening are no exception, but, for most, the anxiety is short-lived.⁵⁸ Given that the major “harm” (“harm” is pejorative, it should be called “risk”) from screening is the anxiety of being recalled, it is beyond paternal/maternalistic to advise women that it is preferable to let them die an avoidable death than to be made anxious by a recall.

Conflict of interest

The makeup of the USPSTF panel almost ensures that breast screening will not receive a fair review, and changes are needed.

In a supposed effort to avoid biases from panel members who have a conflict of interest (COI), the USPSTF has prevented anyone with actual expertise in breast cancer screening from serving on its panel. Consequently, panel members have been unable to critically sort through the available data and understand the validity or lack of validity of the material they have been asked to review.

This has also given “advisers” to the panel extraordinary influence to “guide” an experientially and factually naive panel. In the past, the vast majority of advisers to the USPSTF panel reviewing breast cancer screening have been individuals who have expressed their opposition to screening and have clearly had great influence on the panel. Many of the advisers have been viewed as having no conflicts of interest when, in fact, this is not true.

Without an obvious COI it is impossible to gain expertise in a field. Experts, such as I, who earn a living related to breast cancer screening, have an obvious and open conflict of interest. However, advisers who have received and continue to receive grant support for their research efforts are viewed as free of conflict, when in fact, theirs is a far less obvious conflict of interest.

Granting agencies, including the U.S. National Cancer Institute (NCI) and foundations have undeclared biases. When the work of a grantee supports the biases of the grantor, grants are likely to be renewed. Grant or foundation support is a far more insidious conflict of interest than those that are out in the open.

The practice of excluding experts from the USPSTF panel should stop. Conflicts of interest should be detailed, but rather than being excluded, experts are critical for an accurate analysis of the data to provide the most factual and evidence-based advice. Guidelines panels, including the USPSTF, should have leading experts involved in their decisions and the public should be provided with “minority” reports should there be unresolvable disagreements.

Problems with the USPSTF 2021 review

There are numerous potential problems with the USPSTF’s current review of breast screening. The task force is not going to include the NCI/CISNET computer models to project the potential outcomes of various screening protocols. Without these, the task force will be guessing in their predictions. It would appear that CISNET modeling has been dropped because the models all showed that the most lives are saved by annual screening beginning at the age of 40.

Although a reduction in advanced stage disease is a potentially useful “surrogate endpoint,” it is critical to remember that lives are lost among women diagnosed at all stages of breast cancer. It has been shown that reducing the size of cancers within stages is also a major benefit from screening that reduces deaths.

A critical fact that has been, repeatedly, overlooked by analyses that denigrate the value of screening and (falsely) suggest massive overdiagnosis, is the false claim that the background incidence of breast cancer has not increased over time. This has been the fundamental piece of misinformation that has been used to promote the false concepts of massive overdiagnosis and the false claim that there has not been a reduction in advanced cancers.

The data clearly show that the baseline incidence of breast cancer has increased steadily by 1%-1.3% per year dating back to at least 1940,⁵⁹ long before there was any screening, which did not start until the mid-1980s. If the correct increasing baseline is used, not only is there no apparent “overdiagnosis” of invasive cancers, but it appears that there has been a major reduction in the incidence of invasive cancers.⁶⁰ Although unproven, this is likely due to the removal of ductal carcinoma in situ (lesions almost exclusively detected by mammography) precluding the future development of invasive cancers.

By using the correct baseline incidence and extrapolation it is also clear that there has been a major reduction in the rate of advanced cancers.

January 26, 2021 — In the last 10 years, we have witnessed growing negativity regarding mammography screening. Numerous myths have sprung up about mammography, its effectiveness, and its potential complications, such as overdiagnosis.

These unfortunate attitudes appear to be associated with the U.S. Preventive Services Task Force’s (USPSTF) revision of mammography screening recommendations — no longer recommending mammography screening for women ages 40 to 49.

History of the USPSTF’s decision in 2009

The USPSTF is a volunteer group of independent medical experts with preventive services expertise. Its primary task is making recommendations regarding screening tests, medications, and counseling services to prevent diseases. The USPSTF is funded by the U.S. Department of Health and Human Services; however, it makes its decisions independently.

In 2002, the USPSTF advised that women should begin mammography at age 40 — however, this guidance was never formalized. In 2007, a new board evaluated five-year data to compare both new and old results. These evaluations led to the formulation of new modeling, leading to the 2009 mammography recommendation updates, which removed the recommendation that women in their 40s undergo regular breast screening.

Loud outcries erupted over the 2009 mammography policy changes. Emotions ran high among healthcare professionals, including the American College of Radiology, which proclaimed, “Two decades of decline in breast cancer mortality could be reversed, and countless American women may die needlessly from breast cancer each year.”

Politics became involved, too, as politicians wrangled over mammography and the Patient Protection and Affordable Care Act. Concern rose over medical rationing. Sen. Tom Coburn of Oklahoma, a physician, wrote an editorial for the Wall Street Journal, talking about a 33-year-old patient who developed breast cancer. Rep. John Shadegg of Arizona warned about the consequences of the new USPSTF mammogram policy. Rep. Frank Pallone Jr. called for hearings on the USPSTF new recommendations on breast cancer screenings.

In the end, the Senate voted 61 to 39 to guarantee coverage for mammography.

Yet, the damage had been done with conversations about “overdiagnosis.” Some studies stated that “mammograms pick up cancers that don’t need to be found.” Costs crept into the controversy with conversations about screening costs to save just one life. Concern over rationing health screening became an issue. Fears of overtreatment surfaced.

Even conflict of interest concerns appeared, further polarizing proponents and opponents of the USPSTF change in recommendations.

Mammography and breast cancer in 2020

Since 2010, the percentage of women having a mammogram has been decreasing. According to a Kaiser Family Foundation study, only 72% of women over 40 had a mammogram within the last two years between 2016 and 2018. The average size of tumors in the newly diagnosed has crept back over 2 cm. The myth that “mammography does more harm than good” continues to perpetuate itself.

Many mammograms have been postponed or canceled due to the COVID-19 pandemic. Numerous women are afraid to go to in-person medical appointments and have delayed their annual mammogram well into 2021 or beyond.

Ways to overcome the antimammography movement

One of the most effective ways to overcome the antimammography movement is by providing accurate and factual data. Be proactive when talking to patients. Talk to them about their fears and objections to having annual mammograms. Empathy goes a long way in overcoming patients’ objections.

Learning why a patient is delaying or avoiding her mammogram is the first step in enabling her to schedule and keep her mammogram appointment. Some objections can be more easily addressed than others. Here are some of the objections that patients may offer:

• Fear of the unknown (i.e., first mammogram): Reassure patients about their first mammogram. Take a few minutes to explain the procedure so they know what to expect during the exam and how they will be notified of the results.
• Pain during the mammogram: Don’t belittle or degrade a woman who experienced pain during mammography. Their mammogram might have occurred just before their period when breasts are most tender and sensitive. Suggest that scheduling a week after their period and avoiding caffeine for 24 hours before their mammogram may lessen the chance of discomfort.
• Fear of excessive radiation exposure: Reassure patients that the risk of excessive radiation is virtually nonexistent. Every person in the U.S. is exposed to “background” radiation from their surroundings — about 3 mSv annually. A mammogram is the equivalent of seven weeks of background radiation.
• Fear of the results: Detecting cancer is the goal of annual mammography so that treatment will be successful. Women without insurance may defer mammography because they don’t have the financial means to get treatment. Reassure patients that you’ve had other patients in their situation and that financial aid is available to help uninsured patients.
• False positives: Remind patients that the purpose of mammography is to find abnormalities in the breast tissue. Just because we find a suspicious-looking area doesn’t mean that it’s cancer. We may ask the patient to come in for some additional views. If there is still an area of concern, a biopsy may be required. Only about 20% of breast biopsies are positive for cancer. We compare next year’s mammogram with the previous one to help prevent additional testing.
• Overtreatment: While we cannot predict if early-stage cancer will be aggressive, we would be doing a disservice to our patients if we did not provide annual mammography beginning at age 40. Despite mammography’s limitations, it is the best screening tool for women’s most common cancer (except skin cancer). One out of every eight women in the U.S. will be diagnosed with invasive breast cancer in her lifetime.
• Fear of thyroid cancer: The American Thyroid Association’s research shows that the recent increase in thyroid cancer diagnoses is not related to mammograms, dental x-rays, or chest x-rays.
• USPSTF guidelines: Not even one of the taskforce members who recommended the changes for timing and frequency of mammography in 2009 had experience in the diagnosis or treatment of breast cancer. The institutions involved in breast cancer diagnosis and treatment recommend that women have their first mammogram at age 40 (or earlier if they are at increased risk) and continue having mammograms annually.

You and your staff can make a difference. Empathy, kindness, enhanced patient education, and a dose of good old “bedside manner” will help your patients overcome the negativity sometimes associated with mammography.

A 23-year follow-up of a large UK trial found that screening women aged 40-49 led to a substantial and significant 25% reduction in breast cancer mortality in the first 10 years.

The UK, along with many other countries, has a breast cancer screening programme offering mammography to women aged 50–70 years every 3 years. However, uncertainty currently exists over whether to start screening at a younger age, including whether it might lead to over-diagnosis of breast cancer.

Between 1990 and 1997, the UK Breast Screening Age Trial randomised more than 160,000 UK women aged 39-41 to receive either annual mammography, or the usual National Health Service (NHS) breast screening which commences at age 50. The primary outcome was mortality from breast cancers diagnosed prior to first NHS breast screen.

In a new analysis, which presents the 23-year follow-up results of the trial, it was found that screening women aged 40-49 led to a substantial and significant 25% reduction in breast cancer mortality in the first ten years. The total years of life saved from breast cancer in the intervention group was estimated as 620, corresponding to 11.5 years saved per 1,000 women invited to earlier screening.

The results also suggest at worst modest over-diagnosis in this age group, and that any over-diagnosed cancers would otherwise be diagnosed at NHS screening from 50 years of age. Therefore, screening in the age group of 40–49 years does not appear to add to over-diagnosed cases from screening at age 50 years and older.

Lead researcher Professor Stephen Duffy from Queen Mary University of London said: “This is a very long-term follow-up of a study which confirms that screening in women under 50 can save lives. The benefit is seen mostly in the first ten years, but the reduction in mortality persists in the long term at about one life saved per thousand women screened.

“We now screen more thoroughly and with better equipment than in the 1990’s when most of the screening in this trial took place, so the benefits may be greater than we’ve seen in this study.”

The researchers say that more research is needed to clarify whether progress in early detection technology and treatment of breast cancer might modify the screening-related reduction in mortality in the 40-49 age group. They also did not consider the cost-effectiveness of lowering the screening age.

The study was funded by the National Institute for Health Research Health Technology Assessment programme, and included researchers from King’s College London, University of Nottingham, University of Dundee and Tel Aviv University.

In a commentary in the journal, Anthony B Miller, from the Dalla Lana school of public health at Toronto University in Canada, said the trial had not ended the debate over when to start screening. The trial did not have a control group of individuals who were not screened, he pointed out, and he was surprised that few women had been wrongly diagnosed with breast cancer – a big concern that has led to increased warnings in the leaflets given out by the NHS breast cancer screening programme.

“It could be argued that breast screening with mammography should not be initiated at any age, but rather women should be encouraged to practise breast awareness, with mammography used as a diagnostic test,” he is quoted in The Guardian as saying.

Abstract

Background: The appropriate age range for breast cancer screening remains a matter of debate. We aimed to estimate the effect of mammographic screening at ages 40–48 years on breast cancer mortality.

Methods: We did a randomised, controlled trial involving 23 breast screening units across Great Britain. We randomly assigned women aged 39–41 years, using individual randomisation, stratified by general practice, in a 1:2 ratio, to yearly mammographic screening from the year of inclusion in the trial up to and including the calendar year that they reached age 48 years (intervention group), or to standard care of no screening until the invitation to their first National Health Service Breast Screening Programme (NHSBSP) screen at approximately age 50 years (control group). Women in the intervention group were recruited by postal invitation. Women in the control group were unaware of the study. The primary endpoint was mortality from breast cancers (with breast cancer coded as the underlying cause of death) diagnosed during the intervention period, before the participant’s first NHSBSP screen. To study the timing of the mortality effect, we analysed the results in different follow-up periods. Women were included in the primary comparison regardless of compliance with randomisation status (intention-to-treat analysis). This Article reports on long-term follow-up analysis. The trial is registered with the ISRCTN registry, ISRCTN24647151.

Findings: 160 921 women were recruited between Oct 14, 1990, and Sept 24, 1997. 53 883 women (33·5%) were randomly assigned to the intervention group and 106 953 (66·5%) to the control group. Between randomisation and Feb 28, 2017, women were followed up for a median of 22·8 years (IQR 21·8–24·0). We observed a significant reduction in breast cancer mortality at 10 years of follow-up, with 83 breast cancer deaths in the intervention group versus 219 in the control group (relative rate [RR] 0·75 [95% CI 0·58–0·97]; p=0·029). No significant reduction was observed thereafter, with 126 deaths versus 255 deaths occurring after more than 10 years of follow-up (RR 0·98 [0·79–1·22]; p=0·86).

Interpretation: Yearly mammography before age 50 years, commencing at age 40 or 41 years, was associated with a relative reduction in breast cancer mortality, which was attenuated after 10 years, although the absolute reduction remained constant. Reducing the lower age limit for screening from 50 to 40 years could potentially reduce breast cancer mortality.

Funding: National Institute for Health Research Health Technology Assessment programme.

Authors

Stephen W Duffy, Daniel Vulkan, Howard Cuckle, Dharmishta Parmar, Shama Sheikh, Robert A Smith, Andrew Evans, Oleg Blyuss, Louise Johns, Ian O Ellis, Jonathan Myles, Peter D Sasieni, Sue M Moss

Queen Mary University of London material The Lancet Oncology abstract

Source: Medical Brief

A promising new protocol for diffusion-weighted MRI (DWI-MRI) resulted in better image quality and improved signal-to-noise ratio for breast lesions, according to a prospective study published online on May 29 in Radiology: Imaging Cancer.

The protocol, multiplexed sensitivity-encoding (MUSE) DWI, splits a single-shot imaging acquisition into multiple shots, which can help reduce the technique’s sensitivity to motion. Researchers from the University of Arizona had previously explored MUSE-DWI’s potential to produce high-quality brain images with a 15-minute MRI scan, but its use for breast imaging hasn’t been as readily studied.

“MUSE DWI yielded significantly improved image quality compared with single-shot DWI in phantoms and participants,” wrote the international team of authors, led by Dr. Isaac Daimiel Naranjo from the breast imaging service at Memorial Sloan Kettering Cancer Center in New York City.

DWI analyzes the distribution of water to evaluate breast tissue structures at a microscopic level without the need for a contrast agent. Prior research has found the MRI technique can reduce false-positive findings and increase breast cancer detection.

However, single-shot DWI can also lack high spatial resolution and is especially sensitive to patient motion. The authors investigated the MUSE protocol for DWI as one solution to overcome these limitations, while also potentially speeding up contrast-free MRI times.

For their prospective study, the authors optimized MUSE DWI for breast phantoms. They tested multiple MUSE DWI acquisition techniques and selected one with the best quality for breast imaging.

Once the protocol was established, the authors enrolled 30 women with BI-RADS category 2-5 lesions found through contrast-enhanced MRI. The patients first underwent imaging with DWI, followed immediately by MUSE DWI.

Two breast imaging radiologists independently read the DWI and MUSE DWI images, grading each images’ fat suppressing, artifacts, lesion visibility, and overall quality.

Comparison of single-shot DWI (ss-DWI), MUSE-DWI, and dynamic contrasted-enhanced (DCE-MRI) axial images for two patients with biopsy-proven invasive ductal carcinoma. Image courtesy of the RSNA.

The researchers consistently ranked the quality of MUSE DWI images higher than the quality of single-shot DWI. One author rated MUSE DWI images higher in 58% of cases, while the other ranked MUSE DWI higher 65% of the time.

“In accordance with these previous investigations, our preliminary study in the breast found that the quality of the image with MUSE DWI was ostensibly better, resulting in improved lesion delineation compared with single-shot DWI,” the authors wrote.

Further, MUSE DWI demonstrated significantly better signal-to-noise ratio and improved fat suppression and artifact correction. The researchers also found no difference in the apparent diffusion coefficient values of the two procedures.

Because the MUSE technique improved DWI image quality, the authors noted it may be possible to cut down on MRI scan time while keeping image quality consistent. However, this study only tested the protocol with a small number of patients and a limited number of small lesions.

Although the findings look promising for clinical application, future studies should evaluate the protocol for smaller lesions, in shorter scan times, and compared with other DWI protocols, the authors noted.

Source: AuntMinnie.com staff writer

Women with dense breast tissue want adjunct screening that is sensitive and inexpensive — although higher sensitivity might outweigh cost, according to a study published February 28 in the Journal of Breast Imaging.

A team led by Dr. Matthew Miller, PhD, of the University of Virginia in Charlottesville conducted a survey of 508 patients with dense breast tissue presenting for screening mammography. The survey asked

participants to do the following:

• Estimate their personal breast cancer risk compared with their peers
• Indicate their level of concern related to recalls, radiation exposure,
  and intravenous contrast allergies
• List factors that might prevent them from getting supplemental screening exams.

Of survey participants, 59.9% believed it was likely or very likely that a cancer could be missed on a mammogram, but only 8.9% had undergone supplemental screening in the past three years. The most common deterrents to additional screening were pain (66.9%) and anxiety that supplemental screening would lead to additional procedures (31.1%). Survey participants were asked to select among three hypothetical adjunct breast cancer screening modalities — breast MRI, contrast-enhanced spectral mammography (CESM), and automated breast ultrasound (ABUS) — and they strongly preferred whichever exam was most sensitive, even if this meant higher cost (31.9%) or administration of IV contrast (62%). “Our data suggest that patients with dense breasts prefer adjunct screening exams that are both sensitive and inexpensive, although an increase in sensitivity could outweigh additional cost or even IV-line placement,” the team concluded.

Source: AuntMinnie.com staff writer