New breast cancer screening guidelines empower women.

The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)
The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)

Recently, Canadian Medical Association Journal (CMAJ December 10, 2018) published new recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer.

These guidelines apply to women with no previous history of breast cancer, no history of the disease in a first-degree relative like a mother or sister, no known BRCA genetic mutation and no previous exposure to therapeutic radiation of the chest wall.

The recommendations come from the Canadian Task Force on Preventive Health Care. The new recommendations update guidelines first published in 2011. The guidelines are summarized below:

1. There should be no routine mammography for most women aged 40 to 49 because the risk of cancer is low in this group while the risk of false-positive results and overdiagnosis and overtreatment is higher.

2. Routine screening mammography should be done every two to three years for women aged 50 to 69.

3. For women aged 70 to 74, routine screening mammography should be done every two to three years.

4. MRI and ultrasound should not be used for screening purposes.

5. Routine clinical breast examinations or breast self-examinations to screen for breast cancer is discouraged.

Although we rely on mammography for screening the fact remains it is not a perfect screening tool. Screening may lead to overdiagnosis, resulting in unnecessary treatment of cancer that would not have caused harm in a woman’s lifetime and false-positive results that can lead to both physical and psychological consequences. Overdiagnosis and false-positives with subsequent biopsies are more common in younger women.

Other risks and limitations of mammograms include: exposure to low-dose radiation, having a mammogram may lead to additional testing in about 10 per cent of cases. Mammograms can miss one in five cancers in women.

On the other hand, mammography is the only technique proven to be safe and effective in screening for breast cancer, and mammography equipment is the only imaging technique licensed by Health Canada for breast cancer screening. It is good at finding breast cancer, especially in women ages 50 and older. Overall, the sensitivity of mammography is about 87 per cent. Screening may identify breast cancer earlier and lead to more effective and less invasive treatment.

What about women aged 40 to 49 years? Research shows balance of benefits and harms from screening is less favourable for women in this age group than for older women. If a woman in this category requests a mammogram then the guidelines suggest she should not be denied.

Death rates from female breast cancer dropped 40 per cent from 1989 to 2016. Since 2007, breast cancer death rates have been steady in women younger than 50, but have continued to decrease in older women (www.cancer.org).

You may ask, if none of the screening tests are perfect then why is there a decline in the death rate from breast cancer?

A review article in the Lancet Oncology (Why is breast-cancer mortality declining? April 2003), the authors argue that although some of the decline in breast-cancer mortality is due to a reduction in breast-cancer risk, most of it can probably be attributed to adjuvant systemic therapy and the earlier detection of palpable tumours. The authors also explain in the article why advances in the treatment of breast cancer might be outpacing the value of mammography screening.

Important thing to remember is new guidelines empower women to be in charge of their own screening protocol. The final decision on whether to be screened should fall to the patient as long as that patient understands the risks. Patients should be left ultimately to decide what is best for them.

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One Reply to “New breast cancer screening guidelines empower women.”

  1. Here is a copy of the letter I sent to members of the Canadian Task Force:
    February 21, 2019
    To Whom It May Concern:

    I was diagnosed with breast cancer in 2013, at age 42. Didn’t have any family history or genetic mutations. I had very dense breasts, but was not told; the cancer progressed. My doctor at the time relied on my mammogram and never mentioned my breast density. Following my diagnosis, my surgeon informed me that my mammogram was like looking for a polar bear in a snowstorm – white on white. Cancer was hidden by my dense breast tissue and left there to progress.

    I am writing to express how alarmed I am at the recent guidelines for breast cancer screening put forth by the Canadian Task Force. Had I followed such guidelines, I would likely be dead by now. I am 48 years old.

    Because I was diagnosed at a later stage, I underwent 16 chemotherapy treatments, port-a-cath surgeries, a bilateral mastectomy, lymph node surgery and reconstructive surgery. Following all this, I had to do physical therapy for the pain associated with chemotherapy and the surgeries, and to regain mobility.

    I am aware that none of the Task Force members are breast cancer experts. I also know that the guidelines are based on old, flawed studies, where dated equipment was used. I know that even if you consulted with experts, you didn’t take into account their current input. As a patient and survivor, I speak with specialists in the field. I also base my knowledge on my own experience and those of fellow patients and survivors that I have met through my volunteer work as an ambassador for the Quebec Breast Cancer Foundation. You may already know this, but I will say it anyway; some women have actually died, left families, children and loved ones behind following missed diagnosis due to the secrecy about their breast density. If the guidelines are followed, they will cause countless deaths, simply because you feel it shouldn’t be protocol to tell women about a well-known, well established risk factor. About their OWN BODIES.

    The Canadian Task force throws the word overdiagnosis all over the place, exaggerating the anxiety and “consequences” related to a call back for further screening, etc. All that talk about “over treatment” of a cancer that possibly wouldn’t have progressed…yet, it is an established fact that there is no way at this time to determine which cancers will stay put, and which ones will progress and kill. You are playing Russian roulette with women’s lives.

    You advise women not to check their bodies, you tell doctors not to perform clinical breast exams, and you dismiss women 40-49 by recommending not to screen. I had no risk factors, except for the well-kept secret of my breast density. Which, for your information, made it so I was NOT at average risk. With my breast density, my risk was actually higher than having a family history. With a clear conscience, you are asking women in their forties to wait it out?!? Should they consult once the mass is visible? That is the only way they will know that something may be seriously wrong. Please cross your fingers that the cancers that go undetected due to your guidelines don’t metastasize. I am outraged by your negligence. Your guidelines show a blatant disregard for women’s lives and wellbeing.

    Women are not dumb. They are not weak. You claim that the new guidelines give women more power. The fact that you do not recommend they be informed of their breast density and associated risks, and try to alarm them with the fear of “overdiagnosis” and over treatment, takes away their right to make informed decisions. AND WE KNOW IT. You do know this is the year 2019? Why do you continue to recommend keeping secrets from women about their own bodies? Don’t you see that this is condescending? IT’S A RISK FACTOR – TELL WOMEN! Would you ever recommend not telling a patient that their blood pressure is elevated? Of course not. Yet, not telling women about their breast density seems to make sense to you. Well, it doesn’t. Not even close.

    I am asking you this very direct question: Have you ever been victim of an under-diagnosis? Been told you were fine, when indeed you had a cancer growing in your body? Had to undergo aggressive treatments and invasive surgeries? Mr. Thombs, as a psychologist, I’m sure you can understand the trauma.

    Mortality isn’t the only thing to consider. Missed and delayed diagnosis have serious consequences. Chemotherapy, mastectomies, lymphedema, reconstructive surgeries, etc. are traumatic and extremely painful, emotionally as well as physically.

    I sincerely hope that you will take time to review and correct those dangerous and very alarming recommendations. The lives of so many Canadian women depend on it.

    I remain available to discuss further if you are interested in educating yourselves on the real issues women affected by breast cancer face every day.

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