Snake oil or good treatment?

Every so often I become a skeptic, well maybe a bit more frequently, but sometimes I am just not sure what I think of new treatment options. And here is an example.

Women with dense breasts run a higher risk of breast cancer being detected later as opposed to sooner as the density makes it more difficult to detect tumors by mammography. So in Australia, there is a new treatment for women with dense breasts. It is an implantable tablet that is placed under the skin and lasts for about four months before they need to go through it again. It has two benefits - reducing breast density and to reduce perimenopausal symptoms. You can see a video on it here and visit their website for more information here.

But its hormones - testosterone and others. Its called T+Ai.... Me I am not a big fan of hormone treatments after what happened to women who were treated with them in the 1980s and 1990s and then found it lead to higher rates of breast cancer. I know testosterone is not a breast cancer hormone per se but I feel it would be messing with my body's balance too much. And if it reduces breast density it is making a permanent change in your body which can't be undone.

It sounds good and could help women be able to detect breast cancer sooner. But is it fear mongering? OMG, you have dense breasts and that means you will get breast cancer and die because it won't be detected early no matter what you do?!!!! Maybe for high risk women with dense breasts but not for huge groups of women.

So my jury, of one, is still out on this one. I am a skeptic.

Putting emotion into our medical decisions

Have you ever gone to the doctor and insisted that you needed a specific test or treatment? You were so wrapped up in the emotions of moment and the ailment that you were not being rational.

You aren't alone. Emotion often leads us to choose unwisely. An example of this is the mammogram decision. Why have one? What if the result is bad? (This is the reason I will never go to a psychic.) Who wants to get bad news. And then the worst, what if the bad result is wrong and its actually nothing. That would be a false positive.

But apparently women do not think about the risk of false positive when they have mammograms.

"American women face conflicting advice about whether to be screened for breast cancer, at what age and how often. The decisions they make are often more strongly influenced by fear or a friend’s experience than by a thorough understanding of the benefits and risks of mammography."

But before we have any test or procedure, we need to be sure we educate ourselves on the possible outcomes and potential problems. In the case of breast cancer, it can be anything from a false positive to over treatment of a cancer. We just need to know first and make a smart decision.

The mammogram benefit discussion

There have been a few (thousand) discussions on the benefits of regular mammograms in the past few years. There are all sorts of claims on the problems of false positives, over diagnosis, false negatives, and all that.

So stop the presses and read the results of this latest survey. Its a bit of a statistics lesson so allow me to break it down with my stellar liberal arts education and marketing background

This survey looked at the incidence of breast cancer and the increased diagnosis trend from 1941 on. The first half of the time studied was from 1941 to the 1970s before mammograms - the base data.* Then it looked at the rates of diagnosis from the 1970s to the present.

What they could tell from the base data is the trend in increase in breast cancer from increased environmental or whatever factors and got their base rate of increase of 1.3% annually - or the expected rate of increase in breast cancer diagnosis. They also got their percentages of expected diagnoses of early and late stage diagnosis.

Then they looked at the date from the 1970s to present. What they then determined is that since the introduction of mammograms, the proportion of diagnoses of early stage cancer are up significantly and there is a 30% decrease in the expected rates of late stage diagnosis.

That is the benefit of mammography. The 30% decrease in late stage diagnosis. If you wish to debate the benefits or lack of benefits of mammography, please figure out a way to dispute that point.

*My 1981 cancer resource book from my first thyroid cancer diagnosis does talk about how mammography was being considered for annual screening for all women.

3D Mammography

3D Mammography, also known as digital breast tomosynthesis, has been around for the past few years. Originally I hadn't heard such great things about it but now I have heard more and find it an acceptable addition to cancer screening. Or at least in my opinion, which is what counts for me.

Basically in 3D mammography they take lots of pictures of slices of your breast as opposed to the single image from regular mammography. (Think CT vs x-ray) It takes a little longer for the radiologist to read all the pictures because there are so many of them, but they do  provide much clearer images, better detection, and fewer false positives.

When I went for my annual mammogram a few weeks ago, something I chose not to discuss until I got the results, I had a 3D mammogram. The hospital has added the newer machines in the past year. Their current arrangement is that if you have a doctor appointment the same day, you get a regular digital or screening mammogram. But if you do not have a doctor appointment the same day, meaning the radiologist has lots of time to read all the pictures from a 3D mammogram, that is what you get.

I had decided I see too many doctors and cut back on my radiation oncologist - I don't know why I was still seeing her anyway - and canceled that appointment this year. Some how my surgeons office never scheduled my annual appointment with them, even though I thought I was supposed to be followed by them for life, so I am down two appointments for the year. I will talk to my medical oncologist and my primary care when I see them to make sure I am getting the follow ups I should.

And I learned something, I will have my annual mammogram without a doctor appointment the same day so that I get the 3D mammogram. And my results this year were clean.

A Way to End the What Age for Mammograms Controversy?

Work with me here, what if everyone could agree on one option for the mammogram controversy? Wouldn't it make a lot more sense? I mean there has been so much ink about this single issue. On one hand is prevention and on the other is over diagnosis and false positives, with a lot of other data, crap, history, and arguments added on to each. So what is the real answer?

I believe JAMA has the right idea here. In the age of personalized medicine, why are we hung up on cross the board requirements? JAMA suggests that we "Stop One Size Fits All Mammography".

"A woman's decision to undergo mammography "should be individualized based on patients' risk profiles and preferences," concludes a systematic review of 50 years of breast cancer screening data, published in the April issue of JAMA.

How to best go about achieving that individualization is not entirely clear, but clinicians need to make an effort with the tools that are currently available, such as decision aids and risk models, 
suggest Lydia Pace, MD, MPH, and Nancy Keating, MD, MPH, both from Brigham and Women's Hospital in Boston, in their review."

Their argument is that a woman should be able to make a decision on mammography with their doctor based on their risk. The problem is that current science does not allow us to accurately estimate all women's risk of breast cancer. So the problem isn't with mammography but with the ability to predict breast cancer.

Before we jump ahead to that issue, let's stick with making mammography a personalized decision. I think this is a great idea. If someone has a high risk background, they should start mammograms earlier. If they do not have one, they should decide with their doctor when they should start them. Insurance companies should cover them regardless. There doesn't have to be a national rule on when they should be started.

Now switching to being able to predict breast cancer. We can't really. The BRCA genes allow us to predict women who are high risk but that does not cover all women who will get breast cancer, really less than 10% I believe. There can be other risk factors, family history, genetic background, and more.

Since we can't really tell who will or will not get breast cancer and may never be able to, we do need to use whatever screening methods we have. Until we have something better than mammography, it is our tool to use as best we can. But it should be the patient's choice and not the insurance company's.

Blood tests for breast cancer?

You mean maybe we could skip the annual mammogram and just have another blood test? That would be too cool. Now I couldn't read the article without subscribing to another magazine but suffice to say the abstract is promising enough:

"A new blood test may be able to detect the early stages of breast cancer, researchers say. Scheduled to begin vigorous clinical testing in early 2014, the test successfully identified the presence of breast cancer cells from serum biomarkers in preliminary testing, a huge step forward that could make breast cancer testing more widespread and more regularly detected early..."

Wouldn't it be nice if a test could be replaced by a blood test? How much money would be saved? How much time could be saved? Mammograms and MRIs only after an older age - 55? - or for high risk groups? This is something I would call progress - of the good kind.

3D Mammography

3D Mammography, also known as digital breast tomosynthesis, has been around for the past few years. Originally I hadn't heard such great things about it but now I have heard more and find it an acceptable addition to cancer screening. Or at least in my opinion, which is what counts for me.

Basically in 3D mammography they take lots of pictures of slices of your breast as opposed to the single image from regular mammography. (Think CT vs x-ray) It takes a little longer for the radiologist to read all the pictures because there are so many of them, but they do  provide much clearer images, better detection, and fewer false positives.

When I went for my annual mammogram a few weeks ago, something I chose not to discuss until I got the results, I had a 3D mammogram. The hospital has added the newer machines in the past year. Their current arrangement is that if you have a doctor appointment the same day, you get a regular digital or screening mammogram. But if you do not have a doctor appointment the same day, meaning the radiologist has lots of time to read all the pictures from a 3D mammogram, that is what you get.

I had decided I see too many doctors and cut back on my radiation oncologist - I don't know why I was still seeing her anyway - and canceled that appointment this year. Some how my surgeons office never scheduled my annual appointment with them, even though I thought I was supposed to be followed by them for life, so I am down two appointments for the year. I will talk to my medical oncologist and my primary care when I see them to make sure I am getting the follow ups I should.

And I learned something, I will have my annual mammogram without a doctor appointment the same day so that I get the 3D mammogram. And my results this year were clean.

Snake oil or good treatment?

Every so often I become a skeptic, well maybe a bit more frequently, but sometimes I am just not sure what I think of new treatment options. And here is an example.

Women with dense breasts run a higher risk of breast cancer being detected later as opposed to sooner as the density makes it more difficult to detect tumors by mammography. So in Australia, there is a new treatment for women with dense breasts. It is an implantable tablet that is placed under the skin and lasts for about four months before they need to go through it again. It has two benefits - reducing breast density and to reduce perimenopausal symptoms. You can see a video on it here and visit their website for more information here.

But its hormones - testosterone and others. Its called T+Ai.... Me I am not a big fan of hormone treatments after what happened to women who were treated with them in the 1980s and 1990s and then found it lead to higher rates of breast cancer. I know testosterone is not a breast cancer hormone per se but I feel it would be messing with my body's balance too much. And if it reduces breast density it is making a permanent change in your body which can't be undone.

It sounds good and could help women be able to detect breast cancer sooner. But is it fear mongering? OMG, you have dense breasts and that means you will get breast cancer and die because it won't be detected early no matter what you do?!!!! Maybe for high risk women with dense breasts but not for huge groups of women.

So my jury, of one, is still out on this one. I am a skeptic.

The mammogram benefit discussion

There have been a few (thousand) discussions on the benefits of regular mammograms in the past few years. There are all sorts of claims on the problems of false positives, over diagnosis, false negatives, and all that.

So stop the presses and read the results of this latest survey. Its a bit of a statistics lesson so allow me to break it down with my stellar liberal arts education and marketing background

This survey looked at the incidence of breast cancer and the increased diagnosis trend from 1941 on. The first half of the time studied was from 1941 to the 1970s before mammograms - the base data.* Then it looked at the rates of diagnosis from the 1970s to the present.

What they could tell from the base data is the trend in increase in breast cancer from increased environmental or whatever factors and got their base rate of increase of 1.3% annually - or the expected rate of increase in breast cancer diagnosis. They also got their percentages of expected diagnoses of early and late stage diagnosis.

Then they looked at the date from the 1970s to present. What they then determined is that since the introduction of mammograms, the proportion of diagnoses of early stage cancer are up significantly and there is a 30% decrease in the expected rates of late stage diagnosis.

That is the benefit of mammography. The 30% decrease in late stage diagnosis. If you wish to debate the benefits or lack of benefits of mammography, please figure out a way to dispute that point.

*My 1981 cancer resource book from my first thyroid cancer diagnosis does talk about how mammography was being considered for annual screening for all women.

The age range

There has been the on going controversy on when to start annual mammograms for all women - is it 40? Is it 50? Many go with age 40 but some don't. And its another debate.

But there is the other end of the scale - when to stop yearly mammograms. Breast cancer becomes more common in women as we age. The older you are the more likely you are to be diagnosed with breast cancer. Its a known fact. But when do we stop screening women for breast cancer? (There is the same conversation about colonoscopies on when is too old.) Currently the advice is stop at age 75.

Seriously. I had never really known this. As we age, we become less healthy and less able to tolerate cancer treatment. Its pretty nasty.

A friend's great aunt was diagnosed with colon cancer at age 98. She was too fragile to stand treatment. My aunt was diagnosed with early stage breast cancer at age 76. She had a lumpectomy, radiation and is on an aromatase inhibitor (I'm not sure which one). If she was younger, they might have recommended chemotherapy.

Another side of this issue is the increasing costs on medicare for continued mammograms for women over 75. Yale did a recent study on this. Part of the increase is due to the switch from the cheaper older film mammograms to the new digital ones (from $73 to $115). But also the continued mammograms after age 75.

One side says the stress and anxiety for older women along with the costs are reasons enough for stopping them.

""Clinicians and patients need to start thinking about the bang they are getting for their buck," said Dr. Anees Chagpar, director of the Breast Center – Smilow Cancer Hospital at Yale-New Haven, and a co-author of the study. "We must be cognizant of our use of technology and healthcare dollars."

"Our country and health system have finally recognized that this aggressive and dramatic rise in health care costs is not sustainable," said Dr. Cary Gross, director of the Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale Cancer Center and one of the study's lead authors. "We need to make choices about how to prioritize our healthcare spending.""


The other side says that as long as women are healthy, they should continue to have them.

""Women should get an annual mammogram as long as they are healthy, and age should not be the discriminator," said Gruen. "Breast cancer is the enemy. We should not politicize things (such as screening mammography) that have been shown to save lives.""

So the age range for mammograms is somewhere around 40-75. If you get breast cancer before age 40 and after age 75, you may be SOL. Let's take the politics out of this and stop 'prioritizing' crap and look at the health of women as the real concern.

Putting emotion into our medical decisions

Have you ever gone to the doctor and insisted that you needed a specific test or treatment? You were so wrapped up in the emotions of moment and the ailment that you were not being rational.

You aren't alone. Emotion often leads us to choose unwisely. An example of this is the mammogram decision. Why have one? What if the result is bad? (This is the reason I will never go to a psychic.) Who wants to get bad news. And then the worst, what if the bad result is wrong and its actually nothing. That would be a false positive.

But apparently women do not think about the risk of false positive when they have mammograms.

"American women face conflicting advice about whether to be screened for breast cancer, at what age and how often. The decisions they make are often more strongly influenced by fear or a friend’s experience than by a thorough understanding of the benefits and risks of mammography."

But before we have any test or procedure, we need to be sure we educate ourselves on the possible outcomes and potential problems. In the case of breast cancer, it can be anything from a false positive to over treatment of a cancer. We just need to know first and make a smart decision.

First mammogram at what age?

This will open up a new debate I am sure. A new study is due out today from Harvard showing that younger women should get mammograms. The thought process being start the screening younger to build better habits.

"This new Harvard Medical study looked at more than 7,300 women diagnosed with breast cancer. Just over 600 died. Among those who died, 65 percent had never had a mammogram.

Researchers concluded earlier screening could have saved lives."

An additional note is that half of the women who died were under the age 50 as well.

In 2009, research suggested that women should not get mammograms until age 50. That caused a big hoo-hah if you recall. Now they are suggesting that younger women, no age range suggested, get mammograms, so brace yourself for another huge debate.

The news just covered this story as well. The upside to starting mammograms at a younger age is deaths can be prevented. But how many women would need to be screened to save a single life? And how many false positives would be detected causing unnecessary stress and additional medical costs in the meantime?

I also question the increased cost burden on the medical insurance system. We complain about medical costs increasing but then we expect more and more screening tests. It is a careful balance to achieve - who should get screenings should probably depend on a patient's medical history.

Personally, I have had annual mammograms since age 24 because I had a benign tumor, and a cancer history, so when my breast cancer was detected at 45, it was not my first mammogram. But if not for that benign tumor, I would probably not have had a mammogram until at least 40.

Every patient is different so the advice should be discuss this with your doctor for now.

A Way to End the What Age for Mammograms Controversy?

Work with me here, what if everyone could agree on one option for the mammogram controversy? Wouldn't it make a lot more sense? I mean there has been so much ink about this single issue. On one hand is prevention and on the other is over diagnosis and false positives, with a lot of other data, crap, history, and arguments added on to each. So what is the real answer?

I believe JAMA has the right idea here. In the age of personalized medicine, why are we hung up on cross the board requirements? JAMA suggests that we "Stop One Size Fits All Mammography".

"A woman's decision to undergo mammography "should be individualized based on patients' risk profiles and preferences," concludes a systematic review of 50 years of breast cancer screening data, published in the April issue of JAMA.

How to best go about achieving that individualization is not entirely clear, but clinicians need to make an effort with the tools that are currently available, such as decision aids and risk models, 
suggest Lydia Pace, MD, MPH, and Nancy Keating, MD, MPH, both from Brigham and Women's Hospital in Boston, in their review."

Their argument is that a woman should be able to make a decision on mammography with their doctor based on their risk. The problem is that current science does not allow us to accurately estimate all women's risk of breast cancer. So the problem isn't with mammography but with the ability to predict breast cancer.

Before we jump ahead to that issue, let's stick with making mammography a personalized decision. I think this is a great idea. If someone has a high risk background, they should start mammograms earlier. If they do not have one, they should decide with their doctor when they should start them. Insurance companies should cover them regardless. There doesn't have to be a national rule on when they should be started.

Now switching to being able to predict breast cancer. We can't really. The BRCA genes allow us to predict women who are high risk but that does not cover all women who will get breast cancer, really less than 10% I believe. There can be other risk factors, family history, genetic background, and more.

Since we can't really tell who will or will not get breast cancer and may never be able to, we do need to use whatever screening methods we have. Until we have something better than mammography, it is our tool to use as best we can. But it should be the patient's choice and not the insurance company's.

Thoughts on mammograms and false positives

There has been a lot of controversy in recent years about the benefits of mammography and false positives. I read Dr Susan Love's take on how "Mammography is like the TSA" and the comments left by women. It made me think.

I started having annual mammograms at age 22 because of a benign fibroadenoma so I am sort of out of the discussion. My breast cancer was discovered 23 annual mammograms later at age 45. I went to all those mammograms without any concern until the one in 2007 (and if you are trying to figure out how old I am, currently I am 37) which turned into an ultrasound, a lot of denial on my part, followed by two surgeries, chemo, radiation, and hormone therapy to where I am now.

But if it was me to do it all over again, at this point I would rather be over treated and have a few false positives along the way than to have a cancer missed. My cancer could not be felt in a manual exam. My benign one way back when could be felt. My subsequent benign fibroademona, six months after my diagnosis, could not be felt either due to scar tissue. But it was visible in an MRI and ultrasound.

If you think about it, we have a tool available to us that helps with early detection and that alone does equate to saving lives. Its like wearing your seat belt. If you wear it every day, you are making your best effort. But on the one day you need it when that car pulls out of a side road in front of you, you are saved.

Dr Love makes an analogy of a mammogram like TSA screening which I can understand as well. Any effort we can make to help us live more safely makes sense. You can opt out of wearing your seat belt at your own risk. You can opt out of your annual mammogram at your own risk. But there shouldn't be someone blocking you from access.

The risk for breast cancer starts to increase for women at age 40 so there is no reason to delay mammograms until age 50 - just because the risk is significantly greater. As Dr Love points out there are many types of cancers and each are different. She raises the question that we may need to reevaluate the goal for early detection . But until it is changed, I am sticking with my annual mammogram.