The Breast Cancer Dilemma

As a doctor and specialist in Women’s Health and Hormonal Health in particular, I have been concerned for years about misconceptions and misinformation about breast cancer, its causes and methods of early detection. Each new study highlighted in the media comes with an increased risk for women (and their doctors) developing the wrong ideas about how breast cancer begins and the best methods of detection and treatment.

According to the American Cancer Society, 1 of 8 invasive breast cancers occur in women younger than 45, while around 2 of 3 invasive breast cancers occur in women older than 55. The American Cancer Society guidelines recommend that women begin having clinical breast exams every three years starting in the 20s, and annual mammograms after the age of 40.

In February of 2013, the U.S. Preventive Services Task Force (USPSTF) examined U. S. Breast Cancer screening strategies and concluded that biennial mammograms achieved most of the benefits of annual screens, and cause less harm to women. The task force recommended that the age for beginning routine screening be raised from age 40 to 50 and end at age 74 for women with average-risk. Based on these new guidelines, there is a strong chance that insurers will stop paying for annual mammograms and screenings for women in their 40s or over the age of 74. Even more controversially, the USPTF guidelines suggested women should no longer be taught how to examine their breasts, citing studies that conclude that self-exams have little value. Women know their own bodies best, and many physicians disagree with the idea that regular self-exams are of no value.

The new USPSTF guidelines, which dramatically conflict with those of The American Cancer Society, were discussed at the San Antonio Breast Cancer Symposium held in December of 2013. The discussion became a heated debate, where many physicians expressed the opinion that ductal carcinoma in situ, or DCIS, (the presence of abnormal cells inside a milk duct in the breast) should not carry a diagnosis of Stage 1 breast cancer and insist that we are over-treating women. Others advocate invasive treatments like lumpectomy, mastectomy and radiation or chemotherapy or a combination of these procedures to prevent DCIS from becoming invasive breast cancer.

Recently, the five-year follow up results of the Canadian National Breast Screening Study were released, and they indicate that it doesn’t matter if breast cancer was found on a mammogram or during clinical or self-exams. Statistically, the death rate for each group was the same. Finding tumors before they get to 2cm in size is good, and the study shows that a good clinical exam or self-exam can detect them just as well as a mammogram. Large amounts of time and money are going towards searching for tumors at early stages, however the results of the Canadian follow up study also suggests that doctors are over-diagnosing and over-treating lesions that may never develop into breast cancer.

So what does this all mean? The results of both studies do suggest that frequency of clinical exams and mammograms be reevaluated. The survival rate for women with breast cancer is 95% at 5 years if it is caught and treated early. Regular self-exams, clinical exams and mammograms remain important to early diagnosis no matter what the age group. The USPSTF guidelines pose additional problems for providers, who will be reluctant to advise women to forgo annual mammograms simply because they can and will be sued should one of their patients develop breast cancer and die.

Happily, there are some recent medical advances that offer doctors additional, less invasive tools for early detection. One of the most exciting developments in recent years is the DtectDx™ Breast test; designed to be used in conjunction with mammography. This advanced blood test can detect key markers in the patient’s blood that indicate early stages of breast cancer. Test results allow the physician to decide whether a routine mammogram, more extensive 3-D imaging or biopsy is appropriate for the patient. While this test is relatively new, it is particularly useful in women under age 50, as results are not affected by dense breast tissue or scar tissue from previous biopsies.

Risk factors for developing breast cancer include gender – women are far more likely to develop breast cancer than a man. Aging is another factor – as women age and hormone levels fall, risk increases. Other risk factors to consider are genetic mutations, family history of breast cancer in a close relative, as well as race and ethnicity. Lifestyle risk factors include smoking, excess alcohol consumption, being overweight or obese, lack of regular exercise, poor dietary habits, long-term use of oral contraceptives and chemical exposure from the environment.

Understanding personal cancer risk factors and the early detection are important, however, women must advocate for their own health. While the powers-that-be debate about the frequency and effectiveness of clinical screenings and mammograms, women should continue doing regular self-exams. If changes are found, see a doctor immediately.