Smoking is the number one cause of lung cancer and lung cancer is the leading cause of cancer related deaths in the United States. (More than breast, colorectal and prostate cancer combined!) A proper medical history should always include a smoking history and medical care should include therapies (and ongoing encouragement) to stop if a patient is still smoking. But what about screening and follow up? Despite advances in diagnosis, staging and treatment, only 18% of patients with lung cancer are still alive five years after diagnosis.There is an understandable goal by all of us to do better…

An article published in the November 6 issue of the New England Journal of Medicine has provided data that helps improve smoking mortality statistics; it demonstrates the efficacy of screening with low-dose CT scans of the lungs. The National Lung Screening Trial (NLST), enrolled more than 50,000 persons at 33 US centers. They included individuals who were 55 to 74 years of age with a smoking history of at least 30 pack years. (That means that they smoked one pack for 30 years or two packs for 15 years or, and I am not sure how one does this…3 packs for 10 years.) They included both current smokers and former smokers who had quit within the previous 15 years.

The findings were very significant. There was a 20% reduction in lung cancer mortality with low-dose CT scan diagnosis and treatment versus those who were diagnosed with lung cancer by simple chest x-ray. In absolute terms, this translated to approximately three fewer deaths from lung cancer per 1000 high risk persons who underwent low-dose CT scanning.This is as great a benefit as that reported for breast cancer mortality with annual mammography screening among women 50 to 59 years of age.

There were false positives…(The scan can pick up abnormalities that are not cancer). To decrease the false positive results and unnecessary biopsies and/or surgery, participants found to have a nodule were followed with additional CT screening and only when a lesion got bigger or more worrisome was a biopsy performed. In the end, relatively few of the surgeries (24%) were performed in patients who had benign nodules.

What also got my attention was the fact that screening with low-dose CT was much more cost-effective among women then among men. Scanning was also more likely to have a mortality impact in the groups with the highest risk of lung cancer such as those who were still smoking and those who were older.

And now a very recent headline: Medicare just announced that they “will cover annual screenings for lung cancer for older Americans with a long history of heavy smoking”. They “will extend coverage for CT scans to Medicare beneficiaries who smoked at least a pack a day for 30 years or the equivalent, even if they quit as long as 15 years ago”. According to their announcement the scans will be free for recipients and “the coverage would apply to beneficiaries through age 74.”

Bottom line: If you are a former smoker of the equivalent of one pack of cigarettes a day for 30 years or, heaven forbid, you are a current smoker and you’re over the age of 55, talk to your physician about getting a low dose CT scan of your lungs. Based on the recent studies and the fact that Medicare has announced that they will pay, this should be affordable (if you are not yet on Medicare) or free if you are 65 or older. Too bad the cost of future CT scans are not charged to tobacco companies every time they sell a pack of their poison!

We all know what comes with our 50th birthday… The advice by your physician to get colon cancer screening. And then comes the yuck factor; discussion of the ways to do a colon cleanse in order to be able to view the interior aspects of this very long digestive conduit with either a “true” or virtual colonoscopy. (I discuss both in previous websites.) Although I know that the best way to detect precancerous polyps and/or early cancer is with colonoscopy, I am willing to discuss alternatives such as the virtual “look see” and now a new stool test. It is aptly named Cologuard.

Remember, when found early colorectal cancer is highly treatable.The five-year survival for early-stage cancer is greater than 90%. And if a pre-cancerous polyp is found and removed the cancer can be prevented! However, 23 million Americans between 50 and 75 are not getting screened as recommended, and as a result, colorectal cancer remains the second leading cancer killer in the United States.

According to the manufactures of this new test, “it offers people 50 years and older who are at average risk for colorectal cancer an easy to use screening test which they can do in the privacy of their own home.” Normally I don’t use my website to talk about new products but I was impressed by the fact that the FDA has approved Cologuard and that Medicare now pays for it.

This is a test in which a small sample of stool is tested for cancer associated DNA markers as well as the presence of occult hemoglobin (blood). When you have a bowel movement, your stool picks up cells that are shed from the colon lining. If any cells have abnormal DNA or there is a minute amount of blood, the test is meant to detect this. If it’s positive it may indicate the presence of colorectal cancer or advanced adenoma (precancerous polyp). Colorguard was studied in a large clinical trial which included more than 10,000 patients at 90 sites in the US and Canada. The participants in the study completed Cologuard as well as a fecal chemical test for occult blood before having a standard colonoscopy. They wanted to see how well Cologuard detected cancer and pre-cancer compared to a colonoscopy. What they found was that Cologuard found 92% of colon cancers and 42% of pre-cancers. When the Cologuard test was negative it was accurate 87% of the time.

These are pretty good statistics…certainly not perfect. But for those who put off screening, don’t have access to a facility that can perform colonoscopy or can’t afford payment, this test may increase early diagnosis and “rule in” those individuals who absolutely need referrals for colonoscopy and biopsy.

The test requires a special collection kit which has to be ordered by your physician. It can’t be purchased over-the-counter. Once you get it there are directions that are fairly easy to follow as to how to collect (a weird word in this context) the stool sample. The kit has prepaid UPS labels so it can be sent to the laboratory that does the testing. The results will then go to your physician.

Or you can do the colon cleanse and bypass this…it is worth a discussion.

The incidence of BRCA1 and BRCA2 mutations is higher in the Ashkenazi Jewish population and hence studies on population screening have initially been done in Israel. This week we celebrate the Jewish New Year…and the latest JAMA article on population based screening for these mutations was most timely.

The article published in the September 17 JAMA is based on the 2014 Lasker Award. This award in medical science was presented to Dr. Mary-Clair King to recognize and honor her “for bold and imaginative contributions to medical science and society – exemplified by her discovery of a single gene BRCA1 that causes a… form of hereditary breast cancer…” The article both describes the application of this discovery and suggests that population-based screening of women for BRCA1 and BRCA2 should become a routine part of clinical practice.

Just to remind you: BRCA1 mutation carriers have a combined risk of developing either breast or ovarian cancer of 60% by age 60 and 83% by age 80. For BRCA2 mutation carriers, risk is 33% by age 60 and 76% by age 80.

A recent study in Israel recruited more than 8000 healthy Ashkenazi Jewish men. The men were tested as a gateway to families for breast and ovarian cancer. (The men were unaffected by breast-cancer themselves but if they were positive, it would enable researchers to identify female mutation carriers, not based on their personal or family history of cancer.) 175 men were identified as carriers of the mutation and genetic testing was offered to all of their female relatives. Surprisingly, 50% of families found to harbor BRCA1 or BRCA2 mutation had no history of breast or or ovarian cancer that would have triggered clinical attention. However, female mutation carriers from these theoretically low-cancer- incidence families had similar cancer risks to female carriers from families with high cancer incidence. Low-cancer-incidence families were simply smaller with fewer females and hence were less likely to exhibit a significant breast or ovarian cancer history.

The authors of the article point out that without population-wide screening, women with BRCA1 or BRCA2 mutation from such families would not have been identified until they developed cancer; a failure of cancer prevention. This study has significant implications for preventive care in Israel which has a large population of Ashkenazi Jews. But in another study, it was found that only 35% of families with high incidence of breast or ovarian cancer had even previously been referred for genetic counseling, despite common knowledge of the increased risk due to BRCA1 and BRCA2 in the Ashkenazi Jewish population and the availability in that country of free testing and counseling.

In the United States, the number of carriers of mutations in the BRCA1 and BRCA2 genes is estimated to be between 1 in 300 and 500 women or between 250,000 and 450,000 adult women for whom breast and ovarian cancer is both highly likely and potentially preventable. Wide scale population genetic counseling and screening should go on our medical wish list. But at present, the US Preventive Services Task Force (USPSTF) supports BRCA1 and BRCA2 testing based on family history and ancestry, but not for the entire female population. Unfortunately only 19% of US primary care physicians accurately assess family history for BRCA1/BRCA2 testing. This is clearly unacceptable.

The author states at the end of the article that “population wide screening will require significant efforts to educate the public and to develop new counseling strategies, but this investment will both save women’s lives and provide a model for other public health programs in genomic medicine…. Women should have the choice to learn if they carry an actionable mutation in BRCA1 or BRCA2.” We have much to learn and do…

The media has been recently focused on this (at least when not reporting on ISIS). It’s likely that many of you have heard about the report that came out comparing mortality rates for three types of surgery for breast cancer: bilateral mastectomy (both breasts), unilateral mastectomy (single) or lumpectomy with radiation. The article that the media has been quoting was published in the September 3 issue of JAMA.

The reported study included 189,734 California women who were diagnosed with breast cancer in stages 0 to 3 between January 1998 and December 2011. The researchers reviewed the types of treatments they received, their follow up and the death certificates of those who died during the follow up. They excluded those women who were diagnosed after 2010 because of incomplete mortality data. If appropriate records were not available they also eliminated some of the patients, so basically, the final analysis included 174, 917 women whose medium follow up time was 89.9 months. (I am not sure you wanted all these numbers but I thought I would try to be as exact as possible,at least at the beginning of this website article.)

What they found was that the rate of bilateral mastectomy increased from 2% in 1998 to 12.3% in 2011 and this represented an annual increase of 14.3%. Women younger than 40 were most likely to have an increased rate of bilateral mastectomy which went from 3.6% in 1998 to 33% in 2011. This procedure was more often used by non-Hispanic white women, those with private insurance and those who received care at a National Cancer Institute (NCI) designated cancer center (8.6% among NCI cancer center patients versus 6% among non-NCI cancer patients). Unilateral mastectomy (obviously on the side diagnosed with breast cancer) was more often used by racial/ethnic minorities and those with public/Medicaid insurance (up to 52%). Breast conserving surgery with radiation was done in about 55% of all patients but again varied according to age, insurance and tumor size.

The important conclusions of the study was that compared with breast conserving surgery (lumpectomy) with radiation that had an overall ten-year mortality of 16.8%, unilateral mastectomy was associated with a higher all-cause mortality and a ten-year mortality rate of 20.1%. There was no significant mortality difference between lumpectomy and radiation and bilateral mastectomy (in which the ten-year mortality rate was 18.8%).

I know these mortality rates seem high. But there was a huge variability in cancer stage between zero and stage III, so the rates included the higher stage cancers. The study was not randomized and treatment was dependent on a lot of other factors including size of the tumor, tumor features that suggested a poor prognosis as well as lymph node metastases, receptor status and genetic changes which could worsen the prognosis. And as new reconstruction procedures were developed (which look better and allow symmetry), it was likely that some women would choose to have bilateral rather than unilateral mastectomy. Finally, younger women who have a longer period of time for risk of recurrent or new cancer or have a higher probability of carrying genetic mutations were more likely to chose to have surgery on both breasts.

The conclusion of the authors was that although the use of bilateral mastectomy increased throughout California through 2011, overall it was not associated with lower mortality than that achieved with breast conservativeness surgery and radiation. Unilateral mastectomy was actually associated with higher mortality than the other two surgical options.

I want to add my own take on this… it is an important study, but the fact that so many stages of breast cancer were lumped together and prognostic features were varied, there are significant drawbacks. Today with MRI, genetic tumor analysis and profiling, the prognosis of a woman’s breast cancer is more defined, allowing therapy to be targeted and of course improved. When deciding on the course of surgery, considerations of family history, ability to follow up with therapy and surveillance as well as complications of radiation and/or extensive surgery warrant careful consideration. Insurance status is an issue and is unfortunate; hopefully in the future no woman will be denied appropriate care. Every woman who has a diagnosis of breast cancer should carefully consider all choices of therapy with her physicians. Taking a few weeks to consider these will not make a difference in the outcome. This study should be part of the discussion.

There is a precancerous condition that can lead to esophageal cancer called Barrett’s esophagus. When we complain of the heartburn symptoms that can be due to GERD (gastroesophageal reflux disease) most physicians (and those ubiquitous TV ads) suggest an antacid or a PPI (protein pump inhibitor such as Nexium and Prevacid). There is a concern however, that if reflux symptoms continue, long term use of the PPI’s or antacid may cause us to ignore the warning sign that Barrett’s esophagitis or even esophageal cancer has developed. (Note PPI’s have patient instructions that they should be used for just 14 days and if longer use is needed a physician should be consulted.) Over the last few weeks my reflux has returned and indeed I started a PPI… so my interest was piqued when I read the review article in the New England Journal of Medicine on Barrett’s esophagus. Here are some of the highlights:

It is estimated that 5.6% of adults in the United States have Barrett’s esophagus. This is a condition in which the cells lining the esophagus undergo injury or metaplasia due to damage from reflux of gastric acid produced in the stomach. The metaplastic cells are then more likely than normal cells to undergo malignant changes. This can result in development of esophageal adenocarcinoma which is considered a deadly tumor. Unfortunately, the incidence of this cancer has increased seven fold in the US during the past four decades The diagnosis of Barrett’s esophagus requires a biopsy of the abnormal mucosa cells via endoscopy, a procedure done under anesthesia.

There are both risk factors and protective factors for Barrett’s esophagus and esophageal adenoma carcinoma and I thought it would be interesting to list them.

Risk factors include:

  • Older age
  • White race
  • Male sex
  • Chronic heartburn
  • Age under 30 at onset of GERD symptoms
  • Hiatal hernia
  • Obesity with abdominal fat distribution
  • Metabolic syndrome (obesity, hypertension, prediabetes, high triglycerides etc.)
  • Smoking
  • Family history of GERD, Barrett’s esophagus or esophageal adenocarcinoma
  • Obstructive sleep apnea
  • Low birth weight
  • Consumption of red meat or processed meat
  • HPV infection
  • Protective factors:
  • Use of statins
  • H. pylori infection
  • A diet high in fruits and vegetables
  • Breast feeding (for the mother)
  • Tall height

So look at this list and calculate if you are at risk. If you have ongoing GERD symptoms and especially if you also have significant risk factors, you should consider an endoscopy. There are new therapies for Barrett’s in which the abnormal cells are ablated or destroyed. This has been shown to diminish the risk of esophageal cancer. So talk to your doctor or ask for a referral to a gastroenterologist. Barrett’s is not an esophageal friendly disease.

And if my symptoms don’t go away in the near future I may have to do this… Just so you know, I do follow most of the medical advice I give. I had an endoscopy a number of years ago; thank goodness it was clear.

I have devoted several website articles about the importance of HPV vaccination to help prevent cervical cancer in women and genital and anal cancer in men. I now have another reason to promote this vaccine. It comes from news from the Centers for Disease Control and Prevention reported in last week’s JAMA. The journal summarized an article that was published in the Journal of Infectious Diseases on the correlation between HPV infection and oral and or throat cancers. (Note, there’s a medical journal on everything, I don’t get a chance to read most of them and depend on JAMA or the New England Journal of Medicine to bring important articles to my attention.)

A recent analysis showed that 72% of 557 invasive oral pharyngeal squamous cell carcinoma samples tested positive for human papilloma virus (HPV). In nearly 2/3 of the samples, the investigators detected HPV-16 and HPV-18, the strains most often linked with cervical cancer. The HPV vaccines that are currently available actually target HPV-16 and -18 and therefore should be highly effective against this type of cancer.

The current estimates indicate that worldwide there are about 85,000 cases of oropharyngeal cancers that are diagnosed annually and in the United States about 12,000 new diagnosis are made each year. Most are classified as this type of squamous cell carcinoma. Wouldn’t it be amazing if we could immunize all adolescents and young adults and prevent these often fatal cancers! One more reason to make sure that the vaccine is given.

I know most of you may not be reading this email on Friday because it’s the Fourth of July. I’ll try to send it out earlier or you might pick it up after the holiday. So Happy 4th and enjoy the barbecue, parades and fireworks.

I couldn’t let the week go by without reporting on an article in the June 25 issue of JAMA that reports on a study of breast cancer screening using a method called tomosynthesis. The efficacy of tomosynthesis combined with digital mammogram was compared to digital mammogram only for breast cancer screening. A debate about the utility of digital mammogram has once more been brought up by the recent publication of the 25 year follow-up results from the Canadian National Breast Screening Study. It showed that there was no difference in breast cancer-related mortality in screened women versus controls. Many physicians and organizations have however, countered that these results were not valid for current U.S.policy; that the study was based on mammograms that were of poor image quality and that there were significant problems in randomization. Indeed, 14 more recent studies published between 2001 and 2010 have indeed shown a 25 to 50% reduction in breast cancer related mortality for women aged 42 to 74 years who had modern (and presumably better) types of digital mammogram screening. The American Cancer Society, the American Congress of Obstetricians and Gynecologists and other organizations still recommend screening mammography annually for women older than 40 years. The American Cancer Society also recommends annual MRI for women with a 20 to 25% or higher lifetime risk of breast cancer.

The article in JAMA is a retrospective analysis of screening in 13 centers over two time periods. During the initial period more than 281,000 examinations were done with digital mammogram alone. The second period included more than 173,000 examinations during which patients underwent combined digital mammogram and tomosynthesis screening. I know the word “tomosynthesis” sounds very synthetic biology. It is high tech but but not a biological creation. Basically, it is composed of a set of low-dose images produced by x-rays as they moves across the breast. The images are then put together to form a picture by a computer algorithm (of course) that reconstructs the images as slices of the breast. The advantage is in the resolution and clarity of the final image. An area may look suspicious because tissue overlaps from the pressure of a simple mammogram procedure; tomosynthesis is meant to prevent this effect and hence reduce false densities while making a cancer appear more conspicuous.

So does adding tomosynthesis to usual breast screening make a clinical difference? In this study the authors found that the introduction of tomosynthesis was associated with a significant decrease in recall rate (i.e the. need to get additional films, ultrasound, MRI or even biopsy) of 1.6%. There was however, a significant increase in the biopsy rate (1.3%), but perhaps the biopsies were more likely to confirm a cancer. There was an increase in the cancer detection rate of 0.12%. The latter doesn’t sound like much, but it made a difference for the 1.2 women whose cancer was found per 1000 screenings… They might not have had that early diagnosis with standard mammograms. There is however, as always, a drawback in medical innovation and the one here is that tomosynthesis requires twice as much radiation as a regular digital mammogram. And it is too early to know if adding this procedure will impact mortality rates from breast cancer.

In an editorial in the same journal the authors state that “Recent work has suggested that tomosynthesis is likely to outperform mammogram in finding small invasive cancers and lobular cancers, the ones that are most likely to be lethal.”

This and other studies raise some major questions for both physicians and women. Should we seek screening with tomosynthesis over digital mammogram? Should breast cancer screening centers convert to tomosynthesis and abandoned digital mammography? (Which will be costly.) Right now there doesn’t seem to be enough data or financial incentive to do so. But, tomosynthesis may indeed be an advance over digital mammogram for breast cancer screening and one day may become the norm in breast screening. As usual, I’ll end with the off-stated refrain…More studies are needed.

Oy! (Probably not the best word to start my website this week, but I couldn’t come up with a different one.) Right after I wrote about the recommendations for women who were found to have dense breasts during their screening mammogram, I, and everyone in the media, read the article published in last week’s JAMA titled ” A Systemic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions”.

The authors, who are on the faculties of Brigham and Women’s Hospital and Harvard Medical School, reviewed articles that were published between 1960 and 2014. They searched for information on the benefits of mammogram, harms of mammogram and modes of individualized mammography screening decisions including communication of risks and benefits. The article is long and the citations many, but basically, the conclusion is that there was an overall 15 to 20% decrease in the relative risk of breast cancer-specific mortality as a result of mammography screening. Broken down by age groups, mammography screening was associated with a 15% decrease in breast cancer mortality for women in their 40s and 32% for women in their 60s.

So that’s the good news. The bad news is (according to the article) that the risk of a false positive diagnosis was high… For a 40- or 50- year old woman undergoing 10 years of annual mammograms, the risk of false positive results over that period of time was about 61% and for women aged 66 to 74 who had annual mammograms over 10 years, the false-positive rate was 49.7%. (A false positive result raises suspicion for breast cancer and leads to further testing, additional imaging and/or biopsy but does not result in a cancer diagnosis.) The authors also considered the statistics from published trials on overdiagnosis. (I know this term is difficult to understand when we are discussing breast cancer but basically it means that the type of tumor that was detected, such as DCIS, will not eventually lead to invasive or life-threatening disease and/or the patient will die of something else and not from her breast tumor.)

In order to better convey the context of these statistics, the authors discuss lifetime risk of breast cancer as well as risk at any age. For a woman in United States, the average lifetime risk of breast cancer is 12.3%. However, the 10 year risk of invasive breast cancer at age 40 is “only” 1.5%, at age 50, it’s 2.2% and at age 60 it is 3.5%. (These numbers may somewhat decrease the concerns for many of us who worry about our breast health risk in the decade to come.) The high 12.3% number represents a risk over an entire lifetime… well into our late 80s or even early 90s.

So how do we look at risk-benefit when it comes to screening mammogram? If dollar cost is the issue, it accounts for almost $8 billion in annual health care expenditures in United States. But for those women whose lives have been saved or who had to undergo lesser procedures in order to treat their breast cancer, national cost is probably not an issue. Therapies have improved and most women diagnosed with breast cancer do not die from the disease, even if their tumors were detected without mammography. However, as pointed out in an editorial in the same JAMA issue “many women diagnosed with late stage disease who were not screened recently wrongly blame themselves, encouraging others not to make the same “mistake”. Others attribute their survival to screening mammogram received even when this is unlikely to be the case.”I hope this doesn’t sound too cavalier. These were statements in the articles and I, like many women and physicians, feel that any deaths from breast cancer are tragic.

So how do you decide if and how often you should get screened? The authors give a a list of pointers that should be considered by each woman when she considers making her mammogram appointment and by her physicians who suggest she get screened, especially at an early, under 50 age.

* Many cancers will be found, but most women diagnosed with breast cancer will survive regardless of whether the cancer was found by a mammogram.

* Some cancers that are found would have never caused problems.

* Often, women are called back for further testing because of an abnormality that is not cancer.

* Mammography decreases the number of women who will die from breast cancer. This benefit is greater for women who are at higher risk for breast cancer based on older age or other risk factors such as family history.

* The number of women whose lives are saved because of mammography varies by age. For every 10,000 women who get regular mammograms for the next 10 years, the number whose lives will be saved because of the mammograms over each age group is approximately

- 5 of 10,000 women aged 40 to 49 years
- 10 of 10,000 women aged 50 to 59 years
- 42 of 10,000 women age 60 to 69 years

* If your breast cancer risk is higher than average, you may benefit more from a mammogram than someone with average risk.

* About half or more of women who have a mammogram yearly for 10 years will have a false positive mammogram and need additional studies. Up to 20% of these women will need a biopsy.

* In some women the mammogram will find an invasive cancer or noninvasive conditions such as DCIS that would never have caused problems. We cannot tell which these are so they will be treated just like other cancers. There is about a 19% chance that the cancer is overdiagnosed and treatment may be unnecessary.

I know this all sounds complicated and makes decisions about screening more difficult. But in the end it really has to do with your values and your personal philosophies regarding healthcare. Do you prefer to do more to insure that a diagnosis of this malignancy be made or do you think less is more and want minimize the risk of a false positive result that could cause anxiety, procedures and cost? I prefer the former but realize that many women don’t.

Firm is good, dense may not be… I’ve written articles on the current California law that requires imaging centers to send you a letter if, at time of mammogram, it’s noted that your breasts are dense. And as I expected, I’ve received quite a few phone calls with queries as to what sort of follow up “dense” mandates. The official committee opinion from the American College of Obstetricians and Gynecologists on this subject was published in April 2014 in (you guessed it) the Journal of Obstetrics and Gynecology.

Perky, firm and dense (breasts) are not always synonymous. Dense breast tissue is usually found in younger women. When we are (were) young, our breasts lack abundant fat separating the glands. And some of us stay that way breast-wise… Dense glands in breast tissue absorb more radiation during mammography than fat and look radiographically white whereas fatty tissue allows the radiation to pass through and appears more translucent in the image. A small tumor or calcification that could be the hallmark of a very early cancer or DCIS will also appear white on mammogram. White on white does not allow for good differentiation. And to somewhat complicate the matter it turns out that women with dense breasts i.e. glands that are close together with less surrounding fat, have a modestly increased risk of breast cancer in addition to a reduced sensitivity of mammography to detect cancer.

Just so you know how we categorize breast density by mammogram, the percent of the women within each category and what that means, here is a chart:

DENSITY

PERCENT

MAMMOGRAM
SENSITIVITY

RELATIVE RISK CANCER
(compared to average density)

Almost entirely fat:

10 %

88%

-

Scattered densities:

43%

82%

-

Heterogeneously dense

39%

69%

Relative risk 1.2

Extremely dense

8%

62%

Relative risk 1.4

Once the imaging center lets you know that your mammogram demonstrated that your breasts are dense, their letter then states that this increased density limits their ability to diagnose cancer (which also covers their tuches) and they usually go on to suggest that you discuss this with your physician. In turn, we then may recommend that you get additional ultrasound tests and perhaps even an MRI to address your newly induced concerns. Offering these exams also diminishes potential physician neglect and culpability and, of course, also gives reassurance that a diagnosis of early breast cancer is not missed.

I wish I could leave it at that, but the committee opinion does not agree with this line of action. They negate the need for these extra tests stating they are not appropriate in women with dense breasts who do not have additional risk factors. They state that “current published evidence does not demonstrate meaningful outcome benefits (eg, reduction in breast cancer mortality) with supplemental test (eg, ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (eg, breast tomosynthesis or thermography).” They go on to say “evidence is lacking to advocate for additional testing until there are clinically validated data that indicates improved screening outcomes.”

But before we all feel frustrated, please note that the committee did bless mammogram, especially digital mammogram as the best diagnostic screening tool that has consistently demonstrated a reduction in breast cancer mortality. The College does not, however, recommend routine use of alternative or adjunctive test to screening mammogram in women with dense breasts who have no symptoms and no additional risk factors.

I still urge you to call your physician if you get that “density” letter. We can then discuss your risk factors such as family history, previous biopsies, excessive alcohol consumption, obesity, even hormone therapy and try to figure out how to best to assess and reassure you.

It’s been 50 years since the 1964 Surgeon General’s report that stated that smoking was harmful to our health. The Smoking and Health Report (what it was formally called) was based on a review of an estimated 7000 documents. It concluded that “cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking outweighs all the factors; and the risk of developing lung cancer increases with the duration of smoking and number of cigarettes smoked per day, and diminishes by discontinuing smoking.” Just so we women don’t feel left out, subsequent studies and reports stated that it was just as harmful and perhaps even more addictive for women, but I digress…

The January 8 issue of JAMA was dedicated to the last 50 years of tobacco control. In an editorial, some fascinating statistics were presented that I would like to share:

Half a century after the release of the 1964 report, tobacco dependency continues to devastate US society. Nearly 42 million smokers still struggle with this addiction. Unfortunately, even though 70% want to quit only 3 to 5% annually can do so on their own. New estimates of annual tobacco related deaths now approaches half a million in the United States and more than 5 million worldwide. Children and adolescents are especially affected by tobacco dependency through secondary smoke an onset of smoking. Other vulnerable populations include the poor, those with mental illness or substance-abuse disorders, lesbian, gay, bisexual and transgender population as well as the homeless and those who are incarcerated. The tobacco industry spends more than $8 billion a year in the United States to advertise and market cigarettes and smokeless tobacco, while also promoting cigars, pipe-tobacco and newer products which include dissolvable tablets and electronic cigarettes.

But before you grasp your head and begin to shake it and moan oy! there are some encouraging statistics. Although there have been 17.6 million smoking attributable deaths in the last 50 years, it’s estimated that 8 million premature deaths have been prevented because of tobacco control measures. It’s estimated that one-third of the gains in life expectancy for men (30%) and 29% of the gains for women during these past 50 years were due to declines in smoking. Moreover six nations, including the United States, have had reductions in smoking prevalence of greater than 50% during the past 25 years.

Another article in JAMA points out the factors that have helped smoking cessation in the U.S. Firstly, documentation of the danger of environmental tobacco smoke which has led to a flurry of clean indoor air legislation. Currently, 26 states and the District of Columbia ban smoking in enclosed public spaces. Secondly, the 1988 Surgeon General’s report documenting tobacco use as an addiction changed public perception of tobacco use from habit to “of free choice” to true drug dependency similar to that of heroin and cocaine.Thirdly, cigarette tax increases, clean indoor air laws and efforts to prevent adolescents from purchasing tobacco or starting to smoke have proved effective. Fourthly, there has been some very public litigation by private individuals, the States and the US Department of Justice against the tobacco industry. Indeed, there was a settlement in 1998 mandating that the tobacco industry pay the States $246 billion over 25 years. (The tobacco companies are bad… to add to their list if immoral and death producing offenses, in 2006 they were found guilty of racketeering.) But let’s get back to “the making a difference” factors… There are current evidence-based smoking cessation treatments – both counseling and FDA approved medications – that can markedly increase cessation rates among smokers trying to quit. And these will now be paid for by the Affordable Care Act

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