Screening for breast cancer seems like a good idea and mammograms are the gold standard for screening. The main risk factors for breast cancer are age and gender which unfortunately, we have little control over. With the incidence of breast cancer being 1 in 8 in a women’s lifetime, why would women not want to screen for cancer before any symptoms appear? Well, screening has some drawbacks, so consider some of the benefits and possible harms.

Lets first look at the benefits:
1. If your mammogram is normal and shows no signs of cancer, then that can be reassuring.
2. Most if not all insurance companies will cover the cost of a mammogram.
3. If the screening test shows signs of pre-cancer or early cancer, treatment may be shorter and simpler and prognosis is much better.

The downside of screening:
1. False positive result: This is when the findings suggest that you could have an early cancer when you really don’t. This can lead to further testing such as more breast images or a biopsy. As you can imagine, this leads to anxiety, inconvenience, discomfort and the expense of extra testing even though you don’t have cancer.
2. False negative result: This is when a mammogram misses a cancer that is actually present. This gives you a false reassurance that everything is OK.
3. Overdiagnosis: This occurs when a cancer is present, but it is one that does not interfere with the length or quality of your life. Not all cancers cause death or illness even though we may think the worst. In fact, some cancers would have never been found during your lifetime if you hadn’t had the screening test. This is known as an “indolent” cancer. Even oncologists cannot tell the difference between an indolent cancer and one that will progress. Therefore the cancer will probably be treated (unnecessarily) with surgery, radiation or medication. On the other hand…if the cancer found is a “real” cancer (one that would grow and perhaps spread), then early diagnosis with a mammogram would allow the patient to avoid more extensive treatment, such as chemotherapy, and it may have prevented her from dying of breast cancer.
The issue of overdiagnosis is confusing for both women and clinicians. So how often does overdiagnosis occur? Unfortunately, it cannot be directly measured because the incidence of cancer varies widely with geographic region and race/ethnicity of the study population and methods of research used.

This issue complicates the decision on whether to have a screening test at all. So what to do? Ask yourself these questions…
1. Is this cancer preventable (or easier to treat successfully) if it’s found by screening?
2. Do I have a higher then average chance of developing this type of cancer? For example, those with a family history of breast or ovarian cancer or those who have a genetic mutation will have a higher risk of developing breast cancer. It makes sense for these women to follow screening recommendations given by their practitioner.
3. Will finding this type of cancer early make a difference in how well treatment works?
4. How do I personally feel about being screened?

Consult with your doctor or practitioner on what they specifically recommend for you.

Reference: Kaunitz, A. Understanding Overdiagnosis as a Consequence of Cancer Screening. NEJM Journal Watch: Women’s Health September 2018 Vol. 23 No. 9; 68-70.

 

Mammograms continue to be the gold standard for breast cancer screening. How often to do these tests for average risk women is debatable depending on the health organization that you follow or discuss with your health practitioner. This site can be helpful https://ww5.komen.org/BreastCancer/BreastCancerScreeningforWomenatAverageRisk.html.

Many facilities also now offer a breast Tomosynthesis test along with your mammogram, which does make the screening more sensitive to finding breast cancer lesions. This 3-D mammogram may find up to 47% more cancers in women with dense breasts according to a Norway study in 2012. But be aware that it delivers twice as much radiation than traditional mammograms and the breast is compressed for about 48 seconds compared with about 20 seconds for a standard exam. Ouch!!

The question many women are asking is if they should get a breast MRI or when that would be indicated. Investigators performed an observational study in which they used > 2 million images from 6 breast cancer surveillance consortium registries to evaluate biopsy and pathology results after screening mammography and compared that with breast MRI. They looked at women with and without personal histories of breast cancer.

Results showed more high-risk benign (non-cancer) lesions involving biopsies with breast MRI than with mammogram regardless of personal history of breast cancer. Overall, biopsy rates were fivefold higher for MRI than mammography.

Recommendations are that women should not undergo routine breast MRI for cancer surveillance unless they meet certain criteria which includes:

1. Strong family history of breast cancer
2. Oncogenic hereditary mutation
3. Extremely dense breasts
4. High-risk lesions such as lobular carcinoma in situ

Of course, discuss recommendations with your practitioner to determine the best screening for you.

Reference: Buist DSM et al. Breast biopsy intensity and findings following breast cancer screening in women with and without a personal history of breast cancer. JAMA Intern Med 2018 Feb 12; [e-pub]. (https://doi.org/10.1001/jamainternmed.2017.8549).

 

Some of you may have seen this report on TV or scanned through it while reading the paper. It is worth discussing because the concerns lie in not just birth control pills but in any device containing synthetic Progestin, which is different than Progesterone (not synthetic).

This Danish study followed 1.8 million women of childbearing age for more than a decade drawing data from national prescription and cancer registries. During that time, over 11,000 cases of breast cancer were found. The researchers concluded that women using hormones experienced a 20% increase risk of developing breast cancer compared to nonusers. In other words, for every 100,000 women using hormonal birth control, there are 68 cases of breast cancer annual, compared to 55 cases a year among nonusers. The risk also increased with age and varied by formulation. Limitations in the hormonal birth control study include the fact that physical activity, breast feeding and alcohol consumption which can influence breast cancer risk were not accounted for.

The link between birth control pills and breast cancer has always been somewhat controversial. But this is the first study that looked at the risks associated with current low dose birth control pills and devices in a large population. These devices include Progestin implants (Nexplanon) and intrauterine devices (IUD) that release Progestin. The research suggests that the hormone Progestin may be raising breast cancer risk. Thats an important thing to remember because the thought has always been that estrogen causes cancer. And this is not the only time that Progestin has been implicated in the risk of breast cancer.

One of the most popular studies that shed some light on this subject was the 2002 Women’s Health Initiative (WHI) Trial. This study evaluated the use of conventional hormone replacement therapy (HRT) in the form of oral conjugated estrogens and oral medroxyprogesterone acetate (MPA). There was quite a shock over the negative outcomes of this study which included increased cardiovascular and cerebrovascular (stroke) disease, breast cancer, and thromboembolic events (blood clots). We finally dug deeper in the research to find some of the causes.

The first potential cause is the oral ingestion of estrogen. When you take estrogen in a pill form it is presented to the liver in a much more direct concentrated way. The liver synthesizes certain proteins such as clotting factors, sex hormone binding globulin and thyroid-binding globulin. What does that mean?? It means oral estrogen, whether it be a birth control pill or oral HRT stresses the liver and produces inflammatory proteins and more clotting factors. Of course this is dependent on the amount of estrogen consumed. Synthetic hormones also produce unfavorable metabolites that have the potential to change DNA that raises breast cancer risk.

The second issue is progestin (synthetic) vs natural progesterone. There are many studies that indicate that medroxyprogesterone acetate is detrimental to cardiovascular function. A popular study known as the Postmenopausal Estrogen/Progestin intervention (PEPI) trial, found that at the end of 3 years, oral estradiol increased HDL (good cholesterol) by 7%, but this increase was reduced when MPA was added. Oral progestins also under go a substantial first-pass effect on gut and liver metabolism. Is it the progestin metabolites themselves that increase the risk of breast cancer or the fact that progestins turn on estrogen receptor expression that allows more estrogens to be shunted down “bad” pathways?

Women who stayed on these hormones for 10 years or more experienced a 38% increase in their risk for developing breast cancer compared to nonusers. In contrast, there was no increase in breast cancer risk for those using hormones for less than 1 year. That being said, these types of birth control methods in general are safe, effective and accessible options for many women. Perhaps women can change to a different form of non-hormonal birth control, such as an IUD without hormones (Paraguard), condoms or a diaphragm.

Talk to your doctor or practitioner about the pros and cons of different types of contraceptives. A hormonal birth control method may be fine for now, but you may want to reassess its use as you get older or if you have been using a hormonal form for more than 10 years.

Birth Control Pills Still Linked to Breast Cancer, Study Finds – The New York Times: “”

 

The Women’s Health Initiative (WHI) study from 2013 seems like a long time ago but it’s impact is still reverberating throughout the health community as well as with women’s  feelings about hormone replacement therapy (HRT). The take-away message at that time was:  ‘hormones are bad;  they cause heart disease, blood clots and breast cancer and even dementia. Go off of them because the consequences and risks are way worse than any benefits they may have’. Well…things have changed since then.

Where do I begin?

First, we need to remember that the average age of women in the study was 63 years. Most women start HRT in their 50’s. The number of women who developed breast cancer was statistically insignificant compared to those that were not on HRT. Second, there was a difference in those women starting hormones that were within 10 years of menopause onset which showed less adverse effects than those who started later. Third, the majority of women whom developed dementia were over the age of 85. Research shows that 1 out of 2 people over the age of 85 develops dementia.

This study was a large NIH-funded placebo-controlled randomized trial and evaluated only those women on oral estrogen (Premarin) or estrogen-progestin (Prempro) pills. That is to say that HRT comes in many shapes and sizes… topical, vaginal, creams, gels, sublingual trouches and patches. These forms were not tested and studies have shown that these forms of hormones are safer and better tolerated than oral.

Investigators of the WHI reported a 13-year cumulative follow-up of mortality in the 27,347 women who participated in the study. They found that prior use of oral hormones when initiated by women aged  <60 or within 10 years of starting menopause did not affect risk for overall, cardiovascular, or cancer mortality. These findings support guidance from the North American Menopause Society and the Endocrine Society which endorse HRT for symptomatic management in recently postmenopausal women without contraindications.

In my practice I reassure my recently menopausal women that initiating HRT can not only help with bothersome symptoms (hot flushes, insomnia, cognitive impairment, low libido, vaginal dryness), but can delay or prevent degenerative diseases such as osteoporosis. I use only bio-identical hormones and prefer to use topical options for women. The important thing is to individualize treatment for each woman.

Reference: Kaunitz, A. Extended Follow-up of Mortality in WHI Participants: Continuing Reassurance About Hormone Therapy. Journal Watch: Women’s Health                         October 2017; p. 80.