breast cancer screening – watercress words by Dr Aletha

This post has been updated June 11, 2021

Both doctors and patients have mixed emotions about diagnostic tests done to screen for disease. We physicians want to help patients stay healthy, prevent disease, and treat problems early and effectively.But the time spent counselling, ordering, performing, and reviewing these tests means less time available to manage patients’existing medical problems.

I agree with Dr. William Zinn, family physician in Boston, who wrote

“Keeping track of the ever-increasing health maintenance requirements and cancer screening sometimes make it hard to remember why the patient came to the office in the first place.”
JAMA, January 7, 2020

For patients the issues are similar. While they want to stay healthy, prevent disease, and get treated promptly, they don’t like the inconvenience, time away from work, cost, and sometimes discomfort the tests require.

What are screening tests?

A screening medical test is done to uncover a disease or disorder in a person who may or may not be a risk for it and who otherwise feels well and has a normal exam. Suppose we are considering screening a group of people for disease X. Let’s start by dividing them into 3 groups.

Those with no symptoms, feel fine, at average risk of health condition X.
Those with no symptoms, feel fine, at increased or high risk of condition X.
Those who have symptoms suggestive of condition X, or have had other testing that suggests they might have it

Screening for X in groups 1 and 2 might be appropriate, based on medical guidelines, physician judgement, and patient preference. For group 3, with symptoms of condition X, testing would be considered diagnostic; a doctor would test for X, and possibly other conditions that the symptoms suggest.

Diagnostic vs Screening

That might seem like a picky difference, but there are several implications for both doctors and patients.

Documentation- The medical record needs to reflect accurately why a test is being ordered and done. This is necessary for billing because inaccurate coding can make doctors and clinics liable for fraud. Also, the government and other payers are starting to judge doctors’ quality of care based on medical record audits of care given or not given, and why.

Interpretation and Follow up-A test is rarely interpreted in isolation. The history and exam together with the test lead to a diagnosis.

Reimbursement– Most if not all insurances, including Medicare, reimburse differently based on whether a test is diagnostic or screening. And this usually determines how much the patient pays for each. Screening tests are usually covered 100% while diagnostic testing may require a deductible or copay .

A Country Doctor Writes blog explains this dilemma in detail –

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.
read more at this link

This link at FamilyDoctor.org helps explain

Health Insurance: Understanding What It Covers

Cervical cancer screening frequency also now takes into account a woman’s HPV, human papilloma virus, status. Go here to learn

When should a woman begin cervical cancer screening, and how often should she be screened?

a microscope image of a cell infected with HPV

A koilocyte is a squamous epithelial cell that has undergone structural changes as a result of infection by human papillomavirus (HPV). This image of a koilocyte shows human ectocervical cells (HEC) expressing HPV-16 E5 oncoprotein, and immortalized with HPV-16 E6 and E7 oncoproteins. Formation of koilocytes requires cooperation between HPV E5 and E6 oncoproteins. The cell culture is stained with hematoxylin and eosin (H&E).National Cancer Institute \ Georgetown Lombardi Comprehensive Cancer Center, Ewa Krawczyk, public domain

Does disease screening make a difference?

Screening tests don’t prevent disease although they may be helpful for health maintenance or improvement. They may prevent progression or complications of a disease, but don’t prevent it’s onset. They may not even prevent death from the disease, although we like to believe they do. Screening may diagnose the disease before symptoms develop, so the patient lives longer with the disease, but not affect the eventual outcome.

Doctors can now offer patients another option that is more accurate than the stool blood test and less invasive than colonoscopy.

Stool DNA testing looks for certain DNA or gene changes in cells that can get into the stool from polyps (pre-cancerous growths) or cancer cells. It may also check for blood in the stool. For this test, people use a take-home kit to collect a stool sample and mail it to a lab. Cologuard^® is the name of the stool DNA test that is currently FDA-approved. This stool test needs to be done every 3 years.

So when should we offer screening tests?

If there is a clear benefit to patients from an effective treatment available to make a difference in the disease course or

If knowledge of the condition helps the patient and family make choices about managing the condition’s likely course or the need for family members to be screened

If the test is reliable enough to identify most people with the disease without falsely identifying people who don’t have it. The scientific terms for this are sensitivity and specificity.

When the benefits clearly outweigh the risks and costs.

a mammogram image — a mammogram revealing a breast cancer image source- National Library of Medicine, Open-i

How to decide for yourself

These are just some of the factors involved in deciding when to undergo screening tests. To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals. Then the doctor can make recommendations based on your needs and desires with the help of expert guidelines published by medical organizations who carefully review the medical literature.

Review the graphics in this post for recent guidelines from professional organizations and discuss with your physician. Help your doctor help you by scheduling a health maintenance visit rather than bringing it up when you are there sick or for chronic care. These discussions deserve your physician’s full attention.

further information from the National Institutes of Health.

To Screen or Not to Screen

¿Hacer o no hacer pruebas de detección?

exploring the HEART of health maintenance

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During Breast Cancer Awareness Month I want to remind you of physician recommendations for screening. Currently, the only test recommended for screening is mammography.

a woman having a mammogram done by a technician — image used courtesy of the Public Health Image Library, CDC

No other test has evidence that its use will decrease breast cancer deaths, although they may be useful for diagnosis in women who have breast symptoms.

These guidelines for screening apply only to women at average risk of breast cancer, which is most women. They do not apply to women who have ever been diagnosed and/or treated for breast cancer, or to women who currently have symptoms related to their breasts, such as a lump, pain, discharge, or skin changes.

Guidelines for screening come chiefly from two organizations- The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF). Other organizations such as the American Academy of Family Physicians (AAFP) , of which I am a member, usually follow their recommendations .

guidelines from the ACS

Offer annual screening to women age 40 to 44 years.
Perform a mammogram annually in women 45 to 54 years.
Perform a mammogram annually or every other year starting at age 55 years.
Continue screen mammography as long as a woman’s overall health is good, with a life expectancy of 10 years or longer.
Routine breast exams by either the patient or a physician are not recommended.

guidelines from the U.S. Preventive Services Task Force (USPSTF)

For ages 40-49 years, individualize the decision to screen every 2 years
For ages 50-74 years, screen every 2 years
For ages 75 years and older there is no recommendation.

Both organizations recommend that physicians discuss the decision to screen or not to screen with patients and base the decision after considering possible harms versus potential benefit.These are guidelines for physicians to apply to each individual patient, not hard and fast rules.

Screening guidelines are not used for high risk women- women with

a history of previous breast cancer or ovarian cancer
a suspected or confirmed genetic mutation , BRCA, known to increase breast cancer risk
a history of radiation to the chest
a close family history of breast history, usually meaning parent, sibling, child, grandparent, aunt/uncle, or first cousin.

Breast cancer in young women can be hereditary. — graphic courtesy of the CDC, U.S. Department of Health and Human Services

Screening guidelines also do not apply to women with breast symptoms suggestive of cancer.

a lump in the breast or axilla (armpit)
pain, especially in only one breast
nipple discharge
persistent rash or skin changes over the breast

These women need appropriate diagnostic testing which might include

mammography,
ultrasound,
MRI,
biopsy.

Here are sources for more information

Breast Cancer

“Both women and men can get breast cancer, though it is much more common in women. Other than skin cancer, breast cancer is the most common cancer among women in the United States.”

Mammography

“You should talk to your doctor about the benefits and drawbacks of mammograms. Together, you can decide when to start and how often to have a mammogram.”

Screening Guidelines

“Mammograms are not perfect tests. They can miss some cancers, and they can find lesions that may look like cancers but are not actually cancers (false-positive results), resulting in additional testing and procedures. They can also find very low-risk cancers that would never have caused any health problems if they were never found or treated (overdiagnosis).”

Breast cancer screening benefits and harms

“Each woman also has different personal values, especially toward the idea of unnecessary medical tests and treatments.

Talk to your doctor if you are younger than 50 years and have questions about whether you should get a mammogram.”