Clinical Breast Exam Photo © National Cancer Institute

When the U.S. Preventive Services Task Force (USPSTF) released its new guidelines for breast screening in November, they included some remarks about the value of breast self-exams and clinical breast exams. The USPSTF said that women of any age should not be taught to do breast self-exams, but they did not forbid BSE for women or men. The USPSTF also said that clinical breast exams won't be required before screening mammograms, because CBE appears to add no benefit to the information gained from a mammogram.

Many of you wrote in comments about finding your own lump before the age of 50, which is the new age at which the USPSTF recommends starting screening mammography. You used breast self-exams and mammograms to find these problems, and probably saw a doctor as well, for your clinical exam. Good for you!

With health care reform still being hotly debated in the government, the nightly news, and around the dinner table, I am wondering how much early detection we may lose when we are given a new health care plan. In the last 30 years, several cancer types have been caught sooner, treatments have improved, and survival rates have climbed. Will this all be given away to save money? Or will the voice of the average person - folks like you who have been practicing early detection - be bypassed?

I'd love to hear from you about this. Would you give up doing your breast self-exams? Did having a clinical breast exam help you get a clear diagnosis and treatment (if you needed it) for breast cancer? How do you think the lack of these early screening tools would affect your health?

Film Mammography A.D.A.M.

The new guidelines for breast screening, released on Monday by the U.S. Preventative Services Task Force, have been causing confusion, division, outrage, and much discussion. Health professionals, breast cancer support organizations, breast cancer survivors, and health journalists have been speaking out on the recommendation to move screening mammograms from age 40 to age 50. Emotions have been running high, and the barrage of commentary is generating a fog of confusion and misunderstanding about mammography guidelines in general.

The Task Force based its study on traditional film mammography - but most radiology clinics now use digital mammography. In the report explaining their recommendations, the Task Force rated digital mammograms as having "insufficient data" as to their accuracy. The USPSTF is a fairly conservative organization in how they view data - they may have been using statistics that were not quite current. Now we know that digital mammograms are superior to film mammograms: they are faster, use less radiation, and according to the National Cancer Institute, they are more accurate than film at finding cancer in women less than 50 years old, and women who have dense (not fatty) breast tissue.

Based on current facts like these, many prominent agencies are not changing their breast screening guidelines. The American Cancer Society as well as the National Cancer Institute have issued statements maintaining their current recommendations to begin screening mammography at age 40, doing monthly breast self-exams, and having a physician do a clinical breast exam once a year. Other notable organizations are sticking with the "start at 40" guidelines - the American College of Radiology, the American College of Obstetricians and Gynecologists, and the National Comprehensive Cancer Network stood together citing that the benefits of screening mammography from age 40 and monthly BSEs outweigh the risks. State regulations, which affect insurance coverage, will also affect the age at which women will be covered for their first screening mammogram.

Dr. Susan Love has come out on the side of the U.S. Preventative Services Task Force, saying, "While this is a shift in guidelines, it was long overdue, and now brings us into line with most other countries, many of which have government funded mammography screening programs." Some advocacy groups like Breast Cancer Action and the National Breast Cancer Coalition say that, "fewer mammograms is good news."

The United States is currently haggling over health care reform, and some fear that mammograms will in future be rationed, leaving many without screening when they actually need it. Dr. Gail Lebovic, a breast surgeon with 20 years experience, reminds women that, "Here in the United States, over 50% of the cancers we find are found on a mammogram. They cannot be felt by a woman, they cannot be felt by a doctor. So, without screening mammography, we would not have been able to make the progress that we have been able to make over the last 30 years." The American Society of Breast Disease, for which Dr. Lebovic is president, is concerned that the new USPSTF Guidelines are aimed primarily at cost effectiveness.

Let me have your comments on this controversy. Would you give up screening mammograms before you turn 40? Would you give up monthly breast self-exams?

Start When You Are 50

The standard schedule of starting screening mammograms at age 40 may soon change, and breast cancer prevention strategies would be improved, according to the U.S. Preventative Services Task Force. Women may not begin to have screening mammograms until they are 50, and they may cease doing breast self-exams altogether, if the newest guidelines for breast cancer screening from the USPSTF are widely adopted. In Canada and the United Kingdom, 50 is already the age at which screening mammography is begun. These new guidelines may have an impact on what health insurance providers will pay for.

The U.S. Preventative Services Task Force, a branch of the U.S. Department of Health and Human Services, has updated its recommendations for breast cancer screening.  After using computer simulation models to project the results of different screening strategies, the task force said that they recommend the changes because they want to cut down on the "harms" and risks of testing, which they believe do not outweigh the benefits. They cite too many false positives, unnecessary biopsies, anxiety, or in short, overdiagnosis. Their November 2009 guidelines suggest:

• Women between 40 and 49 years old should not be having routine screening mammograms.  Instead, they say that women should make an informed decision about screening mammography before 50, and weigh their potential risks and benefits with their doctors.
• Women who are 50 to 74 years old should be having a screening mammogram every other year, because the risk for breast cancer increases as you age. 
• Women over 74 years old are not given specific guidelines about routine screening mammography - as their risk of death from heart disease and other ailments is greater than from breast cancer.
• Women of any age should not be taught to do breast self-exams, but BSE is not forbidden.
• Clinical breast exams will not be required before screening mammograms, because CBE appears to add no benefit to the information gained from a mammogram.

In 2002, the USPSTF guidelines for breast cancer screening stated that women 40 and older should have annual mammograms to screen for breast cancer.  The American Cancer Society and the National Cancer Institute have also agreed on screening mammograms for women ages 40 to 70. The The American Cancer Society will maintain their recommendation to start screening mammograms at age 40.

Mammography is not a perfect tool and neither is a breast self-exam. But it seems odd to take away these two tools, which we have been told are important, for women aged 40 - 49. This same battle has been fought before, in the mid-1990s. It was resolved by 1997, when the National Cancer Institute agreed to support mammograms for women in their forties.

In an editorial published in Annals of Internal Medicine, Dr. Karla Kerlikowske says that the focus should shift from screening and early detection to breast cancer prevention interventions.  But for this to be effective, Dr. Kerlikowske says that we need a better risk model, more research on prevention, and standards "for routinely assessing risk factors, calculating breast cancer risk, and reporting risk to women and providers in an easily understandable format." Couldn't we wait, until more research has been done, before we change screening guidelines? Won't women be more at risk for ten years of their lives, if they are not having a mammogram and doing their self-exams?

I'm all in favor of better prevention - but I want it to include lifestyle changes, diet recommendations, exercise programs, and ways to detoxify your environment, as well as better breast imaging technologies and guidelines, and better risk assessment.  Yes, I still want The Cure - but I want to prevent breast cancer even more - so that someday soon, nobody will have to hear the words, "You have breast cancer."

How do you feel about these guidlines changing? Would you give up your monthly BSEs? Leave a comment below and tell me what you think.

Ben Simons, SeaBee, WW2 Photo © Dora Simons

Veterans' Day is being celebrated today, but after the mass shooting at Ft. Hood, and other events going on this week, my thoughts are circling around our veterans and what they may face during military service and after.  My father, Ben Simons, signed up with the SeaBees when he was just days away from his 18th birthday.  The son of hard-working people who grew up in the dustbowl of Oklahoma, Dad was determined to join up and make a difference - and come home to a better life.  He spent almost three years in the South Pacific with the SeaBees, got married to my mother when he returned, and went to college on the G.I. Bill.  He became a civil engineer, and to this day still has a fine eye for lines, dimensions, and well-built roads and bridges.  He seldom speaks of his time in the Navy, but always remembers it in positive terms when he does mention it.  For the record, Dad is my hero.

Many war veterans experience PTSD or Post-Traumatic Stress Syndrome.  Symptoms may include flashbacks, nightmares, upsetting memories, or physical responses to trauma that are similar to the fight or flight reaction.  When a person has PTSD, they may find it hard to talk about it, or might avoid the place or people related to the trauma.  PTSD can make you feel disconnected from other people, or as if death is around every corner.  You may feel jumpy, easily irritable, or be prone to emotional outbursts.  If these symptoms sound familiar to you, it's because breast cancer survivors can also experience PTSD.

After I fired my first oncologist, I could barely stand to drive by that cancer clinic, or even go near the part of town where it was located.  My heart would constrict, I sometimes felt nauseous, I would feel like weeping.  Eventually, as I moved past those feelings, I felt happy when I passed that way.  Mainly, I was happy that I never had to go there again and have the experience of being a widget on a cancer treadmill - a widget that had never fit into their program!  Maybe I had a light case of PTSD, it's hard to say from a distance of seven years.

There are many treatments available to anyone who has PTSD.  Therapy can be tailored to your particular type of trauma, and medication may also help.  I recently read about EMDR - Eye Motion Desensitization and Reprocessing therapy.  It requires a trained therapist to successfully treat PTSD with EMDR.  But one veteran of the war in Iraq calls EMDR a cure for PTSD.  It has helped people recover from abusive childhoods, from catastrophic loss of loved ones, sexual abuse, chemical dependancy, and from the psychological impact of breast cancer diagnosis.  Getting help for PTSD can be part of recovering from treatment for breast cancer.

If you're a veteran of the armed services, I salute you and thank you for your service.  You've put your life at risk for my freedom.  You've made this country a place that people all around the world would love to live in.  And if you are a breast cancer survivor, I also salute you, as a fellow veteran of the war on cancer, no matter where you are in the fight.  Let us fight on, until the world is free for all to live in, and free of cancer.

Have you tried EMDR therapy for trauma?  Let me know how it worked for you.