Winning the War on Cancer? U.S. Death Rates Show Broad Decline.

Ars Technica

President Nixon declared war on cancer in 1971 and, since then, the National Cancer Institute (part of the NIH) has funded research on prevention, surveillance, and treatments. But, despite the effort, progress has been elusive, leading to press reports in Newsweek, Fortune, and The New York Times suggesting that, at best, cancer is fighting us to a draw. But a new analysis of death rates, performed by staff at the American Cancer Society, indicates that cancer death rates peaked around 1990, and have been declining broadly since. As a result, they're now below where they started in 1970.

The dynamics in many specific populations are quite distinct. Relative to women, men started out with a higher age-standardized death rate, saw a more rapid increase, peaked a year earlier, and then have seen a far more dramatic decline. Various ethnic groups also had different trajectories, but all have shown declines in recent years. The trends have been more dramatic in younger populations as well.

The changes also vary based on cancer types. "The 2006 death rates for Hodgkin lymphoma in men, cervical cancer in women, and stomach cancer in both men and women were less than one-third of the 1970 rates," the authors conclude. In contrast, liver cancer death rates are increasing, as are pancreatic cancers in women, and melanoma and esophageal cancer in women. But, for 15 of the 19 cancers studied, rates have dropped.

The biggest factor in the change, according to the authors, is prevention: people are smoking less, and we should see continued improvements in this regard due to the decreased rates of smoking in adolescents. Mammograms, the Pap smear, and increased colonoscopy rates all account for drops in their relevant cancers, indicating that detection is also playing a role, while new cancer treatments Indianapolis had impacts in lymphomas, leukemias, and testicular cancer.

There are a couple of take-home messages here. For one, we tend to expect success in the war on cancer to come in terms of treatments, but prevention and early detection are having a far more significant effect. But they take much longer; the oldest generations are missing out on the drop in smoking because the time-lags are so long. Finally, there's some indication that the rise in a few cancers may be tied to increased obesity, however, so there's no guarantee of continued success.

Cancer Survivor, Radiologist Speak Out About New Mammogram Guidelines

mLive

SWARTZ CREEK, Michigan — Three times was the charm for Swartz Creek breast cancer survivor Carla Lazar.

Lazar, 42, has had three mammograms since age 38, each ordered by her primary care physician as a routine part of her preventive health care program.

She’ll never forget the third, done Dec. 22 of 2008 at the age of 41.

It’s the one that saved her life.

It’s also a mammogram she never would’ve had, under controversial new mammography guidelines from the United States Preventive Services Task Force.

The new federal guidelines — which no longer recommend  routine screening for women ages 40-49 unless they are genetically predisposed to breast cancer, and once every two years rather than annually for women ages 50-74 — have caused an uproar within the medical and patient advocacy communities since being released on Nov. 16.

Diagnosed with stage one breast cancer, Lazar underwent lumpectomy surgery to remove the tumor, then three months of chemotherapy followed by seven weeks of radiation.

She credits her medical team and the support of friends and family for her survival — but none of that would’ve been possible without the test that detected the disease, she said.

“My prognosis now is good, God willing. Luckily for me that’s how it played out because I had no symptoms, no risk factors. If my doctor wasn’t diligent in ordering these tests, this might’ve been a very different conversation,” said Lazar.

“If these new guidelines were already in place, I wouldn’t even get my first mammogram until I turn 50. By then, we probably wouldn’t even be having this conversation.”

That’s exactly what has alarmed physicians like radiologist Dr. Linda  Lawrence Murphy, director of imaging for McLaren Regional Medical Center and McLaren Imaging Center.

“We are diagnosing women younger and younger all the time. We’ve gotten so much better at detecting breast cancer at a smaller stage when it is curable. So many are women under age 50. This is a huge step backwards in early detection,” said Lawrence Murphy. “I feel like we are going back to the dark ages in women’s health care.”

Supporters of the Task Force report have said the findings simply indicate not enough lives of younger women are being saved to justify the expense, stress and risk of unnecessary mammography.

Lazar finds that notion disturbing.

“I don’t know if this is about insurance companies not wanting to pay for all these tests but if they save one life, it’s worth it. It’s my life. It may be your own,” said Lazar. “I can understand not putting women through biopsies and additional testing that end up not being anything, but what if it was  something like in my case? I’m so grateful we have a system in place now that is ready to treat this right at the offset.”

Lazar was also bothered that the report advised against teaching women to do breast self-exams.

“I can’t imagine how it could hurt to be proactive with our own bodies. It’s got to be a good thing anytime a woman is in tune with her own body enough to recognize a change,” said Lazar.

Lawrence Murphy said the study had a very big, basic flaw: it was based on results from an older style of film screen mammography that is rapidly being replaced by more accurate digital screening.

“Probably close to 80 percent of women are getting digitals now, which is far superior in detecting cancer in women under age 50, those with dense breasts and those who are peri-menopausal,” said Lawrence Murphy.

Lawrence Murphy said the report distorted the reality of unnecessary biopsies too.

“It’s true mammograms aren’t perfect and we do some biospies that are benign. But these are not major surgeries in the hospital. Most are done using a simple needle under local anestheisa. The patient has a bandaid when she leaves,” said Lawrence Murphy.

Meanwhile, groups like the American Cancer Society, Black Women’s Health Imperative and American Society of Breast Surgeons continue to line up in opposition to the guidelines, which some fear could eventually eliminate mammography coverage as a prevention service and negatively impact Michigan women's health.

“Nobody involved with this report is looking at what we are saving on the other end by curing these women earlier, before it requires more expensive surgery and could’ve spread to other organs,” said Lawrence Murphy. “It’s like telling someone don’t look both ways before you cross the street because it causes anxiety and hasn’t been shown to save lives. It’s just ridiculous.”

Breast-Screening Advice Upended

Wall Street Journal

For years, women have been taught to perform regular breast self-exams and those 40 and older told to undergo annual mammograms to detect breast cancer, a disease that kills about 40,000 people in the U.S. every year. Now, new guidelines released by an influential government-funded authority on screening offer this message: never mind.

The new U.S. Preventive Services Task Force guidelines, published Monday in the Annals of Internal Medicine, state that routine mammograms aren't necessary for women of average cancer risk in their 40s, and that women between 50 and 74 years old don't need to undergo mammograms more often than every other year. They also recommend that physicians abstain from teaching women how to examine their breasts for signs of cancer because of a lack of evidence that it is of any benefit.

The guidelines were based on a routine review of research published since the last set of recommendations and a new analysis of data. The guidelines were formed by weighing benefits of screening compared with the harms of false positives, such as anxiety and unnecessary additional tests and biopsies, which are expensive and time-consuming, according to Diana Petitti, vice-chairman of the task force.

The task-force recommendations only apply to women without a family risk of breast cancer and who don't have genetic mutations known to be associated with breast cancer, such as the presence of BRCA1 or BRCA2 genes.

By scrubbing the previous recommendation of annual mammograms for women 40 and older, the new guidelines are likely to be controversial and confusing. They also raise concerns that health insurers will curtail coverage and reimbursements for screenings that fall outside the guidelines, according to doctors and groups including the American Cancer Society.

Phil Evans, a professor of radiology at the University of Texas Southwestern Medical Center and president of the Society for Breast Imaging, says he was "shocked" by the changes. "There's a ton of scientific data in this country and others on screening that shows a significant benefit for women between 40 and 49 to be screened," he says.

The National Comprehensive Cancer Network, the American Cancer Society and the American Medical Association recommend annual mammograms for women starting at age 40, while the American College of Physicians recommends women in their 40s decide for themselves whether to seek annual exams.

USPSTF Breast Cancer Screening Guidelines: Then and Now

Mammography

2002: Recommended every 1 to 2 years for all women older than 40

2009: Recommends against routine screening for women 40 to 49; recommends mammograms every 2 years for women 50 to 74; insufficient evidence to conclude benefit or harm of mammograms for women 75 and older

Breast Self-Examination

2002: Insufficient evidence to conclude benefit or harm

2009: Recommends against teaching BSE

Digital and MRI Mammography

2002: Not addressed in guidelines

2009: Insufficient evidence to conclude benefit or harm 

Source: U.S. Preventive Services Task Force guidelines published in 2002 and 2009

The task force, which receives funding from the federal Agency for Healthcare Research and Quality but is independent from the government, last issued guidelines for breast cancer in 2002. "The task force isn't saying there isn't a benefit" to screening women in their 40s, but "we're saying the benefit is small," Dr. Petitti said. "The change really is a change between do it routinely and don't do it routinely." Women 40 and older who are free of any symptoms should talk with their doctors and decide with them whether to put off screening for a few years, she said.

Dr. Petitti's advice is less nuanced about the issue of breast self-examinations. "Women should know it doesn't work," she said. Two large studies published since the last guidelines, involving 200,000 women in China and more than 100,000 in Russia, showed no benefits from breast self-examinations, she said.

There is agreement among scientists that mammography saves lives but that it also gives rise to numerous false positives. It reduces cancer death by about 15% in women ages 39 to 59, according to the task force's review of published data.

There are fewer cases of cancer in younger women, which means there are fewer absolute benefits when weighed against risks for women in their 40s. For each case of cancer death prevented among younger women, 1,900 women must be screened, according to the task force's review of published data. That ratio drops to 1 for 1,300 for women 50 to 59 years old, and 1 for 377 for women 60 to 69 years old, according to the task force.

The task force's interpretation of the data overstates the downsides of mammography for women in their 40s and doesn't take into account the fact that saving a younger woman leads to more "life years saved" than for older women, Dr. Evans says.

About $3.3 billion was spent on mammograms in the last 12 months, according to the American College of Radiology.

Whether the new guidelines lead to changes in insurance reimbursement is likely to be a big concern among health providers and patients.

The Centers for Medicare and Medicaid Services, which administers government health benefits for the elderly and the poor, says the new guidelines wouldn't change how it covers mammograms for Medicare patients. But that may not be the case for private insurance. The task force guidelines tend to influence public and private insurers' coverage decisions, though they aren't the only factor, according to John Ayanian, a professor of medicine and health-care policy at Harvard Medical School who published a paper last year on the impact of cost-sharing on mammogram usage rates in the New England Journal of Medicine.

Susan Pisano, spokeswoman for America's Health Insurance Plan, an industry trade group, says she anticipates mammogram coverage will continue even for those who fall outside the new guidelines' target age range. What may change, she says, are insurers' aggressive outreach efforts to get women to get their screening, such as the reminder postcards they used to receive about getting their annual mammogram.

Eric Winer, chief scientific adviser of Susan G. Komen for the Cure, a breast-cancer advocacy foundation, and director of the Breast Oncology Center at Dana-Farber Cancer Institute in Boston, says that "at a minimum, what we can say is that women and their doctors have a right to make a decision about whether they should be screened. If they don't have financial coverage, then they don't have that right."