New breast cancer guidelines: screen later, less often

(CNN) In a move sure to befuddle women -- and anger some breast cancer survivors -- the American Cancer Society has issued new guidelines saying less screening for breast cancer is better than more.

The venerated cancer organization says women should start getting mammograms at 45 instead of 40, and that everyone can skip the routine manual breast checks by doctors.

An exhaustive review of the medical literature shows these measures just aren't very effective, according to the group. "The chance that you're going to find a cancer and save a life is actually very small," said Dr. Otis Brawley, the society's chief medical officer.

Now three key groups -- the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force -- recommend different ages for starting regular mammograms: 40, 45 and 50 respectively.

While mammograms save lives, they can also cause harm, and each group does a different job of balancing the pros and cons.

Earlier testing is not necessarily better

The problem with mammograms is that they have a relatively high false positive rate, which means women sometimes have to undergo painful and time-consuming tests only to find out they never had cancer in the first place.

The chances of false positives are especially high for women under 45, as they have denser breasts and tumors are harder to spot on an image. "If she starts screening at age 40, she increases the risk that she'll need a breast cancer biopsy that turns out with the doctor saying 'You don't have cancer, so sorry we put you through all this,'" Brawley said.

He said he knows women who've had false positives year after year. "False positives are a huge deal," he said. "These women are so frightened and inconvenienced they swear off mammography for the rest of their lives."

Six years ago, the federal government's Preventive Services Task Force caused a furor when it declared that women in their 40s didn't need to get routine mammograms. Younger women whose breast cancers were caught by mammograms angrily responded that they would have been dead if they'd followed that guideline.

They said they'd gladly risk a false positive, with all the inconvenient and sometimes painful followup, for the chance of finding a cancer.

Learning from that experience, the American Cancer Society has sought to soften its message, emphasizing that women in their early 40s should still be able to get mammograms if they want them, as long as they understand the risks.

There's the risk of a false positive, plus the risk that a mammogram could catch a very small breast cancer that will go away on its own, or never progress to the point that it hurts a woman. In other words, a mammogram could catch a tumor that isn't really worth catching.

But since doctors can't reliably discern the harmful from the harmless cancers, they treat them all. This means some women are getting potentially harmful treatments, such as radiation, chemotherapy and surgery, when their tumor would never have caused a problem, Brawley says.

A Canadian study looked at 44,925 women who were screened for breast cancer, and 106 of them fell into this category and were treated for breast cancer "unnecessarily," according to a review in the New England Journal of Medicine.

New guidelines have their critics

While agreeing with the American Cancer Society that mammograms aren't perfect, some advocates for women criticized the group's new guidelines. First, they said the society looked mostly at studies of film mammography, which in the United States has almost been entirely replaced by digital mammography.

Digital mammograms generate clearer images and do a better job of finding cancer and have a lower false positive rate.

"It's like standard versus HD TV," said Dr. Therese Bevers, the chair of the National Comprehensive Cancer Network's guidelines panel for breast cancer screening and diagnosis, and the medical director of the Cancer Prevention Center at the MD Anderson Cancer Center.

Second, critics said the cancer society looked only at whether screening saved a woman's life, and not at whether screening caught a cancer early, so the woman could avoid the most drastic treatments, such as chemotherapy or mastectomy.

"The American Cancer Society made the value judgment that screening is only worth it if improves survival," said Dr. Marisa Weiss, a breast cancer survivor and president of Breastcancer.org. "There's an arrogance to that. Let women decide what's meaningful to them."

Insurance companies also decide

The new guidelines also state that women over age 55 can choose to get a mammogram every other year, since breast cancers in post-menopausal women tend to develop more slowly.

To a great extent it will be insurance companies that decide at what age women get mammograms. In 2009, they typically continued to pay for mammograms starting at age 40 even though the government's task for force recommended mammograms starting at age 50.

But it's not clear what they'll do now that the American Cancer Society has also raised the age for mammograms.

"(Insurance) plans will certainly take these updated recommendations into account when evaluating their coverage policies," Clare Krusing, a spokeswoman for America's Health Insurance Plans, wrote to CNN in an email.

The new guidelines are meant for women at average risk of breast cancer. The society says women with a family history or who carry a gene that predisposes them to breast cancer may need to start screening earlier and more frequently.

As for the recommendation to discontinue routine manual breast exams by doctors, many advocates for women with breast cancer agree there's a lack of good evidence that they save lives, but some said they saw no reason to get rid of them.

"It's a free and added way of knowing whether or not a lump is there," said Leigh Hurst, founder of the Feel Your Boobies Foundation.

In the end, with so many different opinions on preventing breast cancer, experts are worried women will throw up their hands.

"Our biggest concern is that this will create a lot of potential havoc in the day-to-day practice of caring for women," said Dr. Christopher Zahn, the vice president of practice activities for ACOG.

Test Tells Breast Cancer Patients Who Can Safely Skip Chemo

by MARILYNN MARCHIONE, THE ASSOCIATED PRESS

Many women with early-stage breast cancer can skip chemotherapy without hurting their odds of beating the disease — good news from a major study that shows the value of a gene-activity test to gauge each patient's risk.

The test accurately identified a group of women whose cancers are so likely to respond to hormone-blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks. In the study, women who skipped chemo based on the test had less than a 1 percent chance of cancer recurring far away, such as the liver or lungs, within the next five years.

"You can't do better than that," said the study leader, Dr. Joseph Sparano of Montefiore Medical Center in New York.

An independent expert, Dr. Clifford Hudis of New York's Memorial Sloan Kettering Cancer Center, agreed.

"There is really no chance that chemotherapy could make that number better," he said. Using the gene test "lets us focus our chemotherapy more on the higher-risk patients who do benefit" and spare others the ordeal.

The study was sponsored by the National Cancer Institute. Results were published online Monday by the New England Journal of Medicine and discussed at the European Cancer Congress in Vienna.

The study involved the most common type of breast cancer — early stage, without spread to lymph nodes; hormone-positive, meaning the tumor's growth is fueled by estrogen or progesterone; and not the type that the drug Herceptin targets. Each year, more than 100,000 women in the United States alone are diagnosed with this.

The usual treatment is surgery followed by years of a hormone-blocking drug. But many women also are urged to have chemo, to help kill any stray cancer cells that may have spread beyond the breast and could seed a new cancer later. Doctors know that most of these women don't need chemo but there are no great ways to tell who can safely skip it.

A California company, Genomic Health Inc., has sold a test called Oncotype DX since 2004 to help gauge this risk. The test measures the activity of genes that control cell growth, and others that indicate a likely response to hormone therapy treatment.

Past studies have looked at how women classified as low, intermediate or high risk by the test have fared. The new study is the first to assign women treatments based on their scores and track recurrence rates.

Of the 10,253 women in the study, 16 percent were classified as low risk, 67 percent as intermediate and 17 percent as high risk for recurrence by the test. The high-risk group was given chemotherapy and hormone-blocking drugs. Women in the middle group were randomly assigned to get hormone therapy alone or to add chemo. Results on these groups are not yet ready — the study is continuing.

But independent monitors recommended the results on the low-risk group be released, because it was clear that adding chemo would not improve their fate.

After five years, about 99 percent had not relapsed, and 98 percent were alive. About 94 percent were free of any invasive cancer, including new cancers at other sites or in the opposite breast.

"These patients who had low risk scores by Oncotype did extraordinarily well at five years," said Dr. Hope Rugo, a breast cancer specialist at the University of California, San Francisco, with no role in the study. "There is no chance that for these patients, that chemotherapy would have any benefit."

Dr. Karen Beckerman, a New York City obstetrician diagnosed with breast cancer in 2011, said she was advised to have chemo but feared complications. A doctor suggested the gene test and she scored very low for recurrence risk.

"I was convinced that there was no indication for chemotherapy. I was thrilled not to have to have it," and has been fine since then, she said.

Mary Lou Smith, a breast cancer survivor and advocate who helped design the trial for ECOG, the Eastern Cooperative Oncology Group, which ran it, said she thought women "would be thrilled" to skip chemo.

"Patients love the idea of a test" to help reduce uncertainty about treatment, she said. "I've had chemotherapy. It's not pretty."

The test costs $4,175, which Medicare and many insurers cover. Others besides Oncotype DX also are on the market, and Hudis said he hopes the new study will encourage more, to compete on price and accuracy.

"The future is bright" for gene tests to more precisely guide treatment, he said.

Aspirin may cut risk of breast cancer recurrence

By Lara Salahi

Regular use of anti-inflammatory drugs such as aspirin or ibuprofen may lower the risk of breast cancer recurrence in some overweight women, a new study found.

Researchers at the University of Texas took blood from 440 women who were diagnosed with invasive, estrogen receptor alpha-positive breast cancer. Nearly 26 percent of the women were overweight and 58 percent were obese. They re-created cancer cells, fat cells, and immune cells in the lab and injected the blood into these cells. Blood samples that were taken from overweight or obese women caused the cancer cells to grow faster than blood taken from women who were not overweight. Blood from the obese patients contained more fatty acids, which caused inflammation and promoted tumor growth, the study found.

The researchers then looked at the patients’ medical records and divided them between those who regularly took anti-inflammatory drugs like aspirin or ibuprofen — known as NSAIDs — and those who did not. Women with a body mass index greater than 30 who took NSAIDs reduced their rate of recurrence by 50 percent and were disease-free for more than two years longer than women who didn’t take the pills.

The findings suggest that taking NSAIDs could help reduce inflammation in tumor cells, especially among overweight or obese breast patients, the researchers wrote.

BOTTOM LINE: Regular use of anti-inflammatory drugs may lower the risk for breast cancer recurrence among some women.

CAUTIONS: The study cannot determine which overweight women will benefit from taking NSAIDs.

Study Shows Third Gene as Indicator for Breast Cancer

As appeared in the New York Times
By NICHOLAS BAKALAR

Mutations in a gene called PALB2 raise the risk of breast cancer in women by almost as much as mutations in BRCA1 and BRCA2, the infamous genes implicated in most inherited cases of the disease, a team of researchers reported Wednesday.

Previous data had indicated that mutations in PALB2 were linked to breast cancer, and many genetic tests already screen for them. But it had not been clear to what extent these mutations raised a carrier’s odds of developing the disease.

Dr. Marc Tischkowitz, an associate professor of medical genetics at the University of Cambridge, and his colleagues studied 362 members of 154 families with PALB2 mutations. None had BRCA1 or BRCA2 mutations, but all had at least one family member with breast cancer and a mutation in PALB2. There were 311 women with PALB2 mutations, of whom 229 had breast cancer, and 51 men with the mutation, of whom seven had the disease.

The results were published in The New England Journal of Medicine.

Over all, the researchers found, a PALB2 mutation carrier had a 35 percent chance of developing cancer by age 70. By comparison, women with BRCA1 mutations have a 50 percent to 70 percent chance of developing breast cancer by that age, and those with BRCA2 have a 40 percent to 60 percent chance.

The lifetime risk for breast cancer in the general population is about 12 percent.

The breast cancer risk for women younger than 40 with PALB2 mutation was eight to nine times as high as that of the general population. The risk was six to eight times as high among women 40 to 60 with these mutations, and five times as high among women older than 60.

The scientists were not able to explain why younger women with the mutations were at higher risk. And there were too few men, Dr. Tischkowitz said, to make a judgment about their risk.

The data also indicated that women with the PALB2 mutations were slightly more likely to have “triple negative” breast cancer — a form resistant to hormone treatment, more aggressive, and more likely to recur than other subtypes.

Dr. Anees B. Chagpar, the director of the breast center at Yale-New Haven Hospital, who was not involved in the work, said she was impressed with the study but cautioned that other factors must be considered in evaluating a woman’s risk.

“This has to be tailored to the patients, who may have other mutations and varying family risk,” she said. “With no family history, the increase they found is 35 percent. If you have two or more family members with cancer, they found a risk of 58 percent.”

The study used data from 14 sites in eight countries but found no significant geographic variations in its prevalence. The researchers write that larger studies are needed to detect such differences, as well as to assess the role of lifestyle and hormone use on breast cancer risk in PALB2 mutation carriers. Breast cancer risk depends not just on genes, but how they interact with the environment.

Official guidelines do not recommend screening for breast cancer genes in most women, only for those with a family history of the disease. Dr. Tischkowitz said that such women should consider testing for PALB2 mutations if they are negative for BRCA1 and BRCA2 mutations.

Dr. Chagpar said: “As the testing becomes more common, we’ll hopefully end up with studies with thousands of patients in them. We’re going to start getting answers to hard questions.”

Exercise Cuts Breast Cancer Risk For All Women Everywhere

This could be the simplest bit of health advice ever: Exercise reduces women's risk of breast cancer, no matter what kind of exercise they do, how old they are, how much they weigh, or when they get started.

Researchers in France looked at studies that involved more than 4 million women around the world who participated in prospective studies from 1987 to 2013. They found that the more active a woman is, the better her odds of avoiding breast cancer. Women who were most active, with more than an hour a day of vigorous activity, got the most benefits, lowering their cancer risk by 12 percent.

But women weren't as active saw reduced risk, too, notes Mathieu Boniol, research director at the Strathclyde Institute for Global Public Health in Lyon, France. More activity was better, but anything was better than nothing. He presented the data Thursday at the European Breast Cancer Conference in Glasgow.

"This decrease is the same whatever the country, whatever the age, whatever the menopausal status," Boniol told Shots. And it didn't matter if women were active in work, activities of daily living, or sports. "It's very good news."

Scientists don't know why physical activity reduces breast cancer risk. There's been speculation about exercise's effect on hormones and inflammation, but no one knows for sure.

Other studies have found breast cancer risk reductions as high as 25 percent from physical activity, but Boniol says that because of the huge number of women included in this analysis, the 12 percent reduction is more accurate.

Women who were overweight or obese benefited a little less, but still lowered their risk by 10 percent overall.

And women who got moving after menopause also saw benefits from exercise. "It's not something to say, 'Oh, I've never done sports why do that right now?' " Boniol says. "We now have evidence that it could still be beneficial. And it's cheap. It's a very cheap way to do prevention of breast cancer."

What's Your Mammogram Risk?

BY DR. NANCY SNYDERMAN

A review of 50 years of studies of mammograms released Tuesday finds that the benefits have often been overstated and the harms minimized — adding to the confusion about what remains an annual ritual for many American women.

But do the benefits of a mammogram outweigh the risks for you or your family members? That's a very personal question, and not one with an easy answer.

Each patient has different risks that should be discussed with a doctor, but here are answers to some of the questions raised by the latest research.

We're seeing a lot in the news about this. What should I know about this particular study?

The study published Tuesday looks at 50 years' worth of international studies. It reminds us that mammograms are not perfect tests and that the benefits of the screening are often overestimated, while harms are underestimated.

According to the review, mammography screening is associated with a 19 percent overall reduction in deaths from breast cancer. This rate was not the same for all women, however. It reduced deaths by only 15 percent for women in their 40s and about 32 percent for women in their 60s. All of this underscores what we already know: This is not a perfect test and there is no hard and fast rule for mammograms that fits every woman.

What are the risks of mammograms? Isn't it better safe than sorry?

This study finds that for a 40- or 50-year-old woman who gets an annual mammogram, the risk of getting a false positive over 10 years is 61 percent. That means that 61 out of 100 women will have a false positive test. False positives don't just cause emotional distress — they often require repeat imaging and can also mean more invasive procedures like a biopsy.

I'm 40 and healthy. Should I get a mammogram?

What this study shows is that there is not a one-size-fits-all approach to breast cancer screening. What is appropriate for one woman is not always appropriate for her mother or her best friend. Decisions about whether to have a mammogram should be made with your doctor and based on your individual risk for cancer.

Women with a higher risk of breast cancer based on family history or individual risk factors will benefit more from mammography than women of lower risk. Factors to consider include age, a history of cancer, genetic risk factors like the BRCA1 and BRCA2 genes, use of certain medications like some hormone replacement, increased alcohol use, obesity and not having a child before age 30.

We're seeing studies talking about the risk of mammograms. Why are doctors still using them?

Breast cancer kills 40,000 American women per year. At this point, mammograms are the best screening tool that we have. They aren't perfect, but used correctly, they can be lifesaving. However, doctors and researchers are working to develop better tools and one day these might replace mammograms.

Should I do breast self-exams?

While an awareness of your body is always a good idea, the evidence does not show that self-exam does a good job of detecting breast cancer. The U.S. Preventive Services Task Force recommends against teaching breast self-examination.

What age should women stop getting mammograms?

There is not enough evidence to recommend for or against mammograms after age 75, according to the task force. Another study published Tuesday suggests that this decision should be based on your life expectancy. For example, if your life expectancy is less than 10 years due to an illness, mammograms might not be the best choice. Again, it's an individual decision and should involve a thoughtful conversation and consideration of your unique medical profile.

Study ties breast gene to high-risk uterine cancer

BY MARILYNN MARCHIONE
AP Chief Medical Writer

Women with a faulty breast cancer gene might face a greater chance of rare but deadly uterine tumors despite having their ovaries removed to lower their main cancer risks, doctors are reporting.


A study of nearly 300 women with bad BRCA1 genes found four cases of aggressive uterine cancers years after they had preventive surgery to remove their ovaries. That rate is 26 times greater than expected.

"One can happen. Two all of a sudden raises eyebrows," and four is highly suspicious, said Dr. Noah Kauff of Memorial Sloan Kettering Cancer Center in New York.

His study, reported Monday at a cancer conference in Florida, is the first to make this link. Although it's not enough evidence to change practice now, doctors say women with these gene mutations should be told of the results and consider having their uterus removed along with their ovaries.

"It's important for women to have that information ... but I think it's too early to strongly recommend to patients that they undergo a hysterectomy" until more research confirms the finding, said Dr. Karen Lu, a specialist in women's cancers at MD Anderson Cancer Center in Houston.

She plans to study similar patients at her own hospital, the nation's largest cancer center, to see if they, too, have higher uterine cancer risks.

About 1 in 400 women in the U.S., and more of eastern European descent, have faulty BRCA1 or BRCA2 genes that greatly raise their risks for breast and ovarian cancer. Doctors advise them to be screened early and often for breast cancer, and to have their ovaries out as soon as they have finished having children to help prevent ovarian and breast cancer, because ovarian hormones affect breast cancer as well.

But the role of BRCA genes in uterine cancer isn't known, Kauff said.

His study looked at 1,200 women diagnosed with BRCA gene mutations since 1995 at Sloan Kettering. Doctors were able to track 525 of them for many years after they had surgery that removed their ovaries but left the uterus intact.

The vast majority of uterine cancers are low-risk types usually cured with surgery alone. Aggressive forms account for only 10 to 15 percent of cases but more than half of uterine cancer deaths.

Researchers were alarmed to see four of these cases among the 296 women with BRCA1 mutations. None were seen in women with BRCA2 mutations, Kauff said.

The study was discussed Monday at the Society of Gynecologic Oncology's annual meeting in Tampa, Fla.

Last year, the actress Angelina Jolie revealed she had preventive surgery to remove both breasts because of a BRCA1 mutation. Her mother had breast cancer and died of ovarian cancer, and her maternal grandmother also had ovarian cancer.

What you need to know about BRCA gene testing

What is BRCA gene testing?
Everyone has BRCA genes that produce tumor-suppressing proteins. But risky BRCA1 and BRCA2 gene mutations leave a person more susceptible to cancers, including breast and ovarian cancers. BRCA testing is used to determine whether a person has such a mutation, which can be inherited from either parent. Each child of a parent who has a mutation in one of these genes has a 50 percent chance of inheriting the mutation.

What does the test entail?
BRCA gene mutations are detectable through DNA from a blood or saliva sample. It usually takes about a month to get results once your sample is sent to a lab for analysis.

What does a positive result mean?
A woman's lifetime risk of developing cancer is “greatly increased,” if she has a harmful BRCA mutation, according to the National Institutes of Health. About 12 percent of women will develop breast cancer at some point compared with up to 65 percent of women who inherit a harmful BRCA1 mutation. Other cancers are linked to mutations in BRCA1 and BRCA2, including fallopian tube, abdominal and pancreatic cancers. Men with harmful BRCA gene mutations face higher risk of prostate cancer.

How common are high-risk BRCA gene mutations?
The likelihood of carrying a BRCA gene mutation is extremely low for people with no family history of breast or ovarian cancer. Only about 10 percent of all breast cancers and 15 percent of all ovarian cancers can be traced back to inherited genetic mutations.

Who should take the test?
Because BRCA gene mutations are relatively rare, many doctors agree only those who have specific family patterns of cancer should consider the test. Such patterns include having multiple family members who have been diagnosed with breast or ovarian cancer, especially at a young age; cases of male breast cancer; and two or more cancers in one family member.

For anyone thinking about such testing, experts strongly recommend genetic counseling by someone who is experienced in cancer genetics. Counseling can help assess the need for testing in the first place, as well as facilitate discussion about what kinds of decisions a person faces once she gets her results.

What kinds of decisions should you be prepared to make?
A person who finds out she has a BRCA gene mutation faces some difficult decisions. Some women choose enhanced cancer screening, beginning with regular mammograms in their 20s, for example. Others choose risk-reducing surgeries like mastectomies or the removal of the ovaries and fallopian tubes. People also consider chemo-prevention regimens of drugs and vitamins to delay or reduce cancer risk. Finding out you have a harmful BRCA mutation indicates a higher risk for your siblings, too, so what you learn can affect multiple family members.

How much does it cost?
Some insurance companies cover BRCA testing, which can range in cost from hundreds to thousands of dollars. The National Cancer Institute urges people to contact their insurance companies to discuss cost before getting the test. For those without insurance, some genetic testing companies offer free or discounted pricing for individuals who meet certain medical or financial eligibility standards.

Who can help?
There are myriad resources for people considering BRCA gene testing, including the Cancer Information Service at the National Institutes of Health (NIH) and many nonprofit organizations. Live and anonymous online chatting is available from the NIH weekdays from 8 a.m. to 11 p.m. ET (5 a.m. to 8 p.m. PT at http://livehelp.cancer.gov. You can also call 1-800-4-CANCER.