Thursday, February 22, 2018

OCMA Blog

USPSTF Recommendations Ignore Reality of Breast Cancer


This article is brought to you by: Breastlink

visit www.breastlink.com for more information

 

Annual mammogram screening beginning at age 40 saves lives. U.S. Preventive Services Task Force (USPSTF) recommends less frequent screening at a later age, not because screening will not save lives, but because it will not save sufficient numbers of lives when started before age 50. The recommendations are based on outdated, blemished data and do not evaluate cost-effectiveness or any other benefits of early detection. In fact, USPSTF states, “Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.”[1]

Women need to empower themselves with accurate information about screening to benefit from early detection.

The Reality of Breast Cancer in Younger Women

Women younger than 50 are diagnosed with and die from breast cancer. Research proves that mammogram screening can prevent breast cancer deaths in these women.

Nearly 65,000 women younger than 50 were diagnosed with breast cancer in 2013, according to the American Cancer Society. Nearly 5,000 women in this age group died from breast cancer.[2] Within its own recommendations, even USPSTF recognizes that mammogram screening contributed to a 15 percent decrease in breast cancer mortality among women aged 39 to 49.[3]

Decreasing mortality is not the only benefit from early detection with screening mammography – it is simply the most important benefit. There are many other potential benefits to identifying and treating cancer in its earliest stages:

·         Prevent chemotherapy

·         Prevent lymphedema

·         Limit surgery

·         Minimize radiation therapy

·         Decrease psychosocial impact

·         Maximize number of treatment options available

Mammogram is superior to clinical breast exam or self-exam at identifying small tumors. Tumors detected under 1cm in size, regardless of their biology, can almost always be treated without chemotherapy. About 20 to 30% of these tumors will have aggressive biology and if left to grow for one to two years, they would certainly require more aggressive treatment. USPSTF has failed to acknowledge the harms of chemotherapy needed for more advanced tumors.

Identifying tumors that have not spread to lymph nodes can minimize surgical and radiation treatments. Breast conservation and partial breast irradiation are options with early stage breast cancers. Surgical complications decrease when radiation can be avoided in the setting of mastectomy with reconstruction. Avoiding lymph node dissections also decreases the incidence of lymphedema. USPSTF has failed to acknowledge the burden of lymphedema when disease has spread to lymph nodes.

Aggressive treatments also represent a cost burden to individuals and to society. The total cost of treating all cancers exceeded $216 billion in 2009, according to the National Institutes of Health.[4] Breast cancer accounts for a significant portion of this. By detecting cancer at its earliest stages, the cost of cancer care can be greatly diminished. This cost burden inevitably has a direct psychosocial and economic impact to cancer patients, their families and society as a whole. The “harms” of a false-positive mammogram are almost trivial in comparison to the burden of advanced cancer care. USPSTF has failed to acknowledge the emotional and cost burden of delaying breast cancer diagnosis.

Due to significant advances in adjuvant therapies, death from breast cancer has improved even at advanced stages of diagnosis. However, USPSTF has failed to acknowledge 10 years’ worth of advancements in breast cancer treatment focused on minimizing surgery and radiation treatment when cancer is detected at early stage. These advancements have helped to decrease morbidity while improving quality of life for cancer survivors.  These benefits depend on early detection enabled by annual mammogram screening.    

It is irresponsible for USPSTF to describe harms of false-positives and anxiety of testing without discussing the benefits of avoiding aggressive treatment. Women should be empowered to make their own decisions about their health care. Failure to provide this information and limiting access to mammogram screening does not help to accomplish this. Furthermore, these “recommendations” made by USPSTF can be inappropriately used to limit insurance coverage for annual screening, prevent primary care providers and OB/GYNs from ordering screening, and discourage women from obtaining routine mammograms. By recommending annual screening beginning at age 40, women are encouraged to begin thinking about their breast cancer risk and breast health.

The Argument Against Mammogram Screening

USPSTF recommendations suggest women should begin screening at the age of 50 and continue screening every two years until the age of 74. This decision was made in 2009, reversing an earlier stance for annual screening beginning at age 40. A recent review of the 2009 decision upheld the reversal. These recommendations are based heavily on data provided by flawed research studies:

Canadian National Breast Screening Study

The Canadian National Breast Screening Study is one of the studies used to support current USPSTF recommendation.[5] Multiple independent researchers who reviewed this study noted multiple problems.[6]

·         Outdated mammogram technology from the 1970s.

·         Women included in the study were not appropriately placed in the screening and control groups.

·         Technicians performing exams did not receive special training in mammogram screening.

·         Radiologists interpreting mammograms were not trained specifically in breast imaging.

USPSTF recommendations also consider harms and risks like patient anxiety, false-positive results, recalls and overdiagnosis. These are important concerns to recognize, but are sometimes overstated. The Swedish Two-County Trial found that two lives are saved for every instance of overdiagnosis.[7] This trial also showed that recalls affected less than 1 in 20 women.

While it is necessary to talk about the harms and risks, physicians should discuss them with patients rather than denying them access to mammogram screening.

The Benefits of Mammogram Screening

The American Cancer Society, Society of Breast Imaging and American College of Radiology all recommend women receive mammogram screening once every year for as long as they are healthy. Numerous studies and data support this position.

National Cancer Institute SEER Data

While cancer treatments have improved, early detection enabled by mammogram has helped to reduce the mortality rate. Data collected by the National Cancer Institute over the last several decades supports this.

Mammogram Screening Rates

Breast Cancer Mortality Rates

1987: 22%

1990: 33%

2010: 67%

2010: 22%

Over a similar period of time, mammogram screening rates skyrocketed while breast cancer mortality rates decreased by one-third.[8][9]

University of Michigan Comprehensive Cancer Center

The ability of mammogram screen to aid early diagnosis is also evident in research published May 2014 in Cancer. Researchers compared data collected from 1977 to 1979 with data collected from 2007 to 2009. While incidences of early-stage breast cancer rose by one-half based on projected rates, incidences of late-stage breast cancer would have dropped 37 percent.[10]

Analysis of Mammogram Screening in Women Aged 40 to 49

Prior to its 2009 reversal, USPSTF recommended annual screening beginning at age 40. These recommendations relied on an analysis of eight randomized clinical trials, published 1997 in Journal of the National Cancer Institute.

Results from this analysis showed that women aged 40 to 49 benefitted from mammogram screening. Incidences of breast cancer and breast cancer deaths were lower among women aged 40 to 49 than for women aged 50 or older. A mortality reduction of 23 percent was noticed in this study when screening in women aged 40 to 49.[11]

More Deaths in Unscreened Women

A failure analysis published September 2013 in Cancer determined that most breast cancer deaths occur in women who do not receive routine screening. Unscreened women accounted for 71 percent of breast cancer deaths. Additionally, approximately one-half of these deaths were in women younger than 50.[12]

Breastlink Position

In summary, we agree with the USPSTF that screening mammography saves lives. We also agree with the American Cancer Society and many others that screening should begin at age 40 for average risk women and should occur annually while women are healthy. We believe this will maximize the benefit of early detection by not only saving lives, but also by reducing the need for more aggressive treatments.

Signed:

Dr. Nimmi Kapoor

Dr. John Link

Dr. John West

Dr. Lisa Curcio

Dr. Amy Bremner

Dr. Samantha Kubaska

Dr. June Chen

Dr. Wade Smith

Dr. Tchaiko Parris

Dr. Justin West

Dr. Mark Gaon

 



[1] U.S. Preventive Services Task Force. “Draft Recommendation Statement: Breast Cancer: Screening.” April 2015.

[2] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[3] U.S. Preventive Services Task Force. “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.” Annals of Internal Medicine. November 2009.

[4] National Heart, Lung, and Blood Institute. “NHLBI Fact Book, Fiscal Year 2012.” 2013.

[5] Miller et al. “Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial.” The BMJ. February 2014.

[6] Daniel B. Kopans. “Arguments Against Mammography Screening Continue to be Based on Faulty Science.” The Oncologist. February 2014.

[7] Tabár et al. “Swedish Two-County Trial: Impact of Mammographic Screening on Breast Cancer Mortality during 3 Decades.” Radiology. September 2011.

[8] National Center for Health Statistics. “Health, United States, 2013: With Special Feature on Prescription Drugs.” 2014.

[9] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[10] Helvie et al. “Reduction in late-stage breast cancer incidence in the mammography era: Implications for overdiagnosis of invasive cancer.” Cancer. September 2014.

[11] Hendrick et al. “Benefit of Screening Mammography in Women Aged 40-49: A New Meta-Analysis of Randomized Controlled Trials.” Journal of the National Cancer Institute. January 1997.

[12] Webb et al. “A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened.” Cancer. September 2014.


Do Breast Density Laws Improve Public Knowledge of Breast Density Issues?

 


This article is brought to you by: Breastlink

visit www.breastlink.com for more information



It is essential that women and their physicians understand how breast density affects breast cancer risk and screening. As of December 2014, 18 states had passed breast density laws to help improve public knowledge surrounding breast density by requiring radiologists to inform patients when mammography reveals dense breast tissue. Despite these developments, several recent surveys suggest that neither patients nor physicians fully understand the relationship between dense breast tissue, breast cancer risk, and breast cancer screening.

Patient Knowledge Regarding Breast Density

Public awareness campaigns to promote mammography screening have been effective and a significant reason breast cancer mortality has fallen over the past several years. In a survey conducted by the Working Mother Research Institute (WMRI), which we covered here, 70 percent of more than 2,500 respondents reported they had received a mammogram.

However, there seem to be gaps in public knowledge of the importance of breast cancer screening, particularly when it comes to breast density. Less than one-half of those surveyed for the WMRI report were aware that mammography is less accurate in women with dense breasts than those with fatty breasts. Only 13 percent were aware that dense breast tissue is a risk factor for developing breast cancer.

A recent international survey conducted by GE Healthcare, which included responses from 1,000 American women, returned similar results. Overall, 30 percent of respondents from 10 countries were not aware of the link between breast cancer and dense breast tissue. In the United States, less than 20 percent of women were aware of this link.

Physician Knowledge Regarding Breast Density

Physicians are partly to blame for the lack of widespread awareness around breast density. Primary care physicians have traditionally not received extensive training on breast density issues. These include dense breast tissue as a risk factor for breast cancer, the effect of dense breast tissue on mammogram sensitivity, and the use of supplemental screening in women with dense breast tissue.

To gauge how a breast density law in California has affected physician awareness, researchers from the University of California, Davis surveyed 77 primary care physicians. Results were published December 2014 in Journal of the American College of Radiology.

· About one-half were unaware that a breast density law had been passed.

· About two-thirds reported no change in patient concern regarding breast density.

· About one-fifth reported they had never had a patient bring up a breast density notification letter.

· Six percent reported they were “completely comfortable” answering questions regarding breast density.

· Three-fourths expressed interest in attending an educational presentation on breast density issues.

Researchers concluded that the California breast density law did not lead to a rise in familiarity of breast density issues among primary care physicians. “The results of this study suggest that 10 months after enactment of the California Breast Density Notification Law, the intent of the legislation has not been fully realized,” wrote lead author Kathleen A. Khong, M.D.

Breastlink is committed to sharing accurate, up-to-date facts regarding breast density with our patients and the physicians we work with. This includes information posted to our website and shared in our offices, continuing medical education courses, and educational community events. We believe that knowledgeable, well-informed patients and physicians working together leads to shared-decision making that results in the best possible outcomes.

To learn more about breast density, whether you are a patient of physician, please get in touch using our online ‘Contact Us’ form.


ATTN OCMA Members: Amendment to Bylaws for Review-2015

Dear OCMA Membership,

The Bylaws Committee of the Orange County Medical Association has reviewed and updated the organization's bylaws. The revisions have been approved by the Board of Directors and now need to be approved by the general membership. Therefore, for the next two months (April and May 2015) you may review the revised Bylaws by Clicking Here

 
Please submit any comments in writing via email to ocma@ocma.org or mail to 17322 Murphy Avenue, Irvine, CA 92614.



 


Women’s Imaging Centers Will Operate Under Breastlink Name


For more than 15 years, breast imaging specialists of West Coast Radiology have worked with referring physicians of Orange County to provide comprehensive breast imaging services through a network of dedicated women’s imaging centers. As of April 11, 2015, the dedicated women’s imaging centers where these radiologists work will be rebranded as Breastlink Women’s Imaging Centers. 

The current team of expert breast imaging specialists working out of these locations will continue interpreting women’s imaging exams performed at these centers, with the added benefit of being able to work more closely with Breastlink’s multidisciplinary team of breast cancer experts. While the name has changed, patients and referring physicians can continue to expect the same exceptional services from the same expert team. 

Breastlink physicians and staff are excited to continue working with these talented radiologists, who possess decades of combined sub-specialty experience in breast imaging, and to expand imaging options available to women under the Breastlink name as part of a comprehensive breast health care model. 

Where to Find Breastlink Imaging Centers 

The dedicated women’s imaging centers now known as Breastlink Women’s Imaging Centers were previously known as: 

  • West Coast Breast Center Irvine 
  • West Coast Breast Center Laguna Hills 
  • Breast Care & Imaging Center of Orange
  • West Coast Breast Center Santa Ana
  • Breast Care Center Temecula Valley

Patients and referring physicians can visit or call these five centers at: 

Breastlink Women’s Imaging Center Irvine
16300 Sand Canyon Avenue, Suite 203
Irvine, CA 92618 
949-752-9090

Breastlink Women’s Imaging Center Laguna Hills 
23961 Calle de la Magdalena, Suite 130 
Laguna Hills, CA 92653
949-272-2202

Breastlink Women’s Imaging Center Orange 
230 S Main Street, Suite 100 
Orange, CA 92868
714-541-0101

Breastlink Women’s Imaging Center Santa Ana 
1100-A N Tustin Avenue
Santa Ana, CA 92705
714-543-9927

Breastlink Women’s Imaging Center Temecula Valley 
25455 Medical Center Drive, Suite 210 
Murrieta, CA 92562
951-600-2839

For more information, please visit Breastlink.com


Autism Spectrum Disorder — The Importance of Early Identification and Behavior Intervention

By Donald Sharps, M.D.
CalOptima Behavioral Health Medical Director

 

Early identification of children with delays in development or those at risk of delays provides primary care providers with a critical opportunity to pinpoint special health care needs. 

The main path to the early identification is a developmental screening in the primary care setting. In particular, early identification of autism spectrum disorder (ASD) can help a child significantly. According to the Centers for Disease Control and Prevention (CDC), early treatment services can improve a child’s development by helping the child talk, walk and interact with others. Therefore, it is important to screen children for ASD or any other developmental problems in their early years. 


The CDC and CalOptima recommend that all children be screened for developmental delays and disabilities during regular well-child doctor visits at: 
  • 9 months
  • 18 months
  • 24 or 30 months

If a child is at high risk for developmental problems due to preterm birth, low birth weight or other reasons, additional screenings might be required.

Additionally, all children should be screened specifically for ASD during regular well-child doctor visits at:

  • 18 months
  • 24 motnhs

Further screenings might be needed if a child is at high risk for ASD (e.g., having a sibling or other family member with ASD) or if behaviors sometimes associated with ASD are present.

Identifying a child as having a special health care need is only the first step. Once developmental delays are identified then an appropriate diagnostic work-up and follow-up must occur. It is in this next step that the relationship between the primary care provider and an early behavior intervention service becomes critical.

Effective September 15, 2014, CalOptima covers behavioral health treatment for ASD. This treatment includes Applied Behavior Analysis and other behavior intervention services. The services help develop or restore, as much as possible, the daily functioning of a member with ASD.

If the developmental screening is positive for signs of developmental delays associated with ASD, you may be able to conduct the additional assessment for ASD, or you may refer the patient to a specialist for a comprehensive diagnostic evaluation. Alternatively, Medi-Cal members can call the Orange County Mental Health Plan Access Line at 1-800-723-8641 to request the evaluation or to access other mental health services.

Resources:

http://www.cdc.gov/ncbddd/autism/screening.html

http://www.cdc.gov/ncbddd/autism/facts.html

 


Community Partnerships: Bringing Health and Wellness to Where We Live and Work

By Annette Walker, Executive Vice President, Strategic Services at St. Joseph Hoag Health

Keeping people – and communities – healthy means more than treating illness and injury. It means partnering with people before they get sick and making it easy and convenient for them to exercise, get preventive care like vaccines and screenings and learn how to eat right.

But in today's fast-paced lifestyle, a lifestyle where we're eating breakfast in the car and checking emails at night on our phones, our health sometimes takes a back seat. But what's the solution? Health and wellness professionals need to meet people where they live and work.

One way we are addressing this at St. Joseph Hoag Health is through our Wellness Corners which are located in neighborhood and office settings. This is helping local employees and residents get their screenings, making them healthier than ever because health care services are available within steps of their offices and front doors.

Offering basic medical care, the Wellness Corner focus on services that help to improve our overall health and wellness and prevent chronic conditions through lifestyle management programs. Members of the local workforce and residential community can stop by to get a flu shot, review his lab test results to ensure that his cholesterol levels have gone down (due to a new healthy eating routine) and attend a seminar about the benefits of mindful meditation.

Our centers located at Four Park Plaza at Jamboree Center, the Park Place business community and The Village at Irvine Spectrum neighborhood are emerging as successful clinics that empower people to take control of their health to prevent illnesses and increase their well-being. We are planning to open additional locations throughout Orange County soon, each with the goal to make healthy living for our family, friends and neighbors more convenient, flexible and accessible.

By making access to health care and wellness programs convenient, we can help people manage their health and ward off illness. This is the health care model of the present and of the future.

Annette Walker is executive vice president, strategic services for St. Joseph Hoag Health where she is responsible for the strategy, business development, marketing and communications. She works directly with senior executives and physicians to develop, support and implement the strategic objectives and competitive positioning of the health ministry. For additional information about the Wellness Corners, click here.


Mental Health Services Access Hotline for Patients and Physicians

The Orange County Mental Health Plan has a hotline available to help Orange County patients locate mental health services. This includes outpatient mental health services provided by mental health professionals and psychiatric inpatient services. Physicians can also utilize the number to locate services for patients. 

Click here for more information.

Orange County Mental Health Plan:

1-800-723-8641


Measles Outbreak Update

Measles has now been confirmed in 22 Orange County (OC) residents, signaling ongoing transmission in the community and at the Disneyland Parks. Thirteen of these cases spent time at the Disneyland Parks since mid-December, 2014. In California, as of today, 59 cases of measles have been confirmed since the end of December; 42 of these had an exposure in December at Disneyland or California Adventure Park. Additional cases have been identified that were at the park while infectious in January, including within the last week. Nine of the OC cases have no Disney or other known measles exposure. Additional cases are expected in Orange County.
 

Of the 22 Orange County cases, five are children, of whom four were not vaccinated and two were hospitalized. Although some of the confirmed cases occurred in people with a history of vaccination, their illness is generally milder and typically not as infectious. Vaccination is critical to prevent the ongoing spread of disease.

  • Although the overall risk of getting measles in Orange County remains low, residents who have not received any measles-containing vaccine should get a dose of MMR vaccine.
  • Two doses of measles-containing vaccine (MMR vaccine) are more than 99% effective in preventing measles. The first dose is routinely given at 12-15 months of age, with the second dose usually at age 4-6 years. The second dose may be given any time ≥28 days after the first dose.
  • All healthcare workers (HCW) should have two documented doses of MMR or serologic evidence of measles immunity. HCW who are exposed to a case of measles may be excluded from work until they provide evidence of immunity.
  • If exposed to measles, all, children and school/child care staff without documented immunity will be removed from work/school/child care from day 7 after the first exposure to day 21 after the last exposure.

Measles is highly contagious and people can be exposed by just being in the same room as a measles case during their infectious period (4 days before onset of rash until 4 days after). Several of the cases have potentially exposed patients in healthcare facilities, resulting in large contact investigations and persons needing immune globulin administration, post-exposure vaccination, or serologic testing for immunity.

  • Any patient suspected of having measles should be masked immediately and promptly moved to a negative pressure room when available. Providers seeing patients in an office or clinic setting should consider options such as arranging to see suspect measles cases after all other patients have left the office, or assessing patients outside of the building to avoid having a potentially infectious patient enter the office.
  • Notify Orange County Public Health Epidemiology immediately at 714-834-8180 (or 714-628-7008 after hours) about any suspect cases. Do not wait for laboratory confirmation before reporting a suspect case. Do NOT refer patients to Public Health without first discussing with one of our staff.
  • DO NOT send potentially infectious suspect measles patients to a reference laboratory for specimen collection.

For more information on measles, see www.ochealthinfo.com/measles.


2015 Young Physicians Patient Safety Award

The Doctors Company Foundation is now accepting essays for the 2015 Young Physicians Patient Safety Award. The annual award recognizes six third- and fourth-year students attending U.S. medical schools who write winning essays about the most instructional patient safety event they have experienced in a clinical rotation. Winners each receive a $5,000 award from The Doctors Company Foundation,which co-sponsors the contest with the Lucian Leape Institute of the National Patient Safety Foundation.
 

For more information on the award and how to apply, please visit www.tdcfoundation.com/2015ypawards. Essays are due by Monday, February 2, 2015 (5:00 PM PST).


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