Below the Belt: Women's Health

November 2009 has been a rough month for both women and their doctors. Within one week women were told to cut back on their usage of both screening mammograms and routine PAP smears. The purpose of this blog post is to give you specific information which can help you negotiate with your own GYN, or clinic, about which frequency of these two screening tests is right for you.

Who is making these new pronouncements?
The suggested screening mammogram guidelines were announced by the U.S. Preventative Services Task Force (USPTF). This group makes recommendations, based upon the most current scientific evidence, for screening tests in persons without apparent symptoms of a disease. That is, apparently healthy persons without marked risk factors. In the case of the breast screening tests, women without a strong family history of breast cancer, without genetic traits (e.g., BRCA-1 gene mutation), no personal history of breast cancer, no radiation to the chest, and no breast mass are the target group for these recommendations.

The new PAP smear recommendations were announced by the American College of Obstetricians and Gynecologists (ACOG). This group is compromised by OB/GYNs with special expertise who are selected by their profession to review current scientific evidence. Their goal is to help doctors make the most informed decision about how to test or treat patients.

Are these recommendations really new and different?
The current breast screening guidelines are an update of the 2002 breast screening recommendations. At that that time the USPTF recommended a screening mammogram every one to two years for all women over 40 years old. Also at that time the USPTF stated there was insufficient evidence to encourage breast self exam by women, nor clinical breast exams by doctors.

The 2009 recommendations for breast cancer screening now are:

No routine screening mammograms in low risk women until age 50 then every other year until age 75.
Teaching women to do breast self exams is not recommended.
Clinical breast exams by doctors are still not supported by sufficient evidence.

The suggested use of PAP smears as a screening test has been slowly undergoing a transformation. Many of you may remember the practice of everyone getting a yearly PAP smear. Over time it became apparent (at least in developed countries) that the incidence of cervical cancer was declining. The majority of cervical cancer was found in women who had not had a PAP smear in five or more years. Many other developed nations (i.e., Canada) had moved to less frequent PAPs as long as the woman had no symptoms or risk factors suggesting cervical cancer. ACOG has finally moved into line with other countries and other published guidelines.

The 2009 recommendations for cervical cancer screening are now:

Women over the age of 30 can now get PAP smears only every three years IF they have had three normal PAP smears in a row.
If women have risk factors (e.g., as prior abnormal PAPs), or have decreased immune functions (e.g., organ transplant recipients, HIV) they should get more frequent PAP smears.
Routine screening PAP smears should begin at age 21-not as a teenager.
Women who have received the HPV vaccine to reduce cervical cancer are still subject to these standards. But as more data is gained this may be reassessed.

What is the benefit to the patient of these newest recommendations?
The primary benefit for reduced mammograms is fewer "false positive" results. That is, the mammogram suggests a worrisome finding when there really isn't one. There are more frequent false positives among younger women (age less than 50). Younger women have both more dense breast tissue (making mammograms more difficult to interpret) and less risk over all for breast cancer (risk rises with age). False positives often lead to unneeded biopsies. It should also be noted that 10-15% of breast cancers in this younger group are missed by mammograms.

The primary benefit for reduced PAP smear screening would be less over treatment-especially in younger patients. In the 1980s I can remember young women being sent for laser destruction of cervical tissue for what we now consider to be mild dysplasia or CIN 1. Some of the more aggressive treatments can remove a significant amount of cervical tissue. If the removal of cervical tissue is extensive (removal of tissue can range from a few millimeters to slightly less than an inch) it can undermine the ability of the cervix to remain closed until full term delivery.

Fortunately studies were done that demonstrated young women with a healthy immune system were able to clear many mild cervical cell changes on their own. This was true in about 60% of mild cases. More frequent PAP smears in this group for one to two years after diagnosis would identify the small group that did not spontaneously clear.

What is the risk to the patient?
The gravest risk for less breast screening tests would be development of an advanced stage breast cancer. Breast cancer is the most common GYN cancer. Its incidence is 135 in 100,000 women. Its mortality rate is 27 per 100,000 women. Compare this to cervical cancer where the incidence is 9.3 per 100,000 women with a mortality of 2.9. It's no wonder that women feel vulnerable about breast cancers.

In a brand new meta-analysis (Nelson, 2009), the assertion that screening mammograms saves lives has been reaffirmed. Currently, 1,904 women in their 40's would have to be screened to extend the life of one woman. Among women in their 50's, 1,339 women would need to be screened to extend the life of one woman. The statistical risk reduction for the two age groups is 15% and 14%. The reason the "50 somethings" have been given the green light for routine mammograms is that they are at greater risk because of advancing age. It is this point which is the most heavily debated. Is it not worth it to save the life of one woman by having to screen 565 more women? Most women have a personal connection to one, or more women, who have had cancer diagnosed at an early age by a mammogram.

The gravest risk for less frequent PAP smears would be the development of a cervical cancer. Fortunately cervical cancer is relatively slow growing with precancerous changes showing up well before true invasive cancer.

What about the low tech things such as self breast exam and a doctor's breast exam?
Many of the largest studies to show no benefit for breast self exam (BSE) were done in counties outside the US (e.g., Shanghai China in 2002 and Russia in 2003). In addition to no decrease in breast cancer deaths, the largest studies showed an increased number of biopsies which found no cancer. It is difficult to know if the outcome would be the same if a woman was instructed using the newest BSE technique taught to GYNs in the US.

The issues surrounding the clinical breast exams (CBE) done by doctors are similar. There is a large Canadian study (Miller, 1992) which suggested five year survival rates were the same in women who received only CBE and those who received CBE plus screening mammogram. One of the current discussions explores the quality of CBE. There are several techniques used; and some MDs do a more thorough and systemic breast exam than their colleagues.

So what are you going to endorse, Jane?
I cannot argue with a cold statistical approach to identify which forms of healthcare seem to be better for a healthy population. The approach stated by the U.S. Health and Human Services Secretary (Kathleen Sebelius) on November 18th 2009 really offers the best advice:

Keep doing what you have been doing for years - talk to your doctor about your individual history, ask questions and make the decision which is right for you.

As for me I am comfortable with reduced PAP smear frequency, but still believe that a woman can benefit from a yearly pelvic exam and clinical breast exam. This is an opportunity to check for pelvic masses, talk about contraception options, and discuss new recommendations for women's care.

If a younger woman, after hearing the pluses and minuses of early screening mammography, wants a mammogram I would definitely order one. My best GUESS is that women, and their doctors, are not going to abruptly abandon doing mammograms for women in their 40's. Moreover, I think a thorough, systematic breast exam performed by a well trained MD, DO, NP, or ND can be an additional check on breast health. If the woman wants to perform self breast exam I absolutely support that and would hope to give her the right training. Here is a link to an updated BSE (now called "Breast Self Awareness") training guide from the Susan G. Komen Foundation.

For those of you who would like to read the original recommendations and the accompanying data here are the sources: