Breast Cancer

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Estradiol testing may guide treatment for patients with estrogen receptor-positive breast cancer, but researchers from Rush University Medical Center in Chicago, Illinois, have a cautionary report about relying on that when fulvestrant, an estrogen receptor antagonist, is used with standard steroid immunoassays. They report on a patient who had a falsely elevated estradiol reading that led to unnecessary procedures. 

Related: Delayed Adjuvant Chemotherapy Significantly Affects Breast Cancer Recovery

Their patient underwent a bilateral oophorectomy and was then started on anti-estrogen therapy with letrozole and fulvestrant, as well as zoledronic acid. At the patient’s request, her primary oncologist obtained a serum estradiol level, which was “unexpectedly” high. The finding was puzzling, the authors say, because she had reported menopausal symptoms, such as hot flashes, which were not consistent with the estradiol level obtained. She also had a complete clinical response to treatment, according to symptoms, radiologic findings, and decreasing levels of carcinoma antigen 125.

A pelvic ultrasound revealed a possible small soft tissue density in the left adnexal region—a “concerning” finding suggesting ovarian remnant syndrome, a rare condition in which ovarian tissue remains after oophorectomy.

Related: Extending Therapy for Breast Cancer

After additional imaging and laparoscopy, pathology revealed fibrovascular and adipose tissue, but no ovarian tissue, ruling out ovarian remnant syndrome as the cause of the elevated estradiol.

Endocrinologists suspected that fulvestrant, which has a molecular structure similar to that of estradiol, was reacting with the standard estradiol immunoassay. That theory was confirmed by testing the serum estradiol levels with the more sensitive, specific liquid chromatography-tandem mass spectrometry, which showed that the levels were actually undetectable.

Related: USPSTF Supports Mammography Starting at Age 50

Fulvestrant has no known agonist effects; it has not previously been reported to elevate estradiol levels or cross-react with estradiol immunoassays, the authors say. Neither the package insert for fulvestrant nor the product insert for the immunoassay warn about the interaction. The authors, therefore, advise clinicians to be aware of the “high likelihood” of this potential drug-assay interaction.

Source:
Berger D, Waheed S, Fattout Y, Kazlauskaite LU. Clin Breast Cancer. 2016;16(1)e11-e16.
doi: 10.1016/j.clbc.2015.07.004.

Estradiol testing may guide treatment for patients with estrogen receptor-positive breast cancer, but researchers from Rush University Medical Center in Chicago, Illinois, have a cautionary report about relying on that when fulvestrant, an estrogen receptor antagonist, is used with standard steroid immunoassays. They report on a patient who had a falsely elevated estradiol reading that led to unnecessary procedures. 

Related: Delayed Adjuvant Chemotherapy Significantly Affects Breast Cancer Recovery

Their patient underwent a bilateral oophorectomy and was then started on anti-estrogen therapy with letrozole and fulvestrant, as well as zoledronic acid. At the patient’s request, her primary oncologist obtained a serum estradiol level, which was “unexpectedly” high. The finding was puzzling, the authors say, because she had reported menopausal symptoms, such as hot flashes, which were not consistent with the estradiol level obtained. She also had a complete clinical response to treatment, according to symptoms, radiologic findings, and decreasing levels of carcinoma antigen 125.

A pelvic ultrasound revealed a possible small soft tissue density in the left adnexal region—a “concerning” finding suggesting ovarian remnant syndrome, a rare condition in which ovarian tissue remains after oophorectomy.

Related: Extending Therapy for Breast Cancer

After additional imaging and laparoscopy, pathology revealed fibrovascular and adipose tissue, but no ovarian tissue, ruling out ovarian remnant syndrome as the cause of the elevated estradiol.

Endocrinologists suspected that fulvestrant, which has a molecular structure similar to that of estradiol, was reacting with the standard estradiol immunoassay. That theory was confirmed by testing the serum estradiol levels with the more sensitive, specific liquid chromatography-tandem mass spectrometry, which showed that the levels were actually undetectable.

Related: USPSTF Supports Mammography Starting at Age 50

Fulvestrant has no known agonist effects; it has not previously been reported to elevate estradiol levels or cross-react with estradiol immunoassays, the authors say. Neither the package insert for fulvestrant nor the product insert for the immunoassay warn about the interaction. The authors, therefore, advise clinicians to be aware of the “high likelihood” of this potential drug-assay interaction.

Source:
Berger D, Waheed S, Fattout Y, Kazlauskaite LU. Clin Breast Cancer. 2016;16(1)e11-e16.
doi: 10.1016/j.clbc.2015.07.004.

Estradiol testing may guide treatment for patients with estrogen receptor-positive breast cancer, but researchers from Rush University Medical Center in Chicago, Illinois, have a cautionary report about relying on that when fulvestrant, an estrogen receptor antagonist, is used with standard steroid immunoassays. They report on a patient who had a falsely elevated estradiol reading that led to unnecessary procedures. 

Related: Delayed Adjuvant Chemotherapy Significantly Affects Breast Cancer Recovery

Their patient underwent a bilateral oophorectomy and was then started on anti-estrogen therapy with letrozole and fulvestrant, as well as zoledronic acid. At the patient’s request, her primary oncologist obtained a serum estradiol level, which was “unexpectedly” high. The finding was puzzling, the authors say, because she had reported menopausal symptoms, such as hot flashes, which were not consistent with the estradiol level obtained. She also had a complete clinical response to treatment, according to symptoms, radiologic findings, and decreasing levels of carcinoma antigen 125.

A pelvic ultrasound revealed a possible small soft tissue density in the left adnexal region—a “concerning” finding suggesting ovarian remnant syndrome, a rare condition in which ovarian tissue remains after oophorectomy.

Related: Extending Therapy for Breast Cancer

After additional imaging and laparoscopy, pathology revealed fibrovascular and adipose tissue, but no ovarian tissue, ruling out ovarian remnant syndrome as the cause of the elevated estradiol.

Endocrinologists suspected that fulvestrant, which has a molecular structure similar to that of estradiol, was reacting with the standard estradiol immunoassay. That theory was confirmed by testing the serum estradiol levels with the more sensitive, specific liquid chromatography-tandem mass spectrometry, which showed that the levels were actually undetectable.

Related: USPSTF Supports Mammography Starting at Age 50

Fulvestrant has no known agonist effects; it has not previously been reported to elevate estradiol levels or cross-react with estradiol immunoassays, the authors say. Neither the package insert for fulvestrant nor the product insert for the immunoassay warn about the interaction. The authors, therefore, advise clinicians to be aware of the “high likelihood” of this potential drug-assay interaction.

Source:
Berger D, Waheed S, Fattout Y, Kazlauskaite LU. Clin Breast Cancer. 2016;16(1)e11-e16.
doi: 10.1016/j.clbc.2015.07.004.

SAN ANTONIO – A definitive phase III randomized controlled trial of statin therapy during adjuvant endocrine therapy for breast cancer is warranted in light of recent encouraging evidence pointing to a protective effect against disease recurrence, Melissa L. Bondy, Ph.D., said at the San Antonio Breast Cancer Symposium.

“The next phase of research in this area is to learn whether we can improve survival in breast cancer patients by having them take cholesterol-lowering medication. We really need to have a phase III trial in the adjuvant setting that includes these cholesterol-lowering drugs,” said Dr. Bondy, professor of cancer prevention and population sciences at Baylor Medical College, Houston.

Her call for a formal, randomized trial came while serving as discussant for two positive reports of an apparent beneficial effect of statins on breast cancer recurrence-free survival: one from the BIG 1-98 trial of adjuvant endocrine therapy for early-stage breast cancer, the other a meta-analysis of 12 published studies totaling 72,774 breast cancer patients.

Dr. Bondy found particularly compelling the Breast International Group (BIG) 1-98 study results presented by Dr. Signe Borgquist, an oncologist at Lund (Sweden) University. This secondary analysis of the impact of cholesterol-lowering medication included 7,963 postmenopausal women with early-stage, estrogen receptor–positive invasive breast cancer who were randomized to 5 years of tamoxifen, the aromatase inhibitor letrozole (Femara), or the two drugs in sequence. Serum total cholesterol levels and the use of cholesterol-lowering medications – a decision left up to individual physicians and patients – were assessed at baseline and again every 6 months for 5.5 years.

With a median 8 years of prospective follow-up, during which 1,432 patients experienced breast cancer recurrence, the disease-free survival rate was 18% higher in the 637 patients already on cholesterol-lowering medication – mainly statins – at enrollment, compared with those who were not. The distant recurrence-free interval was 19% better as well, with both analyses adjusted for their form of endocrine therapy, tumor size and grade, nodal status, local therapy, peritumoral vascular invasion, and other potential confounders.

Another 697 BIG 1-98 participants initiated cholesterol-lowering medication during their adjuvant endocrine therapy. In multivariate adjusted analyses, their disease-free survival rate was 21% greater and distant recurrence-free interval was 26% better than in participants not on a statin or other cholesterol-lowering medication during the trial.

As a possible mechanism by which statins might exert anticancer effects, Dr. Borgquist proposed that lowering cholesterol levels may deprive tumor cells of the ability to satisfy their increased demand for cholesterol uptake. This is a result of attenuated signaling through the estrogen receptor by the cholesterol metabolite 27-hydroxycholesterol, levels of which correlate with systemic total cholesterol.

Dr. Bondy offered another possible explanation for the reduced risk of breast cancer recurrence seen in women on cholesterol-lowering medication in BIG 1-98: “Many groups have shown that LDL affects the immune system by binding and inactivating all kinds of microorganisms and their toxic products. In other words, statins appear to affect the microbiome.”

She commented that, although the use of statins was nonrandomized in BIG 1-98, she was favorably impressed by the 8-year follow-up and careful monitoring of total cholesterol levels at 6-month intervals throughout the 5 years of adjuvant endocrine therapy.

Dr. Bondy noted that other studies – again, nonrandomized – suggest statins also interrupt the growth of colorectal cancer and other malignancies.

Dr. Sashidhar Manthravadi presented a meta-analysis of the 12 published studies that have reported data on the association of statins with recurrence-free and/or overall survival in breast cancer patients. Statin use was associated with a significant 34% improvement in recurrence-free survival.

Moreover, this benefit was confined to breast cancer patients on the lipophilic statins atorvastatin and simvastatin; the use of hydrophilic statins was not associated with a significant improvement in recurrence-free survival, according to Dr. Manthravadi, an internal medicine resident at the University of Missouri, Kansas City.

The use of statins also was associated with a 27% improvement in breast cancer–specific survival and a 33% improvement in overall survival, compared with statin nonusers; however, neither of these results achieved statistical significance, he added.

Dr. Bondy cautioned against making too much of the apparent distinction between lipophilic and hydrophilic statin in terms of protection against breast cancer recurrence, given the inherent limitations of a meta-analysis.

“There’s always a lot of missing information, as well as a failure to adjust for comorbidities. And follow-up times in these 12 studies ranged from 2.5 to 11.5 years,” she noted.

The ongoing BIG 1-98 trial is sponsored by the International Breast Cancer Study Group. Dr. Borgquist, Dr. Bondy, and Dr. Manthravadi reported having no financial conflicts of interest.

[email protected]

SAN ANTONIO – A definitive phase III randomized controlled trial of statin therapy during adjuvant endocrine therapy for breast cancer is warranted in light of recent encouraging evidence pointing to a protective effect against disease recurrence, Melissa L. Bondy, Ph.D., said at the San Antonio Breast Cancer Symposium.

“The next phase of research in this area is to learn whether we can improve survival in breast cancer patients by having them take cholesterol-lowering medication. We really need to have a phase III trial in the adjuvant setting that includes these cholesterol-lowering drugs,” said Dr. Bondy, professor of cancer prevention and population sciences at Baylor Medical College, Houston.

Her call for a formal, randomized trial came while serving as discussant for two positive reports of an apparent beneficial effect of statins on breast cancer recurrence-free survival: one from the BIG 1-98 trial of adjuvant endocrine therapy for early-stage breast cancer, the other a meta-analysis of 12 published studies totaling 72,774 breast cancer patients.

Dr. Bondy found particularly compelling the Breast International Group (BIG) 1-98 study results presented by Dr. Signe Borgquist, an oncologist at Lund (Sweden) University. This secondary analysis of the impact of cholesterol-lowering medication included 7,963 postmenopausal women with early-stage, estrogen receptor–positive invasive breast cancer who were randomized to 5 years of tamoxifen, the aromatase inhibitor letrozole (Femara), or the two drugs in sequence. Serum total cholesterol levels and the use of cholesterol-lowering medications – a decision left up to individual physicians and patients – were assessed at baseline and again every 6 months for 5.5 years.

With a median 8 years of prospective follow-up, during which 1,432 patients experienced breast cancer recurrence, the disease-free survival rate was 18% higher in the 637 patients already on cholesterol-lowering medication – mainly statins – at enrollment, compared with those who were not. The distant recurrence-free interval was 19% better as well, with both analyses adjusted for their form of endocrine therapy, tumor size and grade, nodal status, local therapy, peritumoral vascular invasion, and other potential confounders.

Another 697 BIG 1-98 participants initiated cholesterol-lowering medication during their adjuvant endocrine therapy. In multivariate adjusted analyses, their disease-free survival rate was 21% greater and distant recurrence-free interval was 26% better than in participants not on a statin or other cholesterol-lowering medication during the trial.

As a possible mechanism by which statins might exert anticancer effects, Dr. Borgquist proposed that lowering cholesterol levels may deprive tumor cells of the ability to satisfy their increased demand for cholesterol uptake. This is a result of attenuated signaling through the estrogen receptor by the cholesterol metabolite 27-hydroxycholesterol, levels of which correlate with systemic total cholesterol.

Dr. Bondy offered another possible explanation for the reduced risk of breast cancer recurrence seen in women on cholesterol-lowering medication in BIG 1-98: “Many groups have shown that LDL affects the immune system by binding and inactivating all kinds of microorganisms and their toxic products. In other words, statins appear to affect the microbiome.”

She commented that, although the use of statins was nonrandomized in BIG 1-98, she was favorably impressed by the 8-year follow-up and careful monitoring of total cholesterol levels at 6-month intervals throughout the 5 years of adjuvant endocrine therapy.

Dr. Bondy noted that other studies – again, nonrandomized – suggest statins also interrupt the growth of colorectal cancer and other malignancies.

Dr. Sashidhar Manthravadi presented a meta-analysis of the 12 published studies that have reported data on the association of statins with recurrence-free and/or overall survival in breast cancer patients. Statin use was associated with a significant 34% improvement in recurrence-free survival.

Moreover, this benefit was confined to breast cancer patients on the lipophilic statins atorvastatin and simvastatin; the use of hydrophilic statins was not associated with a significant improvement in recurrence-free survival, according to Dr. Manthravadi, an internal medicine resident at the University of Missouri, Kansas City.

The use of statins also was associated with a 27% improvement in breast cancer–specific survival and a 33% improvement in overall survival, compared with statin nonusers; however, neither of these results achieved statistical significance, he added.

Dr. Bondy cautioned against making too much of the apparent distinction between lipophilic and hydrophilic statin in terms of protection against breast cancer recurrence, given the inherent limitations of a meta-analysis.

“There’s always a lot of missing information, as well as a failure to adjust for comorbidities. And follow-up times in these 12 studies ranged from 2.5 to 11.5 years,” she noted.

The ongoing BIG 1-98 trial is sponsored by the International Breast Cancer Study Group. Dr. Borgquist, Dr. Bondy, and Dr. Manthravadi reported having no financial conflicts of interest.

[email protected]

SAN ANTONIO – A definitive phase III randomized controlled trial of statin therapy during adjuvant endocrine therapy for breast cancer is warranted in light of recent encouraging evidence pointing to a protective effect against disease recurrence, Melissa L. Bondy, Ph.D., said at the San Antonio Breast Cancer Symposium.

“The next phase of research in this area is to learn whether we can improve survival in breast cancer patients by having them take cholesterol-lowering medication. We really need to have a phase III trial in the adjuvant setting that includes these cholesterol-lowering drugs,” said Dr. Bondy, professor of cancer prevention and population sciences at Baylor Medical College, Houston.

Her call for a formal, randomized trial came while serving as discussant for two positive reports of an apparent beneficial effect of statins on breast cancer recurrence-free survival: one from the BIG 1-98 trial of adjuvant endocrine therapy for early-stage breast cancer, the other a meta-analysis of 12 published studies totaling 72,774 breast cancer patients.

Dr. Bondy found particularly compelling the Breast International Group (BIG) 1-98 study results presented by Dr. Signe Borgquist, an oncologist at Lund (Sweden) University. This secondary analysis of the impact of cholesterol-lowering medication included 7,963 postmenopausal women with early-stage, estrogen receptor–positive invasive breast cancer who were randomized to 5 years of tamoxifen, the aromatase inhibitor letrozole (Femara), or the two drugs in sequence. Serum total cholesterol levels and the use of cholesterol-lowering medications – a decision left up to individual physicians and patients – were assessed at baseline and again every 6 months for 5.5 years.

With a median 8 years of prospective follow-up, during which 1,432 patients experienced breast cancer recurrence, the disease-free survival rate was 18% higher in the 637 patients already on cholesterol-lowering medication – mainly statins – at enrollment, compared with those who were not. The distant recurrence-free interval was 19% better as well, with both analyses adjusted for their form of endocrine therapy, tumor size and grade, nodal status, local therapy, peritumoral vascular invasion, and other potential confounders.

Another 697 BIG 1-98 participants initiated cholesterol-lowering medication during their adjuvant endocrine therapy. In multivariate adjusted analyses, their disease-free survival rate was 21% greater and distant recurrence-free interval was 26% better than in participants not on a statin or other cholesterol-lowering medication during the trial.

As a possible mechanism by which statins might exert anticancer effects, Dr. Borgquist proposed that lowering cholesterol levels may deprive tumor cells of the ability to satisfy their increased demand for cholesterol uptake. This is a result of attenuated signaling through the estrogen receptor by the cholesterol metabolite 27-hydroxycholesterol, levels of which correlate with systemic total cholesterol.

Dr. Bondy offered another possible explanation for the reduced risk of breast cancer recurrence seen in women on cholesterol-lowering medication in BIG 1-98: “Many groups have shown that LDL affects the immune system by binding and inactivating all kinds of microorganisms and their toxic products. In other words, statins appear to affect the microbiome.”

She commented that, although the use of statins was nonrandomized in BIG 1-98, she was favorably impressed by the 8-year follow-up and careful monitoring of total cholesterol levels at 6-month intervals throughout the 5 years of adjuvant endocrine therapy.

Dr. Bondy noted that other studies – again, nonrandomized – suggest statins also interrupt the growth of colorectal cancer and other malignancies.

Dr. Sashidhar Manthravadi presented a meta-analysis of the 12 published studies that have reported data on the association of statins with recurrence-free and/or overall survival in breast cancer patients. Statin use was associated with a significant 34% improvement in recurrence-free survival.

Moreover, this benefit was confined to breast cancer patients on the lipophilic statins atorvastatin and simvastatin; the use of hydrophilic statins was not associated with a significant improvement in recurrence-free survival, according to Dr. Manthravadi, an internal medicine resident at the University of Missouri, Kansas City.

The use of statins also was associated with a 27% improvement in breast cancer–specific survival and a 33% improvement in overall survival, compared with statin nonusers; however, neither of these results achieved statistical significance, he added.

Dr. Bondy cautioned against making too much of the apparent distinction between lipophilic and hydrophilic statin in terms of protection against breast cancer recurrence, given the inherent limitations of a meta-analysis.

“There’s always a lot of missing information, as well as a failure to adjust for comorbidities. And follow-up times in these 12 studies ranged from 2.5 to 11.5 years,” she noted.

The ongoing BIG 1-98 trial is sponsored by the International Breast Cancer Study Group. Dr. Borgquist, Dr. Bondy, and Dr. Manthravadi reported having no financial conflicts of interest.

[email protected]

The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.

Courtesy Jorge Barrios/Wikimedia Creative Commons License

Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.

Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”

The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.

Courtesy Jorge Barrios/Wikimedia Creative Commons License

Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.

Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”

The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.

Courtesy Jorge Barrios/Wikimedia Creative Commons License

Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.

Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”

Women aged 50-74 years should undergo biennial screening mammography, and the decision to screen before age 50 should be individualized, according to a final recommendation from the U.S. Preventive Services Task Force.

© Bill Branson/National Cancer Institute

The recommendation statement, published Jan. 11 in Annals of Internal Medicine, is based on a comprehensive review of data since 2009, when the USPSTF last released breast cancer screening recommendations, and follows a public comment period in early 2015.

“The task force continues to find that the benefit of mammography increases with age, and recommends biennial screening in women ages 50 to 74. Mammography can also be effective for women in their 40s, but the benefits are less and the harms potentially greater. The decision by women to start screening in their 40s should be an individual one, made in partnership with a doctor,” according to a statement from the USPSTF.

The new recommendations will not affect private insurance coverage of mammography without cost sharing as outlined in the Affordable Care Act. As part of a spending bill enacted in December 2015, Congress passed a provision placing a 2-year moratorium on the use of any new USPSTF recommendations related to breast cancer screening to determine coverage, effectively preserving mammography coverage without cost sharing for women aged 40 years and older.

Recommendations by age

The latest USPSTF recommendations by age state that women aged 40-49 years should base their screening decision on personal values, preferences, and health history; women with a family history of breast cancer may benefit more than average-risk women by beginning screening before age 50. This is a C recommendation, indicating “moderate certainty that net benefit is small.”

The recommendation for biennial screening of those aged 50-74 is a B recommendation indicating “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial,” Dr. Albert L. Siu, task force chair, reported on behalf of the USPSTF (Ann Intern Med. 2016;164:279-96. doi: 10.7326/M15-2886).

The task force found inadequate evidence to recommend for or against screening those aged 75 and older.

Final evidence documents, including a systematic review of data on the harms associated with breast cancer screening and a modeling study of the benefits and harms associated with different screening strategies, are published along with the recommendation statement.

The USPSTF did not make a recommendations about the use of digital breast tomosynthesis as a primary screening method for breast cancer, noting that the current evidence is insufficient. Evidence also was insufficient to make a recommendation on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, digital breast tomosynthesis, or other methods in women with dense breasts who had a negative screening mammogram.

Dousing the ‘firestorm’

In an editorial penned by Annals of Internal Medicine Editor-in-Chief and Senior Vice President of the American College of Physicians Christine Laine and her colleagues, they urged a dousing of the “firestorm around breast cancer screening.”

That firestorm was ignited with the 2009 USPSTF breast cancer screening recommendation and was rekindled when the current recommendation was presented in draft form in 2015.

However, “the USPSTF did a difficult job well” and based its recommendations on an important understanding of the updated evidence, as well as potential harms and tradeoffs of different screening strategies, the authors wrote.

“When the USPSTF posted its draft recommendations for comment, it noted, ‘Women deserve to be aware of what the science says so they can make the best choice for themselves, together with their doctor.’ We could not agree more. Let’s douse the flames and clear the smoke so that we can clearly see what the evidence shows and where we need to focus efforts to fill gaps in our knowledge so that women, along with their health care providers, can make the best decision to reduce their risk for breast cancer–related morbidity and mortality,” they wrote (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-2978).

ACOG supports screening at 40

The American College of Obstetricians and Gynecologists is standing by its recommendation of annual mammograms beginning at age 40 and continues to support use of clinical breast examinations. In a Jan. 11 statement, Dr. Mark S. DeFrancesco, ACOG president, said that “evidence and experience have shown that early detection can lead to improved outcomes in women diagnosed with breast cancer.”

The organization similarly stood by its recommendation in October 2015, when the American Cancer Society released recommendations for annual screening mammography for asymptomatic women at average risk for breast cancer beginning at age 45 years, with a transition to biennial screening mammography beginning at age 55 (JAMA. 2015;314[15]:1599-1614. doi: 10.1001/jama.2015.12783).

ACOG also supports the omnibus legislation passed by Congress in December that provides 2 years of no-copay coverage of breast cancer screening after age 40 via a moratorium on new breast cancer screening recommendations to allow time for additional research, an ACOG spokesperson said in an interview.

“ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential,” Dr. DeFrancesco said. “Given the differences among current organizational recommendations on breast cancer screening, we recognize that there may be confusion among women about when they should begin screening for breast cancer. ACOG encourages women to discuss this with their doctor, including concerns such as family history of cancer, risk factors such as overweight, and their own personal experiences with breast cancer. Moreover, it is essential that physicians counsel women about the potential consequences of mammography, including false positives.”

ACOG will convene a consensus conference later in January “with the intent to develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide” in an effort to “avoid the confusion that currently exists among the women we treat,” according to the statement.

The issue of divergence – and convergence – among various guidelines was the topic of another editorial published in conjunction with the USPSTF recommendations. In that article, task force chair Dr. Siu and his colleagues acknowledged that disagreements exist but stressed that “it would be a disservice to women and their clinicians if these disagreements obscured a strong emerging convergence among groups who have recently issued evidence-based guidelines” (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-3065).

The operations of the USPSTF are supported by the Agency for Healthcare Research and Quality. One of the members of the USPSTF reported receiving past grants and contracts from the National Cancer Institute and the Centers for Disease Control and Prevention.

[email protected]

Women aged 50-74 years should undergo biennial screening mammography, and the decision to screen before age 50 should be individualized, according to a final recommendation from the U.S. Preventive Services Task Force.

© Bill Branson/National Cancer Institute

The recommendation statement, published Jan. 11 in Annals of Internal Medicine, is based on a comprehensive review of data since 2009, when the USPSTF last released breast cancer screening recommendations, and follows a public comment period in early 2015.

“The task force continues to find that the benefit of mammography increases with age, and recommends biennial screening in women ages 50 to 74. Mammography can also be effective for women in their 40s, but the benefits are less and the harms potentially greater. The decision by women to start screening in their 40s should be an individual one, made in partnership with a doctor,” according to a statement from the USPSTF.

The new recommendations will not affect private insurance coverage of mammography without cost sharing as outlined in the Affordable Care Act. As part of a spending bill enacted in December 2015, Congress passed a provision placing a 2-year moratorium on the use of any new USPSTF recommendations related to breast cancer screening to determine coverage, effectively preserving mammography coverage without cost sharing for women aged 40 years and older.

Recommendations by age

The latest USPSTF recommendations by age state that women aged 40-49 years should base their screening decision on personal values, preferences, and health history; women with a family history of breast cancer may benefit more than average-risk women by beginning screening before age 50. This is a C recommendation, indicating “moderate certainty that net benefit is small.”

The recommendation for biennial screening of those aged 50-74 is a B recommendation indicating “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial,” Dr. Albert L. Siu, task force chair, reported on behalf of the USPSTF (Ann Intern Med. 2016;164:279-96. doi: 10.7326/M15-2886).

The task force found inadequate evidence to recommend for or against screening those aged 75 and older.

Final evidence documents, including a systematic review of data on the harms associated with breast cancer screening and a modeling study of the benefits and harms associated with different screening strategies, are published along with the recommendation statement.

The USPSTF did not make a recommendations about the use of digital breast tomosynthesis as a primary screening method for breast cancer, noting that the current evidence is insufficient. Evidence also was insufficient to make a recommendation on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, digital breast tomosynthesis, or other methods in women with dense breasts who had a negative screening mammogram.

Dousing the ‘firestorm’

In an editorial penned by Annals of Internal Medicine Editor-in-Chief and Senior Vice President of the American College of Physicians Christine Laine and her colleagues, they urged a dousing of the “firestorm around breast cancer screening.”

That firestorm was ignited with the 2009 USPSTF breast cancer screening recommendation and was rekindled when the current recommendation was presented in draft form in 2015.

However, “the USPSTF did a difficult job well” and based its recommendations on an important understanding of the updated evidence, as well as potential harms and tradeoffs of different screening strategies, the authors wrote.

“When the USPSTF posted its draft recommendations for comment, it noted, ‘Women deserve to be aware of what the science says so they can make the best choice for themselves, together with their doctor.’ We could not agree more. Let’s douse the flames and clear the smoke so that we can clearly see what the evidence shows and where we need to focus efforts to fill gaps in our knowledge so that women, along with their health care providers, can make the best decision to reduce their risk for breast cancer–related morbidity and mortality,” they wrote (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-2978).

ACOG supports screening at 40

The American College of Obstetricians and Gynecologists is standing by its recommendation of annual mammograms beginning at age 40 and continues to support use of clinical breast examinations. In a Jan. 11 statement, Dr. Mark S. DeFrancesco, ACOG president, said that “evidence and experience have shown that early detection can lead to improved outcomes in women diagnosed with breast cancer.”

The organization similarly stood by its recommendation in October 2015, when the American Cancer Society released recommendations for annual screening mammography for asymptomatic women at average risk for breast cancer beginning at age 45 years, with a transition to biennial screening mammography beginning at age 55 (JAMA. 2015;314[15]:1599-1614. doi: 10.1001/jama.2015.12783).

ACOG also supports the omnibus legislation passed by Congress in December that provides 2 years of no-copay coverage of breast cancer screening after age 40 via a moratorium on new breast cancer screening recommendations to allow time for additional research, an ACOG spokesperson said in an interview.

“ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential,” Dr. DeFrancesco said. “Given the differences among current organizational recommendations on breast cancer screening, we recognize that there may be confusion among women about when they should begin screening for breast cancer. ACOG encourages women to discuss this with their doctor, including concerns such as family history of cancer, risk factors such as overweight, and their own personal experiences with breast cancer. Moreover, it is essential that physicians counsel women about the potential consequences of mammography, including false positives.”

ACOG will convene a consensus conference later in January “with the intent to develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide” in an effort to “avoid the confusion that currently exists among the women we treat,” according to the statement.

The issue of divergence – and convergence – among various guidelines was the topic of another editorial published in conjunction with the USPSTF recommendations. In that article, task force chair Dr. Siu and his colleagues acknowledged that disagreements exist but stressed that “it would be a disservice to women and their clinicians if these disagreements obscured a strong emerging convergence among groups who have recently issued evidence-based guidelines” (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-3065).

The operations of the USPSTF are supported by the Agency for Healthcare Research and Quality. One of the members of the USPSTF reported receiving past grants and contracts from the National Cancer Institute and the Centers for Disease Control and Prevention.

[email protected]

Women aged 50-74 years should undergo biennial screening mammography, and the decision to screen before age 50 should be individualized, according to a final recommendation from the U.S. Preventive Services Task Force.

© Bill Branson/National Cancer Institute

The recommendation statement, published Jan. 11 in Annals of Internal Medicine, is based on a comprehensive review of data since 2009, when the USPSTF last released breast cancer screening recommendations, and follows a public comment period in early 2015.

“The task force continues to find that the benefit of mammography increases with age, and recommends biennial screening in women ages 50 to 74. Mammography can also be effective for women in their 40s, but the benefits are less and the harms potentially greater. The decision by women to start screening in their 40s should be an individual one, made in partnership with a doctor,” according to a statement from the USPSTF.

The new recommendations will not affect private insurance coverage of mammography without cost sharing as outlined in the Affordable Care Act. As part of a spending bill enacted in December 2015, Congress passed a provision placing a 2-year moratorium on the use of any new USPSTF recommendations related to breast cancer screening to determine coverage, effectively preserving mammography coverage without cost sharing for women aged 40 years and older.

Recommendations by age

The latest USPSTF recommendations by age state that women aged 40-49 years should base their screening decision on personal values, preferences, and health history; women with a family history of breast cancer may benefit more than average-risk women by beginning screening before age 50. This is a C recommendation, indicating “moderate certainty that net benefit is small.”

The recommendation for biennial screening of those aged 50-74 is a B recommendation indicating “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial,” Dr. Albert L. Siu, task force chair, reported on behalf of the USPSTF (Ann Intern Med. 2016;164:279-96. doi: 10.7326/M15-2886).

The task force found inadequate evidence to recommend for or against screening those aged 75 and older.

Final evidence documents, including a systematic review of data on the harms associated with breast cancer screening and a modeling study of the benefits and harms associated with different screening strategies, are published along with the recommendation statement.

The USPSTF did not make a recommendations about the use of digital breast tomosynthesis as a primary screening method for breast cancer, noting that the current evidence is insufficient. Evidence also was insufficient to make a recommendation on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, digital breast tomosynthesis, or other methods in women with dense breasts who had a negative screening mammogram.

Dousing the ‘firestorm’

In an editorial penned by Annals of Internal Medicine Editor-in-Chief and Senior Vice President of the American College of Physicians Christine Laine and her colleagues, they urged a dousing of the “firestorm around breast cancer screening.”

That firestorm was ignited with the 2009 USPSTF breast cancer screening recommendation and was rekindled when the current recommendation was presented in draft form in 2015.

However, “the USPSTF did a difficult job well” and based its recommendations on an important understanding of the updated evidence, as well as potential harms and tradeoffs of different screening strategies, the authors wrote.

“When the USPSTF posted its draft recommendations for comment, it noted, ‘Women deserve to be aware of what the science says so they can make the best choice for themselves, together with their doctor.’ We could not agree more. Let’s douse the flames and clear the smoke so that we can clearly see what the evidence shows and where we need to focus efforts to fill gaps in our knowledge so that women, along with their health care providers, can make the best decision to reduce their risk for breast cancer–related morbidity and mortality,” they wrote (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-2978).

ACOG supports screening at 40

The American College of Obstetricians and Gynecologists is standing by its recommendation of annual mammograms beginning at age 40 and continues to support use of clinical breast examinations. In a Jan. 11 statement, Dr. Mark S. DeFrancesco, ACOG president, said that “evidence and experience have shown that early detection can lead to improved outcomes in women diagnosed with breast cancer.”

The organization similarly stood by its recommendation in October 2015, when the American Cancer Society released recommendations for annual screening mammography for asymptomatic women at average risk for breast cancer beginning at age 45 years, with a transition to biennial screening mammography beginning at age 55 (JAMA. 2015;314[15]:1599-1614. doi: 10.1001/jama.2015.12783).

ACOG also supports the omnibus legislation passed by Congress in December that provides 2 years of no-copay coverage of breast cancer screening after age 40 via a moratorium on new breast cancer screening recommendations to allow time for additional research, an ACOG spokesperson said in an interview.

“ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential,” Dr. DeFrancesco said. “Given the differences among current organizational recommendations on breast cancer screening, we recognize that there may be confusion among women about when they should begin screening for breast cancer. ACOG encourages women to discuss this with their doctor, including concerns such as family history of cancer, risk factors such as overweight, and their own personal experiences with breast cancer. Moreover, it is essential that physicians counsel women about the potential consequences of mammography, including false positives.”

ACOG will convene a consensus conference later in January “with the intent to develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide” in an effort to “avoid the confusion that currently exists among the women we treat,” according to the statement.

The issue of divergence – and convergence – among various guidelines was the topic of another editorial published in conjunction with the USPSTF recommendations. In that article, task force chair Dr. Siu and his colleagues acknowledged that disagreements exist but stressed that “it would be a disservice to women and their clinicians if these disagreements obscured a strong emerging convergence among groups who have recently issued evidence-based guidelines” (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-3065).

The operations of the USPSTF are supported by the Agency for Healthcare Research and Quality. One of the members of the USPSTF reported receiving past grants and contracts from the National Cancer Institute and the Centers for Disease Control and Prevention.

[email protected]