WOMEN'S HEALTH: SPOTLIGHT ON BREAST CANCER
What's a Woman To Do? New Evidence About Breast Cancer Detection
It’s not just in caries detection that we need to worry about sensitivity and specificity. With an estimated 215,990 annual cases in 2004, breast cancer is the second most common cancer, second only to nonmelanoma skin cancers. More than 2 million American women are estimated to be living with breast cancer, including those in treatment. Many are unaware that an estimated 1,450 American men will be diagnosed with breast cancer in 2004.
New evidence from the prestigious journal, The New England Journal of Medicine, cites greater sensitivity of magnetic resonance imaging (MRI) in detecting early breast cancer among women with a family history of breast cancer. These women and women with genetic risk factors, such as the BRCA genetic mutations, may fare better with MRI than mammograms in detecting breast cancer. For the full text of the abstract below, go to http://content.nejm.org/cgi/content/abstract/351/5/427. Even though it has greater sensitivity than mammograms, MRI is not recommended for routine screening for breast cancer because it has more false positives, or lower specificity, and is much more costly. Additional outcomes-based research will assess women of varying risks to determine if further recommendations are needed for women in the early detection of breast cancer.
SOURCE: Kriege M, et al. Efficacy of MRI and mammography for breast cancer screening in women with a familial or genetic predisposition. New England J of Medicine. July 29, 2004; 351:#5:427-437.
Background: The value of regular surveillance for breast cancer in women with a genetic or familial predisposition to breast cancer is currently unproven. We compared the efficacy of magnetic resonance imaging (MRI) with that of mammography for screening in this group of high-risk women.
Methods: Women who had a cumulative lifetime risk of breast cancer of 15 percent or more were screened every six months with a clinical breast examination and once a year by mammography and MRI, with independent readings. The characteristics of the cancers that were detected were compared with the characteristics of those in two different age-matched control groups.
Results: We screened 1,909 eligible women, including 358 carriers of germ-line mutations. Within a median follow-up period of 2.9 years, 51 tumors (44 invasive cancers, six ductal carcinomas in situ, and one lymphoma) and one lobular carcinoma in situ were detected. The sensitivity of clinical breast examination, mammography, and MRI for detecting invasive breast cancer was 17.9 percent, 33.3 percent, and 79.5 percent, respectively, and the specificity was 98.1 percent, 95.0 percent, and 89.8 percent, respectively. The overall discriminating capacity of MRI was significantly better than that of mammography (P<0.05). The proportion of invasive tumors that were 10 mm or less in diameter was significantly greater in our surveillance group (43.2 percent) than in either control group (14.0 percent [P<0.001] and 12.5 percent [P=0.04], respectively). The combined incidence of positive axillary nodes and micrometastases in invasive cancers in our study was 21.4 percent, as compared with 52.4 percent (P<0.001) and 56.4 percent (P=0.001) in the two control groups.
Conclusions: MRI appears to be more sensitive than mammography in detecting tumors in women with an inherited susceptibility to breast cancer.
Breast Cancer Vaccine Trials Are Underway for Those Diagnosed With Breast Cancer
A Phase I B breast cancer vaccine trial is underway in two sites for preventing breast cancer. A natural protein HER-2 on the cancer tumor becomes the growth center for the tumor. The vaccine, called E-75, mimics the protein and primes the cells to sensitize T cells to recognize them as if they were HER-2, providing protection.
Coordinated through Walter Reed Army Medical Center, eligibility for participants in the clinical trials research for a breast cancer vaccine is strictly for persons who have been diagnosed with breast cancer. For additional information on the breast cancer vaccine trial, call Dr. George Peeples at (202) 782-9698 or the Joyce Murtha Breast Care Center toll-free at (866) 253-4703.
Women Seeking Only a Second Opinion May Not Always Be Seen
In a surprising move, the University of Texas M.D. Anderson Cancer Center will no longer provide second opinions to breast cancer patients who intend to be treated elsewhere. The Breast Center will provide second opinions to women “considering treatment” at their facility, but will not accept patients who state that they plan to take this leading facility’s advice back to their hometown doctors. Both ethicists and breast cancer advocates are questioning this type of policy, as it may discriminate against women who have limited access to health care, or whose physicians do not offer the latest advances in breast cancer therapy, or deny their right to equal access of information.
Ask Your Patients What Alternative Medicine They Use To Avoid Drug Interactions
Alternative medicine use is a fact of today’s practice. With disappointing results from randomized controlled trials of hormone replacement therapy, women are left to alternatives. But it’s not only women who use alternative medicines that may interact with local anesthesia and prescription drugs. A 1990 Harvard study estimated that a third or more of Americans used alternative methods (about 60 million people) with an estimated annual out-of-pocket cost of $14 billion. About 20 million people saw alternative practitioners, with most not disclosing that information to their physicians or dentists. Be sure to ask about alternative medicine use on your health history update.
Eisenberg DM, et al. Unconventional medicine in the U.S. Prevalence, costs, and patterns of use. New England J of Med. 1993; 328, 246, 28.
Financial Disclosure for Authors of Scientific Studies
The Center for Science in the Public Interest found that authors of published scientific studies in prestigious medical journals failed to disclose their financial conflicts of interest. The Center reviewed four journals: The New England Journal of Medicine, The Journal of the American Medical Association, Environmental Health Perspectives, and Toxicology and Applied Pharmacology. Disclosure of financial interests by authors has come under increasing scrutiny and the Center found that authors of nearly eight percent of articles (13 of 163) did not disclose potential financial conflicts of interest with drug or industry.
* ... to Dr. Martha Carr for the new addition to her family: Elise Claire Falkenstein born on Aug. 12, 2004. Congrats to a whole new generation of future women dentists!
* ... to Dr. Jeanne Sinkford for pioneering efforts in assisting all women and minorities to be included in the policies and advancement into academic leadership formally at the American Dental Education Association. Kudos also for spearheading and planning the Sept. 2005 Montreal meeting of the Third International Women’s Leadership Conference, in conjunction with the Federation Dentaire Internationale.
AOS (American Orthodontic Society) - Oct. 21-24, 2004; Westin Riverwalk; San Antonio, Texas; www.orthodontics.com; (813) 264-6677
GNYDM (Greater New York Dental Meeting) - Nov. 26-Dec. 1, 2004; Jacob K. Javitz Center; New York, N.Y.; www.gnydm.com; (212) 398-6922
Yankee Dental Congress (Mass. Dental Society) - Jan. 27-30, 2005; Hynes Convention Center; Boston, Mass.; www.yankeedental.com; (508) 480-9797
CDS (Chicago Midwinter Dental Meeting) - Feb. 24-27, 2005; McCormick Place Lakeside Center; Chicago, Ill.; www.cds.org; (312) 836-7300
American Cancer Society Recommendations for Early Breast Cancer Detection
• Women age 40 and older should have a screening mammogram every year and continue to do so as long as they are in good health.
• Women in their 20s and 30s should have a clinical breast examination (CBE) as part of a periodic (regular) health exam by a health professional preferably every three years. After age 40, women should have a breast exam by a health professional every year.
• For more information, go to http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_ be_found_early_5.asp.
Other Breast Cancer Resources
• Agency for Health Research and Quality - http://www.ahrq.gov/research/brstinfo.htm
• American Medical Women’s Association Position on Breast Cancer Detection - http://www.amwa-doc.org/index.cfm?objectid=0A902656-D567-0B25-50051C751AD3100A
• Centers for Disease Control and Prevention - http://www.cdc.gov/cancer/nbccedp/Age
• For local and state databases with information on sites in your area for early detection of breast cancer - http://www.cancercare.org/HelpingHandsGuide/DatabaseSearch.cfm
• National Cancer Institute, National Institutes of Health - http://www.cancer.gov/cancerinfo/pdq/screening/ breast/HealthProfessional
• Programs for Needy Women Through Avon Breast Cancer Crusade - http://www.avonbreastcare.org
• Support for Breast Cancer Awareness and Detection, Susan G. Komen Race for the Cure, and walks in your area - http://www.komen.org
“Early detection through screening is our best defense against morbidity and mortality from breast and cervical cancers and precancers.” - Julie L. Gerberding, MD, MPH, Director, Centers for Disease Control and Prevention