The New Mammogram Recommendations
November
26 ,
2009
The dust has yet to settle on the latest hot topic in obgyn, but it is important for us to consider the latest recommendations of the U.S. Preventive Services Task Force (USPSTF) in our blog. Certainly, anyone who has recently watched the news or read a newspaper has heard about the latest mammogram recommendations that have come from this government sponsored organization.
First, let me summarize exactly what they said. They basically made five recommendations, as follows:
The USPSTF recommended against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
The USPSTF recommended biennial screening mammography for women aged 50 to 74 years.
The USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
The USPSTF recommended against teaching breast self-examination (BSE)
The USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
This was a change from previous recommendations from 2002, where they recommended that women over 40 get bienniel screening, and that there was insufficient evidence for recommending for or against both BSE and CBE.
There has been an uproar among medical societies and in the lay press, and among concerned people across the country, especially over the recommendation NOT to routinely screen women over 40. The main reason for this uproar is that aproximately 17% of breast cancers occur in women ages 40-50. According to ACOG, (the American College of Obstetricians and Gynecologists) approximately 6,800 lives are saved every 10 years in the US by routine screening mammography in women ages 40-50.
Doing away with an intervention that has been PROVEN to save 6,800 lives every 10 years, does not sound like very good medicine to me! So what in the world are they thinking? How could a medical organization make such recommendations regarding something that even they recognize will result in the loss of 6,800 lives? Here is their argument. Every intervention has both risks and benefits, and we need to consider the entire impact of every intervention, not just its benefits. So What negative impacts are there to doing screening mammograms on all women ages 40-50? Well, in the words of the USPSTF, "although women in their 40s and women in their 50s benefit equally from routine screening mammography, women in their 40s experience greater harms from screening than do women in their 50s. ..... Rather than benefit from screening, women without cancer who undergo mammography, additional imaging, and biopsies may incur harm. These outcomes were more common in women in their 40s (see Table). In addition, because the prevalence of breast cancer is higher in women in their 50s and because younger women are more likely to have dense breasts that may be difficult to assess on mammography, women in their 40s had more false-positive mammograms and underwent more additional imaging than women in their 50s."
According to ACOG, "The USPSTF also considered pain and psychologic responses as harms. The USPSTF notes that "anxiety, distress, and other psychosocial effects. . . fortunately are usually transient, and some research suggests that these effects are not a barrier to screening. . . Other potential harms, such as pain caused by the procedure, exist but are thought to have little effect on mammography use."
So the harms of routine mammography screening in this age group, outweigh the benefits, according to the USPSTF.
Now I am just a simple doctor, but I am absolutely baffled, amazed, and astounded by these recommendations. Without belittling the discomfort and inconvenience of getting mammograms, let's look at this for real. It saves 6,800 lives every 10 years! I agree that the pain of the procedure, the discomfort, the psychological harms and anxiety are important. But how can that compare to the pain of 6,800 women dying of cancer? How does that compare to 6,800 families who are left without a Mom, Wife, Sister, Aunt etc? How can you compare the anxiety of wiating for the result of a potentially unneccessary biopsy to the anxiety a family has when they need to adjust to a life without their Mom?
Am I crazy, or have they simply lost their mind? As far as unneccessary biopsies and complications are concerned, the biopsies done on breast masses are generally very low risk, and done under local anesthesia. While risks certainly do exist, they very rarely result in serious injury or harm.
Another point. They do admit that, "biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms".
Now THAT is quite a statement. There is NO guidance as to who fits into this nebulous group of where "context" should be taken into account. What about smokers? What about women who drink alcohol? What about women who are obese? What about women who never breastfed? What about women who never were pregnant? These are ALL women who are at slightly increased risk of developing breast cancer, so do they need screening? Frankly, if they DID need screening, that doesn't leave very many women who don't need screening anymore.
I am going to leave out the issues of CBE (clinical breast exam by the health care provider) AND BSE (breast self exam) for now. However, BTW, ACOG still recomeends these as well. We will have to discuss these issues at a later date.
I am very happy that ACOG and many other medical societies have not adopted these recommendations yet. Until I hear a really good explanation, I am sticking with the old guidelines.
When and how often do i need a pap smear?
November
16 ,
2009
In response to an overwhelming volume of questions about this confusing topic, I am writing this blog post to clear up for all of you these perplexing questions. How often do women need screening with annual pap smears? At what age should I start having pap smears? Will I need pap smears for the rest of my life?
Now let me make one thing very clear before I start. this refers to women with NO history of abnormal pap sm,ears or known cervical dysplasia. If you have been told by your doctor that you have had an abnormal pap smear, or that you have been diagnosed with HPV, or cervical dysplasia, then PLEASE follow your doctors instructions and follow up with appropriate care. However, if you have never had an abnormal pap, and you want to know how often you need routine screening, then the following guidelines apply to you.
These guidelines are according to ACOG - the American College of Obstetricians and Gynecologists.
Start pap screening at age 21, or three years after starting to have sexual intercourse
Stop Pap screening in older women is based on each individual (discuss this with your doctor, as this depends on each woman's history, but there will usually be an age beyond which you don;t need pap smeasr anymore)
Annual screen for all women under 30
Once you are over 30, reduce frequency of pap smeasr to every 2-3 years for women IF you have hadh 3 consecutive normal Pap test OR you have had a normal pap and a negative HPV screen.
If you have had a total hysterectomy (with removal of the cervix) for benign disease (not cancer) then you do not need pap smears anymore.
Pap screen should be combined with HPV testing in women over 30
I hope this clears up some of the confusion, and I welcome your comments. I'm especially interested in hearing from women who have been getting unnecessary pap smears.
I have been asked by so many people about this, I decided to write a blog post, despite the fact that there is SO much information about this vaccine in pregnancy already. We offer this vaccine in my practice to every pregnant woman when they come for their prenatal appointment. So obviously, I do encourage everyone to get it. Let me review the questions I get from women concerned about the vaccine.
Q # 1 Isn't this a new vaccine? Shouldn't I be concerned since it is so new and hasn't yet been tested on pregnant women?
A - It is not a new vaccine. It is the same vaccine as the regular flu vaccine, and it is made in the same way. Millions of pregnant women have received the flu vaccine over the years, and the safety record is well established. It is very important to understand a little bit about the flu virus. The flu virus is a very tricky virus. The same little virus has two major types, influenza A and influenza B. Each virus has certain antigens that the immune system recognizes, and helps identify the virus. The flu is very tricky, and it manages to switch the antigens constantly so the body has a hard time recognizing it. Every year, when they are developing the new vaccine, they try to identify what the antigens are that the flu will be using this year to trick your immune system. Once they identify these, they create a vaccine to help your body recognize and destroy this year’s version of the same old flu virus.
The H1N1 virus is simply just another type of influenza A, just like every year. The H1N1 vaccine is the same as every year's vaccine; just it is designed to fight this particular antigen called H1N12 that the flu is using to try to trick your immune system. So it is tested, and it is safe. There are also many ongoing trials that you can read about here.
Q # 2 - I'm worried about my baby, what if I get sick from the vaccine?
A - If you were really worried about your baby, then GET the vaccine! Pregnant women are MUCH more likely to be admitted to the hospital, to the ICU, and even to die from H1N1 than are non pregnant women. Do you think that would be good for the baby? I have unfortunately admitted at least three pregnant patients to the hospital, and believe me; you do not want to be one of them. Remember, everything you do in life is about risks and benefits.
Please use your head and weigh the risks and benefits of getting the shot, which has been proven to be safe, and getting the disease, which has been proven to be potentially deadly.
Q # 3 - Isn't there mercury in the shot? Won't that cause my baby to be autistic?
A - I will try to avoid the whole autism and vaccine debate as much as I can here. However, the fact is that thimerasol is used in the multidose vials that most people use for the flu shot. This is because it has been proven time and time again to be safe and effective, and it is used to preserve the vaccine to be used for multiple doses. The amount of mercury contained in the thimerasol in one dose of vaccine, is miniscule, and way less than you would get from a spoonful of tuna fish. If you are still concerned, there is supposedly a limited supply of thimerasol free vaccine available in single dose vials. However, I'm not sure how to get it, and I haven't seen too much of it around.
Please do yourself and your baby a favor and get the vaccine if you are pregnant. Please speak with your doctor if you have any other concerns. Please don't let yourself become another H1N1 statistic that could have been prevented.
