Doctors’ Orders Differ from Mammogram Guidelines

Study finds that most still recommend the breast cancer screen for women in their early 40s


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There are numerous expert organizations out there such as the ACR, SBI, ACOG, and NCCN that continue to recommend annual screening beginning at age 40. Even the ACS that supports annual screening beginning at age 40 OR 45. Only 1 organization, the USPSTF, recommends biannual screening beginning at age 50. The USPSTF analysis on which their recommendation was made admits more women will die from breast cancer with their recommendation. Why wouldn’t doctors continue to recommend screening beginning at age 40?.

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Is it Time to Move on from the Preoperative Wire Localization?

For those unfamiliar, preoperative wire localization is the procedure performed on the overwhelming majority of patients undergoing lumpectomy or excisional biopsy prior to surgery. The general idea is that one or more needles and wires are inserted into the area in question before surgery with imaging guidance to assist the surgeon in removing the correct area of the breast that could not otherwise be felt or seen by the surgeon. The procedure remains essentially unchanged from its development in the 1970s and has been performed on millions of women and thousands of men across the United States. Although without question this method is cheap, reliable, and effective, it also suffers from some limitations.

Wire Localization

One limitation is that the wire must be inserted on the day of the procedure, most often immediately before surgery. This not only creates an inconvenient rate-limiting step for all parties working the patient through the modern day surgical process, but more importantly it can become a safety issue. The pressure to rapidly move patients through the procedure on the day of surgery can be a source of latent errors. I have witnessed at least one sentinel event root cause analysis committee list an impatiently waiting surgical team and “time-crunch” as a reason for the wrong area of the breast being localized and subsequently removed.

Another important limitation often overlooked is patient comfort. At best, following the procedure a wire (and sometimes needle) is left dangling out of the breast with an awkward tape-job which sometimes includes a styrofoam cup or other device taped to the patients’ chest in order to secure the wire and or needle in an attempt to keep them from becoming dislodged and out of site. In patients requiring more than one wire for surgical planning, it can leave the patient looking like some awkward form of radio-frequency receiver. Both cases leave the patient feeling uneasy, sometimes even grossly nauseated while looking at their breast with wires hanging out of it prior to surgery. Quite simply the look and feel from the patient perspective is “barbaric.”

Throughout the years there have been numerous devices and procedures to improve on the traditional needle localization, but none have ever taken root in mainstream clinical practice patterns. There is a newer method however, which appears in my mind to potentially hold enough promise to prompt change from years of habit it in the breast imaging and surgical community. Specifically, the new device implants special reflectors in the breast that allows for radar localization. This allows for placement many days before surgery if needed and does not make the patient feel as uncomfortable. This month, original research was published about this method in the journal of Radiology that examined the effectiveness of this method using the Scout device in 100 women over the course of a year. The results showed that it was effective for localizing breast lesions even when reflectors were placed closely together to “bracket” the lesions.

Beyond Wires and Seeds: Reflector-guided Breast Lesion Localization and Excision. 

Given this evidence and the above considerations, I think this is an excellent time for the breast imaging and surgical community to start seriously considering changes or at least alternatives to the traditional wire localization procedure.

Ryan Polselli, M.D.
Fellowship Trained, Breast Imaging Radiologist

What Really was Said at the Water Cooler in 2009: USPSTF Breast Cancer Screening Recommendations and Current Physician Practice Patterns

In 2009 the United States Preventative Services Task Force (USPSTF) updated their now infamous breast cancer screening recommendations. In their report, the so-called experts (many of whom had no direct affiliation with patient breast cancer screening) voted that a total of 12 mammograms throughout a woman’s lifetime should be enough to effectively screen women for a disease that is the second leading cause of death among women in the United States and kills an average of 40,000 women every year.

Ryan Polselli Cartoon

These new recommendations came at a time when studies throughout the world were repeatedly confirming annual screening mammograms reduce breast cancer deaths anywhere between 30-45% with newer advances in screening and treatment decreasing the death rate an additional 2.5% each year. In essence, the recommendation to cut back on screening mammograms was made by the USPSTF at a time when mammography was being hailed as the poster-child of a successful cancer screening program. Contact us.

Not unexpectedly, when the report was originally released, most of the medical community and media gathered around the report like co-workers around the water cooler—everyone expected to discover the missing piece of evidence—perhaps there was some flaw in the system and perhaps mammograms were not as useful as we thought?

However, a review of the report still left most of the medical community scratching their heads. The report contained no evidence that mammograms were not doing their job or saving lives. There was actually evidence to the contrary. In fact, the USPSTF data even acknowledged that if their recommendations were followed, additional women would die. Some experts even estimated that up to 100,000 more women would die over time if the recommendations were adopted into mainstream clinical practice. Sure, most of the medical community understood the report was trying to make an argument for the potential harms that a woman could endure as a result of over-diagnosis from too many mammograms, but they couldn’t justify the lives lost. As a result, most in the medical community left the water cooler that day and returned to their desks unswayed from their decision to recommend annual mammograms. Most believed the task force simply voted the wrong way and that ultimately there was no more to the story.

But the story didn’t actually end there.

The majority of the media and a few impressionable souls in the medical community remained gathered around the water cooler that day. While the concept of mortality in the setting of breast cancer screening was perhaps the “real” news of the day, it wasn’t “exciting” news and quickly became overshadowed by discussion of the relatively new and intriguing concept of “over-diagnosis.” By 6 o’clock, all major networks became pseudo-educators for the masses and carried stories about the “harms of over-diagnosis” from annual screening mammography. In some circles, knowledge of the concept even became a surrogate marker for supposedly intelligent discussion of breast cancer screening.

All of this occurred without significant mention of the fact that more of the women we love—wives, mothers, and friends would die if these recommendations were adopted.

This month, JAMA Internal Medicine published a research letter showing that most practicing clinicians continue to recommend annual screening mammograms contrary to the USPSTF recommendations. While that’s no surprise, you wouldn’t know it by the recent headlines. You would think most doctors have lost their minds. I even read one article that went so far as to suggest insurance companies should take the lead and quit paying for yearly mammograms. Think about that for a moment. In any event, it seems that now is a good time to remind a majority of the media and some in the medical community about the original takeaway from the “water cooler discussion” in 2009.

Ultimately and always—Do no harm.

Ryan Polselli, M.D.
Breast Imaging Radiologist