Special CME Issue - West Virginia State Medical Association

Table 2. Mammography screening recommendations
5, 9, 10
and ACS still recommend it.
Breast self examination (BSE) has
a sensitivity around 26%. Two
large trials including over 300,000
women showed no difference in
breast cancer mortality with BSE,
and only one showed increased
detection. More biopsies were done
in the intervention arm so it may
do more harm than good. 12 ACS
and ACOG (American College
of Obstetrics and Gynecology)
recommend BSE with some
reservations. 9, 10 However, USPSTF
now recommends against teaching
BSE (D recommendation), a change
from their previous I statement. 5
This was announced with their new
mammogram recommendations,
adding to the screening controversy.
to recommend mammograms
every 2 years starting at age
50 (B recommendation). The
new recommendations call for
individualized decision-making
and consideration of benefits/
harms before the age of 50 (C
recommendation). 5 The task force
had previously recommended
annual mammography starting at
40. These guideline changes created
a significant amount of controversy,
and many politicians, health care
organizations, and US women
disputed them. One criticism was that
USPSTF did not emphasize the data
on life-years gained as much as the
data on mortality. Also, the CISNET
study was limited, as are all computer
modeling studies, by the fact that
modeling requires assumptions.
Many opponents disagreed with
the value judgments of the task
force, with some believing that
additional false positives, anxiety,
and cost are worthwhile if even a
small number of lives are saved.
Other organizations’ screening
recommendations vary, as shown in
Table 2. 8-10 ACP (American College
of Physicians) guidelines, which
preceded USPSTF, resemble the new
task force recommendations, and
were based on similar reasoning. 8
Guidelines in many other countries
such as Canada, Britain, and
Italy, as well as the World Health
Organization, target the age
group of 50-69 for screening. 11
Screenings with modalities other
than mammography have been
considered. Breast MRI is more
sensitive than mammography but
less specific. No mortality data is
available. Breast cancer screening
with MRI is only recommended by
ACS (American Cancer Society), and
only for high risk (>15% lifetime
risk, which can be determined by
online calculators that consider
risk factors). 9 USPSTF gives
screening breast MRI an I statement
for insufficient evidence. 5, 9
Recommendations for screening
with breast examination are
shown in Table 3. Clinical breast
examination (CBE) has a sensitivity
of 40-69%, specificity of 88-99%,
and a PPV of 4-50%. There is no
mortality data available. While
USPSTF says that the evidence is
insufficient to address CBE, ACOG
Cervical cancer
Cervical cancer is decreasing
in incidence, but is still the 10th
leading cause of cancer death in
women. Pap tests are the mainstay
of screening. HPV is known to be
a necessary precursor and HPV
testing can be done in conjunction
with a Pap test. Most cervical cancer
deaths occur in women who had
not been screened in the last 5 years.
Survival depends heavily on stage
at diagnosis. Ninety-two percent
will survive 5 years when cancer is
localized but only 13% will survive
distant disease. The sensitivity of a
single Pap test is 60-80% for highgrade
lesions. Observational evidence
strongly suggests that Pap test
screening programs reduce cervical
cancer incidence and mortality. 5
Institution of these programs is
considered to be one of the biggest
cancer screening success stories.
However, potential harms from
screening exist. Surgical intervention
such as LEEP (loop electrosurgical
excision procedure) for cervical
lesions has been associated with
approximately twice the risk of
preterm birth (RR 1.99, 95% CI 1.81-
2.2), and some of the increase in US
preterm births has been attributed
72 West Virginia Medical Journal