Editorials

Screening for Breast Cancer

Am Fam Physician. 2000 Aug 1;62(3):500-501.

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In this issue of American Family Physician, Dr. Apantaku's article, titled “Breast Cancer Diagnosis and Screening,”1 provides a useful overview of issues that pertain to breast cancer. The importance of this topic is confirmed by the emphasis that breast cancer is accorded in the recently published Healthy People 2010.2 Objective 3–3 in Healthy People 20102 establishes the target of reducing the death rate attributable to breast cancer by 20 percent by the year 2010. As cited by Apantaku,1 the incidence of breast cancer is higher in white women than in black women aged 50 and older. Yet, the breast cancer mortality rate in 1997 was 28.0 deaths per 100,000 in white women of all ages, compared with a rate of 37.7 deaths per 100,000 in black women.2 Attention to facilitating earlier diagnoses of breast cancer must be a high priority, especially among black women.

Objective 3–13 in Healthy People 20102 articulates the goal of “increas[ing] the proportion of women 40 years and older who have received a mammogram within the preceding two years.” The target for 2010 is that 70 percent of women in this age group would have had a mammogram during the preceding two years.

There is a direct association between level of education in women and adherence to mammography screening guidelines. When queried in 1994, only 47 percent of women with less than a high school education had received a mammogram during the past two years, compared with 67 percent of women who had at least some college education.2 Family income was also found to affect use of mammography, with poor and near-poor women having adherence rates of 43 and 48 percent, respectively, compared with a rate of 67 percent in women in middle- or high-income brackets.2 Given the inequities in the present health care financing system, clinicians face a challenge when trying to help uninsured and underinsured women with the lowest adherence rates and lowest incomes obtain their mammograms at the recommended intervals.

Debate persists regarding whether women ages 40 to 49 years should receive routine mammography.3 A meta-analysis4 performed in 1995 found a reduction of 20 to 39 percent in breast cancer deaths in women ages 50 to 74 years and of 17 percent in women ages 40 to 49 years who had received mammography screening. Other researchers5,6 dispute these data, stating that randomized trials have not yet shown conclusively that periodic mammographic screening for women aged 40 to 49 improves survival. The 1997 National Institutes of Health Consensus Development Conference recommended that the low-risk woman aged 40 to 49 years “should decide for herself whether to undergo mammography.”7 The American Academy of Family Physicians' (AAFP) practice guideline recommends discussing the risks and benefits of mammography with women between the ages of 40 and 49 and recommends encouraging women between the ages of 50 and 69 to obtain mammograms every one to two years.

Despite the data showing the effectiveness of early detection of breast cancer in reducing mortality in women 50 years and older, very few physicians have reminder and tracking systems in their practices to aid with the provision of preventive services. Studies have shown that using computer-generated reminders can increase mammography screening compliance.8,9 Bruce Bagley, M.D., president of the AAFP, emphasizes the need for more physicians to use electronic medical records in their practices.10 Such systems can be used to track the adherence of patients to a wide range of preventive service guidelines and to prompt physicians and patients when screening procedures, such as mammograms, are due.

Use of tamoxifen has been shown to reduce the incidence of breast cancer in high-risk women.11 Additional research studies designed to better identify factors that will decrease the risk of breast cancer in women will assist in determining which patients to target with more vigorous screening programs.12 In the meantime, it is incumbent on physicians to remain well-informed about recommendations for breast cancer prevention and early detection, and to employ systems in their practices to help them improve the prevention and early detection of diseases such as breast cancer.

Dr. Garr is the Associate Dean for Primary Care and Professor of Family Medicine at the Medical University of South Carolina College of Medicine, Charleston. He graduated from Duke Medical School and served a family practice residency at Highland Hospital in Rochester, N.Y. He completed a cancer prevention research fellowship at the Fred Hutchinson Cancer Prevention Research Program in Seattle, Wash. His areas of special interest are preventive medicine and community-oriented primary care.

Address correspondence to David R. Garr, M.D., Department of Family Medicine, 295 Calhoun St., P.O. Box 250192, Charleston, SC 29425.

REFERENCES

1. Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician. 2000;62:596–602.

2. Healthy People 2010 (Conference Edition). Vol 1. U.S. Department of Health and Human Services, 2000.

3. Kopans DB. The breast cancer screening controversy and the National Institutes of Health Consensus Development Conference on Breast Cancer Screening for Women Ages 40–49. Radiology. 1999;210:4–9.

4. Kerlikowski K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. JAMA. 1995;273:149–54.

5. Sirovich BE, Sox HC Jr. Breast cancer screening. Surg Clin North Am. 1999;79:961–90.

6. Sox HC. Current controversies in screening: cholesterol, breast cancer, and prostate cancer. Mt. Sinai J Med. 1999;66:91–101.

7. National Institutes of Health Consensus Development Panel. NIH Consensus Development Conference Statement: breast cancer screening for women ages 40–49. January 21–23, 1997. J Natl Cancer Inst. 1997;89:1015–20.

8. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. J Fam Pract. 1991;32:82–90.

9. Cooley KA, Frame PS, Eberly SW. After the grant runs out. Arch Fam Med. 1999;8:13–7.

10. Bagley B. Personal communication to American Academy of Family Physicians' members, February 2000.

11. Fisher B, Costantino JP, Wickerham DL, Redmond CK, Kavanah M, Cronin WM, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90:1371–88.

12. Armstrong K, Eisen A, Weber B. Assessing the risk of breast cancer. N Engl J Med. 2000;342:564–71.


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