Editorials

Screening for Breast Cancer

DAVID R. GARR, M.D.
Medical University of South Carolina
Charleston, South Carolina

See article in this issue.

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 researchers^5,6 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.

REFERENCES

1. Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician 2000;62:596-602,605-6.
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 40­49. 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 40­49. 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.

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.

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Meningococcal Vaccine for College Freshmen

James C. Turner, M.D.
University of Virginia School of Medicine
Charlottesville, Virginia

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has modified its guidelines¹ for use of the meningococcal polysaccharide vaccine in the prevention of bacterial meningitis and septicemia. The changes are particularly significant for college freshmen who live in dormitories, a group that has been found to be at a modestly increased risk of meningococcal disease compared with other college students.¹

During its fall 1999 meeting, ACIP reviewed published data^2-5 and data from studies recently conducted by the CDC, which identified a sixfold to sevenfold increased risk of invasive meningococcal disease among freshman dormitory residents compared with all college students.⁴ As a result, ACIP recommended that those who provide medical care to this group inform students and their parents about meningococcal disease and the benefits of vaccination. Vaccination should be provided for or made available to freshmen who wish to reduce their risk of disease. Other nonfreshmen undergraduate students who wish to reduce their risk for meningococcal disease may also choose to be vaccinated.¹

College students are likely to be at greater risk for meningococcal disease for the same reasons that 15- to 19-year-old students have a higher incidence of endemic disease than the general population. This elevated incidence has been attributed to risk factors associated with meningococcal transmission and invasion, such as crowding, active or passive smoking, and exposure to oral secretions and strains of Neisseria meningitidis to which there was no previous exposure during early childhood.⁶ The risk may be increased by features of college life, such as dormitories crowded with students of diverse geographic backgrounds, frequent respiratory infections and patronage of bars or parties with students jammed into smoke-filled rooms.

Other evidence supports the potential benefit of immunization of college students. Although rare, this bacterial infection has unacceptably high rates of morbidity and mortality. Despite prompt diagnosis and treatment, the case fatality rate of invasive meningococcal disease remains unchanged at 10 percent.⁶ Among survivors, 3 to 15 percent suffer permanent sequelae such as skin scars, amputation, hearing loss and renal problems.⁷ Also, serogroup distribution has changed significantly in the past 10 years, and now 70 to 80 percent of cases among college students are potentially preventable with vaccination.^3,4 Furthermore, compared with serogroup B, case fatality rates are higher among patients infected by vaccine-preventable serogroups, and permanent sequelae are more frequent as well.^6,7

A compelling argument against preexposure immunization of college students can be made from a public health perspective. A cost benefit to society cannot be demonstrated because the disease is rare, protective antibodies last only three to five years, and the vaccine lacks coverage for serogroup B (which accounts for up to 30 percent of cases of disease); therefore, the cost of vaccination of college students is greater than the societal cost of disease.⁸ As a result, ACIP has not drafted a stronger recommendation to avoid committing limited public health resources to a meningococcal vaccination program.

However, the economic analysis has not taken into account the costs associated with long-term care (hemodialysis and renal transplantation), rehabilitation (prostheses, physical therapy), social services (disability, Medicaid), university response to the public health crisis or medicolegal consequences. It is difficult to include these factors in a cost-benefit analysis because specific data are not readily available. Interestingly, a recent report demonstrated that malpractice claims related to meningitis contribute significantly to societal costs, with nearly $92 million paid to plaintiffs between 1985 and 1997.⁹

A cost benefit to society will likely be realized in the future when longer lasting conjugate vaccines and an immunogenic serogroup B vaccine are successfully developed.⁶ In the meantime, a stronger recommendation from ACIP is unlikely and, therefore, a decision about vaccination is one of personal choice. Thus, physicians must be prepared to give college-bound students and their parents accurate information about the relative risks of meningococcal disease and the potential benefits of vaccination and must be willing to make the vaccine available on request. Physicians can anticipate that in the near future more universities will include the meningococcal recommendation on immunization forms, and more students and parents will be requesting the vaccine.

Having observed the horrific toll of meningococcal disease on college students and their families and having experienced the profound disruption and cost to a university, I welcome the ACIP recommendation as a step in the right direction. It will facilitate the education of parents and students about this rare but dreadful disease and afford them the opportunity to make informed choices about vaccination. If enough students elect to receive vaccine, many will be spared the ravages of meningococcal disease, and fewer colleges will have to deal with the public health crisis associated with one or more cases.

REFERENCES

1. Centers for Disease Control and Prevention. Division of Bacterial and Mycotic Diseases. Meningococcal disease and college students. Retrieved June 29, 2000, from the World Wide Web: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4907a2.htm.
2. Froeschle JE. Meningococcal disease in college students. Clin Infect Dis 1999;29:215-6.
3. Harrison LH, Dwyer DM, Maples CT, Billman L. Risk of meningococcal infection in college students. JAMA 1999;281:1906-10.
4. Bruce M, Rosenstein NE, Capparella J, Perkins BA, Collins MJ. Meningococcal disease in college students. [Abstract]. Abstracts of the 37th Annual Meeting of the Infectious Diseases Society of America. Philadelphia, Pa., November 18-21, 1999.
5. Neal KR, Nguyen-Van-Tam J, Monk P, O'Brien SJ, Stuart J, Ramsay M. Invasive meningococcal disease among university undergraduates: association with universities providing relatively large amounts of catered hall accomodation. Epidemiol Infect 1999; 122:351-7.
6. Rosenstein NE, Perkins BA, Stephens DS, Lefkowitz L, Cartter ML, Danila R, et al. The changing epidemiology of menigococcal disease in the United States, 1992-1996. J Infect Dis 1999;180:1894-901.
7. Erickson L, De Wals P. Complications and sequelae of meningococcal disease in Quebec, Canada, 1990-1994. Clin Infect Dis 1998;26:1159-64.
8. Jackson LA, Schuchat A, Gorsky RD, Wenger JD. Should college students be vaccinated against meningococcal disease? A cost-benefit analysis. Am J Public Health 1995;85:843-5.
9. Delmar D. California tort reform law facing challenges. Physicians Financial News July 15, 1998; 16(10):S4,S14.

Dr. Turner is an associate professor of clinical internal medicine and director of student health services at the University of Virginia School of Medicine, Charlottesville. He also chairs the Vaccine Preventable Task Force of the American College Health Association and served on the work group on meningococcal vaccination for the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

Address correspondence to James C. Turner, M.D., Elson Student Health Center, 400 Brandon Ave., P.O. Box 800760, Charlottesville, VA 22908-0760.

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