WHAT ARE THE BEST TESTS TO DETECT BREAST AND CERVICAL CANCER?

I am committed to sharing with you some of the highlights in medicine and science on a regular basis.  Here is one headline that caught my eye this week:

An Ultrasound and Mammogram May Be Better to Detect Breast Cancer in Women who are High Risk

Breast cancer remains the most common cancer and the most feared condition among women. Yet annual mammograms can miss early cancers, especially in women who have dense fibrocystic breasts. Recent guidelines from the American Cancer Society suggest that an annual MRI scan in addition to a mammogram would improve detection of early cancers, but is worth doing only for very high-risk women. The rest of us at average risk (1 in 50 chance at age 50 is considered average risk) would have too many false positive findings on the MRI and would be subjected to anxiety and way too many needless biopsies.

IN THE NEWS: A new study reported this week in the Journal of the American Medical Association (JAMA) found that in women with dense fibrocystic breasts, having an ultrasound in addition to a mammogram increased the chances of finding an early breast cancer - but at a cost. There were many more false positive ultrasounds. This means a number of women with positive tests did not have cancer but had needless biopsies and surely an untold amount of anxiety and stress.

So what is the best way to diagnose breast cancer earlier in women who are at the greatest risk either because they have an inherited breast cancer gene, a strong family history, or very dense fibrocystic breasts? Is an annual mammogram with MRI best? What about the less costly ultrasound along with mammogram? Will there come a time when annual mammograms will be replaced by an MRI or ultrasound for some women?

ON MY MIND: As with any screening test, the right balance seems to be doing the test(s) that lead to the best possible outcome – which also means taking in to account the cost, anxiety from false positive results, biopsies, and other unanticipated results. Unfortunately there is no perfect screening test that separates women with disease from women without disease 100% of the time.  And for breast cancer screening, I suspect that there will never be a one-size-fits-all approach. A woman’s age, her own preference, prior mammogram results, presence of fibrocystic breasts, use of hormones, family history and results of genetic testing will all factor in to a woman’s best decision. The financial cost and availability of the more sensitive and often more accurate digital mammogram (versus the traditional now “old-fashioned” x-ray) is important too.

This reminds me of the ongoing debate about the best way to screen for cervical cancer. Prior to the Pap test, cervical cancer was the number one cause of cancer death in women and remains the number two cause of cancer in the world today! Yet the Pap test is far from perfect - up to 40% of women diagnosed with cervical cancer had normal Pap tests prior to their cancer. Today we have a much more sensitive test for cervical cancer, the HPV test. This test is done at the same time as the Pap and checks for whether any of the high-risk cancer causing strains of the HPV/virus is present in the cervix. Only women who don’t get rid of the virus on their own and therefore test positive for the virus two years in a row are at risk of developing cervical cancer. Only women with two or more positive HPV tests or an abnormal Pap test should undergo more testing such as culposcopy (examining the cervix with a magnifying scope) and biopsy. Many gynecologists do not recommend the HPV test or even mention this option to their patients because they are worried that by doing the more sensitive HPV test, too many women will be needlessly worried and undergo unnecessary testing.

In truth I have found that most women want to know their options.  Whether women are being screened for breast cancer or cervical cancer, they would rather have a false positive result rather than risk missing an early cancer. So in the end, I believe that women need to be given as much information as possible on the pros and cons of every screening test given their unique circumstances so that they can share in the decision to screen with a particular test or not. When it comes to screening, shared decisions make for the best medicine.

As always, I welcome your questions and comments.

Warm regards,

Dr. Marie Savard
ABC News Medical Contributor


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