Running Head: BREAST CANCER SCREENING: EARLY DETECTION VS OVER DIAGNOSIS

Breast Cancer Screening: Early Detection vs Over Diagnosis Ainsley Pauley University of New Hampshire NURS 901

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Abstract Breast cancer has become a globally noted issue within health care and is one of the most highly researched cancers within the United States. Through this research, the use of mammograms as a screening technique has become a current policy, endorsed by several researching agencies. Mammograms have been proven to detect early stages of breast cancer and therefore reduce mortality rates. However, the use of this screening technique has also created the rising dilemma of over diagnosis, associated with emotional and physical distress for the patient, as well as costly additional interventions. This paper will discuss both the successes of mammograms as well as the set-backs, and includes recent literature reviews and research articles. In summary, a personal statement is included with suggestions for future care.

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Breast Cancer Screening: Early Detection vs Over Diagnosis

Breast cancer research and knowledge has increased greatly over the past decade, with new strides made in understanding preventative care methods, treatment regiments and life style modifications. The biggest growth in this area has been the focusing on early recognition and self examination methods, to enhance the patients own self care practices, as well as detect cancer in its earliest stages, optimizing outcomes.

Part of this movement has included mammograms, routinely screening asymptomatic women aged 50-74, as identified in several national guidelines like the American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP), published on the National Guideline Clearinghouse, 2011. Although both organizations support the routine examinations, there are differing opinions on frequency, most often said to be every one to two years. The Centers for Disease Control and Prevention also follows the guidelines set by the ACP and the ACOG and makes recommendations based upon these, as well as funds their own research and community programs. Funded federally, these organizations focus their money on specific parts of breast cancer research, and could change the amount of money allotted for such a task. As reported by the NCI, their 2010 budget for breast cancer research was $631.2 million, far more than any other type of cancer.

The mammogram screening has been heavily supported by research, with one such study by van Schoor, et al., 2011, stating there was a 65% reduction in breast cancer mortality with the inclusion of mammographic screening during the years of 1992-2008 (van Schoor, et al., 2011).

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In an article by Harvard Medical School in Harvard Womens Health Watch, 2012, it discussed a study done in Sweden, completed in 2011 that tracked over 100,000 women for thirty years. What they found was women who had mammograms were 30% less likely to die from breast cancer when compared to those who did not. They also included a study published in the journal of Cancer Epidemiology, Biomarkers and Prevention, done in the Netherlands that concluded mammograms may be able to lower the odds of dying from breast cancer by half (Havard Medical School, 2012).

The ideal age to begin breast cancer screening is a widely discussed topic, with several organizations endorsing various age groups. Overall, the age of 50 is recommended to begin the screening process. However, the American Cancer Society and the National Cancer Institute both recommend starting at an earlier age of 40 while the United States Preventative Services Task Force supports the original age of 50. All clearly state that this decision should be made based on the womans personal risk factors, ie age, family history, etc., and based upon conversations with their primary care providers. In the meta analysis by Fletcher, 2012 on the UpToDate resource, the conclusion is that women between the ages of 50 and 70 be screened and that the benefits and risks of these screenings should be reviewed with the patient.

Over Diagnosis There are risks that are introduced with breast cancer screening. Besides increased exposure to radiation, the mammograms often introduce false-positive results, leading to an over diagnosis

Breast Cancer Screening: Early Detection vs Over Diagnosis 5 and an overuse of unnecessary medical interventions and time. The National Cancer Institute acknowledges that most abnormal test results turn out to not be cancer, and can lead to riskier interventions being done (NCI, 2012). According to a report by Moynihan, et al., 2012, up to 1 in 3 breast cancers may be overdiagnosed, and the costs of treating these mis diagnosed cases could take away from funds for individuals with actual illnesses (Moynihan, 2012). This creates a developing issue within the health care field, as more and more preventative care is practiced, more money and energy is being spent on the interventions, with a related increase of false positive, or benign results.

A false positive result negatively impacts the patient emotionally as well, and can cause months of additional fear and stress (Gotzsche & Nielsen, 2011). The health care agency clearly wants the best evidence based practice, and to provide accurate and efficient care. It would be in their best interest to provide their patients with reliable interventions as well as promote their institute as deeply rooted in evidence based practice. This dilemma calls for an increase in the research being done on early screening, and perhaps identifying alternative ways to screen for early stages of breast cancer that are more reliable and accurate.

A recent study done by Kalager, et al., 2012, found that patients screened for breast cancer with a mammography are often overdiagnosed, which is defined as cancer that is made apparent through screening that otherwise would have not been symptomatic or caused harm. Through their study comparing invasive breast cancer incidences with or without screening, they concluded that 15-25% of cancer cases are over diagnosed (Kalager, et al., 2012). This was also confirmed by another study of Gotzsche and Nielsen, 2011, in which they compared those who

Breast Cancer Screening: Early Detection vs Over Diagnosis 6 received mammographic screening to those who did not, and found a 30% rate of over diagnosis with mammograms, concluding that for every 2000 women, 200 would experience life altering distress and interventions that were not needed (Gotzsche & Nielsen, 2011).

Although the risk of overdiagnosis is significant, it has not affected the now standing policies and guidelines, because early preventative care as a result of these mammograms have reduced mortality from breast cancer greatly. And now with the passing of the Affordable Care Act, breast cancer mammogram screening will be covered for women over 40 (Health care, 2012). Considering the cost of care for breast cancer, reported by Kruse et al.,2008, to be an approximate $5,000 per patient per month in the US, with the increase use of the health care resources to be screened, one can predict a related increase in mis-diagnosis and therefore increase in costs for the patient. This was echoed by Dr. Barry Kramer, director of the Division of Cancer Prevention for the NCI, who explained ..with increasingly sensitive screening tests for a variety of cancers, [this] problem is likely to increase (Winstead, 2012).

Alternatively, the mammogram and other early screening techniques have cued health care providers in on early stage cancer, and therefore result in much better outcomes for the patients. By providing easy, accessible resources for the public and uninsured, complications from breast cancer can be avoided. In a sad yet true case study of an uninsured woman in Minnesota, by C., 2011, her limited access to a mammogram screening and inability to afford the care associated with her diagnosis resulted in an untimely death and preventable case.

Breast Cancer Screening: Early Detection vs Over Diagnosis 7 Through the efforts of the ACA related programs and Medicaid, access to earlier screenings will be available, but as discussed, how reliable these screenings will be are a controversy. Insurance companies will not cover screening if it is deemed unreliable or considered an unneeded step, and so determining the necessity of a mammogram screening and the costs associated with it would be a priority. As of now, Medicare will cover annual screening for participants 40 or older, and there are low cost or free mammography programs through NCI (NCI, 2012). Policy makers have paid special attention to this aspect of care, as much research has been put in into determining the age range and frequencies of these screenings, however, these policies can be adapted as better evidence and research is completed.

Nursing Implications Nursing implications regarding this particular health care discrepancy include keeping the patient current and informed with all the resources available to them. Pointing them in the right direction for programs that will help them with their finances and make health care access equal and realistic for them would also be important. Another task would be providing the patient with unbiased, current information regarding their procedures, implications of the results, as well as the potential for false results. As a nurse leader or researcher for the institution, efforts should be put forth to identify up- coming advances in preventative and preliminary screening that would lead to more accurate results. In considering this topic, one such research advance would be the First Warning Breast System, which is a non-invasive temperature analysis of breast tissue. This new intervention would provide highly accurate readings on breast tissue and aid in identifying abnormal cell growth in

Breast Cancer Screening: Early Detection vs Over Diagnosis 8 the earliest of stages. It could also reduce the number of mis diagnosed or undiagnosed tumors as well as provide the results quickly and efficiently (First Warning Systems, 2012).

Alternatively, further research into screening methods for breast cancer led to the article by Fletcher, MD, 2012,stating that no agency recommending screening techniques currently endorses thermography, as there has been limited research in proving its efficacy, and it too demonstrates a greater risk of false positives, as well as false negatives. With public statements made, the American Cancer Society and the American College of Radiology specifically implied they do not support the current methods of thermography. Furthermore, the FDA issued a public communication alert, indicating that thermography is not a replacement for mammography, and cannot be used by itself for cancer detection (FDA, 2011).

It is clear that there are conflicting and biased research results available, and so, another nursing implication would be to see through these resources and find information that is true, unbiased and clinically supported and accepted.

Personal Statement After considering the research and evidence explored within this paper, and despite the growing issue with over diagnosis, I find no clinical evidence suggesting a better alternative for mammographic screening. Although over diagnosis is a real issue, and a costly one as well, I believe that the benefits seen with early screening outweigh the risks of potentially having a false positive. This is supported through the meta analysis by Fletcher, 2012, which concluded that benefits considered as lives saved and life years gained per 1000 women were far greater than

Breast Cancer Screening: Early Detection vs Over Diagnosis 9 false positives, although many women would be harmed by the additional interventions for every life saved. Also supportive research by the FDA which stated that newer interventions such as thermography was unreliable as a replacement for mammography suggest that mammography still remains as the best first screening technique.

In order to acknowledge the over diagnosis issue, a discussion must be had with the patient receiving the intervention. It must be clear that although mammographies are supported by the major institutes in North America, it is not a definitive action, and does involve some risks, both physically and emotionally. Early screening has proven to reduce mortality rates of breast cancer, but could potentially lead to unnecessary interventions. Providing easily understood verbal and written education to the patient will allow for simple communication and a reduction in patient distress. Also providing online resources and community resources to help explain and even finance health care decisions would create quality, holistic care for the patient, so that they feel confident making their decision.

In an effort to reduce the over diagnosis crisis, as well as improve the accuracy of early screening, I believe that the NCI, as well as other federally, publicly or privately funded institutes need to focus their research efforts into better screening techniques. The mammography was a break through intervention, however, as screening becomes more in depth and more detailed, it has unveiled a new group of complications. Quicker, efficient and reliable screening interventions would result in better patient care, accurate interventions provided, reduction in patient and hospital costs, and an overall improvement in quality of care for breast cancer.

Breast Cancer Screening: Early Detection vs Over Diagnosis 10 Conclusion Breast cancer research has made incredible strides towards early detection, patient advocacy and preventative care, and has been able to reduce mortality rates considerably. With this success comes the issue of over diagnosis and false positive results, which contribute to the emotional and physical distress associated with the idea of cancer. As health care providers, it is extremely important to provide accurate and up to date information regarding these topics to patients, so that mutual decisions can be made in the best interest of the patient. With the downside of increasing expenses for patients and hospitals through unnecessary interventions, the lives potentially saved exceed this harm. It is crucial to be realistic with mammography screening, understanding that it is not a diagnosis, but a helpful intervention to prevent extreme complications from breast cancer. As more research is developed and financed, a focus on improving this process would ultimately improve the lives of many women and men.

Breast Cancer Screening: Early Detection vs Over Diagnosis 11 References

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Centers for Disease Control and Prevention. (2012). Breast Cancer. CDC. Retrieved from: http://www.cdc.gov/cancer/breast/what_cdc_is_doing/index.htm

FDA. (2011). FDA safety communication:breast cancer screening-thermography is not an alternative to mammography. US Food and Drug Administration. Department of HHS. Retrieved from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm257259.htm

First Warning Systems, Inc. (2012)Breast cancer and early screening.First Warning Systems. Retrieved from: http://www.firstwarningsystems.com/technology.html Fletcher, S W, MD. (2012). Screening for breast cancer. UpToDate. Retrieved from: ecapp1003p.utd.com-132.177.228.65-3A564865C3-243782.14

Gtzsche PC, Nielsen M. (2011). Screening for breast cancer with mammography.Cochrane Database Syst Rev. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/19821284

Breast Cancer Screening: Early Detection vs Over Diagnosis 12 Havard Medical School. (2012).Do you need mammograms?: Before you get your next mammogram, learn the pros and cons of this controversial screening test. (2012). Harvard Women's Health Watch, 19(10), 1-7. Retrieved from: http://search.ebscohost.com.libproxy.unh.edu/login.aspx?direct=true&db=rzh&AN=2011 564597&site=ehost-live

Health Care (2012). Preventative Services Covered Under the Affordable Care Act. Retrieved from http://www.healthcare.gov/news/factsheets/2010/07/preventive-serviceslist.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen

Kalager, M., Adami, H., Bretthauer, M., & Tamimi, R. (2012). Overdiagnosis of invasive breast cancer due to mammography screening: results from the norwegian screening program. Annals Of Internal Medicine, 156(7), 491-499

Kruse GB, Amonkar MM, Smith G, Skonieczny DC, Stavrakas S. (2008). Analysis of costs associated with administration of intravenous single-drug therapies in metastatic breast cancer in a US population. J Manag Care Pharm. 2008;14:84457. Moynihan, R., Doust, J, Henry, D. (2012). Preventing overdiagnosis: how to stop harming the healthy. BMJ, doi: 10.1136/bmj.e3502.

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National Guideline Clearinghouse (NGC)(2011) Guideline synthesis: Screening for breast cancer in women at average risk. In: National Guideline Clearinghouse (NGC) [http://guidelines.gov/syntheses/synthesis.aspx?id=35284&search=breast+cancer]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 1998 Dec

van Schoor, G. G., Moss, S. M., Otten, J. M., Donders, R. R., Paap, E. E., den Heeten, G. J., & ... Verbeek, A. M. (2011). Increasingly strong reduction in breast cancer mortality due to screening. British Journal Of Cancer, 104(6), 910-914. doi:10.1038/bjc.2011.44

Winstead, E.R. (2012). Norwegian study estimates overdiagnosis of breast cancer from screening.National Cancer Institute. April 17 2012. 9 (8). Retrieved from: http://www.cancer.gov/ncicancerbulletin/041712/page5