If you are a woman, and you are reading this, odds are you are at increased risk for breast cancer. The U.S. task force recommendations made almost a year ago has everyone debating when mammograms should start. The decision to begin screening under age 50 has been described as discretionary. To quote the task force's confusing statement, "Offer or provide this service only if other considerations support the offering or providing the service in an individual patient." For many years 40 has been the traditional starting age, and remains the recommendation of most organizations participating in the care of women such as: ACOG, ACS, ACR, NCI and others.
Insurance companies will soon be considering restricting benefits to meet the controversial USPSTF recommendations for cost saving reasons. In the meantime, those of us in the business of caring for women are defending long standing routine screening and trying to help patients identify their individual risk factors to aid in the decision of when to start.
Who is at risk? Most of the factors have to do with anthropology, the purpose of the "equipment" we have and the way we choose, or more appropriately do not choose, to use our reproductive organs. Science allows that delaying childbearing and nursing increases the risk of unhealthy breasts. For example, women who wait until after age 30 to conceive have a significantly higher risk of breast cancer. Pregnancy has a protective maturing effect on the breast that helps the breasts' internal immune system; the earlier the first term pregnancy is completed, the lower the risk of breast cancer. Women over 30 who conceive for the first time (such as myself and many of my patients) are at even higher risk than those that never conceive because the increasing likelihood of a small cancer as we age, and the consequence of such a cancer being stimulated by the skyrocketing levels of female hormones associated with pregnancy.
Another contributing anthropologic change is our switch from an outdoor agrarian lifestyle to mostly indoor 24/7 urban living, significantly bringing down our vitamin D stores--low levels of which are now known to increase the risk of breast cancer (and many other disease states). Over processing our food has made it more shelf-stable and tasty, but contributes to obesity and diabetes, both of which again increase the risk of breast cancer.
So, do recent restrictive recommendations about breast cancer screening take into consideration the modern societal behavioral changes and how they affect current and future generations when assessing risk trends? The answer is no; that subject has not been sufficiently addressed ... it is being left to the individual woman and her doctor who may or may not see her yearly now that annual pap smears are being discouraged for many. So who is at risk? The answer is most of us.
Here are some of the factors associated with higher rates of breast cancer:
- Being a woman: When the most common cancer in our sex affects one in eight we all are at risk.
- Women who never conceive
- Women with a family history of breast cancer; the more first-degree relatives (mother, daughter, sister) affected, the higher the risk.
- Women who started menses prior to age 12
- Women who begin menopause after age 55
- Women over 40; the incidence of breast cancer jumps significantly at this age (under age 39, one in 206; age 40-50, one in 27).
- African American women -- actually the incidence is similar, but the mortality is higher. The reasons are not understood, but theories range from poor health care access to low vitamin D levels in African Americans.
- Women low in Vitamin D -- now a known risk factor that may explain why women living in areas of low sunlight have almost double the risk of those living in high sunlight areas.
- Women who have dense breasts -- breast cancer most often arises from the more dense ductal tissue in the breast; the more ducts, the higher the chances of the cancer developing.
- Women with a history of one or more breast biopsies; this may have to due with the predominance of more ductal tissue.
- Women with a history of an atypical breast biopsy
- Women with a history of chest wall radiation
- Women who take combination hormone replacement long term, such as Prempro
- Women exposed to DES while in utero, known as "DES daughters"
- Women who are obese
- Women who have type II diabetes
- Women with metabolic syndrome
- Women who do not exercise regularly
- Women who smoke
- Women who carry the rare hereditary gene alterations such as BRCA I and II and other related genes
- Women of Ashkenazi Jewish descent
- Women with insomnia, sleep apnea or working a night shift
- Women taking hormonal contraception
- Women who live with chronic stress
- Women who take steroids
- Women with depression
- Women who have had breast cancer are at higher risk for a second breast cancer
These are not all of the conditions associated with increased risk of breast cancer, but this list is enough to hint at the challenges with the "ask your doctor" approach as to who should have screening begin at 40.
I spoke with a physician employed by Cigna HealthCare yesterday during what is called
a "peer to peer" review concerning Cigna's denial of a breast MRI for one of my patients that met the latest American Cancer Society's recommendations due to her risk profile. He declined her coverage of the test because her risk factors did not meet "Cigna's requirements." I hung up the phone in my office and wondered-- he doesn't have to speak to her, or see her year after year; is he really my peer?
Women need to prepare for such battles for benefits and remember that times have changed. What used to be health care is now "health care system" because the "care" part by itself is not cost effective. Remember: stay informed, do what you can to lower your personal risks, and save your money for your mammogram, starting at age 40.
