American Society of Breast Surgeons Issues Updated Breast Cancer Screening Guidelines

Among other recommendations, new breast cancer screening guidelines from the American Society of Breast Surgeons (ASBrS) say:

All women age 25 and older should have a formal risk assessment for breast cancer.

Women with an average risk of breast cancer should start annual screening mammograms at age 40.

Women with a higher-than-average risk of breast cancer should start annual screening mammograms at an earlier age and should be offered additional imaging each year.

The guidelines were announced on May 3, 2019, at the group’s annual meeting in Dallas. Read the American Society of Breast Surgeons Position Statement on Screening Mammography.” (PDF)

The mammogram debate

The new ASBrS screening guidelines differ from guidelines from the U.S. Preventive Services Task Force (USPSTF), which recommends that mammograms start at age 50, and the American Cancer Society, which recommends that mammograms start at age 45, and will likely stir up the debate about when mammograms should start and who should have a mammogram.

Several large studies, including a review by the USPSTF in 2009 and a study on the causes of death in the United Kingdom in 2013, have questioned the value of screening mammograms.

Doctors who question the value of mammograms say that while mammograms do save lives, for each breast cancer death prevented, three to four women are overdiagnosed. Overdiagnosis means either:

a screening mammogram finds a suspicious area that would have been eventually diagnosed as cancer by other means, without any effect on prognosis

a screening mammogram finds a suspicious area that never would have affected a woman’s health if it hadn’t been found or treated

False-positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening. When a mammogram shows an abnormal area that looks like a cancer but turns out to be normal, it’s called a false positive. Ultimately the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures, including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.

Since 2013, the American Medical Association, the American College of Obstetricians and Gynecologists, the American College of Radiology, the National Cancer Institute, and the National Comprehensive Cancer Network all have issued guidelines saying that all women should be eligible for screening mammograms starting at age 40.

"Initiating screening mammography at age 40 undoubtedly saves more lives through early detection of disease compared to alternative schedules, and was therefore the 'traditional' age recommended in clinical practice until approximately 10 years ago, when the USPSTF published a revised guideline," Lisa Newman, M.D., chief of breast surgery at New York-Presbyterian/Weill Cornell Medicine in New York City, said in an interview. Newman was one of the authors of the new ASBrS guidelines.

"The ASBrS position statement advocates for annual screening mammography beginning at age 40 years, because we have chosen to prioritize the life-saving benefits of screening mammography," Newman added. "Furthermore, as physicians that guide patients through decisions regarding management of breast cancer on a daily basis, we have unique perspectives regarding the value of early detection and its impact on surgical as well as systemic and radio-therapeutic options."

ASBrS guidelines

The ASBrS guidelines recommend:

All women should have a formal breast cancer risk assessment done by their doctors between age 25 and 30. This assessment should be updated at regular intervals.

All women should have screening with 3D mammograms (also called digital breast tomosynthesis, digital tomosynthesis, or just tomosynthesis), which create a 3D picture of the breast using X-rays. Several low-dose images from different angles around the breast are used to create the 3D picture.

Women at average risk of breast cancer should receive annual screening mammograms starting at age 40. Women at average risk with dense breasts should consider supplemental imaging.

Women with a higher-than-average risk of breast cancer because of a known genetic mutation or radiation to the chest wall earlier in life should receive an annual screening MRI starting at age 25 and annual screening mammograms starting at age 30.

Women with a higher-than-average risk of breast cancer because of a strong family history of breast cancer or who have a lifetime risk of breast cancer that is greater than 20% as calculated by a standard risk model should receive an annual screening mammogram starting at age 35 and supplemental imaging as recommended by their doctors.

Women age 50 or older with a history of breast cancer who have non-dense breasts should have a mammogram every year.

Women younger than 50 with a history of breast cancer, or who have dense breasts, should have a mammogram every year and supplemental imaging as recommended by their doctors.

Women should continue having annual mammograms until their life expectancy is less than 10 years.

"At this point in time we have the most robust data regarding breast cancer risk and screening benefits among women with pathogenic mutations in the BRCA1 and BRCA2 genes," Newman said. "History of therapeutic chest wall radiation during adolescence/early adulthood and women with strong family histories of early onset breast cancer — even if a pathogenic mutation has not been identified in the family — represent other examples where mammographic screening at younger ages, as well as supplemental screening with breast MRI, should be considered."

What this means for you

At Breastcancer.org, we believe that a woman’s best chance for early detection requires coordination of our current screening tools:

high-quality mammography

clinical breast exam

breast self-exam

To not use all three tools in women ages 40 to 45 and to do mammograms alone (without clinical or self-exam) in women older than 45 are missed opportunities for early detection.

The reality is that every woman is at risk for breast cancer, and this risk tends to increase over time. It’s important to understand and regularly update your health information related to breast cancer risk throughout your life with your doctor. To get the conversation started, here are some points to talk to your doctor about:

family history of breast or other related cancers (ovarian, melanoma)

any test results for abnormal genes linked to a high risk of breast cancer

results of past breast biopsies, even if they were benign

personal history of being treated with radiation to the face and/or chest before age 30

breast density

weight, if you’re overweight or obese

level of physical activity

any use of postmenopausal combined hormone replacement therapy (HRT)

alcohol consumption, if you regularly drink more than 3 alcoholic beverages per week

the amount of processed food and trans fats you eat

your smoking history

whether or not you had a full-term pregnancy or breastfed

Breastcancer.org recommends that women at average risk of breast cancer have mammograms annually starting at age 40, and we are pleased to see this in the new ASBrS guidelines. We also believe that monthly breast self-exam and annual physical exams by a doctor are essential parts of an overall breast cancer screening strategy.

If you’re at high risk for breast cancer, you should talk to your doctor about starting annual mammograms at a younger age and consider other screening tools (such as MRI or ultrasound) to maximize the opportunity for early detection.

Does a Low-Fat Diet Reduce the Risk of Dying From Breast Cancer?

Results from the Women’s Health Initiative Trial suggest that postmenopausal women who reduced the amount of fat they ate seem to have a 21% lower risk of dying from breast cancer.

Results were reported at a media briefing for the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting on May 15, 2019. Read the abstract of “Low-fat dietary pattern and long-term breast cancer incidence and mortality: The Women’s Health Initiative randomized clinical trial.”

Diet and breast cancer

Diet is thought to be partly responsible for about 30% to 40% of all cancers. But diet alone is unlikely to be the “cause” or the “cure” of cancer. In the 1970s, the theory that a high-fat diet increased breast cancer risk became popular, and some people still believe that theory. Still, studies done since that time have offered mixed results.

For example, previously reported results from a study called the WHEL (Women’s Healthy Eating and Living) study was designed to see if a strict diet that was low in fat and high in vegetables, fruit, and fiber made a difference in survival or breast cancer recurrence (the breast cancer coming back) in women who had been diagnosed. The results were published in 2007 and showed that the diet had no effect on survival or recurrence, which surprised many people.

The Women’s Health Initiative Trial

This research is part of the very large Women’s Health Initiative Clinical Trial and the Women’s Health Initiative Observational Study. Both studies are commonly called the WHI. Together, the two studies include information from more than 161,608 postmenopausal women who were ages 50 to 79 when they joined between 1993 to 1998. The WHI wants to find any links between health, diet, and lifestyle factors and health problems such as cancer.

The researchers started with information from 48,835 postmenopausal women who enrolled in the WHI between 1993 and 1998. When they enrolled in the study, none of the women had been diagnosed with breast cancer and all reported eating a diet that was more than 32% fat. The women were randomly assigned to one of two diet plans:

19,541 women (40%) were told to eat a low-fat diet (fat intake was supposed to be only 20% of the diet); these women also participated in group sessions led by a nutritionist to teach the women how to reduce their fat intake

29,294 women (60%) were told to eat their usual diet and received educational materials on healthy eating

The women followed the diet plans for about 8.5 years. The women in both groups did about the same amount of exercise.

Most of the women in the low-fat diet group reduced their fat intake to 25% of their diet. This means that most of the women didn’t meet the goal of having fat intake be 20% of their diets.

In 2017, results from the Women’s Health Initiative Trial suggested that postmenopausal women who ate a low-fat diet after a breast cancer diagnosis were less likely to die from any cause compared to women who ate a diet that was higher in fat. In 2018, a secondary analysis of the data suggested that postmenopausal women who ate a low-fat diet after being diagnosed with breast cancer were more likely to be alive 10 years after diagnosis compared to women who ate a diet that was higher in fat after being diagnosed.

For these 2019 results, the women have been followed for nearly 20 years.

Overall, 3,374 cases of breast cancer were diagnosed in the women between 1993 and 2013.

Compared to women who ate their usual diet and were diagnosed with breast cancer, women in the low-fat diet group who were diagnosed with breast cancer had:

a 21% lower risk of dying from breast cancer

a 15% lower risk of dying from any cause

"A dietary change can favorably influence a woman's risk of dying from breast cancer," Rowan Chlebowski, M.D., Ph.D., of the Harbor-University of California-LA Medical Center, said during the media briefing. "It's a dietary change that we think can be achievable by many because it represents dietary moderation, which was achieved by 19,000 participants."

Chlebowski is the WHI’s principal investigator.

What this means for you

While these results are encouraging, it’s important to keep several things in mind:

The study relied on the women accurately reporting what they ate and then estimating the fat content in the food. Sometimes people don’t remember everything they ate or how much they ate, which would affect the results of the study.

The study didn’t look to see if the women stuck to their breast cancer treatment plans completely. Stopping a treatment, such as hormonal therapy, early would affect the study results.

The study only looked at postmenopausal women diagnosed with breast cancer. The results can’t be applied to premenopausal women with breast cancer.

While the women in the study had no history of breast cancer, it's not completely clear if the researchers accounted for differences in family history of breast cancer. This could possibly affect the results of the study.

If you’re a postmenopausal woman who’s been diagnosed with breast cancer, it makes sense to make healthy diet and lifestyle choices to keep your risk of recurrence as low as it can be and your overall health the best it can be, including:

eating a diet low in added sugar and processed foods

eating a diet rich in unprocessed, nutrient-dense foods (foods that have the most vitamins, minerals, and healthy compounds)

exercising regularly at the highest intensity level you’re comfortable with

avoiding alcohol

not smoking

It also makes sense to stick to your treatment plan. Treatments such as chemotherapy and radiation therapy can require trips to the hospital or doctor’s office for several months. You also may need to take hormonal therapy medicines for 5 or 10 years after surgery. You get the best results when you follow your treatment plan completely and on schedule.

FDA Approves Piqray to Treat Advanced-Stage Hormone-Receptor-Positive, HER2-Negative Breast Cancer With PIK3CA Mutation

On May 24, 2019, the U.S. Food and Drug Administration (FDA) approved Piqray (chemical name: alpelisib) in combination with Faslodex (chemical name: fulvestrant) to treat metastatic and advanced-stage, hormone-receptor-positive, HER2-negative breast cancer with a PIK3CA mutation that has grown after hormonal therapy treatment in postmenopausal women and men.

Read the FDA announcement.

Advanced-stage breast cancer is breast cancer that has spread to tissue near the breast. Metastatic breast cancer is breast cancer that has spread to parts of the body away from the breast, such as the bones or liver. Metastatic breast cancer is considered advanced-stage disease.

About Piqray

Piqray is a targeted therapy medicine that inhibits the PI3K pathway. The PI3K pathway helps all cells — both healthy and cancer cells — get the energy they need. When this pathway is overactivated because of a mutation in the PIK3CA gene, it can allow cancer cells to survive and grow. PI3K inhibitors block this pathway, with the goal of killing cancer cells.

Piqray is a pill taken by mouth.

Different mutations in the PIK3CA gene make different forms of the PI3 protein, called isoforms by researchers. There are several isoforms of PI3; one of them is the alpha isoform. Piqray specifically targets the alpha isoform.

 

The FDA approval of Piqray was based on results from the SOLAR-1 trial, which found that Piqray combined with the hormonal therapy Faslodex nearly doubled progression-free survival compared to Faslodex alone (11 months vs 5.7 months) in postmenopausal women and men diagnosed with advanced-stage, hormone-receptor-positive, HER2-negative breast cancer with a PIK3CA mutation.

 

Progression-free survival is how long a person lives without the cancer growing.

 

“Piqray is the first PI3K inhibitor to demonstrate a clinically meaningful benefit in treating patients with this type of breast cancer. The ability to target treatment to a patient’s specific genetic mutation or biomarker is becoming increasingly common in cancer treatment,” Richard Pazdur, M.D., director of the FDA’s Oncology Center of Excellence, said in a statement.

Piqray side effects

The most common side effects of Piqray are:

high blood sugar levels

high creatinine levels, which can mean kidney problems

diarrhea

rash

nausea

fatigue

low white blood cell counts

mouth sores

vomiting

hair loss

loss of appetite

Piqray also may cause serious side effects, including:

Severe skin reactions: In some people, Piqray may cause Stevens-Johnson syndrome or erythema multiforme, skin disorders that may begin with flu-like symptoms followed by a painful rash that blisters. If you have a history of either of these two conditions or other skin disorders, discuss them with your doctor before you start treatment with Piqray.

High blood sugar: The safety of Piqray has not been established in people diagnosed with Type 1 or uncontrolled Type 2 diabetes. If you have diabetes, your doctor will measure your fasting blood sugar levels and will monitor these levels while you’re being treated with Piqray. If you have symptoms of untreated high blood sugar, including frequent urination, blurred vision, or an increase in thirst, tell your doctor immediately.

Pneumonia: Piqray may make some people more likely to develop pneumonia or other upper respiratory infections. Tell your doctor right away if you have chest pain when you breathe or cough, or if you have a fever or chills.

Diarrhea: While moderate diarrhea is a common side effect of Piqray, the medicine also can cause severe diarrhea, which can lead to dehydration and may cause kidney problems. Your doctor will recommend an antidiarrheal medicine while you’re being treated with Piqray. If you have diarrhea, tell your doctor immediately.

What this means for you

If you’re a postmenopausal woman or man who has been diagnosed with advanced-stage or metastatic hormone-receptor-positive, HER2-negative breast cancer with a PIK3CA mutation that has grown after hormonal therapy treatment, you and your doctor will consider a number of treatment options, now including Piqray.

Study estimates 15,000 cancer cases could stem from chemicals in California tap water

Posted: 4:22 AM, Apr 30, 2019 Updated: 4:48 AM, Apr 30, 2019

By: CNN Newsource

A new study finds that drinking tap water in California over the course of a lifetime could increase the risk of cancer.

Researchers from the environmental advocacy group Environmental Working Group estimated that the contaminants found in public water systems in California could contribute to about 15,500 cancer cases there over the course of a lifetime. These contaminants include chemicals such as arsenic, hexavalent chromium and radioactive elements such as uranium and radium. The study was published Tuesday in the journal Environmental Health.

"We need to look at contaminants as a group -- not just one at a time. It's more important to analyze co-occurring contaminants to understand the real world exposure," said lead author Tasha Stoiber , a senior scientist with EWG. She explained that cancer risks are typically determined at the individual element level.

Stoiber and her colleagues evaluated 2,737 different public water systems across the state of California by assessing the level of reported contaminants in the systems. These water systems are the main providers of drinking water in California, serving 98% of the state's population. They are regulated by the federal Safe Drinking Water Act and overseen by state regulators.

Water systems test for a host of both regulated and unregulated contaminants to maintain a safe drinking water supply. The study's authors calculated cancer risk by looking at the reported contaminant levels from 2011 to 2015. assessing the yearly averages of all the reported contaminants and adding them together to determine cumulative risk.

Nearly 500 high-risk water systems

The authors divided the water systems into four different categories of risk. The highest category estimated an additional cancer risk of more than 1 in 1,000 people being diagnosed with cancer over the course of a lifetime from drinking tap water. Researchers did not identify which water systems were considered high risk.

Regardless of the role of drinking water, according to the American Cancer Society, nearly 40% of all Americans will be diagnosed with cancer during their lifetime.

Nearly 500 of the community water systems evaluated fit the highest risk category. The researchers estimated that drinking water from these systems over a lifetime would result in 4,860 cancer diagnosis.

When asked about the report, the California Environmental Protection Agency said it would not comment on the study at this time.

'No safe level' of arsenic

Much of the cancer risk was driven by arsenic contamination. These systems were some of the smallest systems in the state, serving 10,000 residents or less, and relied heavily on groundwater.

"Arsenic is going to be an issue with groundwater in certain areas" said Stoiber.

Arsenic contamination in drinking water can result both from arsenic that naturally occurs because of geology as well as from industrial and agricultural exposure.

Even very low levels of arsenic are considered to be highly carcinogenic.

"There's no safe level," said Kelly Reynolds, director of the Environment, Exposure Science and Risk Assessment Center at the University of Arizona, who was not involved with the study.

Reynolds wasn't surprised that smaller water systems carried higher risks.

"Small utilities tend not to have as advanced treatment capabilities as your larger utilities," she said.

"A lot of the smaller systems don't have the economies of scale compared to larger utilities, and they won't have the resources to improve water quality," explained Stoiber.

That doesn't mean larger systems were without risk. In fact, 43% of the evaluated systems -- including some of the larger systems -- carried some of the higher cancer risks.

The authors found that 47% of estimated lifetime cancer cases were due to arsenic pollution in drinking water. About a third of the estimated cancer diagnoses was attributed to disinfection byproducts -- chemicals that are a byproduct of treating drinking water. Another 16% resulted from hexavalent chromium , the " Erin Brockovich" element.

Stoiber said she and her colleagues acknowledged limitations in their work, noting that interactions between chemical contaminants aren't well known and that their assessment could overestimate or underestimate overall risk.

"That's why we're pushing for this [cumulative risk analysis]," Stoiber said. Understanding the science of contaminant interactions is the next step, she said: "This is where future research is needed."

Reynolds agreed that this research was an important starting point. While the findings themselves may be specific to California, she said this approach to risk assessment could be used by any other community to evaluate its own data and water quality. This kind of work "should drive how we prioritize our resource and how we manage this problem" as a society, she said.

But, she added, home consumers could take simple steps now like adding a certified filter to help reduce their exposure to these contaminants. Filters should be targeted to the contaminants and can either be applied right where consumers use their water, like a faucet filter or water pitcher, or a large whole house system that treats water as it enters the house.

Exposure to Chemicals in Water

Research has shown that the water you drink -- whether it's from your home faucet or bottled water from a store -- may not always be as safe as it could be.

Everyone has a role in protecting the water supply. Before you throw away unused medicines, birth control pills, paint, motor oil, pesticides, cleaners, and other chemical-based products, talk to your local health or hazardous waste departments about how to safely dispose of these products. You also can visit the U.S. Food and Drug Administration for more tips.

Steps you can take

In general, filtered tap (municipal) water is as safe as or safer than bottled water from the store, because bottled water is less regulated.

You may want to consider the following tips to ensure your water is the safest it can be:

If you get your water from a private or small community well, you may want to have your tap water tested. Well water can become contaminated with bacteria, pharmaceuticals, and other toxins. City water supplies and municipal wells that serve large numbers of people are regularly tested for contamination. Private and small community wells are not tested, unless you arrange to have it done. If you don't get a water bill, you most likely have a private or small community well. To find a state-certified water testing lab, contact your local state health or environmental department.

Install a filter on the taps in your house or store drinking water in a pitcher with a filter. Check the box label to make sure you're buying a filter that removes E. coli and Cryptosporidium bacteria, as well as pharmaceuticals. Both Brita and Proctor & Gamble (maker of PUR filters) say their filter pitchers remove both E. coli and Cryptosporidium, as well as more than 96% of pharmaceutical contaminants. These companies also claim that their plastic pitchers are made without bisphenol A. Change the filter at the recommended times. The National Sanitation Foundation website has information on how to choose water filters for your home.

Reverse osmosis systems and ion exchange pour-through filters can remove contaminants that tap filters can't. Certain contaminants, such as hexavalent chromium, a metal used in metal processing, steel and pulp mills, and the tanning industry, aren't removed by standard tap filters. Hexavalent chromium in drinking water has been linked to certain stomach cancers. In December 2010, the Environmental Working Group released a report that found hexavalent chromium in the tap water of 31 of 35 U.S. cities tested. Hexavalent chromium can be removed from drinking water by using reverse osmosis systems and ion exchange pour-through filters. Still, these systems are much more expensive than installing a tap filter. If you suspect the water in your area is contaminated with hexavalent chromium or other heavy metals, you may want to consider taking a tap water sample to a lab for specific heavy metal testing before you invest in a reverse osmosis or ion exchange pour-through filter system.

Boil your water if you think it might be contaminated with bacteria. Bring water to a rolling boil for 1 minute before using it. Boiling kills bacteria and other organisms, but doesn't remove pharmaceutical residues.

Read bottled water labels carefully. Water with labels that say "well water," "artesian well water," or "spring water" may not be any different than your tap water -- or it may be less pure than your tap water. Use of these terms isn't regulated by the U.S. Food and Drug Administration. Choose water with a label that says either:

reverse osmosis treated

filtered through an absolute 1 micron or smaller filter (a 1 micron filter is small enough to trap bacteria and other organisms)

If you're unsure whether your brand of water has been treated by one of these processes, call the Bottled Water Association at 1-800-WATER-11 and ask.

Choose bottled water in a glass or BPA-free plastic container. Most bottled water comes in a plastic bottle with a recycling symbol 1 on it, which doesn't contain bisphenol A (BPA). BPA is a chemical used to make many polycarbonate plastics, including water bottles and other food packaging, baby bottles, and food can linings. BPA can leach into food and beverages from the packaging. If you're concerned about BPA exposure:

Avoid plastic containers with the number 7 recycling symbol on the bottom. This type of plastic is most likely to contain BPA.

Opt for filtered tap water instead of bottled water.

Carry your own water with you in a BPA-free plastic or stainless steel container. Many companies, such as Nalgene and Klean Kanteen, offer BPA-free water bottles. Make sure the label says "BPA-free," and don't buy older plastic water bottles that don't have this label.

Stay clear of public swimming places (beaches or pools) that may have high bacteria counts, especially children's pools. When you swim, you end up drinking tiny amounts of water.