Watching Women's Health

Vitamin D may reduce risk of urinary incontinence

The medical community's growing realization that many Americans are low in Vitamin D has led to an explosion of interest in this vitamin's effects on bones, muscle, pregnancy outcomes, cancer risks and other medical concerns. 

Vitamin D is a fat-soluble vitamin that aids the absorption of calcium from the GI system. In addition to helping mineralize bone, calcium is important in neuromuscular and immune system function.

Vitamin D is produced in skin that is exposed to sunlight. It naturally occurs in only a few foods, fatty fish and cod liver oil (a hardy few consider cod liver oil to be a food). According to the most recent National Health and Nutrition Examination Survey (NHANES), only 17% of US women get enough vitamin D from food alone.

Most health-conscious women protect their skin from the sun and obtain vitamin D from supplements and vitamin D fortified foods. Recently, I have been including serum vitamin D levels in blood work at annual exams, and have found many of my patients have low vitamin D levels, despite our ongoing discussions about adequate calcium and vitamin D intake.

Other risk factors for vitamin D deficiency besides low sun exposure include being over 50, having darker skin pigmentation and being overweight. Breastfed infants have also been found to be at risk, as adequate vitamin D can't be obtained from human milk alone.

A new paper in the gyn literature looked at how vitamin D levels relate to women's risks for pelvic floor disorders — urinary and rectal incontinence and pelvic organ prolapse. In the NHANES data, results from 1,881 women 20 and older included information on pelvic floor disorders and vitamin D.

The mean age of the surveyed women was 47.9 and more than 80% had suboptimal vitamin D levels. 23% reported symptoms of a pelvic floor disorder. Higher vitamin D levels were associated with a lower rate of pelvic floor disorders. The strongest inverse association was in women over 50 with urinary incontinence.  The authors conclude

Given the increase in the number of patients with pelvic floor disorders, further evaluation of the role of vitamin D is warranted, particularly future research to assess the relationship between vitamin D levels and pelvic muscle strength in women of all ages and racial/ethnic groups. Our findings suggest that treatment of vitamin D insufficiency and deficiency in both premenopausal and postmenopausal women could improve pelvic muscle strength, with a possible reduction in the prevalence of pelvic floor disorders including urinary incontinence.

It is encouraging to think that the hugely annoying problem of urinary incontinence could be improved by something as simple as supplementing vitamin D. If you have not had your vitamin D level checked, it is worth doing at your next annual exam. If you have problems with urinary incontinence, it may be worthwhile having it checked sooner.

Spend more of your day moving, having fun

More than two-thirds of adult Americans are overweight or obese, according to a recent national survey. Approximately 10% of children are also above a healthy weight. Fortunately, among both adults and children, the percentage who are overweight and obese is no longer increasing.

One way to address this national public health challenge is to get Americans moving again, through both individual and societal changes. Here are nine ways an individual can be more physically active.

1. Find physical activities you truly enjoy. This is the most important suggestion of all. If you are doing something you like to do, you are not working out, you are having fun. It takes planning, but not really discipline, to make an enjoyable activity part of your day.

2. Find ways to be active in all seasons. In Minnesota, staying active in the winter is a challenge. Many women occupy the summer with gardening, yard work, walking and cycling, but these activities fall by the wayside in the winter. It is actually not hard to dress for the weather and continue usual activities or switch to winter sports. Even in my state, only a handful of winter days are unbearable.

In other parts of the country, a hot and humid summer limits most outdoor exercise to early morning. Be realistic about where you live and either find ways to be out in all kinds of weather or move your activities indoors for part of the year.

3. Be active with friends. I first started exercising as a young adult by swimming at noon with a work friend. We later switched to running when the community pool became too crowded to swim laps. Our friendship made it easy for us to get fit together.

Most of my close adult friendships have been formed because we share physical activities as well as sensibilities. For the past two years, I have admired from afar four women who walk together every morning, regardless of weather. They are always happy and animated - clearly getting together is not a chore for them.

4. Go places under your own power. Day to day, most of us feel pressed for time.  Perhaps the most time-efficient way of getting more exercise is combining it with transportation. Try walking or cycling to work, run errands or get together with friends. To cover long distances, find ways to combine self-locomotion with public transportation.

Many baby-boomers who are downsizing houses would also like to downsize their car fleet as well as their clothing size. When moving, look for neighborhoods that are pedestrian and bicycle-friendly. At least one helpful website lets you analyze the walkability of any address in larger US cities.

Similarly, consider vacation spots that allow you to get around under your own power. This is not only economical but will help counteract the weight gain that seems inevitable with most vacations.

5. Get a dog and give it a great life.  A great life for a dog is a healthy, active life for you. A recent study showed people who walk their dogs see more improvement in their fitness than people who walk with humans. Unlike human companions, dogs don't come up with excuses not to walk. Dogs will happily go out in almost any weather and you find out you can, too.

6. Spend less time sitting. Sitting at a desk at work, watching TV, or at a home computer occupies most of the day for a lot of people. Along with sleeping, sitting in a comfortable chair is the least active thing our bodies can do. Most calorie expenditure charts show standing uses roughly twice as many calories as sitting, and calorie expediture goes up from there with more intense activities. Be creative about finding ways to sit less; when you do sit, try using an exercise ball part of the time (even though the TV comedy The Office made huge fun of this).

Wearing a pedometer is an easy way to quantify how much you are moving around during an average day and has been shown to increase sedentary women's activity levels.

7. Increase your activity gradually. Once you've made up your mind to be more active, don't risk injury by overdoing it in the first several weeks. Remember you're in this for the long haul. Give the weakest parts of your body time to catch up to the strongest. 

8. Mix things up. Humans like variety. If you involve yourself in a variety of activities, you are less likely to get tired of what you are doing and to have overuse injuries. Part of the beauty of living in a place with distinct seasons is engaging in different seasonal activities. For instance, here in Minnesota, we never get tired of cross-country skiing because, believe it or not, the winter is too short.

9. Have a mindset that exercise is a priority, not a luxury. To be healthy, we need physical activity just as we need fluids, nourishment, mental stimulation and sleep. Physical activity should be a normal part of virtually every day, not something we'll do if we have time and inclination. Each day, figure out a way to fit some sort of exercise into even the busiest schedule. 

I've gathered these ideas from talking with my friends and patients, and from my own experience of being physically active throughout my adult life. Even if you have never liked to "exercise," you'll do good things for your health (and have fun) if you move more and sit less.

Obesity replaces smoking as top US health burden

The good news is that smoking is no longer the biggest health threat to Americans.  The not-so-good news is that, while fewer people are smoking, many more, including record numbers of children, have become obese.

The medical definition of obesity is a body mass index (BMI) greater than 30. For example, for a woman who is 5'5", any weight above 180 lbs is in the obese range. BMI for normal weight ranges from 18.5-24.9; the overweight range is from 25-29.9. To be in the normal range, a 5'5" woman would weigh between 112 and 150, a fairly generous spread.

While smoking rates in the US have declined in recent years, obesity has been on the rise. Between 1993 and 2008, obesity in the US increased by 85%.

The risks from smoking and obesity are different. Smoking increases risk of premature death whereas obesity increases risks of morbidity, or ill health.  Both can result in fewer years of quality living, with obesity now edging out smoking as a robber of quality years.

If everyone in our country miraculously became a nonsmoker of normal weight, on average Americans would gain 5 quality years of life.

Obesity can limit normal activities through early arthritis, diabetes and heart disease.  And these progressive conditions lead to less and less physical activity. Like smoking, the problem of obesity is best addressed by prevention. Once a woman has become obese, it is a difficult condition to change.

Physicians regularly encourage smokers to quit and discuss approaches to weight loss with our overweight and obese patients. In my practice, I see smokers quitting and overweight women getting back into a normal weight range far more often than I see obese women succeed in losing weight. Their lack of success seems in large part due to the obesity-related physical ills that do not allow them to be physically active. 

Much has been written about the causes of obesity in the US. At or near the top of everyone's list is a sedentary life style that is so much more common now than even a few decades ago. In my next post, I'll discuss practical approaches to being more physically active.

Screening for ovarian cancer — focus on genetic risks

Most women have just over a 1% lifetime risk of developing cancer of the ovary. However, in some families, there are multiple cases of ovarian and/or breast cancer, and risks are much greater. What do we know about inherited susceptibility to ovarian cancer?

The biggest breakthrough has been the discovery of harmful mutations in the BRCA 1 and BRCA 2 genes. BRCA 1 and 2 are tumor suppressor genes located on chromosome 17 that prevent uncontrolled cell growth. With certain mutations, BRCA genes are less effective in regulating cell growth, and ovarian, breast and other cancers are more likely to occur.

A BRCA mutation can be detected through a blood test. There are well-accepted recommendations about which family cancer histories should trigger genetic counseling and possible BRCA testing. Genetic counseling is helpful, so an accurate family medical tree is constructed and appropriate candidates for BRCA testing are identified. Before getting the blood test, it is important that women fully understand the implications of both positive and negative BRCA results, and also of declining to do the test.

When possible, it makes sense first to test a family member who has been diagnosed with breast or ovarian cancer. If a BRCA mutation is found, other family members can undergo limited testing for that specific mutation.

Both females and males can inherit BRCA mutations. Men with BRCA mutations have an increased risk of breast cancer, as well as pancreatic, early-onset prostate, and possibly, testicular cancer.

Women with BRCA mutations have an increased lifetime risk of ovarian cancer ranging from 20-50%. Risks for developing breast cancer are even higher, in the 60-80% range.

If a harmful BRCA mutation is found, most physicians recommend prophylactic removal of the ovaries after childbearing is complete, in most cases by age 40. (Along with removal of the ovaries, additional steps would be taken to reduce breast cancer risk.)

Prior to completion of childbearing, BRCA positive women should be aware of ovarian cancer symptoms and have regular vaginal ultrasounds and CA-125 testing — though imperfect, these tests are the best we have for screening high risk women. We also recommend younger women use oral contraceptives when feasible. Oral contraceptives can reduce ovarian cancer risk by 50%, though the exact benefit in BRCA positive women is not known.

What if BRCA testing is negative? That means cases of ovarian and/or breast cancer in a particular family are not due to a BRCA mutation, but may be associated with other mutations that have not yet been identified. With high risk family histories, the same risk reducing strategy is appropriate.

Improving ovarian cancer screening in the future, for both high and average risk women, will almost certainly involve more accurate serum markers and better ultrasound discrimination between normal and abnormal ovarian structure.

Does recognizing symptoms lead to early diagnosis of ovarian cancer?

I wrote earlier about the difficulties of diagnosing early ovarian cancer by routinely screening asymptomatic women at average risk for this disease. But what if physicians did a better job of screening women with symptoms linked to ovarian cancer? Could we make the diagnosis at an earlier, more treatable stage?

A recently published study looked at these questions. 

813 women with ovarian cancer (including 212 diagnosed in an early stage) and 1313 otherwise similar women were interviewed about symptoms they experienced before their date of diagnosis (or comparable date for the control group).

Symptoms included early satiety, bloating, abdominal or pelvic pain and urinary changes. A woman was considered symptomatic if she had new onset of any of these symptoms in the year before diagnosis, with symptoms occurring daily for at least a week.

Women who had been diagnosed with ovarian cancer were 10 times more likely than women in the control group to report having had at least one of these symptoms. However, most women reported having symptoms for a relatively short time before diagnosis, regardless of whether their cancer was found in an early or late stage.

(One limitation of the study is that it relied on accurate recollection of symptoms. And, women with a cancer diagnosis may recall symptoms differently than the control group.)

Like other current screening approaches for ovarian cancer, the authors' symptom index had a low positive predictive value. Using their approach, 100 symptomatic women would have to be evaluated to identify one woman with early ovarian cancer.

The other 99 women would undergo ultrasounds, blood work and in some cases, unnecessary surgery, looking for a disease they did not have. At the same time, women who had early ovarian cancer but no symptoms, would not be recognized.

The editorial accompanying the article concludes

Importantly, these findings remind us that wide recognition of symptoms alone will not incrementally improve the overall survival from ovarian cancer. Rather, they highlight the urgent need to develop better molecular markers and improved imaging modalities for ovarian cancer screening. The recognition of specific symptoms associated with ovarian cancer has value. However, to truly affect the cure of ovarian cancer, we need better diagnostic tools for asymptomatic women.

Next, I'll look at what we know about inherited susceptibility to ovarian cancer.

Screening for ovarian cancer —still a work in progress

With good reason, ovarian cancer is the most feared gynecologic malignancy. Hardly a clinic day goes by without one of my patients asking if we've figured out how to screen for cancer of the ovary.

Most often discovered after it has spread from the ovary, ovarian cancer is the leading cause of death from gyn cancers and the fifth-leading cause of cancer deaths in women. Yet, an effective screening test for ovarian cancer, comparable to a pap smear or a mammogram, remains an elusive goal.

Why is it so hard to screen for cancer of the ovary?

The foremost reason (fortunately) is that ovarian cancer is not among the most common cancers — it affects 1.4% of US women. It is easier to develop effective screening tests for more common conditions, especially if we are trying to screen everyone potentially at risk.

Secondly, the ovaries are relatively small organs that are deep in the pelvis. Only with surgery can the ovaries be visualized directly. And, as part of their normal function prior to menopause, they change size and create cysts that come and go. A normal ovary can at times feel concerning on pelvic exam and look concerning on ultrasound, especially in the second half of the menstrual cycle. Even postmenopausal women can have cysts on their ovaries that are completely innocent.

During my residency in the 1980's, there was great hope that regular pelvic ultrasounds and blood tests for a serum marker, CA-125, would prove to be effective screening tests. Unfortunately, these tests did not pan out. 

Compared to control groups, women regularly screened with ultrasounds and CA-125 blood tests had more surgery for benign conditions that didn't actually threaten their health. And they did not have a reduced risk of dying from ovarian cancer. The ovarian cancers that were found in the screened group were often in advanced stages. The goal of finding ovarian cancer early was not met.

There have been ongoing efforts to identify women with ovarian cancer based on family history, genetic testing and a constellation of symptoms involving the pelvic organs. There have also been attempts to create more accurate ultrasound criteria for early diagnosis.

In future posts, I will discuss recent studies involving these approaches. But be forewarned — diagnosing ovarian cancer early enough to save lives remains a formidable challenge.

First gyn visit — not so scary for today's teens

When I was an ob/gyn resident in the 1980's, our program provided care at a community teen clinic. Young women were mostly seeking cycle control and contraception, usually wanting to start birth control pills. The supervising physician instructed us to do full pelvic exams, including pap smears and rectovaginal exams, even though some of these teenagers were not yet sexually active. The exams were almost always normal.

The teens were very nervous, in some cases, terrified about the exams, and it took determination and courage for them to follow through with their appointments. Our university-based residency saw this "service" as community outreach, but the thoroughness of our approach, standard for that time, was probably a barrier to care for many frightened young women.

Because of new adolescent health care guidelines from the American College of Obstetrics and Gynecology (ACOG), today's teens can expect a much less intimidating first gyn visit. Since most teens are unlikely to have pelvic abnormalities, ACOG says physicians don't need to perform a pelvic exam at a first gyn visit unless an individual's medical history suggests there may be abnormal findings.

Many teens seek cycle control and/or reliable contraception, and oral contraceptives (OCs) are usually a good choice. In most cases, OCs can be safely prescribed after a thorough medical, family and social history, and a blood pressure check.

ACOG now recommends doing a first pap smear at age 21, regardless of a young woman's sexual history. We can screen for chlamydia, a common infection in sexually active young women, with a urine specimen.

The main threats to adolescent health are risk-taking behavior and unhealthy lifestyles. ACOG recommends a first gyn visit for girls aged 13-15, so ob/gyn physicians can back up parents in encouraging good choices. Our clinics then become a safe place for teens to go for reliable information and resources that build the foundation for a healthy adulthood. 

Self and clinical breast exams not as helpful we thought

My last two posts addressed mammogram recommendations in the recent US Preventive Services Task Force (USPSTF) report on breast cancer screening. I also have some thoughts about the task force's comments on self and clinical breast exams.

For decades, physicians and breast cancer advocacy groups have recommended a monthly self breast exam (SBE) for adult women. I am not sure exactly when or from where this concept originated.

Monthly SBE apparently seemed like such an obvious good idea, it became standard medical advice without first being tested . Monthly self breast exams, yearly clinical breast exams (CBE) and regular mammograms after a certain age have been longstanding major components of breast cancer screening in the US.

Increasingly in medicine, we are trying to figure out which of our screening practices actually work. In the US, it would be very difficult to study SBE as a primary screening test, in the absence of CBE and mammograms.  So studies on the effectiveness of SBE have come from countries where other breast cancer screening is not readily available.

A major study on SBE, conducted in China, involved 266,064 women, half of whom were repeatedly instructed in SBE and reminded to do the exams. None of the women had access to CBE or mammograms.

After 10 to 11 years of followup, the women who did SBE had the same breast cancer mortality as the control group. The main difference between the two groups was the SBE group had twice as many benign breast biopsies.  A smaller study in Russia also showed no measurable SBE benefit.

On the face of it, these results seem contrary to many women's experience, as a fair number of breast cancers are found by women themselves.

Sometimes women examine their breasts because some life event made them worry in particular about breast cancer. Or, they became aware that their breast looked or felt different and then they did a self exam. Only rarely does one of my patients tell me she found a worrisome lump while doing her regular exam.

SBE every month is much too often to note meaningful change. Even if an area contains breast cancer, it is unlikely to feel different from one month to the next.  Perhaps women themselves intuitively have always known this, as the majority have never done monthly exams.

The USPSTF agrees with what most women actually don't do and recommended against SBE for women at average risk for developing breast cancer.

For women at high risk for breast cancer, SBE appears to be more helpful. At the 2009 American Society of Breast Surgeons annual meeting, a small study found high risk women doing SBE every six months were as accurate as annual mammograms and MRIs in identifying breast cancers.

Being well-trained in SBE may be particularly important for younger high risk women who have not yet begun screening with mammograms.

And what about the clinical breast exam? The USPSTF found no evidence that CBE by itself reduces breast cancer mortality.   

In the US, most women who have regular clinical breast exams also have access to mammograms. It would be difficult, probably ethically impossible, to do a large study of CBE as a stand alone screening test.

Physicians consider breast exams to be an important part of a woman's annual physical. Yet, many physicians could approach breast exams in a more thorough, systematic way. An optimal CBE takes at least one minute per side, with the entire breast being systematically evaluated. Ideally, visual inspection is also done.

If all clinicians perfomed CBE in a more structured, standardized manner, the effectiveness of CBE, though difficult to measure, would almost certainly improve.

So what are women to do? Women at high risk for breast cancer may benefit from learning to do SBE and doing an exam periodically. A six month interval seems reasonable and has a little data to back it up. Women at average risk should be aware of changes in their breasts and seek medical advice about persistent changes.

And all women who have their breasts examined by a medical professional should get the potential benefit of a thorough exam.

Every other year mammograms for age 50 and over?

Anyone in touch with the news knows there has been heated discussion about the recent US Preventive Services Task Force breast cancer screening recommendations. The heat has been largely focused on the suggestion that routine mammograms be deferred until age 50. Less remarked on is the further recommendation that mammograms be done every other year rather than yearly.

How the the task force arrive at this?

They relied on a study that used six independently developed models to calculate the "efficiency" of 20 different mammogram screening strategies. The differing strategies started and stopped mammograms at various ages, and did mammograms either annually or every other year.

A screening strategy was considered "efficient" if it led to an improved health outcome (compared to no screening) and consumed fewer resources (compared to other screening strategies).

An "improved health outcome" was life-years gained or fewer deaths from breast cancer. Starting screening at younger ages led to more life-years gained, while continuing screening through older ages led to fewer deaths from breast cancer.

When the researchers ranked the different strategies, all 6 models predicted the most efficient approach was screening every other year.  The health outcomes were close to those achieved with annual mammograms and there almost 50% were fewer false positives.

In support of using models for this analysis, the researchers said:

Our results are also consistent with current knowledge of disease biology. Slow-growing tumors are much more common than fast-growing tumors, and the ratio of slow- to fast-growing tumors increases with age, so that little survival benefit is lost between screening every year versus every other year. For the small subset of women with aggressive, fast-growing tumors, even annual screening is not likely to confer a survival advantage. Guidelines in other countries include biennial screening. However, whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.

Some have objected to the cold-hearted approach of using models to evaluate screening for breast cancer. The study using models looked at breast cancer screening from a societal, rather than individual perspective.

When physicians see individual patients, subjective values are important. While physician organizations (like the American College of Obstetrics and Gynecology) evaluate these recommendations, many women will continue to have yearly mammograms, starting at age 40.

Physicians need time in clinic to advise our patients about the timing of mammograms. And we all must be able to adjust our medical opinion and advice as new information becomes available and is analyzed.

Unfortunately, early detection helps only a subset of women with breast cancer. The greatest benefits will come when we learn more about how to prevent breast cancer.

Our society will continue to study and discuss how best to allocate breast cancer resources among prevention, early detection and treatment efforts.

New breast cancer screening guidelines allow for individual decision-making

Who would have thought a federal task force with an unpronounceable acronym for a name could stir up so much controversy with one journal article?

Like most physicians who care for women, I was a bit surprised by substantial changes in the US Preventive Services Task Force (USPSTF) screening recommendations for breast cancer released last week.

This past week, I read both the 2002 and 2009 reports, and the evidence reviews they are based on. Here's my take on the new recommendations. This is a longish discussion, so stay with me for a few minutes.

In general accord with the 2002 statement, most US physicians have been recommending mammograms every 1-2 years starting at age 40 and then annually from age 50. We consider clinical breast exams to be an important part of a woman's annual physical and encourage our patients to do regular self breast exams.

For women at average risk of developing breast cancer, the USPSTF now says the best current evidence supports mammograms every other year, starting at age 50 and possibly ending at age 74. The task force points out the usefulness of clinical breast exams has not been proven.

And, on the basis of two large studies, the report also states doing self breast exams does not lead to a lower risk of dying from breast cancer.

Mammogram screening benefits and harms

In making these recommendations, the task force calculated benefits and harms from breast cancer screening. The identified benefit was reduced risk of dying from breast cancer. The harms included false positive results leading to unnecessary further testing and overdiagnosis of non-life threatening cancers.

The task force based its mammogram recommendations on a review that estimated how many women in different age groups would have to have regular mammograms to prevent one woman's death from breast cancer.

For women in their 40s, one life is saved for every 1904 screened women. In comparison, one life is saved by screening 1339 women in their 50s and 377 women in their 60s. The benefit is obviously greatest for women in their 60s.

Here is the review's concluding paragraph:

Our meta-analysis of mammography screening trials indicates breast cancer mortality benefit for all age groups from 39 to 69 years, with insufficient data for older women. False-positive results are common in all age groups and lead to additional imaging and biopsies. Women aged 40 to 49 years experience the highest rate of additional imaging...  Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and society are not clearly resolved by the available evidence.

For physicians who regularly read the medical literature, the USPSTF statement does not come out of the blue.  The effectiveness of screening tests in preventing cancer deaths is regularly addressed in journals we read.

After the report was released, most of the discussion has concerned mammograms not being automatically recommended for women in their 40s.

Screened women in that age group did have a 15% reduction in breast cancer mortality, which seems worthwhile to most physicians. However, women in their forties had significantly more false positives, leading to further imaging and, less often, biopsies.

The task force included anxiety with further testing as a harm from screening.  Many women have spoken up to say they can deal with anxiety to gain a benefit from screening, and they think the task force report was condescending.  Here's what the report said:

False-positive results are common with mammography and can cause anxiety and lead to additional imaging studies and invasive procedures (such as biopsy or fine-needle aspiration). False-positive results and accompanying additional imaging studies are more common in younger women... Anxiety, distress, and other psychosocial effects can exist with abnormal mammography results but fortunately are usually transient, and some research suggests that these effects are not a barrier to screening... Other potential harms, such as pain caused by the procedure, exist but are thought to have little effect on mammography use.

How the task force incorporated these concerns about anxiety and pain into their recommendations is not clear to me.

Another concern is that most of the data comes from outside the US, and may not accurately reflect our current mammography results and breast cancer treatment success.

Mammograms and breast biopsies are only as good as our ability to interpret their results. Some of the most exciting breast cancer research involves individualizing breast cancer treatment by identifying the biological behavior of a woman's specific cancer.

When and if individualized treatment is available, it will spare many women from being overtreated for breast cancer. This research could also save lives of women who have cancers that may require unusually aggressive treatment.

If we significantly back off from our screening programs, fewer women may benefit from these advances.

The review article acknowledges this:

Breast cancer is a continuum of entities, not just 1 disease that needs to be taken into account when considering screening and treatment options and when balancing benefits and harms. None of the screening trials consider breast cancer in this manner. As diagnostic and treatment experiences become more individualized  and include patient preferences, it becomes even more difficult to characterize benefits and harms in a general way.

What to do now

So how will I incorporate the USPSTF report into my practice? The task force made recommendations for the general population, but in clinic, I make recommendations to individuals.

The first step is assess a woman's risk for developing breast cancer. In my clinic, I use the Gail model and any available information about a women's breast tissue density.

For now, I will make sure average-risk women in their 40s are aware that mammogram false-positives are higher for them than for older women. However I will also tell them having mammograms reduces their risk of dying from breast cancer and that today's evidence for and against screening is not the last word. Then we can make a shared decision about mammograms.

As the task force itself says:

The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

That's what I do now and will continue to do. 

In a future post, I'll write about mammograms for women in their 50s and older, as well as clinical and self breast exams.