Breast Cancer Screening - Conflicting Guidelines, Common Goals

Two of the leading organizations issuing guidelines for cancer screening, the United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS), have separately made recommendations for the early detection of breast cancer.  In both cases, data from current research was analyzed and compiled to develop their recommendations.  Not surprisingly, when analyzing complicated research with unanswered questions about a disease, somewhat different conclusions were reached regarding certain aspects of breast cancer screening.  Despite these differing opinions, both groups are acting in the best interest of women and are committed to helping to reduce breast cancer deaths.  All of the authorities on the subject also agree that additional research will be necessary to help clarify and refine these recommendations.

The ACS recommendations come from a 2014 review of the topic and apply primarily to women without breast cancer symptoms who are at average risk for the development of breast cancer.   The USPSTF recommendations are in draft form currently, pending final review.  Their recommendations apply to women age 40 or older who do not show signs of breast cancer, have not been diagnosed with breast cancer previously and who are not at high risk for the development of breast cancer.

Screening Recommendations for Women in their 20s and 30s
 
            ACS:   "For women in their 20s and 30s, it is recommended that clinical breast examination be part of a periodic health examination, preferably at least every three years.  Beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (BSE). The importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who choose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination. It is acceptable for women to choose not to do BSE or to do BSE irregularly."
            USPSTF:  The most recent recommendations did not address this age group of women.

Screening Recommendations for Women between 40 and 49
 
            ACS:  "Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health."  Along with screening, the ACS believes that "women should have an opportunity to become informed about the benefits, limitations, and potential harms associated with regular screening."

            USPSTF:   The USPSTF does not recommend screening mammograms in this age group of women.  While they are aware of some research indicating that mammography screening can be effective in women in their 40's, the USPSTF believes that "The decision to start screening mammography in women before age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin screening between the ages of 40 and 49 years."  Potential harms from breast cancer screening include overdiagnosis and false-positive test results.  Overdiagnosis occurs "when a woman is diagnosed with, and receives treatment for, breast cancer that would not become a threat during her lifetime".  False positives occur when a test indicates has breast cancer when not actually present. This can lead to unnecessary anxiety and invasive procedures, such as breast biopsy.

Screening Recommendations for women ages 50 to 75
 
            ACS:  "Mammograms should be continued regardless of a woman's age, as long as she does not have serious, chronic health problems such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate to severe dementia."

            USPSTF:  "The USPSTF recommends screening mammography every two years"

Both groups agree that screening for early breast cancer with mammograms is particularly applicable to women in the 50 to 75 year age groups, although there is disagreement as to the screening interval.  To complicate things further, other medical groups have offered their own screening recommendations. The American Congress of Obstetricians and Gynecologists and the American College of Radiology recommendations follow closely to the ACS guidelines while recommendations from the Canadian Task Force on Preventive Health Care are similar to those of the USPSTF.

These recommendations relate to women who are of average risk.  Having a parent, sibling, or child with breast cancer, a genetic mutation (such as BRCA), or a history of receiving chest radiation at a young age increases one's risk of developing breast cancer.  These situations should be handled individually and may call for more specialized screening strategies such as shorter screening intervals or the use of other tests, such as breast MRI.

While it may seem troubling that there is no consensus among experts, it is important to note that the development of screening guidelines is an ongoing process with new research updating and refining the criteria along the way.  When there are questions regarding your personal situation, a discussion with your doctor is a good way of determining how you will approach breast cancer screening.

Same Cough, Different Causes

Almost everyone has had a cough. Typically, this occurs in association with an acute infection such as a cold or the flu.  Once the infection runs its course, or following effective treatment, this type of cough goes away within a matter of a few days to a couple of weeks.  A cough that lasts longer than this is termed a chronic cough.  By definition, a chronic cough occurs daily and lasts for at least 8 weeks (4 weeks in children).  This is an important distinction because a chronic cough is usually not related to an infection.  In fact, most cases of chronic cough can be attributed to three causes:  postnasal drip (also known as upper airway cough syndrome), asthma, and gastroesophageal reflux disease (GERD).

Evaluating this type of cough can be a challenge for doctors because all three of these conditions can produce a similar type of cough.

Postnasal Drip

You would think that a problem affecting the lungs would be the most likely cause for a chronic cough. Instead, the most common cause is actually postnasal drip.  With postnasal drip, secretions from the nose drip into the back of the throat, causing inflammation and triggering the cough. The underlying causes of postnasal drip include allergies, colds, and sinusitis. Frequent throat clearing, a constant stuffy or runny nose, and the sensation of drainage in the back of the throat are common features of postnasal drip. On physical examination, the doctor may notice redness or irritation on the back of the throat.  Sinus x-rays or sinus CT (computed tomography) scan may show fluid in the sinuses, indicative of chronic sinusitis. Treatment of chronic cough due to postnasal drip includes the use of decongestants, antihistamines, and nasal steroid sprays. When clinical evidence points to the possibility that postnasal drip is responsible for the cough, the doctor may suggest a “therapeutic trial” of one of these medications.  Improvement in the cough following this medication trial helps to confirm the diagnosis.

Asthma

Coughing is a primary feature of one type of asthma. In cough-variant asthma, the cough is dry and other features of asthma, such as wheezing or shortness of breath, may not be present.  This type of cough can get worse with exposure to dry, cold air, dust or certain fumes or fragrances.  Cough-variant asthma can be a difficult condition to diagnose since the physical examination and lung testing are usually normal in the doctor’s office.  In order to confirm the diagnosis of cough-variant asthma, a special breathing test called a methacholine challenge may be necessary. In someone with asthma, methacholine will cause their airways to constrict which can be detected during pulmonary function testing.  A therapeutic trial of a medication to dilate the bronchioles, e.g. Albuterol inhaler, or steroid inhalers may be tried in this condition. A reduction in coughing following the use of these medication points to asthma as the cause.

Gastroesophageal Reflux

One of the most unusual causes for a chronic cough is gastroesophageal reflux (GERD).  With GERD, stomach acid backs up into the throat, triggering the cough. Often, this diagnosis can be suspected from the classic reflux symptoms of heartburn or sour taste in the mouth.  If these symptoms are present, treatment for GERD may be considered to assess its effect on the cough. Treatment measures include: 1) elevating  the head of the bed, 2) not eating or drinking 2 to 3 hours before bedtime, 3) avoiding certain foods, such as chocolate, alcohol, orange juice, and caffeine, and 4) taking medications directed at reducing acid production in the stomach.  Medications for GERD include antacids (Maalox, Mylanta, others), omeprazole (Prilosec) and esomeprazole (Nexium).

While there are other, and in some cases much more serious, causes for chronic cough, up to 90% of cases can be attributed to one of the three causes discussed.  Any cough, however, that persists past a few weeks deserves medical evaluation.  The first step in finding an effective treatment is to pin down the underlying cause.

Do Microwave Ovens Pose a Health Risk?

According the U.S. Bureau of Labor Statistics, more than 90 percent of U.S. households have a microwave oven.   This method of cooking, which was introduced in 1947 with the "Radarange", uses a form of electromagnetic radiation, not unlike the radio frequency waves used in broadcasting.  Microwaves cook food by causing water molecules within the food to vibrate, producing heat.  Advantages of microwave cooking include quicker cooking times, convenience, and energy conservation.  Despite these advantages, a portion of the American public has concerns regarding the health effects of the radiation produced by the ovens as well as believing that they lower the nutritional value of foods.  These concerns, along with the current trend of cooking "fresh", have negatively impacted microwave sales over the past 10 years.  Let's see what medical experts have to say about some of the concerns related to microwave cooking.


Effects of microwave radiation on you
Like food being cooked, if humans are exposed to high levels of microwaves the heat produced within tissues is capable of causing medical problems such as burns and cataracts.  The Food and Drug Administration (FDA), however, has set limits on the amount of radiation that can leak from the ovens. These limits are set far below those amounts capable of causing harm.  While there are reports of injuries that have occurred while using a microwave oven, the U.S. Occupational Safety and Health Administration (OSHA), contends that these injuries were similar to those that might have occurred with any cooking source, e.g. burning the skin with hot steam or splattered grease.  Microwave cooking does not make food radioactive and microwaves do not have the potential to cause cancer like gamma rays or x-rays.  In the past, there was concern that microwave ovens could interfere with the function of heart pacemakers.  Currently, pacemakers are shielded against this type of electrical interference and the FDA does not consider microwave cooking to be a significant concern for someone with a pacemaker.

 Effects of microwave radiation on food
A quick search of the internet will uncover numerous sources contending that microwave cooking robs nutrients from foods and may even produce "carcinogenic foods".   These claims, however, are not supported by nutritional research.  Microwave cooking is generally faster than conventional cooking and uses less added water during the cooking process.  As a result, microwave cooking has been found to produce less damage to the chemical structure of nutrients and is less likely to "leach" vitamins and minerals into cooking water.  As compared to conventional cooking, studies have shown equal or better retention of nutrients with microwave cooking for the B vitamins, thiamin, riboflavin, folic acid and pyridoxine as well as for vitamin C.  Microwave cooking should always be done in microwave-approved cookware. Using other containers, such as margarine tubs or Styrofoam take-out containers could melt, allowing harmful chemicals to contaminate the food being cooked. 

Most of the research done to date seems to indicate that microwave cooking is not associated with major health risks. The FDA, however, continues to test new microwave ovens to make sure that the limits for radiation leakage are not exceeded.  A microwave oven with a damaged or defective door could leak an excessive amount of radiation and should not be used. Likewise, the concern that microwave cooking robs foods of nutrients appears to be unfounded. The quality of the food being prepared, considering that many microwaveable meals are of the "TV dinner" variety, however, often leaves much to be desired.