Digest #54: Screening Ping Pong – New USPSTF Breast Cancer Screening Updates

June 21, 2024 | By Nora Taranto

Welcome Back to The Curbsiders Digest!

In this issue, we cover  New USPSTF Breast Cancer Screening Updates. Plus climate change and cardiovascular risk, iron repletion in RLS, bariatric surgery and ovulation in PCOS, and PPIs in the critically ill.  Effortlessly absorb important medical news, with our twice monthly newsletter featuring easily digestible analysis of the latest practice-changing articles, and of course…bad puns. 

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Issue 54

06/21/2024

Appetizers (to whet your appetite) 

Palate Cleanser (aka the melon part of the meal) 

The Main Course

A Digestif or two

Appetizers

Brought to you hot off the stove, from a variety of specialties. Delivered in super tasty, bite-sized morsels. 
-Laura Glick MD; Alyssa Mancini MD; Jennifer DeSalvo MD

• Climate change events and cardiovascular risk? JAMA recently published a systematic review of 492 observational studies examining extreme temperature, ground-level ozone, and extreme weather events across 48 high, middle, and low-income countries. Exposure to extreme heat and cold temperature, varying with duration of exposure, was associated with increased risk of cardiovascular morbidity and mortality. The cardiovascular risks associated with higher temperatures were amplified with ground-level ozone exposure. Additionally, extreme weather events, notably hurricanes and dust storms, were associated with increased cardiovascular risk persisting for months after the initial event.  Certain populations, including older adults, racial and ethnic minorities, and lower-wealth communities, had disproportionately higher cardiovascular risks associated with these environmental stressors. (JD)
• Bariatric surgery may help induce spontaneous ovulation in women with polycystic ovarian syndrome (PCOS). The Lancet recently published the BAMBINI trial results – a multicenter, open-label RCT of 80 adult women (median age 31, 79% White) with a diagnosis of PCOS and a BMI < 35 kg/m² who were randomized 1:1 to vertical sleeve gastrectomy or behavioral interventions/medical therapy. The primary outcome was the number of ovulatory events over 52 weeks, biochemically confirmed using weekly serum progesterone measurements. Overall, women in the surgical group had 2.5 times more spontaneous ovulations compared to the medical group (incidence rate ratio 2.5, 95% CI 1.5-4.2). There was significant weight reduction in the surgical but not medical therapy group. There were also more adverse events in the surgical group (66.7% with surgery (wound infections/nutritional deficiencies) vs. 30% in the medical group (primarily nutritional deficiencies)), although without long-term sequelae. (AM) 
• Early diagnosis and treatment of COPD and asthma may pay off (literally).  The NEJM recently published the results of a multicenter RCT that used a case-finding method to identify 508 community-dwelling adults with respiratory symptoms who were found to have COPD or asthma on spirometry. Individuals were randomized 1:1 to evaluation by a pulmonologist and asthma-COPD educator who initiated guideline-based care (intervention) or to receive usual care with their primary care practitioner (usual-care). The primary outcome, the annualized rate of participant-initiated health care utilization for respiratory illness, was lower with the intervention than with usual care (0.53 vs. 1.12 events/person-year). At 1 year, there were greater improvements in disease-specific quality of life, symptom burden, and FEV₁ with the intervention than with usual care. (AM) 
• Iron Repletion in Restless Leg: Mode May Not Matter. Both oral and intravenous (IV) iron are effective in patients with restless leg syndrome (RLS) and iron deficiency anemia (IDA), according to a recent study published in the American Journal of Hematology. In this double-blind, double dummy study, participants with RLS and IDA were randomly assigned to receive oral ferrous sulfate or IV ferumoxytol, with the primary outcome being improvement on a standardized RLS symptom scale at week 6.  Both IV and oral iron were associated with a statistically significant improvement in RLS symptoms, with no statistically significant difference between the two treatment groups. There were no serious adverse events in either group. (LG)
• The PPI Predicament. A recent study published in the NEJM provided some reassuring data on the use of proton-pump inhibitors (PPIs) in lowering the risk of gastrointestinal bleeds in patients undergoing invasive ventilation. In this large RCT across 68 intensive care units, >4,800 critically ill patients were randomized to receive 40mg IV pantoprazole daily or placebo. The primary outcome, clinically important upper gastrointestinal bleeding, occurred in 1% of the patients assigned to the IV pantoprazole group versus 3.5% in the placebo group (hazard ratio 0.30; 95% CI 0.19 to 0.47; P<0.001). There was no significant difference in mortality between the two groups at 90 days. (LG)

Palate Cleanser

The melon part. To get rid of the taste of those pesky apps.  And to fill your brain with some fun facts.

Check out The Moth Podcast! Each podcast episode features storytellers sharing their personal stories live with audiences around the world. Each 20-60 minute episode is centered around a specific theme, from “changes of heart” to “unexpected community” to “don’t stop the music” to “skin tight genes.”  You’ll find yourself laughing, crying, and every emotion in between so take a listen on your morning work commute!

– Jennifer DeSalvo MD 

The Main Course

Alexander Chaitoff MD, MPH

An Update to Breast Cancer Screening Recommendations
In April 2024, the United States Preventive Services Task Force (USPSTF) released their latest recommendations on screening for breast cancer, with a big change.  The USPSTF recommended beginning screening mammography at age 40 (a Grade B recommendation, representing high certainty of moderate benefit or moderate certainty of moderate/substantial benefit). With this recommendation, the USPSTF essentially reverted back to its 2002 recommendation, though it now recommends biennial screening rather than the more vague “every 1-2 years” in the previous statement. The USPSTF recommendations now more closely match those of other professional societies, such as the American Cancer Association and the American College of Radiology.  So what changed to lead to this recommendation?

A (very) brief history of the USPSTF recommendations
Dating back to the 1990s, the USPSTF has most strongly recommended screening after age 50. But that’s just the headline.

Yes, the previous 2016 recommendations only gave a Grade A recommendation (high certainty of substantial benefit) for biennial screening for women aged 50-74 years. However, they included a Grade C recommendation (signifying moderate certainty of small benefit) for screening in women aged 40-49 years, with a lengthy accompanying explanation. 

The reason previous recommendations had not simply suggested screening all patients aged 40-49 was a combination of the relatively low incidence of cancer and the relatively high risk of false positives (and “overdiagnosis”) in this age group, compared to older patients–based in part on data from the 2009 Breast Cancer Surveillance Consortium update. These data suggested that the number needed to screen to diagnose one case of invasive breast cancer was 556 among those 40-49 years, compared to only 200 for those 60-69 years.  Alternatively, the rate of false positive mammography was ~98/1000 screened among those aged 40-49 vs ~79/1000 screened for those aged 60-69.

This all came at a time when the scientific milieu was one of skepticism about whether cancer screening improved all-cause mortality in the current clinical landscape of management options. For example, a 2001 Cochrane Review concluded “there is no reliable evidence that screening for breast cancer reduces mortality…[and] breast-cancer mortality is a misleading outcome measure.” 

What’s Changed Now?
There are many reasons screening recommendations can change. Sometimes screening tools can become more accurate, reducing the likelihood of false-positives. Other times treatments could become more effective and less toxic, meaning those found to have disease have a better chance of survival. And, in the best-case (data) scenario, a giant new randomized trial unequivocally shows the health benefits of screening for wide swaths of society.

While advances in breast cancer imaging and treatment have certainly occurred since 2016, it appears there were two other major drivers for the USPSTF guideline change. First, the 2024 evidence summary much more explicitly mentions disparities in breast cancer mortality, noting for example that Black patients experience higher rates of breast cancer mortality, and that these rates of mortality increase at younger ages compared with White patients. This means blanket statements to defer screening could disproportionately affect certain marginalized groups. Second, the guidelines acknowledged that more young people are getting breast cancer; in fact, rates of breast cancer have been rising yearly in adults <50, in particular over the past half-decade. When the prevalence of a disease rises, so too does the positive predictive value of the screening test, which means a lower ratio of false positives to true positives.

While the guidelines have changed, this is far from the final word. While rising cancer rates in younger adults makes it unlikely the USPSTF will reverse this recommendation anytime soon, future guidelines will undoubtedly further address screening intervals (1 versus 2 years), what to do in older adults, and many, many other questions that remain unanswered on this topic.

Read The USPSTF Guidelines HERE!

Digestifs

Before you go….
we’ve got a few nibbles!

Consolidate your learning with a Quiz!  

This week on The Curbsiders: Episode #444, a LIVE episode featuring expert hematologist Dr. Rakhi Naik at Johns Hopkins Internal Medicine Grand Rounds, covers the highlights of macrocytosis, hemolytic anemia, and myelodysplastic syndrome. Dr. Naik talks us through some important pearls about macrocytosis including the differential to look into (including VEXAS!), as well as the approach to testing in hemolytic anemia. This one’s a high-yield one! 

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The Curbsiders Digest

Issue 54

Editor in Chief: Nora Taranto MD

Banner: Kate Grant  MBChB, DipGUMed

Disclosures:
Jennifer DeSalvo,  Alyssa Mancini, Laura Glick,  and Nora Taranto report no disclosures.

Alex Chaitoff reports consultancy for Alosa Health

Kate Grant reports no disclosures.

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