News From Dr. Fait
Why Is There A Controversy About The Frequency With Which Women Should Get Mammograms?
Before we get into this issue, we should discuss where there is no difference of opinion. There is no controversy concerning women who have a mass or those that are high risk given their genetic predisposition, such as those that carry the BRCA genes. The difference in opinion comes with the screening mammogram and its frequency as well as when to begin screening.
The U.S. Preventive Task Force Service (USPTFS) recently came out with the recommendation that the screening mammogram should begin at 50 and then be performed every two years. The USPTFS is a governmental body that sets payment policy for Medicare and Medicaid populations. The goal is to provide the best medical care for a large population at the cheapest cost with acceptable morbidity and mortality. The reasoning for every two years was due to the number of false positives associated with every test. What the false positive is, in regards to screening mammograms, is a mammogram that requires additional testing. This testing may be other mammogram views, ultrasounds or even biopsies with the end result being normal tissue. These false positive tests lead to more expensive testing, apprehension on the part of the patients and possible risks of further invasive testing, although risks are minimal with biopsy.
The American College of Obstetricians and Gynecologists (ACOG) and American College of Surgeons recommended that screening begin at 40 and continue annually thereafter. These groups base their standards on their clinical meeting with individual patients. Some patients may be more afraid of cancer and therefore would begin testing as early as possible whereas some patients do not want frequent testing for whatever reason. The discussion rests with the patient and their physician, but if the standards change, those women wishing to have yearly mammograms may find their insurance company will only pay every other year from age 50 onward. The net result is that the cancers that are found will be at later stages and, although the mortality may not change, the surgeries and chemotherapy treatments will be more aggressive as well as disfiguring.
The bottom line in this discussion is balancing the risks of false positives and the inherent costs that will be incurred by more frequent and earlier testing versus the cost savings by delaying initiation of screening and more infrequent testing but to intervene later in the disease process leading to more aggressive treatment options to maintain the same mortality numbers. One statistic that stood out to me personally at a recent conference regarding breast cancer screening was that 1 out of every 6 women that develop breast cancer are between 40-50. By following the USPTFS recommendations, these women would not have been screened until a mass is felt by patient or clinician, which means it has been present for between 5-7 years. As has been stated many times, life is about choices and these should be made by an educated patient and not put forward by policies that may be aimed more at saving money.
What We Know About The Zika Virus
The Zika virus is usually transmitted via the mosquito but has been shown to be sexually acquired from a partner’s semen after travel to an endemic area. This is the reasoning behind partners using condoms during the entirety of the pregnancy to prevent infection. It was first noted in the Zika Valley in Africa and made its way to South America via French Polynesia and other small islands. It was not until it reached the more populated areas of Brazil that the maternal-to-fetal transmission was detected. More than 80% of affected individuals are asymptomatic and the incubation period is around two weeks, but the timeframe in the male semen is unknown.
Symptoms of this virus are similar to many other viruses such as measles, rubella, parvovirus, adenovirus, and enterovirus to name a few. The most severe effect on the fetus has been found to be microcephaly, a condition in which the baby’s head is much smaller than normal. There are varying degrees of microcephaly and we are unable to predict the long-term consequences if it occurs. In the past, other infections such as cytomegalovirus, rubella and toxoplasmosis have had similar manifestations. At this time there is no treatment but the CDC and the World Health Organization are working towards a vaccine.
All pregnant women and those wishing to conceive are recommended to avoid travel to locations in which there are outbreaks. At this time South and Central American countries are actively dealing with the infection but it has also been found in Puerto Rico and other Caribbean countries. The virus has now been found to infect the mosquito that resides within the continental borders of the United States. This means it may be a matter of time before the first U.S. outbreak occurs. Recommendations are to stay indoors in air-conditioned environments and to use DEET insect repellant when going outdoors. When outdoors, it is highly recommended to wear long-sleeved shirts and pants at all times with the goal of avoiding mosquito bites and thus transmission of the virus.