Bloomberg recently reported a story that highlighted the recommendations of the U.S. Preventive Service Task Force on yearly mammograms for women aged 40 and above. According to the story, the guidelines released by the task force suggested that annual mammograms for most women in their 40s have more drawbacks than benefits and therefore, women should wait until age 50 to start getting breast cancer screening tests every two years.

Here is the story:

November 17, 2009

Annual mammograms for most women in their 40s have more drawbacks than benefits, said a panel of U.S. doctors that recommended women wait until age 50 to start getting breast cancer screening tests every two years.

The change in guidelines released by the U.S. Preventive Service Task Force, a government-backed physician group, said women in their 40s are more likely to get false-positive tests that can lead to unnecessary biopsies and anxiety. The recommendations, which also said that self-examinations were unnecessary, don’t apply to women who carry a high risk for breast cancer. Those women should talk to their doctors about when to get screening, the panel said.

The new guidelines, published yesterday in the Annals of Internal Medicine, pit the task force against the American Cancer Society, which insisted doctors should still advise women to undergo routine annual screening starting at age 40. About 64 percent of women ages 40 to 49 had an X-ray of their breasts during the past two years, the panel’s report said.

“This is not a blanket recommendation not to worry until age 50,” said Diana Petitti, a disease epidemiologist at Arizona State University in Tempe, Arizona, and vice chair of the panel. “It’s a recommendation to have a discussion with your physician to better understand the trade-offs between starting exams now and starting later.”

Imaging machines for mammograms, and related supplies, are marketed by Fairfield, Connecticut-based General Electric Co., Bedford, Massachusetts-based Hologic Inc. and Munich-based Siemens AG.

Insurer Coverage

J. Leonard Lichtenfeld, the American Cancer Society’s deputy chief medical officer, said the panel’s guidelines may affect insurance payouts. ‘Our hope is that insurers will not make any change in coverage,” Lichtenfeld said.

WellPoint Inc., the top U.S. health insurer by enrollment with 34 million members, pays for annual mammograms for women age 40 in the majority of its health plans. The Indianapolis- based company periodically reviews its reimbursement policies and “doesn’t adhere to any one source” for guidance, said Jill Becher, a company spokeswoman in Milwaukee.

The new guidelines, if widely adopted by physicians and insurers, could reduce the number of U.S. mammogram screenings by 58 percent, from the current 37.2 million annually to 15.6 million under a “worst-case scenario,” Junaid Husain, a Boston-based analyst at Soleil Securities, wrote in a note to investors today.

Detecting Cancer

Mammograms, self-breast examinations, and doctor’s exams are the three main forms of detecting breast cancer. The task force said there was no evidence that self-exams reduce breast- cancer deaths, and insufficient information exists to recommend that doctors do routine physical exams.

The mammograms are used to check for breast cancer in women who have no signs or symptoms of the disease, and also to check for breast cancer after a lump or other signs of cancer have been found, according to the National Cancer Institute.

Breast cancer is the second-leading cause of cancer-related deaths among U.S. women, after lung cancer, killing 40,480 women in 2008, according to the task force report.

The task force analyzed published research and developed computer-simulation models to evaluate the likely health outcomes if mammograms were begun at certain ages and done every one or two years.

Deaths, False Positive Tests

The study confirmed earlier research that women who have mammograms die less frequently of breast cancer than those who don’t have the tests. About two deaths per 1,000 women are averted if women begin annual screenings rather than exams every two years starting at age 40, the task force estimated.

It also estimated that women who begin getting mammograms at 40 will have about 60 percent more false positive results per 1,000 exams than women who start screenings at age 50. A false positive, in which an abnormality is seen that proves not to be cancer, typically leads to additional screenings and tissue biopsies, the panel’s researchers said.

The cancer society challenged the reliability of the task force study’s methods.

“We are reluctant to recommend changing a proven program that has helped to save lives,” Lichtenfeld said. The society questions whether the task’s force computer modeling “is sufficiently sophisticated and accurate enough,” he said.

High-Risk Women

The recommendations aren’t intended for women older than 40 who have a higher risk for breast cancer. Increased risk can come from having a gene mutation linked to breast cancer or having been exposed often to chest radiation, which can raise the probability of breast cancer.

The task force said it didn’t make recommendations for these higher-risk groups because it lacked sufficient data to know the benefits of more frequent screening tests.

Women’s health groups varied in their responses to the new guidelines.

Susan G. Komen for the Cure, the Dallas-based breast cancer advocacy group, said it won’t change its recommendation that women ages 40 to 49 get annual mammograms. “We would not want to see a change in policy or reimbursement for screening mammography at this time,” said Eric Winer, the group’s chief scientific adviser, in a statement.

The task force’s recommendations were applauded by the National Breast Cancer Coalition, a Washington-based advocacy group, which said the guidelines support its position.

‘Deserve the Truth’

“Women deserve the truth even when it is complicated,” said Fran Visco, the coalition’s president, in a statement. “They can accept it.”

The American College of Obstetricians and Gynecologists rejected the task force’s recommendations, maintaining its guidelines that women in their 40s be screened every one to two years and women age 50 and older get annual exams, according to a statement issued by the group on Monday.

Researchers and physicians know that results from the X- rays aren’t as reliable in younger women as in older women. Women in their 40s typically have denser breast tissue, making it more difficult for technicians to determine if an image is normal or cancerous.

After women enter menopause, typically about age 50, the breast tissue becomes less dense and more fat, and the X-rays can be more accurately interpreted, said Susan Love, president and medical director of the Dr. Susan Love Research Foundation in Santa Monica, California.

‘Long Overdue’

The panel’s suggestions for women ages 40 to 49 are “long overdue,” said Love in a telephone interview. “Most countries in the world do not do mammography screening until age 50.”

“There is a lot of anxiety created when someone tells you that there is something that showed up in a test,” said Karla Kerlikowske, an epidemiologist at the University of California, San Francisco, Medical Center who wrote an editorial accompanying the task force report.

Subsequent exams expose women to more radiation, and although biopsies are “low risk,” some patients develop infections or experience pain and bruises, she said.

Screening women ages 50 to 74 every two years “achieves most of the benefit of annual screening with less harm,” the task force said. Now women in the older age group get a mammogram, on average, every 14 months, according to the report.

In forming its guidelines, the task force’s “biggest concern” was that women would be confused by conflicting advice from health experts or wrongly interpret the panel’s message as a blanket recommendation for those ages 40 to 49 to forego screening until they turn 50, Petitti said.

Risks, Preferences

Instead, decisions by women younger than 50 and their doctors should be based on “the risk for breast cancer and preferences about the benefits and harms” the task force wrote in the study.

Although the recommendations are “very clear and thoughtful,” women are likely to be confused by the different advice of health experts, Kerlikowske said.

It may be difficult to persuade many women in their 40s who have been told by their doctors for years that annual screenings are beneficial to accept the panel’s recommendations, said the cancer society’s Lichtenfeld.

“The task force is saying you can get 70 percent of the benefit if you get a mammogram every two years compared with every year,” Lichtenfeld said. “There will be women who say, ‘I want 100 percent of the benefit.’”

Source: Bloomberg

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What is a colonoscopy and why is it necessary?
Colonoscopy is a minimally invasive endoscopic examination that allows your doctor to look at the interior lining of your large intestine (rectum and colon) through a thin, flexible viewing instrument called a colonoscope. It may provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected lesions.

Colonoscopy is done to:
• Detect problems or diseases of the anus, rectum, or large intestine (colon). These tests are often done to investigate symptoms such as unexplained bleeding from the rectum, prolonged diarrhea or constipation, obvious or hidden (occult) blood or pus in the stool (feces), or lower abdominal pain.
• Evaluate the source of internal bleeding.
• Screen for colorectal cancer or polyps.
• Evaluate abnormal results from a barium enema test.
• Monitor the growth of polyps that cannot be completely removed.
• Screen for recurrence of colon or rectal cancer in people who have had surgical treatment for colon or rectal cancer.
• Remove polyps or take tissue samples (biopsy) when colon cancer or other bowel disease is suspected.
• Monitor treatment of inflammatory bowel disease.
• Evaluate an unexplained drop in hematocrit (one sign of anemia), usually along with an EGD (oesophagoastroduodenoscopy), in older patients and sometimes in younger patients as well.
• Remove foreign bodies.
• Evaluate the cause of chronic diarrhea.
• Some patients may need to have the colonoscopy repeated regularly to make sure new abnormalities have not developed.

Due to the high mortality associated with colon cancer and the high effectivity and low risks associated with colonoscopy, it is now also becoming a routine screening test for people 50 years of age or older. Subsequent rescreenings are then scheduled based on the initial results found, with a five- or ten-year recall being common for colonoscopies that produce normal results.

Details of the procedure

What do I need to do before this procedure?
Before the procedure, you will also be asked to go on a clear liquid diet for 1-2 days to help decrease the formation of any stools.
For a colonoscopy, the colon needs to be very clean. For this reason, on the day before the colonoscopy, a laxative and large quantity of fluid will be given to you. This will cause significant diarrhea that will clean the colon of any stools. A whole bowel irrigation may also be performed to clean the colon.

You may be asked to stop taking aspirin products or iron supplements 7 to 14 days before the test to avoid the risk of bleeding if a polypectomy is performed during the procedure. If you take blood-thinning medications regularly, discuss with your doctor how to manage your medication.

What happens on the day of the procedure?
Your surgeon will explain the procedure in detail, including possible complications and side effects. He may use an enema 30 to 60 minutes before the test to completely cleanse your colon.

What type of anesthesia will be used?
During the test, you may receive a pain medication and a sedative through an intravenous (IV) line in your arm or hand. These medications reduce pain and will make you feel relaxed and drowsy during the test. You may not remember much about the actual test.

What happens during colonoscopy, and how is it performed?
You will lie on your side with your knees drawn up toward your abdomen. Once you are in position, the doctor will first check for tenderness or blockage by inserting a gloved finger into your anus. Then, the colonoscope will be inserted and advanced while the intestinal lining of the colon will be examined through the scope. In some settings, the doctor may also view your abdomen on an X-ray screen (fluoroscope) to check the position of the colonoscope.

Your doctor will try to examine the entire length of your large intestine. As the colonoscope is withdrawn, extra care will be taken to examine the entire inner lining of your colon.

The doctor may also insert tiny instruments (forceps, loops, swabs) through the colonoscope to collect tissue samples (biopsy) or remove growths. The biopsy test is completely painless.

The test usually takes 30 to 45 minutes, but it may take longer, depending upon what is found and what is done during the test.

Why is a tissue sample collected during colonoscopy?
In some cases, a sample of tissue (biopsy) may be collected during the colonoscopy. In that case, it will be sent to a lab for further analysis. Samples of colon tissue are usually sent to a pathology lab, where they are examined under a microscope for evidence of certain diseases. Other samples of colon tissue may be sent to a microbiology lab to determine whether certain kinds of infection are present. Your doctor may be able to discuss some of the findings with you immediately after the procedure. Other results are usually available in 2 to 4 days. Tests for certain infections may take several weeks.

How long will I be in the hospital?
A colonoscopy is an outpatient procedure. After the test, you will be observed for 1 to 2 hours until the medications wear off. When you are fully recovered, you will be released from the hospital.

What precautions will I need to take after the procedure?
You will not be able to drive or operate machinery for 12 hours after the test. Your doctor will tell you when you can resume your usual diet and activities. Drink lots of liquids after the test to replace the fluids you may have lost while you were taking the laxative solution but do not drink alcohol.

What are the risks/complications associated with colonoscopy?
A colonoscopy is a very safe procedure that could be life saving. However, as with other procedures, there are some risks and complications attached with it.
• There is a slight risk that a tear or hole in the lining of the colon may occur. This is called gastrointestinal perforation and requires immediate major surgery for repair.
• There is also a slight risk of causing a colon infection.
• Bleeding may occur but such complications can be treated immediately during the procedure by cauterization via the instrument.
• Delayed bleeding may also occur at the site of polyp removal up to a week after the procedure and a repeat procedure can then be performed to treat the bleeding site.
• People who have certain types of heart murmurs, artificial heart valves, or previous infections of a heart valve will need antibiotics before and after the test to prevent infection. An irregular heartbeat may occur during the test but nearly always subsides on its own without treatment.
• Complications due to anesthesia include cardiopulmonary complications such as temporary drop in blood pressure and oxygen saturation.

What should I watch out for?
After the test, you may have bloating or crampy gas pains and may need to pass some gas. If a biopsy was done or a polyp removed, you may have traces of blood in your stool (feces) for a few days. If polyps were removed, you may be instructed to avoid taking aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for 7 to 14 days after the test.
Be sure to call your doctor if any of the following symptoms appear:
• Heavy rectal bleeding
• Severe abdominal pain
• Fever
• Dizziness

Cost and availability

How much does it cost?
Click here for details.

Which countries/hospitals is it available in?
Click here to check the availability of colonoscopy with our partner hospitals.

Healthbase is a medical and dental tourism facilitator that connects patients to leading JCI/JCAHO/ISO accredited hospitals and dental offices overseas through a secure, high-tech, information-rich web portal. Healthbase provides a wide range of medical procedures through its partner hospital network. Over two hundred medical procedures are available in various categories: cosmetic and plastic, orthopedic, dental, cardiac, and many more. The savings are up to 80 percent from typical US prices even after adding up the travel costs, hospital stay and other related expenses. Healthbase offers more than just procedural availability; we also provide customers with extensive information on medical treatments, hospital and doctor profiles to help them make an educated decision regarding their treatment; travel planning and booking; applying for medical/dental loan and much more.

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Note: All information presented here has been obtained from publicly available medical resources and is here for reference purposes only. Healthbase does not claim to be a medical professional and does not provide any advice on any issues relating to medical treatment.

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