447 - Digital Breast Tomography, COPD Screening, Pause Button Recharge

From the Literature

1) Digital Breast Tomography – Fewer False +  than Mammography?

Digital breast tomography (DBT, also called 3D mammography) was approved by the FDA in 2011 to be used only in combination with 2D mammography for breast cancer screening. DBT units take multiple radiographic images while circling around the breast, resulting in about three times the radiation dose per screening (although the FDA has determined that this is still a safe level). Its purported advantage is to reduce the number of false positives in breast cancer screening by getting better images of denser breast tissue. False positives are an important consideration in breast cancer screening, occurring about 6-12% of the time and resulting in false-positive biopsies in 1-2% of the time over a decade of screening. The US Preventive Services Task Force (USPSTF) has recommended biennial (every two year) mammography (B recommendation) in order to reduce the incidence of false positives. The USPSTF has categorized DBT as “emerging technology,” and gives its use an I statement (insufficient evidence to recommend).

A recent retrospective, comparative effectiveness study has examined the false positive rates between DBT and conventional digital mammography. The authors used data from 6 large health systems around the country, excluded first (baseline), unilateral, and short-interval mammograms. They found nearly 3 million mammograms from ~900,000 patients. The radiologists reading these images used standard BIRADS reporting methods which included an assessment of breast density (which is thought to increase the risk of both false positives and false negatives, especially in younger women). The authors looked for the following outcomes: false-positive recall, false-positive short-interval follow-up recommendation, and false-positive biopsy recommendation.

With annual screening, DBT vs. digital mammography resulted in a lower probability of false positive recalls (-6.7% difference, 95% CI -7.4 to -6.1) and fewer false positive short interval follow up recommendations (-1.1% difference, 95% CI -1.7 to -0.6) over 10 years, but the same probability of false positive biopsies. All false positive tests were less common with increasing age, decreased breast density and biennial screening.

John’s Comments:

DBT looks like it may avoid some false positive results for breast cancer screening, but that is not the whole story. It is unclear if DBT has any improved cancer detection capabilities. In addition, evaluating the magnitude and importance of false positives in cancer screening programs, and the resultant procedures and anxiety they cause, is somewhat controversial. Unfortunately, DBT is being instituted in many institutions without consideration of these concerns. The fact that it must be used with mammography may balance the concerns about detection, but it still results in more radiation exposure and more expense than digital mammography. If there is concern about reducing false positives, a better way may be to simply implement the USPSTF recommendation for biennial rather than annual screening.

References:

·         Ho TQH, Bissell MCS, Kerlikowske K, et al. Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography. JAMA Netw Open. 2022;5(3):e222440. Link

·         Siu AL, on behalf of the U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279. Link

From the USPSTF

2)  Screen For COPD?  Not So Fast

Chronic lower respiratory disease, composed mainly of COPD, is the sixth leading cause of death in the US, and in 2020 it was estimated that approximately 6% of adults had been diagnosed with COPD.  The main cause of COPD is cigarette smoking, with other exposure (secondhand smoke, traffic pollutants, wood smoke, and occupational exposure) being a distant 2^nd.  About 15% of current smokers and 8% of former smokers report being diagnosed with COPD, compared with 3% of adults who have never smoked.

Currently, there is no cure for COPD.  Prevention of exposure to cigarette smoke

and other toxic fumes is the best way to prevent COPD.  Pharmacologic therapies (eg, bronchodilators and anti-inflammatory therapies) and nonpharmacologic therapies (eg, interventions addressing self-management of disease, diet, exercise, and immunizations) are available for disease management in persons with mild to moderate or minimally symptomatic COPD

In 2016, the USPSTF reviewed the evidence for screening for COPD and issued a D recommendation (recommend against).  Using a reaffirmation process, the Task Force recently revisited this recommendation and concluded with moderate certainty that screening for COPD in asymptomatic adults has no net benefit.  This recommendation is consistent with the 2011 joint recommendation from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society

The USPSTF recommendation applies to adults who do not recognize or report respiratory symptoms.  It does not apply to people with symptoms such as chronic cough, sputum production, difficulty breathing, or wheezing, or those known to be at very high risk for COPD.  These latter include people with alpha-1 antitrypsin deficiency or workers exposed to certain toxins at their jobs, 

The USPSTF recommends that clinicians ask all adults, including pregnant women, about tobacco use, and if they smoke, to advise them to stop.  It also recommends providing evidence-based interventions for cessation for those who are trying to quit, including pharmacologic therapy.  Additionally, it recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.

Mark’s Comments:

I continue to be dismayed that it seems we as a society are too often content (resigned?) with treating the symptoms of COPD with medication rather than aggressively trying to prevent it, particularly when it comes to smoking cessation.  Perhaps that is because we know that nicotine is a highly addictive substance, with the “delivery system” of inhalation during smoking making it even more so.  But let’s not forget we do have proven ways to help those who are addicted to quit and the 1-800-QUIT-NOW program can provide incredible support in that process (Link).

What about vaping and any relationship to COPD?  Given that COPD can sometimes take decades to manifest symptoms, there isn’t enough research to know the long-term answer to this question.  Likewise with the use of vaping as a transition or substitute for cigarettes in an attempt to cut down or stop cigarette use.  In 2021, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The Task Force recommended that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety. (I statement).

References:

·         USPSTF: Screening for Chronic Obstructive Pulmonary Disease.  US Preventive Services Task Force Reaffirmation Recommendation Statement.  JAMA. 10 May 2022; 327(18): 1806-1811.  Link

·         USPSTF:  Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement.  JAMA. 2021 ;325(3):021;325(3):265-279. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  A Reminder to Regularly Recharge Your “Pause! Button”

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”   Viktor Frankl, MD

It’s been more than 75 years since Viktor Frankl’s life-changing book “Man’s Search for Meaning,” based on his 3 years as Nazi concentration camp prisoner, was published.  I first learned of Dr. Frankl’s work when reading Stephen Covey’s book, “The 7 Habits of Highly Effective People” decades ago.  The first of Covey’s 7 Habits, “Be Proactive,” is anchored in Dr. Frankl’s notion that while we may not have complete control regarding the many challenges that come into our lives (such as COVID-19, economic uncertainty, etc.), we have much more control regarding how we emotionally respond to those stimuli than many realize.  And the secret is in developing the ability to pause and create a  “potential space” between the stimulus and what happens next.

As I began to experience the existence of this potential space, I realized that much of my emotional life was spent in reaction to stimuli – both external circumstances AND my own thoughts, and that many of my stronger negative emotions were being dictated by my amygdala (fight or flight) rather than being regulated by my pre-frontal cortex (the “adult in the room”).   And more importantly, that I had the ability to choose my attitude in any circumstance.  

This understanding that I no longer had to be held captive to my emotions literally changed my life at the time.  But while the concept is seemingly a simple one, I found making the change from “victim” to “owner” was not easy.  One important skill that has helped me with this transition has been a daily meditation practice.   Additionally, I created a literal “Pause! Button” which I wore and would press when I found myself becoming distressed as a reminder for me to provide a space to consider my emotional choices. 

While remembering to “pause” when feeling distressed has become easier over time, strong negative emotions have a way of making me “forgetful” of this life-changing reality.  And there have certainly been many opportunities for this over the past months, with the feelings of frustration, weariness, anger, and powerlessness (and many others) sometimes overwhelming my Pause! Button and draining it of its power.  

Another important way I have found to rechange my Pause! Button is through dialogue with trusted colleagues so we can process our many challenges together.  When one of us is forgetting the existence of that “potential space,” another is there to provide a reminder that while strong negatively charged emotions are certainly an understandable option in the midst of our present challenges, there are other, more life-giving choices as well.  This provides yet one more reason to be connecting regularly with your PeerRxMed partner.  They can help ensure that you are choosing wisely.  

So thank you in advance for doing regular Pause! Button maintenance.   All those who work with you this week (and beyond) will be glad you did … and so will you.    

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org