#544 - Breast CA Screening Update, Sunscreen 2024, We’re In This Together
Take 3 – Practical Practice Pointers©
From the US Preventive Services Task Force (USPSTF)
1) New Breast Cancer Screening Recommendations
Breast cancer screening remains an area where conflicting recommendations between specialty groups persist. Breast cancer is the second most common cancer and second most common cause of cancer death among women. While the incidence is higher in white women, black women die more frequently from breast cancer, despite having greater self-reported screening rates. Finally, the incidence of breast cancer in women aged 40-49 rose two percent per year in the period between 2015 and 2019.
The USPSTF noted that the foundational data on the effectiveness of screening has not changed and relied preliminarily on statistical modeling using data from six different breast cancer registries to analyze questions of starting and stopping ages and screening intervals.
The USPSTF recommendation grading scheme reports on both certainty of evidence and net benefit (benefits minus harms). A ‘B” recommendation is for moderate evidence of a moderate net benefit and a “C” recommendation is for moderate evidence of a small net benefit.
2024 USPSTF Recommendations:
- Screening recommended every 2 years in women 40-74 years (B recommendation)
o Clinical considerations section states conventional mammography or digital breast tomosynthesis (DBT, “3D mammography) are both effective.
- Insufficient evidence (I statement) for:
o Screening in ages 75 and above
o Breast ultrasound or MRI for dense breast tissue
It is worth noting that this new recommendation is similar to their recommendation in 2002, but with more decisiveness about the recommended 2-year interval, which is based on modeling evidence showing this interval best balances the benefits of screening and harms associated with screening (false positives and negatives, overdiagnosis, and radiation exposure).
Historical USPSTF Mammography Recommendations:
- 1996 – Every 1-2 years in ages 50-69 (B recommendation), C recommendation for 40-49 years and C recommendation for 70 and over.
- 2002 – Every 1-2 years, ages 40 and older
- 2009 – Every 2 years, 50-74 years (B recommendation), C recommendation for every 2 years in ages 40-49 years.
- 2016 – Same as 2009. Insufficient evidence on Digital Breast Tomosynthesis (“3D mammography”, I statement).
There are heterogeneous recommendations for breast cancer screening from the interested guideline societies that complicate the public health message, although the USPSTF’s new recommendation does reduce the differences somewhat.
American College of Obstetricians and Gynecologists:
- Offer breast cancer screening between 40 and 49 years.
- Recommend screening between 50 and “at least” 75 years.
- Every 1-2 years.
American Cancer Society
- Ages 40-44 – Offer the option to start yearly screening.
- Ages 45-55 – Recommend yearly screening routinely.
- > 55 years – Recommend screening every 1–2-year screening until life expectancy is limited to under 10 years.
American College of Radiology
- Recommend yearly screening starting age 40 for average risk women.
- Assess breast cancer risk beginning as early as age 25 for high-risk populations (lifetime risk > 20%) and consider implementing both MRI surveillance and yearly mammograms.
As noted, the USPSTF has now quietly included digital breast tomosynthesis (DBT, “3D mammography”) as an adjunct to conventional mammography in its recommended screening methods, noting that, while there is a slight increase in positive predictive value with DBT, no trials have shown a difference in outcomes with its use.
John’s Comments:
It appears that the USPSTF extended a firmer recommendation for screening down to age 40 because it was reacting to the significantly increased rate of cancer incidence (2% per year) in women aged 40-49 over the 2015-2019 period. When addressing the question of how to decrease breast cancer mortality in a population, extending the screening age range is not always the best answer. Ensuring adequate screening rates in the recommended age groups is another way. Current rates hover around 50% for Medicaid patients, and 70% for Medicare and commercially insured patients, and extending the age range will likely just reinforce those disparities. Finally, addressing racial disparities in breast cancer mortality are unlikely to be improved by extending screening ages, but instead by exploring and overcoming differences in the receptor status of breast cancers (black women have more triple-negative cancers which have a worse prognosis) and reducing barriers to treatment.
Reference:
- US Preventive Services Task Force. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online April 30, 2024. Link
From Consumer Reports, the AAD, and in Preparation for Summer
2) Sunscreen 2024: Let the User Beware, But Do Use Something
According to the American Academy of Dermatology (AAD), it is estimated that one in five Americans will develop skin cancer in their lifetime. Sun protection is the most effective way to prevent skin cancer. For sunscreen, the sun protection factor (SPF) is a relative measure of how long a sunscreen will protect from UVB rays, which are the chief cause of sunburn and a contributor to skin cancer. Usually the number is explained as the amount of time it takes an individual’s skin to burn when it’s covered in sunscreen compared with when it’s not. For example, assuming you apply—and reapply—the sunscreen correctly (recommended every 2 hours), if you’d normally burn after 20 minutes it would take 10 hours with the application of SPF 30 sunscreen.
SPF calculations do not apply to UVA rays, which can tan and age skin and cause skin cancer. That’s why it is necessary to use a broad-spectrum sunscreen that provides protection against both types of UV rays. However, no sunscreen blocks 100 percent of UVA or UVB rays. The breakdown: SPF 30 blocks 97 percent of UVB rays, SPF 50 blocks 98 percent, and SPF 100 blocks 99 percent. The AAD recommends everyone use water resistant sunscreen that offers broad-spectrum protection against UVA and UVB rays at a SPF 30 or higher.
It is also important to note that sun protection may be required indoors if much time is spent sitting near a sunny window. Glass blocks UVB rays, but it can let through some UVA rays. Automobile windshields do a good job for both UVA and UVB light (particularly newer models), but automobile side windows don’t provide as effective protection for UVA light.
The Consumer Reports company has recently published its 2024 sunscreen ratings, testing 96 products this year. In the past few years, the company has consistently noted that many tested products perform at less than half their labeled SPF number and many are inconsistent in their protection across product batches and various products from the same company. They’ve also found that cost and brand name do not necessarily correlate with quality. Since the AAD recommends using a product with an SPF of 30 or higher, this means that in many cases, users are not adequately protected, even with listed SPF ratings of 50. This also means that most products with an SPF rating of 30 are not sufficient. All products listed below have a tested SPF of > 30.
Additionally, testing has consistently found that so-called natural or mineral sunscreens (those that contain only titanium dioxide, zinc oxide, or both as active ingredients) have tended to perform less well. This does not include products labeled sunblock, such as higher concentration zinc oxide products (think white noses on lifeguards).
According to the FDA, there are no chemical sunscreens that are generally regarded as safe and effective (GRASE) because additional data is needed. Note, this does not mean they are unsafe (comparable to an “I” recommendation from the USPSTF).
The Top Rated/Recommended Sunscreens per Consumer Reports for 2024:
· Lotion: - Coppertone Water Babies Lotion SPF 50 (Score of 100/100)
- La Roche-Posay Anthelios Kids Lotion SPF 50 (Score 90) (expensive)
- Every Day Humans Oh My Bod! Lotion SPF 50 (Score 83)
- Eucerin Advanced Hydration Lotion SFP 30 (Score 75)
- La Roche-Posay Anthelios Melt-in Milk Lotion SPF 60 (Score 73)
(expensive)
- Alba Botanica Hawaiian Lotion SPF 30 Aloe Vera (Score 70)
- Equate (Walmart) Ultra Lotion SPF 50 (Score 68)
· Spray: - Eucerin Advanced Hydration Spray SPF 50 (Score 88)
- Black Girl Sunscreen Kids Spray & Play SPF 50 (Score 77)
- Trader Joe’s SPF Spray 50+ (Score 74)
- Neutrogena Beach Defense Water + Sun SPF 50 (Score 71)
- Black Girl Make it Glow Spray SPF 30 (Score 68)
- Sun Bum Premium Spray SPF 50 (Score 67)
Other Notable sprays for affordability:
- Equate (Walmart) Sport Spray SFP 50 (Score 65) (< $5)
- Up and Up (Target) Sport Spray SPF 50 (Score 64) (< $5)
Some additional tips regarding sunscreen from Consumer Reports include:
- Check the expiration date (formulated to remain effective for 3 years)
- Shake the product well before applying
- Apply generously at least 15 minutes before going into the sunlight or water
- Don’t forget commonly missed spots, including lips, backs of hands, tops of feet, back of the neck, scalp, and ears.
- Reapply every 2 hours and immediately after swimming or sweati
- Use spray screens appropriately by holding the nozzle 4 to 6 inches away from the skin, spraying until the skin glistens, then rubbing it in, even if it is labeled “no rub.”
Mark’s Comments:
What makes the Consumer Reports evaluation compelling is that the same process was used on all products under the same conditions (less potential bias than a company testing their own product). They also buy the product off the shelf. The Eucerin products are a new addition to the testing this year and scored well for both their lotion and spray products listed. My experience has been that people gravitate toward spray over lotion, so in terms of actual usage, the sprays may be the better choice. However, I also note that often the spray is used incorrectly, so the benefit of “use” may not translate into better protection. And don’t forget to wear a sun protection hat. Baseball caps may be fashionable but they’re not particularly effective for comprehensive protection from the neck up.
References:
From PeerRxMed ( www.PeerRxMed.org )
3) Back to the Fundamentals: We’re In This Together
“Don’t worry! I got your back.” — Anchoring phrase at the 2024 AAFP Physician Well-being Conference
At the recently held American Academy of Family Physicians (AAFP) Physician Well-being Conference, we started our time by considering the conference as our Hero's journey, and together created a group story, facilitated by our incredibly talented colleague and conference faculty member, Belinda Fu, MD.
As we ended the session and set out on our conference “journey,” Belinda encouraged the participants to connect with those sitting near them and with a half-hug, share the phrase, “Don’t worry, I got you back.” The positive energy in the room was palpable and that exercise set the tone for the Spirit of the conference, which became a wonderful space for support and encouragement.
The phrase “I got your back” likely originated from fighter airplane pilots during World War 1 and has lived on through the now popular term “wingman.” However, the importance of having a “buddy” has extended well beyond the military, including the Scouting and YMCA swimming programs. Indeed, it was through my own experience in the YMCA swimming programs and their buddy system that the PeerRxMed program was inspired.
As it became used more commonly and outside of the military, the phrase signified a commitment to watching out for someone's safety and well-being, especially in challenging or even dangerous circumstances, and sends an explicit message of support and solidarity. As used during the conference, the phrase took on a meaning less of being “defended” as of being looked after with care and protection as we allowed ourselves to explore vulnerable parts of our emotional lives. This was demonstrated through heart-felt listening and the gift of “being together,” sending the message that “I’m here for you, I’m with you, I am on your side, we’re in this together.”
The purpose of the PeerRx process is well-captured in the phrase, “I got your back.” Given the challenging circumstances of our work, it would seem that having a colleague who is intentionally supporting us and watching out for our safety and well-being would be mandatory (at least “sanity”) for all of us. Tragically, too many of us continue to “go it alone” even in the face of often overwhelming (yes, even “dangerous”) circumstances. By participating in the PeerRx process, you’ve made a wise decision to not give in to this temptation. Let’s encourage others to “buddy up” as well. Everyone deserves to have buddy who has their back. Remember, when it comes to our “professional Hero’s journey,” we’re in this together.
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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