publication date: Apr. 19, 2019

Clinical Roundup

ACP screening guidance calls for two-year interval between mammograms for women at average breast cancer risk

Average-risk women, between the ages of 50 and 74, who have no symptoms for breast cancer should undergo breast cancer screening with mammography every other year, the American College of Physicians states in a new evidence-based guidance statement published today in Annals of Internal Medicine.

The guideline can be published here.

ACP’s guidance statement does not apply to patients with prior abnormal screening results or to higher risk populations, such as women with a personal history of breast cancer or a genetic mutation known to increase risk.

“Beginning at age 40, average-risk women without symptoms should discuss with their physician the benefits, harms, and their personal preferences of breast cancer screening with mammography before the age of 50,” ACP president Ana María López said in a statement. “The evidence shows that the best balance of benefits and harms for these women, which represents the great majority of women, is to undergo breast cancer screening with mammography every other year between the ages of 50 and 74.”

Every other year mammography screening results in no significant difference in breast cancer mortality while substantially reducing screening harms when compared to annual screening. Women screened annually receive more abnormal results that do not represent an actual breast cancer diagnosis than women screened every other year (7.0% vs. 4.8%). These false-positive findings result in biopsies and surgeries that would otherwise not have been necessary.

About 20% of women diagnosed with breast cancer over a 10-year period will be overdiagnosed and likely overtreated. Overdiagnosis means a woman is diagnosed with a breast cancer that would not have made her sick or led to her death if not diagnosed or treated. Therefore, finding this cancer is not of clinical benefit to the woman.

Harms of breast cancer screening include false positive results (from a test showing an abnormality even though the woman does not have breast cancer), overdiagnosis, overtreatment, radiation exposure, and radiation associated breast cancers and breast cancer deaths, as well as worry and distress from tests and procedures including breast biopsies.

Recommended strategies vary for breast cancer screening in average-risk women. The age to start and discontinue mammography, screening intervals, the role of imaging methods other than mammography, and the role of clinical breast examination have been points of disagreement among guideline developers.

Rather than developing a new clinical practice guideline in these circumstances ACP instead prepares and releases guidance statements that rely on evidence presented or referenced in selected guidelines and accompanying evidence reports. ACP guidance statements do not include new reviews or searches of the literature outside the body of evidence referenced by the reviewed guidelines.

In “Screening for Breast Cancer in Average-risk Women,” ACP reviewed guidelines from the American College of Radiology, American Cancer Society, American College of Obstetricians and Gynecologists, the Canadian Task Force on Preventive Health Care, the National Comprehensive Cancer Network, the United States Preventative Services Task Force, and the World Health Organization.


Artificial intelligence performs as well as experienced radiologists in detecting prostate cancer

UCLA researchers have developed a new artificial intelligence system to help radiologists improve their ability to diagnose prostate cancer. The system, called FocalNet, helps identify and predict the aggressiveness of the disease evaluating magnetic resonance imaging, or MRI, scans, and it does so with nearly the same level of accuracy as experienced radiologists.

In tests, FocalNet was 80.5% accurate in reading MRIs, while radiologists with at least 10 years of experience were 83.9% accurate.

The research is published online in IEEE Transactions on Medical Imaging. The paper was presented at the IEEE International Symposium on Biomedical Imaging in April 2019 and was selected as the runner up-for best paper.

The paper can be found here.

FocalNet is an artificial neural network that uses an algorithm that comprises more than a million trainable variables; it was developed by the UCLA researchers. The team trained the system by having it analyze MRI scans of 417 men with prostate cancer; scans were fed into the system so that it could learn to assess and classify tumors in a consistent way and have it compare the results to the actual pathology specimen. Researchers compared the artificial intelligence system’s results with readings by UCLA radiologists who had more than 10 years of experience.

The research suggests that an artificial intelligence system could save time and potentially provide diagnostic guidance to less-experienced radiologists.

The study’s senior authors are Kyung Sung, assistant professor of radiology at the David Geffen School of Medicine at UCLA; Steven Raman, a UCLA clinical professor of radiology and a member of the UCLA Jonsson Comprehensive Cancer Center; and Dieter Enzmann, chair of radiology at UCLA. The lead author is Ruiming Cao, a UCLA graduate student. Other authors are Amirhossein Bajgiran, Sohrab Mirak, Sepideh Shakeri and Xinran Zhong, all of UCLA.

The work was supported by funds from the Integrated Diagnostics Program, Department of Radiological Sciences & Pathology, David Geffen School of Medicine at UCLA.


Mount Sinai launches clinical trial of new imaging device for head and neck cancer surgeries

Mount Sinai Health System has launched a clinical trial of a new imaging device for detecting head and neck cancer during surgery.

The device, called Otis Wide Field OCT, by Perimeter Medical Imaging, is an ultra-high-resolution imaging system that can image tumor specimens in real time during surgery, allowing surgeons to remove all of the cancerous tissue during one procedure, rather than waiting for traditional pathology results to come in afterward, which can often lead to additional procedures.

Patients in the trial agree to have their tumors placed in the system for imaging, which is then compared to the standard pathology evaluation.

“State-of-the-art imaging platforms, such as the Otis system and others, will likely play a significant role in the future of head and neck cancer surgery. While traditional pathologic examination of tissues is the standard around the world, we need new technology to allow us to detect cancer and ensure adequate resection at the time of surgery,” explains lead investigator Brett Miles, associate professor of Otolaryngology at the Icahn School of Medicine at Mount Sinai, and co-chief of the Division of Head and Neck Oncology for the Mount Sinai Health System.

“Data from this study, and other projects in the optical imaging program, will help us understand how beneficial these technologies may be and drive future innovation during head and neck cancer surgery,” Miles said in a statement.

Men’s risk of contracting these cancers is twice as high as women’s. Tobacco use and excessive drinking are major contributors, especially for male patients over the age of 50. However, cancers of the oropharynx are dramatically increasing among younger men who don’t smoke, because of the human papillomavirus.

The U.S. Centers for Disease Control and Prevention estimates that more than 16,000 HPV-associated oropharyngeal cancers are diagnosed yearly in the United States, while The American Cancer Society says 7% of adult Americans have oral HPV. Men are four times more likely to develop these cancers than women, and this ratio may nearly double by 2030.

“Although no screening test currently exists for early detection of HPV-related oropharyngeal cancers, it is critically important to recognize symptoms of the disease. Any patient with persistent throat pain or a lump in the neck needs to be evaluated by a physician,” Raymond Chai, assistant professor of Otolaryngology at the Icahn School of Medicine at Mount Sinai, and director of Head and Neck Robotic Surgery at Mount Sinai Downtown said.

“The FDA has recently approved the expansion of Gardasil 9, the HPV vaccine, for use in patients from the ages of 27 to 45. The vaccine has been previously demonstrated to prevent over 90% of possible HPV-related cancers,” Chai said in a statement.

Investigators from the Head and Neck Cancer Research Program at the Icahn School of Medicine at Mount Sinai are also conducting a high-risk HPV screening study, along with colleagues from Johns Hopkins University and three other institutions.

The study, known as MOUTH, is a clinical trial to better understand how risk factors affect oral HPV infection rates. In this study, researchers are collecting samples of blood, saliva, and urine to test them for HPV antibodies.

So far, approximately 630 samples have been collected, and patients who screened positive for high-risk HPV viral types are entering the close observational arm of the study, in which they will receive clinical visits and imaging, such as ultrasound and MRI, to monitor them for head and neck cancer. They will be monitored annually for the next five years. The study is currently open and enrolling patients.


Cervical cancer subtype rising in some sub-populations

A new study reports that a type of cervical cancer that is less amenable to Pap testing is increasing in several subpopulations of women, pointing to the growing importance of human papillomavirus testing and vaccination. The study can be found here.

Overall trends in cervical cancer incidence have been driven by declines in squamous cell carcinoma, which account for the majority  of cervical cancers. Most of the rest are adenocarcinomas, for which Pap testing is less sensitive.

While overall cervical cancer rates have been dropping for decades, cervical adenocarcinomas seem to have become more common in the past 20 to 30 years. But there has been limited reporting on recent trends.

To learn more, investigators led by Farhad Islami, analyzed recent cervical cancer incidence trends by histology and age in the U.S. They examined trends in squamous cell carcinoma and adenocarcinoma incidence rates in the U.S. by age group, race/ethnicity, and stage at diagnosis using data from the U.S. Cancer Statistics Incidence Analytic Database.

They found squamous cell carcinoma incidence rates continued to decrease in all racial/ethnic groups except among non-Hispanic whites, in whom rates stopped dropping in the 2010s. For adenocarcinoma, after being stable between 1999 and 2002, incidence rates among non-Hispanic whites rose 1.3% per year during 2002–2015.

Those increases were driven by steeper increases in women ages 40 to 49, among whom cervical adenocarcinoma rates rose 4.4% per year since 2004, and women 50 to 59 years, among whom rates rose 5.5% per year since 2011. Adenocarcinoma incidence decreased in blacks and Hispanics during 1999–2015 and was stable in Asian/Pacific Islanders.

“Increasing or stabilized incidence trends for [adenocarcinoma] and attenuation of earlier declines for [squamous cell carcinoma] in several subpopulations underscore the importance of intensifying efforts to reverse the increasing trends and further reduce the burden of cervical cancer in the U.S.,” the study said.

The authors state that “more efforts are needed to increase screening utilization according to guidelines and appropriate follow-up of positive results” to further reduce the burden of cervical cancer.

They note that increasing the use of HPV testing may improve early detection of adenocarcinoma, but they also recommend research to further improve screening strategies to reduce overdiagnosis, which may be more common with HPV testing. HPV vaccination is an effective tool to prevent cervical cancer because virtually all these cancers are caused by HPV infection.

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