Answers to Viewers' Questions

Question:
It was mentioned that routine screening is not recommended for persons under 30 years old, but no reason for this was mentioned. Is this due to the generally denser breasts in women of that age group which makes tumors more difficult to see on mammograms?

Gerald, Associate Radiological Health Specialist/
Mammography Inspection Program Manager, Troy NY

Answer:
Screening mammography is not recommended for younger women for the very reason you suggest. The breasts of younger women are denser than the breasts of women over 50. Mammography produces a picture (or x-ray) of the breast that shows dense areas in white and less dense areas in tones of gray or black. Breast abnormalities or lesions show up as white or lightened areas on the mammography film. In young women whose breasts are normally dense mammography is not as effective in screening for abnormalities. Their x-rays are not as easy to read correctly and radiologists are less certain about the accuracy of their interpretations.

Instead of mammography, women under 40 years of age should learn how to correctly perform a monthly breast self exam and have their doctor perform a clinical breast exam each year.

Question:
Do lay health workers in the NC project receive compensation? These women have been recruited from rural areas and are likely to be from socio-economically disadvantaged communities. They provide an extremely valuable service that in many cases the PI cannot provide because he/she is not representative of the target audience. Grants should include a modest salary for the lay health workers.

Anonymous

Answer:
As you have pointed out in your question, SOS lay health advisors live and volunteer in some of North Carolina's poorest counties. In addition to being economically disadvantaged, the region is rural and medically underserved. Our aim is to improve the longevity and quality of life for older low-income African American women who live in such economically disadvantaged communities. We focus on breast cancer because it is a leading cause of cancer deaths among African American women. We have adopted volunteer lay health advising as our key strategy because we believe it builds on local capacities and further strengthens them.

Rural communities such as those our program targets often lack financial resources to develop programs to address the critical public health and economic development problems they face. It is important to develop effective strategies that build on the existing strengths within these communities instead of fostering reliance on external resources.

Keeping in mind the importance of developing affordable public health solutions, the Save Our Sisters program featured on the Public Health Grand Rounds program developed a volunteer lay health advisor network. We selectively recruited local women who have reputations for being wise, helpful and trusted. They are the "natural helpers" in their communities, women others naturally turn to for information, advice and support. In addition to participating in the Save Our Sisters Program, these women volunteer for church and civic organizations, serve on local government boards, organize neighborhood projects and festivals. It would be difficult, if not impossible, to place a value on the service and leadership that these 160 women give to their communities. Save Our Sisters is just one of many strategies they use to improve the lives of others.

Most of their LHA activities are informal. For example, an LHA may talk to a woman about mammography in the grocery store check out line or bring up the topic of mammography in a casual conversation with her beautician. But, they have also initiated more formal campaigns during Breast Cancer Awareness Month or for local community events. To help coordinate LHA projects, we have one full-time paid position, a Community Outreach Specialist (COS), in each of the 5 counties. Each COS is a lay health advisor funded by the research project and her local health department to help coordinate lay health advisor activities and evaluate the effectiveness of the program.

As a research project, we want to create sustainable solutions to local community health problems. We believe that developing the lay health advisors into salaried workers would undermine that effort. As it currently exists, the Save Our Sisters program is a useful model for other low-income areas that value community capacity-building and want to develop effective and sustainable health promotion programs, but may not have start-up funds from the National Cancer Institute.

Question:
Is there any evidenced based information available as to whether the use of the beads impacts a women's decision to obtain a mammogram? If so, can you provide a bibliography of articles?

Liz, Nurse Practitioner, Helena MT

Answer:
We recently learned of two evaluation studies of NC-BCSP's beads that are underway. We hope to have more information soon about the design and findings of those studies. Both are being conducted by agencies with no affiliation to NC-Breast Cancer Screening Program or its Save Our Sisters Program. When we know more about those studies we will be glad to pass the information along to you.

Question:
During your presentation it was said that there is no evidence to support that breast self-exam reduces mortality from breast cancer. I would like to know what resource substantiates this statement?

Sheryl, family planning nurse, Yuma AZ

Answer:
Below is a brief summary of the U.S. Preventive Services Task Force on breast self-examinations (BSE). It is an evidence based guide that federal health agencies and other medical centers use to direct health care practices.

Data regarding the accuracy and effectiveness of BSE are extremely limited. There is little or no evidence that BSE reduces mortality from breast cancer. Furthermore, the accuracy of BSE as currently practiced appears to be considerably inferior to that of CBE and mammography. False-positive BSE, especially among younger women in whom breast cancer is uncommon, may lead to unnecessary diagnostic evaluations and anxiety. The time devoted to teaching BSE may reduce time available for prevention efforts with proven effectiveness. Given the present state of knowledge and the potential adverse effects and opportunity cost, a recommendation for or against inclusion of teaching BSE during the periodic health examination cannot be made.

Citation: U.S. Preventive Services Task Force. Guide to clinical preventive services, 2^nd ed. Baltimore: Williams & Wilkins, 1996. Chapter 7, Screening for Breast Cancer, pg 73-87.

Question:
What about inflammatory breast cancer that doesn't involve a lump?

Anonymous

Answer:
All diagnosed breast cancers need appropriate follow-up and treatment. For more information about the treatment, screening, prevention, supportive care and clinical trials for cancers such as inflammatory breast cancer, contact the National Cancer Institute's, cancer information service at 1-800-4CANCER or visit their website at cancernet.nci.nih.gov.

Question:
I am a physician assistant student currently on rotation with the Wise county health department. I viewed the teleconference on breast and cervical cancer screening. My question revolves around the issue of screening when there are no monies for treatment available. It appears as though we have support for the diagnostic procedures, but have left the women in the same situation as they were before they were screened. One of the common barriers to screening is the belief "even if I do have cancer I don't have the money to pay for treatment". Without monies for treatment we have fulfilled their fear of knowing and not being able to take action. It would seem to me, and perhaps naively so in this political world, that support for treatment should have been acquired before you went looking for cases. A case of putting the horse before the cart. Maybe monies are in the pipeline for treatment barely skirting the problem before it arises. I hope so. Please e-mail me with any information you have that would provide treatment, not diagnostics, for those women that are identified as having cancer.

Anonymous

Answer:
As specified by the Public Law establishing the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), participating programs must assure the Center for Disease and Control and Prevention (CDC) that women screened through the program will receive appropriate treatment, even though federal dollars are not allocated for treatment. In every request for program applications, CDC explicitly states that assurances for treatment must be provided by all grantees who are awarded NBCCEDP funds. Grantees are legally bound by this contractual agreement once funds are accepted.

Each program or agency participating in the NBCCEDP has developed a reporting system that captures critical information about women screened through the program. Most of these systems are tied to provider reimbursement forms. NBCCEDP's are required to submit information to CDC semiannually about clinical services. These surveillance systems collect standardized data items that provide important information, such as screening location, demographic characteristics, screening results, diagnostic procedures and outcomes. The data system developed by CDC and its partners to track the Program's screening results. CDC and the individual programs routinely use these data to review time intervals between screening and diagnosis of cancer, and between diagnosis and start of treatment, as well as whether treatment was initiated. Both screening results and initiation of treatment are regularly monitored through the review of the data submitted by participating programs. The most recent surveillance data indicate that more than 92% of all the women diagnosed with breast cancer through the program have initiated cancer treatment.

To document the range of systems and strategies used by states to obtain resources for treatment and ensure that women diagnosed with cancer or precancerous lesions receive timely and appropriate follow-up and treatment services, CDC contracted with Battelle Centers for Public Health Research and Evaluation and the University of Michigan to conduct an in-depth study of how treatment services are provided. Results of this evaluation were published in the MMWR on March 27, 1998 and can be reviewed and downloaded from Creative strategies to assure necessary treatment have been developed by programs.

Findings of the Battelle Study suggest that state programs and their partners have invested significant amounts of time and effort to develop systems of care to assure cancer treatment, and that these systems appear to be working. However, tremendous effort is involved in developing, implementing, and maintaining strategies and systems for treatment services that are often described as tenuous, fragile and short-lived.

CDC continues to work with our programs and partners to improve these systems and assure that treatment services are available to women diagnosed with cancer through the NBCCEDP.

Question:
Younger women are getting breast cancer -- what is the recommendation on screening younger women?

Anonymous

Answer:
All major expert organizations in the U.S. recommend screening begin at either age 40 or age 50. There is no evidence that mammography screening is effective in women younger than 40. For more information about the treatment, screening, prevention, supportive care and clinical trials for breast cancer, contact the National Cancer Institute's, cancer information service at 1-800-4CANCER or visit their website at http://cancernet.nci.nih.gov.

Question:
There is a history of breast cancer in my family - does this change the normal screening recommendations?

Anonymous

Answer:
Screening recommendations apply to all regardless of family history. However, some experts recommend that women with 2 or more first degree relatives diagnosed with premenopause breast cancer begin screening earlier than age 40.

Question:
Are there any plans for CDC to adjust the age limit down for routine mammograms to 40 which complies with current ACS and NCI recommendations? We are finding many women under age 50 with symptoms of breast cancer who need mammograms.

Cathy, RN, Newport News VA

Answer:
The mammography screening policy for CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) resulted from careful review of scientific research, analysis of many complex program issues, the need to be efficient with the resources provided and with input from partners. The policy has been developed to respond to the recent changes in recommendations by National Cancer Institute and American Cancer Society, and the changes in Medicare preventive services coverage. Under the NBCCEDP's policy, at least 75 percent of women provided mammograms by the program must be at least 50 years old and not eligible to receive Medicare Part B benefits or unable to pay the premium to enroll in Medicare Part B. Additionally, women under 40 years old may not be provided mammograms by the NBCCEDP unless they have an abnormal clinical breast exam or breast self exam. The value of any screening test used in an asymptomatic population depends on the incidence and mortality associated with the disease as well as the performance characteristics and shortcomings of the screening procedure.

Question:
Does having cervical cancer increase your risk for breast cancer?

Anonymous

Answer:
There is no known link, or cause and effect between cervical cancer and breast cancer; therefore, one does not increase your potential risk for the other.

Question:
Do women come back for their 2 year follow-up visit within the NBCCEDP?

Anonymous

Answer:
Studies have shown that routine rescreening is needed to see a decrease in mortality from breast and cervical cancer. Therefore, a primary objective of CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is to ensure that women are provided mammograms and Pap smears at regular intervals following their initial screening examinations.

A review of the NBCCEDP's data through September 30, 1997 has shown that 28% of women who have received a mammogram through the program have returned for at least one subsequent mammogram within 18 months. Twenty-seven percent of women who have received a Pap smear through the program have returned for at least one subsequent Pap smear within 18 months. Forty percent and 36%, respectively, have returned within 30 months. It is important to note that women who obtain insurance or have a significant increase in family income become ineligible for NBCCEDP services, thus, rescreening data is no longer collected on these persons. CDC is currently conducting studies to further evaluate the rescreening rate for all women screened at least once by the program and to assess the barriers that reduce rescreening for specific populations.

Question:
Are NBCCEDP's allowed to pay for diagnostic work-up for a women under age 40 if they are symptomatic?

Anonymous

Answer:
Yes. The CDC's National Breast and Cervical Cancer Early Detection Program screens and offers diagnostic services to women eligible for the program regardless of their age when symptoms of breast cancer are present.

Question:
Does CDC have plans to conduct a national media effort such as an 800 number like what's been done for HIV?

Anonymous

Answer:
CDC does provide a toll-free number for women to locate free or low-cost screening services (mammograms and Pap tests) in their area. The CDC collaborates with State, Territory and American Indian health agencies and many partners for example, the National Breast Cancer Awareness Month organization (NBCAM) to disseminate our toll-free number to women across the nation in need of screening services through the National Breast and Cervical Cancer Early Detection Program. CDC's toll-free number is 1-888-842-6355. However, CDC has no immediate plans to develop a nationwide media campaign publicizing this toll free number.

Question:
You only spoke about low-income African American communities! What do you do for communities made-up of low-income white women?

Anonymous

Answer:
The CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP), provides screening services to low-income, uninsured and underinsured women. The NBCCEDP reaches out to all underserved women. Programs reach these women through universal media outlets and strategies. Media campaigns utilizing brochures, posters, billboards, radio and TV public service announcements, and one-on-one outreach are developed to encourage all women who are in need of cervical or breast cancer screening to take advantage of local services.

Question:
Does a clinical breast exam (CBE) come before mammography or do you suggest something else?

Anonymous

Answer:
Generally, a CBE is recommended before mammography, so that if a lump is discovered, the radiologist can be alerted.

Question:
What is the success rate of breast cancer treatment in the African American women?

Anonymous

Answer:
The National Cancer Institute's SEER program, estimates the five year survival rate for all stages of breast cancer among African American women to be 71 percent compared to 86 percent for whites (1989-1995).

Question:
Mammograms are painful! What is being done to reduce the pain?

Anonymous

Answer:
Mammograms should not necessarily be painful; however, some degree of discomfort due to the compression of the breast tissue is often associated with the procedure. The mammography technician who takes the x-rays places the breast between two plastic plates. The plates press the breast and make it flat to take a clear picture. Communicating with the technician regarding your level of discomfort is important to prevent unnecessary pain. If your discomfort is so great that you are considering avoiding your regular mammogram you should consult your physician.

Regularly scheduled screening mammograms, together with clinical breast exams, offer the best chance of finding and treating breast cancer early. Studies show that mammograms reduce the risk of dying from breast cancer. The National Cancer Institute recommends that women in their forties and older have mammograms on a regular basis, every 1 to 2 years.

Question:
Will digital mammography be widely used for screening anytime soon?

Anonymous

Answer:
This information can best be provided by the American College of Radiology at 1-800-227-5463 or the National Cancer Institute (NCI) at 1-800-4CANCER. NCI funds numerous research projects to improve conventional mammography and develop alternative imaging technologies to detect and characterize breast tumors. For breast cancer screening, high-quality mammography, an X-ray technique to visualize the internal structure of the breast, is the most effective technology presently available.

Efforts to improve conventional mammography center on refinements of the technology and quality assurance in the administration and interpretation of the X-ray films. To advance breast imaging, NCI is funding research to reduce the already low radiation dosage; enhance image quality; and develop and evaluate digital mammography as an improvement over the conventional, film-based technique; develop statistical techniques for computer-assisted interpretation of digitized images; and enable long-distance image transmission technology, or teleradiology, for clinical consultations. NCI also funds research on non-X-ray based technologies such as magnetic resonance imaging (MRI), and breast-specific positron emission tomography (PET) to detect the disease.