Breast Cancer

The American Society of Clinical Oncology has issued updated recommendations for the follow-up care of breast cancer survivors, but made no changes from guidelines released in 2006.

The current guidelines include recommendations for all oncologists, primary care providers, and nurses who treat asymptomatic breast cancer survivors. They emphasize physical exams, patient history, and mammography, but discourage routine blood tests, biomarker studies, and other imaging in the absence of symptoms.

An American Society of Clinical Oncology (ASCO) panel reviewed the literature for studies that specifically focused on patient management for patients who had finished their primary therapy to cure breast cancer. The updated recommendations were published online Nov. 5 in the Journal of Clinical Oncology (doi: 10.1200/JCO.2012.45.9859).

Dr. James L. Khatcheressian, from the Virginia Cancer Institute in Richmond, and his associates on the ASCO Clinical Practice Guidelines Committee searched Medline and the Cochrane Library for all systematic reviews, clinical practice guidelines, and randomized controlled trials published between March 2006 and March 2012.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

The committee primarily sought outcomes data on "disease-free survival, overall survival, health-related quality of life, reduced toxicity, and cost effectiveness." Its analysis of nine systematic reviews (including three meta-analyses) and five randomized controlled trials led the committee to conclude that no modifications to the clinical practice guidelines from 6 years ago were necessary.

The recommendations are as follows:

• Providers should give women a physical exam and history every 3-6 months for the first 3 years after they receive primary therapy. Then, a history and physical exam should be conducted every 6-12 months for the next 2 years, followed by annual ones.

• Women who had breast-conserving surgery should receive their first mammogram at least 6 months after completing radiation therapy, followed by a mammogram every 6-12 months. Once they achieve "stability of mammographic findings" after completing locoregional therapy, mammography can be done yearly.

• Women should be advised to do monthly breast self-exams and be educated about symptoms indicating possible cancer recurrence, such as lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches.

• Those who meet the criteria for high risk of family breast cancer should be referred to genetic counseling. These criteria include "Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative."

• Women should also receive regular annual gynecologic care, except those who had a total hysterectomy or oophorectomy, who can have less frequent checkups. Women who take tamoxifen should be instructed to tell their doctor about any vaginal bleeding since they are at a higher risk for endometrial cancer.

Although the committee recommends continuous care by a doctor with experience in breast exams and cancer survivors, they note that "follow-up by a primary care provider seems to lead to the same health outcomes as specialist follow-up, with good patient satisfaction." Women with early-stage breast cancer wishing to be treated by their primary care provider may be transferred a year after diagnosis.

The clinical practice guidelines note that routine blood tests (CBC testing and chemistry panels), breast cancer tumor marker testing, and imaging studies besides mammograms are not recommended if patients have no symptoms. Chest x-rays, bone scans, liver ultrasounds, CT scans, ¹⁸F-deoxyglucose (FDG)–PET scans, and breast MRIs also are not recommended for standard follow-up care.

However, the committee stated that the practice guidelines are voluntary, and "do not account for individual variation among patients and may not reflect the most recent evidence." Therefore, management of each patient should depend on her case history and circumstances, and rely on the professional judgment of her doctor.

While the committee concluded that no new evidence warrants changes to the guidelines, it said that research is needed (in particular, randomized controlled trials) on comparative effectiveness of different surveillance strategies and duration of follow-up. It also called for more research into tumor marker testing and identification of patient subsets that would benefit from various models of care.

The article received no external funding. Lead author Dr. N. Lynn Henry has been paid for consultancy or advisory work for GE Healthcare. No other disclosures were reported.

The American Society of Clinical Oncology has issued updated recommendations for the follow-up care of breast cancer survivors, but made no changes from guidelines released in 2006.

The current guidelines include recommendations for all oncologists, primary care providers, and nurses who treat asymptomatic breast cancer survivors. They emphasize physical exams, patient history, and mammography, but discourage routine blood tests, biomarker studies, and other imaging in the absence of symptoms.

An American Society of Clinical Oncology (ASCO) panel reviewed the literature for studies that specifically focused on patient management for patients who had finished their primary therapy to cure breast cancer. The updated recommendations were published online Nov. 5 in the Journal of Clinical Oncology (doi: 10.1200/JCO.2012.45.9859).

Dr. James L. Khatcheressian, from the Virginia Cancer Institute in Richmond, and his associates on the ASCO Clinical Practice Guidelines Committee searched Medline and the Cochrane Library for all systematic reviews, clinical practice guidelines, and randomized controlled trials published between March 2006 and March 2012.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

The committee primarily sought outcomes data on "disease-free survival, overall survival, health-related quality of life, reduced toxicity, and cost effectiveness." Its analysis of nine systematic reviews (including three meta-analyses) and five randomized controlled trials led the committee to conclude that no modifications to the clinical practice guidelines from 6 years ago were necessary.

The recommendations are as follows:

• Providers should give women a physical exam and history every 3-6 months for the first 3 years after they receive primary therapy. Then, a history and physical exam should be conducted every 6-12 months for the next 2 years, followed by annual ones.

• Women who had breast-conserving surgery should receive their first mammogram at least 6 months after completing radiation therapy, followed by a mammogram every 6-12 months. Once they achieve "stability of mammographic findings" after completing locoregional therapy, mammography can be done yearly.

• Women should be advised to do monthly breast self-exams and be educated about symptoms indicating possible cancer recurrence, such as lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches.

• Those who meet the criteria for high risk of family breast cancer should be referred to genetic counseling. These criteria include "Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative."

• Women should also receive regular annual gynecologic care, except those who had a total hysterectomy or oophorectomy, who can have less frequent checkups. Women who take tamoxifen should be instructed to tell their doctor about any vaginal bleeding since they are at a higher risk for endometrial cancer.

Although the committee recommends continuous care by a doctor with experience in breast exams and cancer survivors, they note that "follow-up by a primary care provider seems to lead to the same health outcomes as specialist follow-up, with good patient satisfaction." Women with early-stage breast cancer wishing to be treated by their primary care provider may be transferred a year after diagnosis.

The clinical practice guidelines note that routine blood tests (CBC testing and chemistry panels), breast cancer tumor marker testing, and imaging studies besides mammograms are not recommended if patients have no symptoms. Chest x-rays, bone scans, liver ultrasounds, CT scans, ¹⁸F-deoxyglucose (FDG)–PET scans, and breast MRIs also are not recommended for standard follow-up care.

However, the committee stated that the practice guidelines are voluntary, and "do not account for individual variation among patients and may not reflect the most recent evidence." Therefore, management of each patient should depend on her case history and circumstances, and rely on the professional judgment of her doctor.

While the committee concluded that no new evidence warrants changes to the guidelines, it said that research is needed (in particular, randomized controlled trials) on comparative effectiveness of different surveillance strategies and duration of follow-up. It also called for more research into tumor marker testing and identification of patient subsets that would benefit from various models of care.

The article received no external funding. Lead author Dr. N. Lynn Henry has been paid for consultancy or advisory work for GE Healthcare. No other disclosures were reported.

The American Society of Clinical Oncology has issued updated recommendations for the follow-up care of breast cancer survivors, but made no changes from guidelines released in 2006.

The current guidelines include recommendations for all oncologists, primary care providers, and nurses who treat asymptomatic breast cancer survivors. They emphasize physical exams, patient history, and mammography, but discourage routine blood tests, biomarker studies, and other imaging in the absence of symptoms.

An American Society of Clinical Oncology (ASCO) panel reviewed the literature for studies that specifically focused on patient management for patients who had finished their primary therapy to cure breast cancer. The updated recommendations were published online Nov. 5 in the Journal of Clinical Oncology (doi: 10.1200/JCO.2012.45.9859).

Dr. James L. Khatcheressian, from the Virginia Cancer Institute in Richmond, and his associates on the ASCO Clinical Practice Guidelines Committee searched Medline and the Cochrane Library for all systematic reviews, clinical practice guidelines, and randomized controlled trials published between March 2006 and March 2012.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

The committee primarily sought outcomes data on "disease-free survival, overall survival, health-related quality of life, reduced toxicity, and cost effectiveness." Its analysis of nine systematic reviews (including three meta-analyses) and five randomized controlled trials led the committee to conclude that no modifications to the clinical practice guidelines from 6 years ago were necessary.

The recommendations are as follows:

• Providers should give women a physical exam and history every 3-6 months for the first 3 years after they receive primary therapy. Then, a history and physical exam should be conducted every 6-12 months for the next 2 years, followed by annual ones.

• Women who had breast-conserving surgery should receive their first mammogram at least 6 months after completing radiation therapy, followed by a mammogram every 6-12 months. Once they achieve "stability of mammographic findings" after completing locoregional therapy, mammography can be done yearly.

• Women should be advised to do monthly breast self-exams and be educated about symptoms indicating possible cancer recurrence, such as lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches.

• Those who meet the criteria for high risk of family breast cancer should be referred to genetic counseling. These criteria include "Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative."

• Women should also receive regular annual gynecologic care, except those who had a total hysterectomy or oophorectomy, who can have less frequent checkups. Women who take tamoxifen should be instructed to tell their doctor about any vaginal bleeding since they are at a higher risk for endometrial cancer.

Although the committee recommends continuous care by a doctor with experience in breast exams and cancer survivors, they note that "follow-up by a primary care provider seems to lead to the same health outcomes as specialist follow-up, with good patient satisfaction." Women with early-stage breast cancer wishing to be treated by their primary care provider may be transferred a year after diagnosis.

The clinical practice guidelines note that routine blood tests (CBC testing and chemistry panels), breast cancer tumor marker testing, and imaging studies besides mammograms are not recommended if patients have no symptoms. Chest x-rays, bone scans, liver ultrasounds, CT scans, ¹⁸F-deoxyglucose (FDG)–PET scans, and breast MRIs also are not recommended for standard follow-up care.

However, the committee stated that the practice guidelines are voluntary, and "do not account for individual variation among patients and may not reflect the most recent evidence." Therefore, management of each patient should depend on her case history and circumstances, and rely on the professional judgment of her doctor.

While the committee concluded that no new evidence warrants changes to the guidelines, it said that research is needed (in particular, randomized controlled trials) on comparative effectiveness of different surveillance strategies and duration of follow-up. It also called for more research into tumor marker testing and identification of patient subsets that would benefit from various models of care.

The article received no external funding. Lead author Dr. N. Lynn Henry has been paid for consultancy or advisory work for GE Healthcare. No other disclosures were reported.

MANCHESTER, ENGLAND – Older women who are breast cancer survivors have a greater risk of developing additional primary cancers in the long term than those under 65 years of age, according to an analysis of data on more than 100,000 survivors in the United States.

Women aged 70-79 years appear to have the highest risk of developing a multiple primary malignancy (MPM), with a crude 10-year incidence of 17.8/10,000 person-years. In comparisons, the rate of risk for survivors younger than 65 was 11.7, increasing to 16.7 for those 65-69 years of age and 16.4 for those 80 years and older.

Other common cancers occurring in the breast cancer survivor population were lung and colon cancers, investigator Kerri Clough-Gorr, D.Sc., reported at the annual meeting of the International Society of Geriatric Oncology. Hematologic malignancies, melanoma, and urinary and digestive tumors were also observed.

"Relative breast cancer survival rates are quite high in the United States, at over 89% at 5 years [after a diagnosis]," said Dr. Clough-Gorr of Boston University and the Institute of Social and Preventative Medicine at the University of Bern (Switzerland).

"Importantly, the vast majority of women with breast cancer become long-term survivors, and they are at risk for developing subsequent malignancies," she added.

It is estimated that there are 2.4 million women in the United States with a history of breast cancer, and the current study aimed to look at survivors’ risk of developing multiple primary cancers over a 20-year follow-up period.

The study analyzed data from 12 SEER (Surveillance, Epidemiology, and End Results) program registry sites on 110,440 women diagnosed with a first primary breast cancer between 1986 and 1994. The women were evaluated for the development of other primary cancers or death up until 2006.

In addition to being more likely to develop another primary cancer, older women were more likely to develop it more quickly. The mean time to develop any MPM was 50 months for women 80-plus years compared with 100 months in those under 65 years. Values for women aged 65-69 and 70-79 were 85 and 72 months.

The stage of the first primary breast cancer at diagnosis did not affect the risk of subsequent MPM, nor were any sociodemographic factors or the year of diagnosis found to be of influence.

"Age was the strongest, significant predictor of multiple primary malignancy risk in this population," Dr. Clough-Gorr noted, adding that the risk was highest in women 70-79 years, with a hazard ratio of 1.48. Hazard ratios for ages 65-69 and 80-plus years were 1.41 and 1.32.

"These findings suggest there are age-related differences in [the] risk of developing an MPM after a primary breast cancer diagnosis," Ms. Clough-Gorr concluded. "In this population, there were no other MPM risk factors that were identified."

The study was supported by the National Cancer Institute. Dr. Clough-Gorr said she had no relevant financial disclosures.

MANCHESTER, ENGLAND – Older women who are breast cancer survivors have a greater risk of developing additional primary cancers in the long term than those under 65 years of age, according to an analysis of data on more than 100,000 survivors in the United States.

Women aged 70-79 years appear to have the highest risk of developing a multiple primary malignancy (MPM), with a crude 10-year incidence of 17.8/10,000 person-years. In comparisons, the rate of risk for survivors younger than 65 was 11.7, increasing to 16.7 for those 65-69 years of age and 16.4 for those 80 years and older.

Other common cancers occurring in the breast cancer survivor population were lung and colon cancers, investigator Kerri Clough-Gorr, D.Sc., reported at the annual meeting of the International Society of Geriatric Oncology. Hematologic malignancies, melanoma, and urinary and digestive tumors were also observed.

"Relative breast cancer survival rates are quite high in the United States, at over 89% at 5 years [after a diagnosis]," said Dr. Clough-Gorr of Boston University and the Institute of Social and Preventative Medicine at the University of Bern (Switzerland).

"Importantly, the vast majority of women with breast cancer become long-term survivors, and they are at risk for developing subsequent malignancies," she added.

It is estimated that there are 2.4 million women in the United States with a history of breast cancer, and the current study aimed to look at survivors’ risk of developing multiple primary cancers over a 20-year follow-up period.

The study analyzed data from 12 SEER (Surveillance, Epidemiology, and End Results) program registry sites on 110,440 women diagnosed with a first primary breast cancer between 1986 and 1994. The women were evaluated for the development of other primary cancers or death up until 2006.

In addition to being more likely to develop another primary cancer, older women were more likely to develop it more quickly. The mean time to develop any MPM was 50 months for women 80-plus years compared with 100 months in those under 65 years. Values for women aged 65-69 and 70-79 were 85 and 72 months.

The stage of the first primary breast cancer at diagnosis did not affect the risk of subsequent MPM, nor were any sociodemographic factors or the year of diagnosis found to be of influence.

"Age was the strongest, significant predictor of multiple primary malignancy risk in this population," Dr. Clough-Gorr noted, adding that the risk was highest in women 70-79 years, with a hazard ratio of 1.48. Hazard ratios for ages 65-69 and 80-plus years were 1.41 and 1.32.

"These findings suggest there are age-related differences in [the] risk of developing an MPM after a primary breast cancer diagnosis," Ms. Clough-Gorr concluded. "In this population, there were no other MPM risk factors that were identified."

The study was supported by the National Cancer Institute. Dr. Clough-Gorr said she had no relevant financial disclosures.

MANCHESTER, ENGLAND – Older women who are breast cancer survivors have a greater risk of developing additional primary cancers in the long term than those under 65 years of age, according to an analysis of data on more than 100,000 survivors in the United States.

Women aged 70-79 years appear to have the highest risk of developing a multiple primary malignancy (MPM), with a crude 10-year incidence of 17.8/10,000 person-years. In comparisons, the rate of risk for survivors younger than 65 was 11.7, increasing to 16.7 for those 65-69 years of age and 16.4 for those 80 years and older.

Other common cancers occurring in the breast cancer survivor population were lung and colon cancers, investigator Kerri Clough-Gorr, D.Sc., reported at the annual meeting of the International Society of Geriatric Oncology. Hematologic malignancies, melanoma, and urinary and digestive tumors were also observed.

"Relative breast cancer survival rates are quite high in the United States, at over 89% at 5 years [after a diagnosis]," said Dr. Clough-Gorr of Boston University and the Institute of Social and Preventative Medicine at the University of Bern (Switzerland).

"Importantly, the vast majority of women with breast cancer become long-term survivors, and they are at risk for developing subsequent malignancies," she added.

It is estimated that there are 2.4 million women in the United States with a history of breast cancer, and the current study aimed to look at survivors’ risk of developing multiple primary cancers over a 20-year follow-up period.

The study analyzed data from 12 SEER (Surveillance, Epidemiology, and End Results) program registry sites on 110,440 women diagnosed with a first primary breast cancer between 1986 and 1994. The women were evaluated for the development of other primary cancers or death up until 2006.

In addition to being more likely to develop another primary cancer, older women were more likely to develop it more quickly. The mean time to develop any MPM was 50 months for women 80-plus years compared with 100 months in those under 65 years. Values for women aged 65-69 and 70-79 were 85 and 72 months.

The stage of the first primary breast cancer at diagnosis did not affect the risk of subsequent MPM, nor were any sociodemographic factors or the year of diagnosis found to be of influence.

"Age was the strongest, significant predictor of multiple primary malignancy risk in this population," Dr. Clough-Gorr noted, adding that the risk was highest in women 70-79 years, with a hazard ratio of 1.48. Hazard ratios for ages 65-69 and 80-plus years were 1.41 and 1.32.

"These findings suggest there are age-related differences in [the] risk of developing an MPM after a primary breast cancer diagnosis," Ms. Clough-Gorr concluded. "In this population, there were no other MPM risk factors that were identified."

The study was supported by the National Cancer Institute. Dr. Clough-Gorr said she had no relevant financial disclosures.

MANCHESTER, ENGLAND – Older women with primary, operable, triple-negative breast cancer may have less aggressive tumor biology despite being treated for larger tumors than their younger counterparts, new data suggest.

Tumor samples taken from women aged 70 years or older were found to be of lower grade with significantly lower expression of the tumor markers Ki67 and p53 than seen in younger women, investigators reported at the annual meeting of the International Society of Geriatric Oncology (SIOG).

These data may help explain why similar clinical outcomes were achieved despite aggressive adjuvant chemotherapy not being given to the more elderly women, said investigator Dr. Kwok-Leung Cheung, of the University of Nottingham, England. "The precise place of adjuvant chemotherapy in the treatment of these patients has yet to be defined," he said.

The new report adds to previous findings presented at the American Society of Clinical Oncology (ASCO) meeting in 2011, (J. Clin. Oncol. 2011;29:abstr 1057), Dr. Cheung noted.

At ASCO, Dr. Cheung and his coauthors reported that they had identified 127 older women with triple-negative breast cancer among more than 2,000 women, aged 70 years and older, who had been treated over a 36-year period (1973-2009) for early operable primary breast cancer at a single clinic and also who had good quality tumor samples available for tissue microarray analysis using indirect immunohistochemistry.

The initial study compared this group’s results with those of 342 women with triple-negative breast cancer in a previously characterized consecutive series of 1,809 patients treated at the same clinic from 1986 to 1998. The rates of 5-year breast cancer-specific survival (73% vs. 79%) and of local (10% vs. 14%), regional (11% vs. 14%), and distant (30% vs. 27%) recurrences were found to be similar in younger and older women, respectively.

"Despite not having received adjuvant chemotherapy, the older series had clinical outcome similar to the younger patients, almost half of which had chemotherapy," Dr. Cheung and team reported at the time.

The current investigation, therefore, looked to see whether age was an important factor in determining clinical outcome, and if so, whether there were any biologic markers.

Older women were found to be more likely to have larger tumors than do younger women, with 66.7% and 50.4% (P = .002), respectively, having tumors of 2 cm or greater in size. There was no difference between them in axillary stage or nodal status.

Fewer women aged 70 years and above had grade 3 tumors: 79.8%, vs. 90.9% of the younger women (P = .007).

Biomarker analysis showed 48% vs. 87.7% (P less than .001) of tumor samples were Ki67- and 44.6% vs. 55.6% (P = .02) p53-positive, comparing the older and younger women. There was also decreased expression of E-cadherin (P = .002) and CK 7/8 (P = .005), but increased expression of bcl2 (P less than .001), CK14 (P = .03), and CK18 (P less than .001) in the older women.

The findings are counterintuitive to what might be expected commented Dr. Catherine Terret of Centre Léon Bérard, in Lyon, France.

"I think this is surprising for the clinician because my feeling is triple-negative breast cancer in the elderly is a very aggressive tumor," Dr. Terret, who was not involved in the study, said. "I’m really surprised [the] biologic results don’t go in the same way as my clinical opinion."

Dr. Cheung and Dr. Terret had no relevant financial disclosures.

MANCHESTER, ENGLAND – Older women with primary, operable, triple-negative breast cancer may have less aggressive tumor biology despite being treated for larger tumors than their younger counterparts, new data suggest.

Tumor samples taken from women aged 70 years or older were found to be of lower grade with significantly lower expression of the tumor markers Ki67 and p53 than seen in younger women, investigators reported at the annual meeting of the International Society of Geriatric Oncology (SIOG).

These data may help explain why similar clinical outcomes were achieved despite aggressive adjuvant chemotherapy not being given to the more elderly women, said investigator Dr. Kwok-Leung Cheung, of the University of Nottingham, England. "The precise place of adjuvant chemotherapy in the treatment of these patients has yet to be defined," he said.

The new report adds to previous findings presented at the American Society of Clinical Oncology (ASCO) meeting in 2011, (J. Clin. Oncol. 2011;29:abstr 1057), Dr. Cheung noted.

At ASCO, Dr. Cheung and his coauthors reported that they had identified 127 older women with triple-negative breast cancer among more than 2,000 women, aged 70 years and older, who had been treated over a 36-year period (1973-2009) for early operable primary breast cancer at a single clinic and also who had good quality tumor samples available for tissue microarray analysis using indirect immunohistochemistry.

The initial study compared this group’s results with those of 342 women with triple-negative breast cancer in a previously characterized consecutive series of 1,809 patients treated at the same clinic from 1986 to 1998. The rates of 5-year breast cancer-specific survival (73% vs. 79%) and of local (10% vs. 14%), regional (11% vs. 14%), and distant (30% vs. 27%) recurrences were found to be similar in younger and older women, respectively.

"Despite not having received adjuvant chemotherapy, the older series had clinical outcome similar to the younger patients, almost half of which had chemotherapy," Dr. Cheung and team reported at the time.

The current investigation, therefore, looked to see whether age was an important factor in determining clinical outcome, and if so, whether there were any biologic markers.

Older women were found to be more likely to have larger tumors than do younger women, with 66.7% and 50.4% (P = .002), respectively, having tumors of 2 cm or greater in size. There was no difference between them in axillary stage or nodal status.

Fewer women aged 70 years and above had grade 3 tumors: 79.8%, vs. 90.9% of the younger women (P = .007).

Biomarker analysis showed 48% vs. 87.7% (P less than .001) of tumor samples were Ki67- and 44.6% vs. 55.6% (P = .02) p53-positive, comparing the older and younger women. There was also decreased expression of E-cadherin (P = .002) and CK 7/8 (P = .005), but increased expression of bcl2 (P less than .001), CK14 (P = .03), and CK18 (P less than .001) in the older women.

The findings are counterintuitive to what might be expected commented Dr. Catherine Terret of Centre Léon Bérard, in Lyon, France.

"I think this is surprising for the clinician because my feeling is triple-negative breast cancer in the elderly is a very aggressive tumor," Dr. Terret, who was not involved in the study, said. "I’m really surprised [the] biologic results don’t go in the same way as my clinical opinion."

Dr. Cheung and Dr. Terret had no relevant financial disclosures.

MANCHESTER, ENGLAND – Older women with primary, operable, triple-negative breast cancer may have less aggressive tumor biology despite being treated for larger tumors than their younger counterparts, new data suggest.

Tumor samples taken from women aged 70 years or older were found to be of lower grade with significantly lower expression of the tumor markers Ki67 and p53 than seen in younger women, investigators reported at the annual meeting of the International Society of Geriatric Oncology (SIOG).

These data may help explain why similar clinical outcomes were achieved despite aggressive adjuvant chemotherapy not being given to the more elderly women, said investigator Dr. Kwok-Leung Cheung, of the University of Nottingham, England. "The precise place of adjuvant chemotherapy in the treatment of these patients has yet to be defined," he said.

The new report adds to previous findings presented at the American Society of Clinical Oncology (ASCO) meeting in 2011, (J. Clin. Oncol. 2011;29:abstr 1057), Dr. Cheung noted.

At ASCO, Dr. Cheung and his coauthors reported that they had identified 127 older women with triple-negative breast cancer among more than 2,000 women, aged 70 years and older, who had been treated over a 36-year period (1973-2009) for early operable primary breast cancer at a single clinic and also who had good quality tumor samples available for tissue microarray analysis using indirect immunohistochemistry.

The initial study compared this group’s results with those of 342 women with triple-negative breast cancer in a previously characterized consecutive series of 1,809 patients treated at the same clinic from 1986 to 1998. The rates of 5-year breast cancer-specific survival (73% vs. 79%) and of local (10% vs. 14%), regional (11% vs. 14%), and distant (30% vs. 27%) recurrences were found to be similar in younger and older women, respectively.

"Despite not having received adjuvant chemotherapy, the older series had clinical outcome similar to the younger patients, almost half of which had chemotherapy," Dr. Cheung and team reported at the time.

The current investigation, therefore, looked to see whether age was an important factor in determining clinical outcome, and if so, whether there were any biologic markers.

Older women were found to be more likely to have larger tumors than do younger women, with 66.7% and 50.4% (P = .002), respectively, having tumors of 2 cm or greater in size. There was no difference between them in axillary stage or nodal status.

Fewer women aged 70 years and above had grade 3 tumors: 79.8%, vs. 90.9% of the younger women (P = .007).

Biomarker analysis showed 48% vs. 87.7% (P less than .001) of tumor samples were Ki67- and 44.6% vs. 55.6% (P = .02) p53-positive, comparing the older and younger women. There was also decreased expression of E-cadherin (P = .002) and CK 7/8 (P = .005), but increased expression of bcl2 (P less than .001), CK14 (P = .03), and CK18 (P less than .001) in the older women.

The findings are counterintuitive to what might be expected commented Dr. Catherine Terret of Centre Léon Bérard, in Lyon, France.

"I think this is surprising for the clinician because my feeling is triple-negative breast cancer in the elderly is a very aggressive tumor," Dr. Terret, who was not involved in the study, said. "I’m really surprised [the] biologic results don’t go in the same way as my clinical opinion."

Dr. Cheung and Dr. Terret had no relevant financial disclosures.

BOSTON – Here’s heartening news that physicians can convey to breast cancer survivors: Modern breast irradiation did not appear to cause late-term cardiac toxicity in a study that examined women a quarter of a century after they were treated.

Investigators found no significant differences in Framingham Heart Study risk scores, hemodynamic parameters, pericardial thickening, or heart failure among 50 women who had been randomized in the 1970s and 1980s to either mastectomy or breast-conserving surgery (BCS) and radiation, Dr. Charles B. Simone II reported at the annual meeting of the American Society for Radiation Oncology.

Neil Osterweil/IMNG Medical Media

Although the survival rate was slightly lower among patients treated with breast-conserving therapy, the difference does not appear to be related to radiation dose to the heart, said Dr. Simone of the Hospital of the University of Pennsylvania in Philadelphia. There were no differences in survival among women treated with BCS and radiation to left- or right-sided tumors.

"Based on this study, in the era of 3D planning, patients with early-stage breast cancer treated with radiotherapy do not have a higher risk of long-term cardiac morbidity compared with patients having mastectomy," he said.

The patients studied included 50 of 102 survivors from an original cohort of 237 women who had participated in the National Cancer Institute’s Breast Conservation Trial (79-C-0111), with randomization from 1979 to 1986. In that trial, women with stage I or II breast cancer received modified radical mastectomy with axillary node dissection or they underwent lumpectomy plus node dissection and a radiation dose of 45-50.4 Gy to the whole breast; the latter came with or without treatment of regional nodes, followed by a boost of 15-20 Gy with either iridium 192 brachytherapy or electrons.

All node-positive patients underwent 6-11 cycles of chemotherapy with doxorubicin and cyclophosphamide, and beginning in 1985 postmenopausal women with positive nodes were given tamoxifen.

The trial was unique at the time in that it used CT simulations for treatment planning and dose inhomogeneity corrections, Dr. Simone noted.

Diverging Survival Curves

At a median of 25.7 years after randomization, 43.8% of mastectomy patients were still alive, compared with 37.9% of BCS patients. Although the difference was not significant, it appeared to represent a divergence of survival curves that had been virtually identical for the first 25 years.

The trend could not be accounted for by secondary malignancies, changes in distant metastasis, or any other breast cancer–related causes, leading the investigators to question whether it might be due to radiation toxicity to the heart, as some studies have suggested.

In all, 26 patients who had had BCS and 24 who underwent mastectomy agreed to come back for the cardiac toxicity study.

The investigators took a detailed cardiac history, and subjected the women to exams, cardiac labs, cardiac MRI with a 3 Tesla magnet to look for anatomic and functional abnormalities, and CT angiogram to look for stenotic coronary disease and determine coronary arterial calcium score (CAC) of atherosclerotic burden.

They also looked at radiation technique parameters such as central lung distance, field size, dose, and boost dose.

On cardiac MRI, they only saw two significant between-group differences. Time to peak filling rate was shorter for BCS patients (487 milliseconds vs. 647 ms for mastectomy patients; P = .02), but there was no difference in the peak filling rate itself. Left ventricular mass was smaller for BCS patients (mean 90.5 gm vs. 111 gm for mastectomy patients), but this difference was no longer significant after adjustment for systolic blood pressure, Dr. Simone noted.

"Interestingly, we didn’t see any evidence of myocardial fibrosis in any patient assessed, and only one patient in each arm had any degree of pericardial thickening," he said.

Reassuring Data

Additionally, investigators saw no significant differences on CT angiography in the presence of visible plaque or significant or severe vascular stenosis. There were also no differences in plaque or stenosis in the left anterior descending arteries of women treated with radiation for tumors on the left or the right side of the body.

"For each and every vessel we looked at, there was no difference in the degree of stenosis," Dr. Simone said.

Median CAC scores were low and in the normal range, but patients who had received chemotherapy had a trend toward increased atherosclerosis and plaque formation, Dr. Simone noted.

The study "gives some reassurance to our patients that, after 25 years of follow-up, using modern radiation techniques the delivery of radiation to the left does not cause cardiac toxicity," Dr. Bruce Haffty, chair of radiation oncology at the Cancer Institute of New Jersey, New Brunswick, said at a briefing.

The study was supported by the National Cancer Institute. Dr. Simone and Dr. Haffty reported no relevant disclosures.

BOSTON – Here’s heartening news that physicians can convey to breast cancer survivors: Modern breast irradiation did not appear to cause late-term cardiac toxicity in a study that examined women a quarter of a century after they were treated.

Investigators found no significant differences in Framingham Heart Study risk scores, hemodynamic parameters, pericardial thickening, or heart failure among 50 women who had been randomized in the 1970s and 1980s to either mastectomy or breast-conserving surgery (BCS) and radiation, Dr. Charles B. Simone II reported at the annual meeting of the American Society for Radiation Oncology.

Neil Osterweil/IMNG Medical Media

Although the survival rate was slightly lower among patients treated with breast-conserving therapy, the difference does not appear to be related to radiation dose to the heart, said Dr. Simone of the Hospital of the University of Pennsylvania in Philadelphia. There were no differences in survival among women treated with BCS and radiation to left- or right-sided tumors.

"Based on this study, in the era of 3D planning, patients with early-stage breast cancer treated with radiotherapy do not have a higher risk of long-term cardiac morbidity compared with patients having mastectomy," he said.

The patients studied included 50 of 102 survivors from an original cohort of 237 women who had participated in the National Cancer Institute’s Breast Conservation Trial (79-C-0111), with randomization from 1979 to 1986. In that trial, women with stage I or II breast cancer received modified radical mastectomy with axillary node dissection or they underwent lumpectomy plus node dissection and a radiation dose of 45-50.4 Gy to the whole breast; the latter came with or without treatment of regional nodes, followed by a boost of 15-20 Gy with either iridium 192 brachytherapy or electrons.

All node-positive patients underwent 6-11 cycles of chemotherapy with doxorubicin and cyclophosphamide, and beginning in 1985 postmenopausal women with positive nodes were given tamoxifen.

The trial was unique at the time in that it used CT simulations for treatment planning and dose inhomogeneity corrections, Dr. Simone noted.

Diverging Survival Curves

At a median of 25.7 years after randomization, 43.8% of mastectomy patients were still alive, compared with 37.9% of BCS patients. Although the difference was not significant, it appeared to represent a divergence of survival curves that had been virtually identical for the first 25 years.

The trend could not be accounted for by secondary malignancies, changes in distant metastasis, or any other breast cancer–related causes, leading the investigators to question whether it might be due to radiation toxicity to the heart, as some studies have suggested.

In all, 26 patients who had had BCS and 24 who underwent mastectomy agreed to come back for the cardiac toxicity study.

The investigators took a detailed cardiac history, and subjected the women to exams, cardiac labs, cardiac MRI with a 3 Tesla magnet to look for anatomic and functional abnormalities, and CT angiogram to look for stenotic coronary disease and determine coronary arterial calcium score (CAC) of atherosclerotic burden.

They also looked at radiation technique parameters such as central lung distance, field size, dose, and boost dose.

On cardiac MRI, they only saw two significant between-group differences. Time to peak filling rate was shorter for BCS patients (487 milliseconds vs. 647 ms for mastectomy patients; P = .02), but there was no difference in the peak filling rate itself. Left ventricular mass was smaller for BCS patients (mean 90.5 gm vs. 111 gm for mastectomy patients), but this difference was no longer significant after adjustment for systolic blood pressure, Dr. Simone noted.

"Interestingly, we didn’t see any evidence of myocardial fibrosis in any patient assessed, and only one patient in each arm had any degree of pericardial thickening," he said.

Reassuring Data

Additionally, investigators saw no significant differences on CT angiography in the presence of visible plaque or significant or severe vascular stenosis. There were also no differences in plaque or stenosis in the left anterior descending arteries of women treated with radiation for tumors on the left or the right side of the body.

"For each and every vessel we looked at, there was no difference in the degree of stenosis," Dr. Simone said.

Median CAC scores were low and in the normal range, but patients who had received chemotherapy had a trend toward increased atherosclerosis and plaque formation, Dr. Simone noted.

The study "gives some reassurance to our patients that, after 25 years of follow-up, using modern radiation techniques the delivery of radiation to the left does not cause cardiac toxicity," Dr. Bruce Haffty, chair of radiation oncology at the Cancer Institute of New Jersey, New Brunswick, said at a briefing.

The study was supported by the National Cancer Institute. Dr. Simone and Dr. Haffty reported no relevant disclosures.

BOSTON – Here’s heartening news that physicians can convey to breast cancer survivors: Modern breast irradiation did not appear to cause late-term cardiac toxicity in a study that examined women a quarter of a century after they were treated.

Investigators found no significant differences in Framingham Heart Study risk scores, hemodynamic parameters, pericardial thickening, or heart failure among 50 women who had been randomized in the 1970s and 1980s to either mastectomy or breast-conserving surgery (BCS) and radiation, Dr. Charles B. Simone II reported at the annual meeting of the American Society for Radiation Oncology.

Neil Osterweil/IMNG Medical Media

Although the survival rate was slightly lower among patients treated with breast-conserving therapy, the difference does not appear to be related to radiation dose to the heart, said Dr. Simone of the Hospital of the University of Pennsylvania in Philadelphia. There were no differences in survival among women treated with BCS and radiation to left- or right-sided tumors.

"Based on this study, in the era of 3D planning, patients with early-stage breast cancer treated with radiotherapy do not have a higher risk of long-term cardiac morbidity compared with patients having mastectomy," he said.

The patients studied included 50 of 102 survivors from an original cohort of 237 women who had participated in the National Cancer Institute’s Breast Conservation Trial (79-C-0111), with randomization from 1979 to 1986. In that trial, women with stage I or II breast cancer received modified radical mastectomy with axillary node dissection or they underwent lumpectomy plus node dissection and a radiation dose of 45-50.4 Gy to the whole breast; the latter came with or without treatment of regional nodes, followed by a boost of 15-20 Gy with either iridium 192 brachytherapy or electrons.

All node-positive patients underwent 6-11 cycles of chemotherapy with doxorubicin and cyclophosphamide, and beginning in 1985 postmenopausal women with positive nodes were given tamoxifen.

The trial was unique at the time in that it used CT simulations for treatment planning and dose inhomogeneity corrections, Dr. Simone noted.

Diverging Survival Curves

At a median of 25.7 years after randomization, 43.8% of mastectomy patients were still alive, compared with 37.9% of BCS patients. Although the difference was not significant, it appeared to represent a divergence of survival curves that had been virtually identical for the first 25 years.

The trend could not be accounted for by secondary malignancies, changes in distant metastasis, or any other breast cancer–related causes, leading the investigators to question whether it might be due to radiation toxicity to the heart, as some studies have suggested.

In all, 26 patients who had had BCS and 24 who underwent mastectomy agreed to come back for the cardiac toxicity study.

The investigators took a detailed cardiac history, and subjected the women to exams, cardiac labs, cardiac MRI with a 3 Tesla magnet to look for anatomic and functional abnormalities, and CT angiogram to look for stenotic coronary disease and determine coronary arterial calcium score (CAC) of atherosclerotic burden.

They also looked at radiation technique parameters such as central lung distance, field size, dose, and boost dose.

On cardiac MRI, they only saw two significant between-group differences. Time to peak filling rate was shorter for BCS patients (487 milliseconds vs. 647 ms for mastectomy patients; P = .02), but there was no difference in the peak filling rate itself. Left ventricular mass was smaller for BCS patients (mean 90.5 gm vs. 111 gm for mastectomy patients), but this difference was no longer significant after adjustment for systolic blood pressure, Dr. Simone noted.

"Interestingly, we didn’t see any evidence of myocardial fibrosis in any patient assessed, and only one patient in each arm had any degree of pericardial thickening," he said.

Reassuring Data

Additionally, investigators saw no significant differences on CT angiography in the presence of visible plaque or significant or severe vascular stenosis. There were also no differences in plaque or stenosis in the left anterior descending arteries of women treated with radiation for tumors on the left or the right side of the body.

"For each and every vessel we looked at, there was no difference in the degree of stenosis," Dr. Simone said.

Median CAC scores were low and in the normal range, but patients who had received chemotherapy had a trend toward increased atherosclerosis and plaque formation, Dr. Simone noted.

The study "gives some reassurance to our patients that, after 25 years of follow-up, using modern radiation techniques the delivery of radiation to the left does not cause cardiac toxicity," Dr. Bruce Haffty, chair of radiation oncology at the Cancer Institute of New Jersey, New Brunswick, said at a briefing.

The study was supported by the National Cancer Institute. Dr. Simone and Dr. Haffty reported no relevant disclosures.

BOSTON – A review of data on nearly 30,000 women suggests older age by itself should not be a barrier to radiotherapy after lumpectomy for early-stage breast cancer.

Older patients treated with both modalities had higher rates of overall and breast cancer–specific survival at 5 and 10 years compared with women who underwent lumpectomy alone, investigators reported at the annual meeting of the American Society for Radiation Oncology.

Courtesy American Society for Radiation Oncology

"The improvement in cause-specific survival with the addition or radiation suggests that in healthy, elderly women, adjuvant radiation should be strongly considered as part of their breast cancer treatment," said Dr. Randi J. Cohen, a radiation oncologist at the University of Maryland in Baltimore.

The review examined Surveillance, Epidemiology, and End Results (SEER) database records on 29,949 women, who were aged 70-84 years at diagnosis with clinical stage I, estrogen receptor–positive breast cancer and survived at least 1 year. About three-fourths underwent radiation after lumpectomy.

Women treated with lumpectomy and radiation had an overall survival rate of 88.6% at 5 years vs. 73.1% among those with no radiation (P less than .0001), Dr. Cohen reported. Overall survival rates at 10 years were 65.0% and 41.7%, respectively.

Cause-specific survival rates at 5 years were 98.3% for patients in the radiation plus surgery group and 97.4% for those with no radiation. At 10 years, the respective rates were 95.5% and 93.3% (P less than .0001 for both comparisons).

The median length of survival also was greater with the addition of radiotherapy – 13.1 years vs. 11.1 years with lumpectomy alone.

Radiation Was Independent Predictor

In multivariate analysis that controlled for age, tumor size, race, ductal histology, lymph nodes and marital status, hazard ratios also showed significantly worse outcomes without radiation – 1.56 in the overall survival analysis and 1.41 in the cause-specific survival analysis.

The results are similar to those in a meta-analysis from the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), said Dr. Cohen. That study showed an absolute benefit for adding radiation of 3% at 10 years, compared with 2.2% at 10 years in the current study.

Dr. Cohen said the review was prompted by questions raised in a 2004 study from the Cancer and Leukemia Group B (CALGB). In that trial, investigators looked at whether adding radiation to lumpectomy plus tamoxifen would have an effect on overall or breast cancer–specific survival in 630 women 70 years and older with early-stage disease. They found that at a median follow-up of 10.5 years, there was an absolute reduction of 6% in same-breast tumor recurrence with radiation, but no difference overall of disease-free survival.

In the much larger EBTCG study and the current study, however, the disease-specific survival advantages with the addition of radiation were likely related to greater locoregional control. Dr. Cohen said that the overall survival advantage in her study was probably due to selection of healthier patients with longer predicted life expectancy for radiotherapy.

She noted, however, that the study was limited by a lack of data on recurrence rates or hormonal therapy.

Strength of Benefit Questioned

"It’s highly unlikely that the magnitude of the benefits of cause-specific survival can be attributed to just radiation alone," said Dr. Meema Moran, the invited discussant. She noted that in EBCTCG study, there was only about a 3% benefit at 15 years in a seemingly low-risk population with shorter follow-up. The favorable survival in the meta-analysis may therefore be partly attributable to treatment selections bias, said Dr. Moran, a radiation oncologist at Yale University in New Haven, Conn.

She also noted that because local recurrence data are not collected in SEER, mastectomy-free survival is used as a surrogate for relapse, but mastectomy rates may vary due to differences in management of ipsilateral recurrence, such as mastectomy or repeat breast-conserving surgery.

The funding source for Dr. Cohen’s study was not disclosed. She reported no conflicts of interest. Dr. Moran reported serving on the Genomic Health Advisory Board.

BOSTON – A review of data on nearly 30,000 women suggests older age by itself should not be a barrier to radiotherapy after lumpectomy for early-stage breast cancer.

Older patients treated with both modalities had higher rates of overall and breast cancer–specific survival at 5 and 10 years compared with women who underwent lumpectomy alone, investigators reported at the annual meeting of the American Society for Radiation Oncology.

Courtesy American Society for Radiation Oncology

"The improvement in cause-specific survival with the addition or radiation suggests that in healthy, elderly women, adjuvant radiation should be strongly considered as part of their breast cancer treatment," said Dr. Randi J. Cohen, a radiation oncologist at the University of Maryland in Baltimore.

The review examined Surveillance, Epidemiology, and End Results (SEER) database records on 29,949 women, who were aged 70-84 years at diagnosis with clinical stage I, estrogen receptor–positive breast cancer and survived at least 1 year. About three-fourths underwent radiation after lumpectomy.

Women treated with lumpectomy and radiation had an overall survival rate of 88.6% at 5 years vs. 73.1% among those with no radiation (P less than .0001), Dr. Cohen reported. Overall survival rates at 10 years were 65.0% and 41.7%, respectively.

Cause-specific survival rates at 5 years were 98.3% for patients in the radiation plus surgery group and 97.4% for those with no radiation. At 10 years, the respective rates were 95.5% and 93.3% (P less than .0001 for both comparisons).

The median length of survival also was greater with the addition of radiotherapy – 13.1 years vs. 11.1 years with lumpectomy alone.

Radiation Was Independent Predictor

In multivariate analysis that controlled for age, tumor size, race, ductal histology, lymph nodes and marital status, hazard ratios also showed significantly worse outcomes without radiation – 1.56 in the overall survival analysis and 1.41 in the cause-specific survival analysis.

The results are similar to those in a meta-analysis from the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), said Dr. Cohen. That study showed an absolute benefit for adding radiation of 3% at 10 years, compared with 2.2% at 10 years in the current study.

Dr. Cohen said the review was prompted by questions raised in a 2004 study from the Cancer and Leukemia Group B (CALGB). In that trial, investigators looked at whether adding radiation to lumpectomy plus tamoxifen would have an effect on overall or breast cancer–specific survival in 630 women 70 years and older with early-stage disease. They found that at a median follow-up of 10.5 years, there was an absolute reduction of 6% in same-breast tumor recurrence with radiation, but no difference overall of disease-free survival.

In the much larger EBTCG study and the current study, however, the disease-specific survival advantages with the addition of radiation were likely related to greater locoregional control. Dr. Cohen said that the overall survival advantage in her study was probably due to selection of healthier patients with longer predicted life expectancy for radiotherapy.

She noted, however, that the study was limited by a lack of data on recurrence rates or hormonal therapy.

Strength of Benefit Questioned

"It’s highly unlikely that the magnitude of the benefits of cause-specific survival can be attributed to just radiation alone," said Dr. Meema Moran, the invited discussant. She noted that in EBCTCG study, there was only about a 3% benefit at 15 years in a seemingly low-risk population with shorter follow-up. The favorable survival in the meta-analysis may therefore be partly attributable to treatment selections bias, said Dr. Moran, a radiation oncologist at Yale University in New Haven, Conn.

She also noted that because local recurrence data are not collected in SEER, mastectomy-free survival is used as a surrogate for relapse, but mastectomy rates may vary due to differences in management of ipsilateral recurrence, such as mastectomy or repeat breast-conserving surgery.

The funding source for Dr. Cohen’s study was not disclosed. She reported no conflicts of interest. Dr. Moran reported serving on the Genomic Health Advisory Board.

BOSTON – A review of data on nearly 30,000 women suggests older age by itself should not be a barrier to radiotherapy after lumpectomy for early-stage breast cancer.

Older patients treated with both modalities had higher rates of overall and breast cancer–specific survival at 5 and 10 years compared with women who underwent lumpectomy alone, investigators reported at the annual meeting of the American Society for Radiation Oncology.

Courtesy American Society for Radiation Oncology

"The improvement in cause-specific survival with the addition or radiation suggests that in healthy, elderly women, adjuvant radiation should be strongly considered as part of their breast cancer treatment," said Dr. Randi J. Cohen, a radiation oncologist at the University of Maryland in Baltimore.

The review examined Surveillance, Epidemiology, and End Results (SEER) database records on 29,949 women, who were aged 70-84 years at diagnosis with clinical stage I, estrogen receptor–positive breast cancer and survived at least 1 year. About three-fourths underwent radiation after lumpectomy.

Women treated with lumpectomy and radiation had an overall survival rate of 88.6% at 5 years vs. 73.1% among those with no radiation (P less than .0001), Dr. Cohen reported. Overall survival rates at 10 years were 65.0% and 41.7%, respectively.

Cause-specific survival rates at 5 years were 98.3% for patients in the radiation plus surgery group and 97.4% for those with no radiation. At 10 years, the respective rates were 95.5% and 93.3% (P less than .0001 for both comparisons).

The median length of survival also was greater with the addition of radiotherapy – 13.1 years vs. 11.1 years with lumpectomy alone.

Radiation Was Independent Predictor

In multivariate analysis that controlled for age, tumor size, race, ductal histology, lymph nodes and marital status, hazard ratios also showed significantly worse outcomes without radiation – 1.56 in the overall survival analysis and 1.41 in the cause-specific survival analysis.

The results are similar to those in a meta-analysis from the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), said Dr. Cohen. That study showed an absolute benefit for adding radiation of 3% at 10 years, compared with 2.2% at 10 years in the current study.

Dr. Cohen said the review was prompted by questions raised in a 2004 study from the Cancer and Leukemia Group B (CALGB). In that trial, investigators looked at whether adding radiation to lumpectomy plus tamoxifen would have an effect on overall or breast cancer–specific survival in 630 women 70 years and older with early-stage disease. They found that at a median follow-up of 10.5 years, there was an absolute reduction of 6% in same-breast tumor recurrence with radiation, but no difference overall of disease-free survival.

In the much larger EBTCG study and the current study, however, the disease-specific survival advantages with the addition of radiation were likely related to greater locoregional control. Dr. Cohen said that the overall survival advantage in her study was probably due to selection of healthier patients with longer predicted life expectancy for radiotherapy.

She noted, however, that the study was limited by a lack of data on recurrence rates or hormonal therapy.

Strength of Benefit Questioned

"It’s highly unlikely that the magnitude of the benefits of cause-specific survival can be attributed to just radiation alone," said Dr. Meema Moran, the invited discussant. She noted that in EBCTCG study, there was only about a 3% benefit at 15 years in a seemingly low-risk population with shorter follow-up. The favorable survival in the meta-analysis may therefore be partly attributable to treatment selections bias, said Dr. Moran, a radiation oncologist at Yale University in New Haven, Conn.

She also noted that because local recurrence data are not collected in SEER, mastectomy-free survival is used as a surrogate for relapse, but mastectomy rates may vary due to differences in management of ipsilateral recurrence, such as mastectomy or repeat breast-conserving surgery.

The funding source for Dr. Cohen’s study was not disclosed. She reported no conflicts of interest. Dr. Moran reported serving on the Genomic Health Advisory Board.

Women offered breast cancer screening have a 20% lower relative risk of dying from breast cancer than women not invited to participate in screening, a epidemiologic study in the Lancet from the United Kingdom has found.

The study also found that women invited to screening are also more likely to be overdiagnosed, meaning that they are treated surgically for tumors that, if not for screening, would have caused no illness and remained undetected. The researchers cautioned, however, that their findings on overdiagnosis were based on lower-quality evidence than that used to determine relative risk reduction.

For their research, published online Oct. 29, epidemiologist Dr. Michael Marmot of University College London and his colleagues conducted a meta-analysis of data from 11 randomized controlled trials (Lancet 2012 [http://dx.doi.org/10.1016/S0140-6736(12)61611-0]).

Altogether, the included randomized trials enrolled about 674,000 women in Canada, Sweden, the United States, and the United Kingdom between 1963 and 1991. Women in the studies were invited for mammographic screening at intervals ranging from 12 to 33 months; their ages ranged from 38 to 75 years.

The relative risk of breast cancer mortality for women invited to screening, compared with controls, was 0.80 (95% confidence interval, 0.73-0.89), Dr. Marmot and his colleagues found. This corresponds to one breast cancer death prevented for every 235 women invited to screening, they said, and to one death averted for every 180 women screened.

Dr. Marmot and his colleagues acknowledged that the trials used in their meta-analysis were heterogeneous in design and populations enrolled, and reflected both older screening techniques and breast-cancer treatments; however, they noted, the mortality benefit arrived at was largely in keeping with that seen in other studies, including recent observational studies.

Dr. Marmot’s research group was convened as an independent panel to review evidence for the benefits and harms of breast screening in the United Kingdom, where, as in the United States, Canada and other countries, there have been fierce debates about the benefits and harms of government breast-cancer screening recommendations. None of the panel’s members – who included epidemiologists, clinicians, and statisticians – had previously published on breast cancer screening.

Women in the United Kingdom aged 50-70 years are invited to have screenings once every 3 years. Therefore, the investigators estimated, for every 10,000 U.K. women invited to screening between the ages of 50 and 70 years, some 681 cancers will be found; 129 of them will represent overdiagnosis and 43 deaths from breast cancer will be prevented.

Thus, among women invited to screening, about 11% of the cancers diagnosed during their lifetimes are considered overdiagnosis, the investigators estimated, and about 19% of the cancers diagnosed during the period while women are being screened are overdiagnosis.

Dr. Marmot and his colleagues emphasized, however, that these overdiagnosis figures represent "best estimates from inadequate data." Only 3 of the 11 trials included in the study, along with some observational studies, provided information relevant to overdiagnosis.

In an unsigned editorial accompanying the article, the editors of the Lancet called Dr. Marmot and his colleagues’ report, "the latest and best available systematic review" to date on breast cancer screening (2012 [http://dx.doi.org/10.1016/ S0140-6736(12)61775-9]). The report, they said, "shows that the U.K. breast-screening program extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening program, and between doctors and their patients."

Dr. Marmot and his colleagues’ study was jointly commissioned by the National Cancer Director of England and Cancer Research UK, and funded by the U.K. Department of Health. None of the panel members declared conflicts of interest.

Women offered breast cancer screening have a 20% lower relative risk of dying from breast cancer than women not invited to participate in screening, a epidemiologic study in the Lancet from the United Kingdom has found.

The study also found that women invited to screening are also more likely to be overdiagnosed, meaning that they are treated surgically for tumors that, if not for screening, would have caused no illness and remained undetected. The researchers cautioned, however, that their findings on overdiagnosis were based on lower-quality evidence than that used to determine relative risk reduction.

For their research, published online Oct. 29, epidemiologist Dr. Michael Marmot of University College London and his colleagues conducted a meta-analysis of data from 11 randomized controlled trials (Lancet 2012 [http://dx.doi.org/10.1016/S0140-6736(12)61611-0]).

Altogether, the included randomized trials enrolled about 674,000 women in Canada, Sweden, the United States, and the United Kingdom between 1963 and 1991. Women in the studies were invited for mammographic screening at intervals ranging from 12 to 33 months; their ages ranged from 38 to 75 years.

The relative risk of breast cancer mortality for women invited to screening, compared with controls, was 0.80 (95% confidence interval, 0.73-0.89), Dr. Marmot and his colleagues found. This corresponds to one breast cancer death prevented for every 235 women invited to screening, they said, and to one death averted for every 180 women screened.

Dr. Marmot and his colleagues acknowledged that the trials used in their meta-analysis were heterogeneous in design and populations enrolled, and reflected both older screening techniques and breast-cancer treatments; however, they noted, the mortality benefit arrived at was largely in keeping with that seen in other studies, including recent observational studies.

Dr. Marmot’s research group was convened as an independent panel to review evidence for the benefits and harms of breast screening in the United Kingdom, where, as in the United States, Canada and other countries, there have been fierce debates about the benefits and harms of government breast-cancer screening recommendations. None of the panel’s members – who included epidemiologists, clinicians, and statisticians – had previously published on breast cancer screening.

Women in the United Kingdom aged 50-70 years are invited to have screenings once every 3 years. Therefore, the investigators estimated, for every 10,000 U.K. women invited to screening between the ages of 50 and 70 years, some 681 cancers will be found; 129 of them will represent overdiagnosis and 43 deaths from breast cancer will be prevented.

Thus, among women invited to screening, about 11% of the cancers diagnosed during their lifetimes are considered overdiagnosis, the investigators estimated, and about 19% of the cancers diagnosed during the period while women are being screened are overdiagnosis.

Dr. Marmot and his colleagues emphasized, however, that these overdiagnosis figures represent "best estimates from inadequate data." Only 3 of the 11 trials included in the study, along with some observational studies, provided information relevant to overdiagnosis.

In an unsigned editorial accompanying the article, the editors of the Lancet called Dr. Marmot and his colleagues’ report, "the latest and best available systematic review" to date on breast cancer screening (2012 [http://dx.doi.org/10.1016/ S0140-6736(12)61775-9]). The report, they said, "shows that the U.K. breast-screening program extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening program, and between doctors and their patients."

Dr. Marmot and his colleagues’ study was jointly commissioned by the National Cancer Director of England and Cancer Research UK, and funded by the U.K. Department of Health. None of the panel members declared conflicts of interest.

Women offered breast cancer screening have a 20% lower relative risk of dying from breast cancer than women not invited to participate in screening, a epidemiologic study in the Lancet from the United Kingdom has found.

The study also found that women invited to screening are also more likely to be overdiagnosed, meaning that they are treated surgically for tumors that, if not for screening, would have caused no illness and remained undetected. The researchers cautioned, however, that their findings on overdiagnosis were based on lower-quality evidence than that used to determine relative risk reduction.

For their research, published online Oct. 29, epidemiologist Dr. Michael Marmot of University College London and his colleagues conducted a meta-analysis of data from 11 randomized controlled trials (Lancet 2012 [http://dx.doi.org/10.1016/S0140-6736(12)61611-0]).

Altogether, the included randomized trials enrolled about 674,000 women in Canada, Sweden, the United States, and the United Kingdom between 1963 and 1991. Women in the studies were invited for mammographic screening at intervals ranging from 12 to 33 months; their ages ranged from 38 to 75 years.

The relative risk of breast cancer mortality for women invited to screening, compared with controls, was 0.80 (95% confidence interval, 0.73-0.89), Dr. Marmot and his colleagues found. This corresponds to one breast cancer death prevented for every 235 women invited to screening, they said, and to one death averted for every 180 women screened.

Dr. Marmot and his colleagues acknowledged that the trials used in their meta-analysis were heterogeneous in design and populations enrolled, and reflected both older screening techniques and breast-cancer treatments; however, they noted, the mortality benefit arrived at was largely in keeping with that seen in other studies, including recent observational studies.

Dr. Marmot’s research group was convened as an independent panel to review evidence for the benefits and harms of breast screening in the United Kingdom, where, as in the United States, Canada and other countries, there have been fierce debates about the benefits and harms of government breast-cancer screening recommendations. None of the panel’s members – who included epidemiologists, clinicians, and statisticians – had previously published on breast cancer screening.

Women in the United Kingdom aged 50-70 years are invited to have screenings once every 3 years. Therefore, the investigators estimated, for every 10,000 U.K. women invited to screening between the ages of 50 and 70 years, some 681 cancers will be found; 129 of them will represent overdiagnosis and 43 deaths from breast cancer will be prevented.

Thus, among women invited to screening, about 11% of the cancers diagnosed during their lifetimes are considered overdiagnosis, the investigators estimated, and about 19% of the cancers diagnosed during the period while women are being screened are overdiagnosis.

Dr. Marmot and his colleagues emphasized, however, that these overdiagnosis figures represent "best estimates from inadequate data." Only 3 of the 11 trials included in the study, along with some observational studies, provided information relevant to overdiagnosis.

In an unsigned editorial accompanying the article, the editors of the Lancet called Dr. Marmot and his colleagues’ report, "the latest and best available systematic review" to date on breast cancer screening (2012 [http://dx.doi.org/10.1016/ S0140-6736(12)61775-9]). The report, they said, "shows that the U.K. breast-screening program extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening program, and between doctors and their patients."

Dr. Marmot and his colleagues’ study was jointly commissioned by the National Cancer Director of England and Cancer Research UK, and funded by the U.K. Department of Health. None of the panel members declared conflicts of interest.

Each October, we celebrate breast cancer survivors, participate in fund-raisers for breast cancer research and awareness, and remember those lost to this brutal disease. As hospitalists, our job is to facilitate the care of our patients suffering from this disease. We admit patients with neutropenic fever after a recent bout of chemotherapy. We order palliative radiation therapy after the cancer has metastasized and causes severe pain and suffering. And, we order morphine drips when all else has failed, and our focus shifts to helping our patients pass on with the most dignity and least pain possible.

As hospitalists, our services typically come into play after the fact, not before. After the complications of chemo; after the cancer has spread; after there is nothing else we can do to prolong the lives of our patients. No doubt, what we do can make a tremendous impact on the lives of our patients, but can we do more? I believe we can.

How many seconds does it take to ask whether our female patients are up to date with their mammograms and Pap smears? Less than 10.

How many seconds would it take to dictate a brief reminder on preventive medical services, such as a screening mammogram, in our H&Ps? Less than 5.

How many women are aware that the American Cancer Society recommends breast MRI along with the yearly mammogram for certain high-risk women? Very few.

Yes, we are all very busy and sometimes it seems if anything else is added to our plates we will explode, but let’s think about the ROI for a moment. If we admit 30 women over age of 40 each month, and spend, on average, 15 seconds inquiring about and recommending routine mammography, at the end of the year we will have invested a whopping 90 minutes of our lives counseling 360 women. If out of those 360 women, 25% (90) are overdue for their mammogram, and a third heed our advice, 30 women will get a mammogram. Since the lifetime risk of breast cancer is close to 1 in 8, chances are, within a year, we could collectively play a vital role in a multitude of women getting an early diagnosis of breast cancer, and thus a high chance of a complete cure.

A few years ago, I had the gut-wrenching experience of watching someone I loved very much die an excruciating death from breast cancer in my home. She told me I could tell her story so others would be spared her fate. Essentially, she waited too long to get a mammogram.

Now I ask you to help me rewrite her story and rewrite the stories of all of our loved ones who have passed away from breast cancer. If even 100 hospitalists will commit to investing 90 minutes over the next year to recommend screening mammography to patients, and perhaps even do a breast exam on some patients when they have a little extra time, I feel confident that someone, somewhere will be spared the ravages of this vicious disease and their deaths will not be in vain. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Each October, we celebrate breast cancer survivors, participate in fund-raisers for breast cancer research and awareness, and remember those lost to this brutal disease. As hospitalists, our job is to facilitate the care of our patients suffering from this disease. We admit patients with neutropenic fever after a recent bout of chemotherapy. We order palliative radiation therapy after the cancer has metastasized and causes severe pain and suffering. And, we order morphine drips when all else has failed, and our focus shifts to helping our patients pass on with the most dignity and least pain possible.

As hospitalists, our services typically come into play after the fact, not before. After the complications of chemo; after the cancer has spread; after there is nothing else we can do to prolong the lives of our patients. No doubt, what we do can make a tremendous impact on the lives of our patients, but can we do more? I believe we can.

How many seconds does it take to ask whether our female patients are up to date with their mammograms and Pap smears? Less than 10.

How many seconds would it take to dictate a brief reminder on preventive medical services, such as a screening mammogram, in our H&Ps? Less than 5.

How many women are aware that the American Cancer Society recommends breast MRI along with the yearly mammogram for certain high-risk women? Very few.

Yes, we are all very busy and sometimes it seems if anything else is added to our plates we will explode, but let’s think about the ROI for a moment. If we admit 30 women over age of 40 each month, and spend, on average, 15 seconds inquiring about and recommending routine mammography, at the end of the year we will have invested a whopping 90 minutes of our lives counseling 360 women. If out of those 360 women, 25% (90) are overdue for their mammogram, and a third heed our advice, 30 women will get a mammogram. Since the lifetime risk of breast cancer is close to 1 in 8, chances are, within a year, we could collectively play a vital role in a multitude of women getting an early diagnosis of breast cancer, and thus a high chance of a complete cure.

A few years ago, I had the gut-wrenching experience of watching someone I loved very much die an excruciating death from breast cancer in my home. She told me I could tell her story so others would be spared her fate. Essentially, she waited too long to get a mammogram.

Now I ask you to help me rewrite her story and rewrite the stories of all of our loved ones who have passed away from breast cancer. If even 100 hospitalists will commit to investing 90 minutes over the next year to recommend screening mammography to patients, and perhaps even do a breast exam on some patients when they have a little extra time, I feel confident that someone, somewhere will be spared the ravages of this vicious disease and their deaths will not be in vain. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Each October, we celebrate breast cancer survivors, participate in fund-raisers for breast cancer research and awareness, and remember those lost to this brutal disease. As hospitalists, our job is to facilitate the care of our patients suffering from this disease. We admit patients with neutropenic fever after a recent bout of chemotherapy. We order palliative radiation therapy after the cancer has metastasized and causes severe pain and suffering. And, we order morphine drips when all else has failed, and our focus shifts to helping our patients pass on with the most dignity and least pain possible.

As hospitalists, our services typically come into play after the fact, not before. After the complications of chemo; after the cancer has spread; after there is nothing else we can do to prolong the lives of our patients. No doubt, what we do can make a tremendous impact on the lives of our patients, but can we do more? I believe we can.

How many seconds does it take to ask whether our female patients are up to date with their mammograms and Pap smears? Less than 10.

How many seconds would it take to dictate a brief reminder on preventive medical services, such as a screening mammogram, in our H&Ps? Less than 5.

How many women are aware that the American Cancer Society recommends breast MRI along with the yearly mammogram for certain high-risk women? Very few.

Yes, we are all very busy and sometimes it seems if anything else is added to our plates we will explode, but let’s think about the ROI for a moment. If we admit 30 women over age of 40 each month, and spend, on average, 15 seconds inquiring about and recommending routine mammography, at the end of the year we will have invested a whopping 90 minutes of our lives counseling 360 women. If out of those 360 women, 25% (90) are overdue for their mammogram, and a third heed our advice, 30 women will get a mammogram. Since the lifetime risk of breast cancer is close to 1 in 8, chances are, within a year, we could collectively play a vital role in a multitude of women getting an early diagnosis of breast cancer, and thus a high chance of a complete cure.

A few years ago, I had the gut-wrenching experience of watching someone I loved very much die an excruciating death from breast cancer in my home. She told me I could tell her story so others would be spared her fate. Essentially, she waited too long to get a mammogram.

Now I ask you to help me rewrite her story and rewrite the stories of all of our loved ones who have passed away from breast cancer. If even 100 hospitalists will commit to investing 90 minutes over the next year to recommend screening mammography to patients, and perhaps even do a breast exam on some patients when they have a little extra time, I feel confident that someone, somewhere will be spared the ravages of this vicious disease and their deaths will not be in vain. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.

Where breast cancer is concerned, every woman’s viewpoint is unique.

And in each individual patient, we’ll never know what that viewpoint is until we ask.

Last week’s blog highlighted the importance of discussing sexual function within the context of breast cancer treatment, not only when a patient expresses concern. A brief recap: 60% of women hope you’ll introduce the topic of sexuality, but the talk takes place just 23% of the time.

Today, we’ll explore sexuality and breast cancer beyond the clinically sterile word, function. Because, as you well know, if you live in the Western world in the 21st century, breasts are not just functional body parts that happen to be a cancer site. Complex doesn’t even begin to describe the role they play in terms of a woman’s sexuality, sexual self-image, and sexual relationships.

Sexuality potentially suffers from many aspects of breast cancer treatment, and that may arise from pain, hormonal changes, relationship upheaval, and a realigning of life priorities following an unexpected and frightening major life event.

When discussing sexuality is taboo, as it all-too-often is, none of these issues come to the fore.

And neither do breasts. Specifically, what they mean to a woman facing tough decisions about treatment alternatives, reconstruction options, and behind-closed-doors scenes that will play out when she’s standing alone before the mirror or sharing an intimate moment with a sexual partner.

In speaking with several survivors, dabbling in the sparse literature on the topic, and eavesdropping on virtual conversations online, I am reminded that today’s women of all ages face complex pressures (cancer-imposed, self-imposed, partner-imposed, and society-imposed) when making cancer-related decisions about their breasts.

Can a woman be a card-carrying feminist and still yearn for a restoration of the beauty as well as the sexual function of her breasts, or the "fetishized sexual objects that men have turned them into" – as one blog poster put it?

Listen to one survivor posting on a British online bulletin board for women, as she asks that very question:

I am and have always been a feminist, raised in a feminist household, raising my [daughter] in a feminist household. Part of my feminist beliefs have always included a firm stance that we as women are more than our biology, are more than our physicality and are more than the way we look. Ergo I have always thought I would shun breast augmentation – presenting oneself as "well-groomed" to the patriarchal world being one thing, cosmetic surgery designed to hyper-sexualise my being another entirely. (note, I judge not those who chose these things, just have always believed they aren’t for me). I now find myself having to think about what I to do in the event of double mastectomy. It seems I am somewhat more attached to my breasts than I thought I was! It seems that my feminine persona is more wrapped up with them than I realized – and I somehow can’t help feeling like I would be less of a woman, or maybe just less of me without them, and its making me really sad trying to imagine dressing differently, having sex differently, etc. And think that I want the reconstruction. But then the "head" part of me thinks that I’m falling into the trap of defining myself by the way I look, all of the things that I’ve spent my life arguing against. Which quite frankly is making my head explode with confusion. Not sure if its even relevant but I have medium-large breasts, I don’t dress to emphasise them, but neither will I apologise for them or dress to hide them – they are there and they are part of me, and if a man thinks that I should hide them away in case he’s tempted to stare at them then that’s his issue not mine. So, what would you do, then? Is this a feminist issue? Am I betraying my principles? It’s not really any better than a boob-job, is it? Or am I just getting myself twisted up over nothing at all?

Answers poured in to the confused poster on the Mumsnet site, with most respondents warmly reassuring "TheBossofMe" that reconstruction was not incompatible with feminist ideology, and that she should do whatever she could to help herself heal.

One poster, for example, responded:

My mother had a single and no reconstruction – I don’t think it was that available then and she always had issues with it – it’s much harder to cope with one in terms of dressing etc. She used to cry when she saw her special bras hanging on the line. Please don’t worry about the decision from a feminist/non-feminist pov – it’s all about how you feel and what will make you feel whole and come to terms with the whole thing.

Others admitted their bias leaning in the other direction, noting complications and mixed results of reconstruction surgery, or mentioning fashion alternatives – "flowing tops or layered tops on top of one another ... interesting scarves and fashionable shawls" that de-emphasize the shape of breasts for women who require mastectomy but choose not to have reconstruction or to use prostheses.

Wanting to further explore the issue of breasts, sexuality, and breast cancer, I spoke with a beautiful young cancer survivor who expressed her tremendous gratitude to an ob.gyn. who openly and in a matter-of-fact way discussed her breasts, sexual relationship, and yes, sexual function in a way her oncologists never had, since she had felt caught unprepared for the catastrophic hit that her sexual relationship, as well as her body, had taken during her cancer battle.

I spoke to another survivor – this one middle-aged – who was stunned into silence when a physician casually noted that she needn’t worry about ever replacing the breast implants she would receive during reconstruction, as is periodically necessary. When that day came she would be in her 70s, he mused, and the implants would simply be removed, since she "wouldn’t be needing" her breasts anymore.

It was against this backdrop that I read the study "Pink Ribbon Pin-Ups: photographing femininity after breast cancer" in the journal Culture, Health & Sexuality (2012;14:753-66).

Author Kaitlyn Regehr described her controversial project, which raised money for the Canadian Breast Cancer Foundation, as a reaction to gallery portraits and coffee table books depicting "haunting" visages of women’s scarred, postmastectomy chests, bald heads, and gauntly disfigured bodies.

A self-described "burlesque expert and television personality," Ms. Regehr recalls her encounter with a breast cancer survivor who had been asked to participate in a "rather provocative photo shoot in which she would be photographed without her wig."

The woman, she said, mentioned feeling like a "victim on display," leading Ms. Regehr to contemplate that "voyeurs of ... cancer" objectify women in a manner no less objectionable than the male-centered cheesecake photography and pin-up photography popularized from 1915 through World War II.

Today’s version of pin-up art is created according to the healthy whims and fantasies of women themselves "for the purposes of personal empowerment and sexual exploration," according to Ms. Regehr.

She invited survivors to apply to be calendar models and set about creating the first in a series of "Pink Ribbon Pin-Ups" in which women would choose how they would be seen, sexually, post-cancer.

Among the first 14 participants, none chose to highlight the scars of their cancer by posing without a wig or prosthetic breasts. Some said frankly that that they had decided to participate as a gift to a significant other, or as a means of reclaiming sexual self-confidence. One young woman described her marriage post-cancer as "predominantly nonsexual" and said she wanted to give her husband the pin-up photo for Christmas. Another survivor, dying of her cancer, was thrilled by the idea that she would be "Miss March" – her husband’s birthday month.

Were the images self-objectifying, or "subscribing to the feminine ideal as defined by the male gaze"? Ms. Regehr asks.

Later in the article she provides her own answer, drawn from the definition of individualized sexual empowerment: "Each woman has the right, and should have the opportunities, to explore and express her post-cancer body."

I’ve encountered women whose empowerment came from saying "no" to any further medical or surgical treatment than was necessary to control their breast cancer. Women whose feminine sense of self never centered on their breasts and who were happy to leave the world of bras behind. Women who were delighted or disappointed by their breast reconstruction or by the appearance of their breast conservation surgery.

In other words, it’s complicated.

And we’ll never understand how it is for a particular woman until we frankly discuss breasts in the context of breast cancer – not just how they appear, clothed or unclothed, but what meaning they hold for her sexuality and sense of self.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. Visit the Views section at www.oncologyreport.com to see what is new in Vitality Signs.

Where breast cancer is concerned, every woman’s viewpoint is unique.

And in each individual patient, we’ll never know what that viewpoint is until we ask.

Last week’s blog highlighted the importance of discussing sexual function within the context of breast cancer treatment, not only when a patient expresses concern. A brief recap: 60% of women hope you’ll introduce the topic of sexuality, but the talk takes place just 23% of the time.

Today, we’ll explore sexuality and breast cancer beyond the clinically sterile word, function. Because, as you well know, if you live in the Western world in the 21st century, breasts are not just functional body parts that happen to be a cancer site. Complex doesn’t even begin to describe the role they play in terms of a woman’s sexuality, sexual self-image, and sexual relationships.

Sexuality potentially suffers from many aspects of breast cancer treatment, and that may arise from pain, hormonal changes, relationship upheaval, and a realigning of life priorities following an unexpected and frightening major life event.

When discussing sexuality is taboo, as it all-too-often is, none of these issues come to the fore.

And neither do breasts. Specifically, what they mean to a woman facing tough decisions about treatment alternatives, reconstruction options, and behind-closed-doors scenes that will play out when she’s standing alone before the mirror or sharing an intimate moment with a sexual partner.

In speaking with several survivors, dabbling in the sparse literature on the topic, and eavesdropping on virtual conversations online, I am reminded that today’s women of all ages face complex pressures (cancer-imposed, self-imposed, partner-imposed, and society-imposed) when making cancer-related decisions about their breasts.

Can a woman be a card-carrying feminist and still yearn for a restoration of the beauty as well as the sexual function of her breasts, or the "fetishized sexual objects that men have turned them into" – as one blog poster put it?

Listen to one survivor posting on a British online bulletin board for women, as she asks that very question:

I am and have always been a feminist, raised in a feminist household, raising my [daughter] in a feminist household. Part of my feminist beliefs have always included a firm stance that we as women are more than our biology, are more than our physicality and are more than the way we look. Ergo I have always thought I would shun breast augmentation – presenting oneself as "well-groomed" to the patriarchal world being one thing, cosmetic surgery designed to hyper-sexualise my being another entirely. (note, I judge not those who chose these things, just have always believed they aren’t for me). I now find myself having to think about what I to do in the event of double mastectomy. It seems I am somewhat more attached to my breasts than I thought I was! It seems that my feminine persona is more wrapped up with them than I realized – and I somehow can’t help feeling like I would be less of a woman, or maybe just less of me without them, and its making me really sad trying to imagine dressing differently, having sex differently, etc. And think that I want the reconstruction. But then the "head" part of me thinks that I’m falling into the trap of defining myself by the way I look, all of the things that I’ve spent my life arguing against. Which quite frankly is making my head explode with confusion. Not sure if its even relevant but I have medium-large breasts, I don’t dress to emphasise them, but neither will I apologise for them or dress to hide them – they are there and they are part of me, and if a man thinks that I should hide them away in case he’s tempted to stare at them then that’s his issue not mine. So, what would you do, then? Is this a feminist issue? Am I betraying my principles? It’s not really any better than a boob-job, is it? Or am I just getting myself twisted up over nothing at all?

Answers poured in to the confused poster on the Mumsnet site, with most respondents warmly reassuring "TheBossofMe" that reconstruction was not incompatible with feminist ideology, and that she should do whatever she could to help herself heal.

One poster, for example, responded:

My mother had a single and no reconstruction – I don’t think it was that available then and she always had issues with it – it’s much harder to cope with one in terms of dressing etc. She used to cry when she saw her special bras hanging on the line. Please don’t worry about the decision from a feminist/non-feminist pov – it’s all about how you feel and what will make you feel whole and come to terms with the whole thing.

Others admitted their bias leaning in the other direction, noting complications and mixed results of reconstruction surgery, or mentioning fashion alternatives – "flowing tops or layered tops on top of one another ... interesting scarves and fashionable shawls" that de-emphasize the shape of breasts for women who require mastectomy but choose not to have reconstruction or to use prostheses.

Wanting to further explore the issue of breasts, sexuality, and breast cancer, I spoke with a beautiful young cancer survivor who expressed her tremendous gratitude to an ob.gyn. who openly and in a matter-of-fact way discussed her breasts, sexual relationship, and yes, sexual function in a way her oncologists never had, since she had felt caught unprepared for the catastrophic hit that her sexual relationship, as well as her body, had taken during her cancer battle.

I spoke to another survivor – this one middle-aged – who was stunned into silence when a physician casually noted that she needn’t worry about ever replacing the breast implants she would receive during reconstruction, as is periodically necessary. When that day came she would be in her 70s, he mused, and the implants would simply be removed, since she "wouldn’t be needing" her breasts anymore.

It was against this backdrop that I read the study "Pink Ribbon Pin-Ups: photographing femininity after breast cancer" in the journal Culture, Health & Sexuality (2012;14:753-66).

Author Kaitlyn Regehr described her controversial project, which raised money for the Canadian Breast Cancer Foundation, as a reaction to gallery portraits and coffee table books depicting "haunting" visages of women’s scarred, postmastectomy chests, bald heads, and gauntly disfigured bodies.

A self-described "burlesque expert and television personality," Ms. Regehr recalls her encounter with a breast cancer survivor who had been asked to participate in a "rather provocative photo shoot in which she would be photographed without her wig."

The woman, she said, mentioned feeling like a "victim on display," leading Ms. Regehr to contemplate that "voyeurs of ... cancer" objectify women in a manner no less objectionable than the male-centered cheesecake photography and pin-up photography popularized from 1915 through World War II.

Today’s version of pin-up art is created according to the healthy whims and fantasies of women themselves "for the purposes of personal empowerment and sexual exploration," according to Ms. Regehr.

She invited survivors to apply to be calendar models and set about creating the first in a series of "Pink Ribbon Pin-Ups" in which women would choose how they would be seen, sexually, post-cancer.

Among the first 14 participants, none chose to highlight the scars of their cancer by posing without a wig or prosthetic breasts. Some said frankly that that they had decided to participate as a gift to a significant other, or as a means of reclaiming sexual self-confidence. One young woman described her marriage post-cancer as "predominantly nonsexual" and said she wanted to give her husband the pin-up photo for Christmas. Another survivor, dying of her cancer, was thrilled by the idea that she would be "Miss March" – her husband’s birthday month.

Were the images self-objectifying, or "subscribing to the feminine ideal as defined by the male gaze"? Ms. Regehr asks.

Later in the article she provides her own answer, drawn from the definition of individualized sexual empowerment: "Each woman has the right, and should have the opportunities, to explore and express her post-cancer body."

I’ve encountered women whose empowerment came from saying "no" to any further medical or surgical treatment than was necessary to control their breast cancer. Women whose feminine sense of self never centered on their breasts and who were happy to leave the world of bras behind. Women who were delighted or disappointed by their breast reconstruction or by the appearance of their breast conservation surgery.

In other words, it’s complicated.

And we’ll never understand how it is for a particular woman until we frankly discuss breasts in the context of breast cancer – not just how they appear, clothed or unclothed, but what meaning they hold for her sexuality and sense of self.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. Visit the Views section at www.oncologyreport.com to see what is new in Vitality Signs.

Where breast cancer is concerned, every woman’s viewpoint is unique.

And in each individual patient, we’ll never know what that viewpoint is until we ask.

Last week’s blog highlighted the importance of discussing sexual function within the context of breast cancer treatment, not only when a patient expresses concern. A brief recap: 60% of women hope you’ll introduce the topic of sexuality, but the talk takes place just 23% of the time.

Today, we’ll explore sexuality and breast cancer beyond the clinically sterile word, function. Because, as you well know, if you live in the Western world in the 21st century, breasts are not just functional body parts that happen to be a cancer site. Complex doesn’t even begin to describe the role they play in terms of a woman’s sexuality, sexual self-image, and sexual relationships.

Sexuality potentially suffers from many aspects of breast cancer treatment, and that may arise from pain, hormonal changes, relationship upheaval, and a realigning of life priorities following an unexpected and frightening major life event.

When discussing sexuality is taboo, as it all-too-often is, none of these issues come to the fore.

And neither do breasts. Specifically, what they mean to a woman facing tough decisions about treatment alternatives, reconstruction options, and behind-closed-doors scenes that will play out when she’s standing alone before the mirror or sharing an intimate moment with a sexual partner.

In speaking with several survivors, dabbling in the sparse literature on the topic, and eavesdropping on virtual conversations online, I am reminded that today’s women of all ages face complex pressures (cancer-imposed, self-imposed, partner-imposed, and society-imposed) when making cancer-related decisions about their breasts.

Can a woman be a card-carrying feminist and still yearn for a restoration of the beauty as well as the sexual function of her breasts, or the "fetishized sexual objects that men have turned them into" – as one blog poster put it?

Listen to one survivor posting on a British online bulletin board for women, as she asks that very question:

I am and have always been a feminist, raised in a feminist household, raising my [daughter] in a feminist household. Part of my feminist beliefs have always included a firm stance that we as women are more than our biology, are more than our physicality and are more than the way we look. Ergo I have always thought I would shun breast augmentation – presenting oneself as "well-groomed" to the patriarchal world being one thing, cosmetic surgery designed to hyper-sexualise my being another entirely. (note, I judge not those who chose these things, just have always believed they aren’t for me). I now find myself having to think about what I to do in the event of double mastectomy. It seems I am somewhat more attached to my breasts than I thought I was! It seems that my feminine persona is more wrapped up with them than I realized – and I somehow can’t help feeling like I would be less of a woman, or maybe just less of me without them, and its making me really sad trying to imagine dressing differently, having sex differently, etc. And think that I want the reconstruction. But then the "head" part of me thinks that I’m falling into the trap of defining myself by the way I look, all of the things that I’ve spent my life arguing against. Which quite frankly is making my head explode with confusion. Not sure if its even relevant but I have medium-large breasts, I don’t dress to emphasise them, but neither will I apologise for them or dress to hide them – they are there and they are part of me, and if a man thinks that I should hide them away in case he’s tempted to stare at them then that’s his issue not mine. So, what would you do, then? Is this a feminist issue? Am I betraying my principles? It’s not really any better than a boob-job, is it? Or am I just getting myself twisted up over nothing at all?

Answers poured in to the confused poster on the Mumsnet site, with most respondents warmly reassuring "TheBossofMe" that reconstruction was not incompatible with feminist ideology, and that she should do whatever she could to help herself heal.

One poster, for example, responded:

My mother had a single and no reconstruction – I don’t think it was that available then and she always had issues with it – it’s much harder to cope with one in terms of dressing etc. She used to cry when she saw her special bras hanging on the line. Please don’t worry about the decision from a feminist/non-feminist pov – it’s all about how you feel and what will make you feel whole and come to terms with the whole thing.

Others admitted their bias leaning in the other direction, noting complications and mixed results of reconstruction surgery, or mentioning fashion alternatives – "flowing tops or layered tops on top of one another ... interesting scarves and fashionable shawls" that de-emphasize the shape of breasts for women who require mastectomy but choose not to have reconstruction or to use prostheses.

Wanting to further explore the issue of breasts, sexuality, and breast cancer, I spoke with a beautiful young cancer survivor who expressed her tremendous gratitude to an ob.gyn. who openly and in a matter-of-fact way discussed her breasts, sexual relationship, and yes, sexual function in a way her oncologists never had, since she had felt caught unprepared for the catastrophic hit that her sexual relationship, as well as her body, had taken during her cancer battle.

I spoke to another survivor – this one middle-aged – who was stunned into silence when a physician casually noted that she needn’t worry about ever replacing the breast implants she would receive during reconstruction, as is periodically necessary. When that day came she would be in her 70s, he mused, and the implants would simply be removed, since she "wouldn’t be needing" her breasts anymore.

It was against this backdrop that I read the study "Pink Ribbon Pin-Ups: photographing femininity after breast cancer" in the journal Culture, Health & Sexuality (2012;14:753-66).

Author Kaitlyn Regehr described her controversial project, which raised money for the Canadian Breast Cancer Foundation, as a reaction to gallery portraits and coffee table books depicting "haunting" visages of women’s scarred, postmastectomy chests, bald heads, and gauntly disfigured bodies.

A self-described "burlesque expert and television personality," Ms. Regehr recalls her encounter with a breast cancer survivor who had been asked to participate in a "rather provocative photo shoot in which she would be photographed without her wig."

The woman, she said, mentioned feeling like a "victim on display," leading Ms. Regehr to contemplate that "voyeurs of ... cancer" objectify women in a manner no less objectionable than the male-centered cheesecake photography and pin-up photography popularized from 1915 through World War II.

Today’s version of pin-up art is created according to the healthy whims and fantasies of women themselves "for the purposes of personal empowerment and sexual exploration," according to Ms. Regehr.

She invited survivors to apply to be calendar models and set about creating the first in a series of "Pink Ribbon Pin-Ups" in which women would choose how they would be seen, sexually, post-cancer.

Among the first 14 participants, none chose to highlight the scars of their cancer by posing without a wig or prosthetic breasts. Some said frankly that that they had decided to participate as a gift to a significant other, or as a means of reclaiming sexual self-confidence. One young woman described her marriage post-cancer as "predominantly nonsexual" and said she wanted to give her husband the pin-up photo for Christmas. Another survivor, dying of her cancer, was thrilled by the idea that she would be "Miss March" – her husband’s birthday month.

Were the images self-objectifying, or "subscribing to the feminine ideal as defined by the male gaze"? Ms. Regehr asks.

Later in the article she provides her own answer, drawn from the definition of individualized sexual empowerment: "Each woman has the right, and should have the opportunities, to explore and express her post-cancer body."

I’ve encountered women whose empowerment came from saying "no" to any further medical or surgical treatment than was necessary to control their breast cancer. Women whose feminine sense of self never centered on their breasts and who were happy to leave the world of bras behind. Women who were delighted or disappointed by their breast reconstruction or by the appearance of their breast conservation surgery.

In other words, it’s complicated.

And we’ll never understand how it is for a particular woman until we frankly discuss breasts in the context of breast cancer – not just how they appear, clothed or unclothed, but what meaning they hold for her sexuality and sense of self.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. Visit the Views section at www.oncologyreport.com to see what is new in Vitality Signs.

In bygone days, October presented itself in orange and black. Autumn leaves swirled in flame-colored piles. Pumpkins, pointy witches’ hats, and dark cats were everywhere, or so it seemed.

Now the hot fall color is pink. Pink ribbons are ubiquitous against nature’s orange-and-black backdrop. And pink wrist bands. And pink football cleats. And pink dresses on Michele Obama and Ann Romney at the second presidential debate. Even Halloween pumpkins are coming up pink all over.

@ Catherine Lane/istockphoto.co

October is National Breast Cancer Awareness month, and unless you have been to Mars during the last few weeks, it’s been hard to miss. Not only breast cancer charities, but also a slew of organizations has slapped pink ribbons on products to advance this popular cause.

For at least a decade, a smattering of groups and individuals has questioned who really profits. Since 2002, Think Before You Pink, a project of Breast Cancer Action, has been urging people to be skeptical before they buy into breast cancer promotions. This year, skeptics are questioning just how much the National Football League takes home after giving the American Cancer Society 5% of its profits on the high-priced pink hats and t-shirts being sold from the Breast Cancer Awareness page at the NFL online store.

Now New York Attorney General Eric T. Schneiderman has entered the fray with a best practices model for pink ribbon–style blends of commerce and charity. The best practices are designed "to promote transparency in charitable ‘cause marketing’ campaigns, a growing billion-dollar-a-year industry in which companies advertise that the sale or use of a product will result in a charitable contribution," according to a statement from Mr. Schneiderman.

His list follows a year-long review of pink ribbon and similar campaigns waged by nearly 150 companies. "While these campaigns have resulted in substantial donations, the attorney general’s review found that consumers often do not have sufficient information to understand how their purchases will benefit charity," the statement said.

The complete best practices and other guidance can be found here. Here, in short, is what the A.G. wants companies to do before they raise money in the name of breast cancer or any other cause:

• Clearly describe the promotion. Promotions should tell the name of the charity; the specific dollar amount per purchase that will go to charity; any caps on the donation; whether any consumer action is required to trigger a donation; and the start and end dates of the campaign.

• Make it easy to determine the donation amount. Companies should set a fixed dollar amount, such as 50 cents for every purchase, rather than use generic phrases like "a portion of proceeds" will go to charity.

• ‘Be transparent about what is not apparent.’ Conditions that are not obvious to consumers should be disclosed. Does the campaign have a contractual limit on the campaign? Will charitable contributions not be made in cash? Has a fixed amount been promised to the charity regardless of the number of products sold?

• Be transparent in social media. Sometimes a company promises to contribute to a cause for a "like" on Facebook or a "follow" on Twitter. The company should disclose how much it will donate for the action, the name of the recipient charity, when the campaign starts and ends, and whether there is a minimum or maximum amount it will donate. And it should be easy to see how much has been donated to date.

• Disclose how much money was raised. When the campaign is over, the company should say so – and tell everyone how much it gave to charity.

Finally, if all that is not clear enough, Mr. Schneiderman proposes a "Donation Information" label – similar to a nutrition label – that could be slapped on any product or website running a campaign.

So far, the Susan G. Komen for the Cure and Breast Cancer Research Foundation have signed on, the A.G. said. Who else is ready to show their true colors?

In bygone days, October presented itself in orange and black. Autumn leaves swirled in flame-colored piles. Pumpkins, pointy witches’ hats, and dark cats were everywhere, or so it seemed.

Now the hot fall color is pink. Pink ribbons are ubiquitous against nature’s orange-and-black backdrop. And pink wrist bands. And pink football cleats. And pink dresses on Michele Obama and Ann Romney at the second presidential debate. Even Halloween pumpkins are coming up pink all over.

@ Catherine Lane/istockphoto.co

October is National Breast Cancer Awareness month, and unless you have been to Mars during the last few weeks, it’s been hard to miss. Not only breast cancer charities, but also a slew of organizations has slapped pink ribbons on products to advance this popular cause.

For at least a decade, a smattering of groups and individuals has questioned who really profits. Since 2002, Think Before You Pink, a project of Breast Cancer Action, has been urging people to be skeptical before they buy into breast cancer promotions. This year, skeptics are questioning just how much the National Football League takes home after giving the American Cancer Society 5% of its profits on the high-priced pink hats and t-shirts being sold from the Breast Cancer Awareness page at the NFL online store.

Now New York Attorney General Eric T. Schneiderman has entered the fray with a best practices model for pink ribbon–style blends of commerce and charity. The best practices are designed "to promote transparency in charitable ‘cause marketing’ campaigns, a growing billion-dollar-a-year industry in which companies advertise that the sale or use of a product will result in a charitable contribution," according to a statement from Mr. Schneiderman.

His list follows a year-long review of pink ribbon and similar campaigns waged by nearly 150 companies. "While these campaigns have resulted in substantial donations, the attorney general’s review found that consumers often do not have sufficient information to understand how their purchases will benefit charity," the statement said.

The complete best practices and other guidance can be found here. Here, in short, is what the A.G. wants companies to do before they raise money in the name of breast cancer or any other cause:

• Clearly describe the promotion. Promotions should tell the name of the charity; the specific dollar amount per purchase that will go to charity; any caps on the donation; whether any consumer action is required to trigger a donation; and the start and end dates of the campaign.

• Make it easy to determine the donation amount. Companies should set a fixed dollar amount, such as 50 cents for every purchase, rather than use generic phrases like "a portion of proceeds" will go to charity.

• ‘Be transparent about what is not apparent.’ Conditions that are not obvious to consumers should be disclosed. Does the campaign have a contractual limit on the campaign? Will charitable contributions not be made in cash? Has a fixed amount been promised to the charity regardless of the number of products sold?

• Be transparent in social media. Sometimes a company promises to contribute to a cause for a "like" on Facebook or a "follow" on Twitter. The company should disclose how much it will donate for the action, the name of the recipient charity, when the campaign starts and ends, and whether there is a minimum or maximum amount it will donate. And it should be easy to see how much has been donated to date.

• Disclose how much money was raised. When the campaign is over, the company should say so – and tell everyone how much it gave to charity.

Finally, if all that is not clear enough, Mr. Schneiderman proposes a "Donation Information" label – similar to a nutrition label – that could be slapped on any product or website running a campaign.

So far, the Susan G. Komen for the Cure and Breast Cancer Research Foundation have signed on, the A.G. said. Who else is ready to show their true colors?

In bygone days, October presented itself in orange and black. Autumn leaves swirled in flame-colored piles. Pumpkins, pointy witches’ hats, and dark cats were everywhere, or so it seemed.

Now the hot fall color is pink. Pink ribbons are ubiquitous against nature’s orange-and-black backdrop. And pink wrist bands. And pink football cleats. And pink dresses on Michele Obama and Ann Romney at the second presidential debate. Even Halloween pumpkins are coming up pink all over.

@ Catherine Lane/istockphoto.co

October is National Breast Cancer Awareness month, and unless you have been to Mars during the last few weeks, it’s been hard to miss. Not only breast cancer charities, but also a slew of organizations has slapped pink ribbons on products to advance this popular cause.

For at least a decade, a smattering of groups and individuals has questioned who really profits. Since 2002, Think Before You Pink, a project of Breast Cancer Action, has been urging people to be skeptical before they buy into breast cancer promotions. This year, skeptics are questioning just how much the National Football League takes home after giving the American Cancer Society 5% of its profits on the high-priced pink hats and t-shirts being sold from the Breast Cancer Awareness page at the NFL online store.

Now New York Attorney General Eric T. Schneiderman has entered the fray with a best practices model for pink ribbon–style blends of commerce and charity. The best practices are designed "to promote transparency in charitable ‘cause marketing’ campaigns, a growing billion-dollar-a-year industry in which companies advertise that the sale or use of a product will result in a charitable contribution," according to a statement from Mr. Schneiderman.

His list follows a year-long review of pink ribbon and similar campaigns waged by nearly 150 companies. "While these campaigns have resulted in substantial donations, the attorney general’s review found that consumers often do not have sufficient information to understand how their purchases will benefit charity," the statement said.

The complete best practices and other guidance can be found here. Here, in short, is what the A.G. wants companies to do before they raise money in the name of breast cancer or any other cause:

• Clearly describe the promotion. Promotions should tell the name of the charity; the specific dollar amount per purchase that will go to charity; any caps on the donation; whether any consumer action is required to trigger a donation; and the start and end dates of the campaign.

• Make it easy to determine the donation amount. Companies should set a fixed dollar amount, such as 50 cents for every purchase, rather than use generic phrases like "a portion of proceeds" will go to charity.

• ‘Be transparent about what is not apparent.’ Conditions that are not obvious to consumers should be disclosed. Does the campaign have a contractual limit on the campaign? Will charitable contributions not be made in cash? Has a fixed amount been promised to the charity regardless of the number of products sold?

• Be transparent in social media. Sometimes a company promises to contribute to a cause for a "like" on Facebook or a "follow" on Twitter. The company should disclose how much it will donate for the action, the name of the recipient charity, when the campaign starts and ends, and whether there is a minimum or maximum amount it will donate. And it should be easy to see how much has been donated to date.

• Disclose how much money was raised. When the campaign is over, the company should say so – and tell everyone how much it gave to charity.

Finally, if all that is not clear enough, Mr. Schneiderman proposes a "Donation Information" label – similar to a nutrition label – that could be slapped on any product or website running a campaign.

So far, the Susan G. Komen for the Cure and Breast Cancer Research Foundation have signed on, the A.G. said. Who else is ready to show their true colors?