A study questioning the effectiveness of mammograms in preventing breast cancer has recently hit the news and caused a lot of women to wonder what to do. Jennifer Harvey, MD, a UVA radiologist who specializes in breast cancer treatment and research, offers her take on the study and its implications.
About the Mammogram Screening Study
This article reports the combined follow-up data at 25 years for two Canadian mammography screening trials: One study of women ages 40-49 and the other for women ages 50-59. The study finds that annual mammography in these women during the study period did not reduce mortality from breast cancer compared with women who had only clinical examination.
The Mammogram Study in Perspective
The important context of this study is that this is one of nine randomized clinical trials that were performed between the late 1960s and the 1980s. Of those nine trials, seven showed a reduction in breast cancer mortality with screening mammography; the Canadian trial was not one of those seven. The fact that the results did not change at 25 years of follow-up is not news. This trial was also one of the most highly criticized, due to likely randomization errors and quality control.
We should also consider the time frame of this study. Today’s mammogram is not your mother’s mammogram. Mammograms obtained today are considerably better in quality than those that were used in the study, which took place when I was a child! Mammography was also in its youth at that time. Mammograms, like our phones and cameras, have advanced in technology over the years.
The Evolution of Mammograms in Pictures
This slide shows the technical changes in mammography over time. Most of the randomized trials were performed in the 1970s and 1980s. Although randomized trials are the “gold standard” for judging a test, the technical changes make the results a bit outdated. Mammography today is far more advanced, and now includes tomosynthesis (3D mammogram). I’ve changed a bit over the years, too!
Does Mammography Work?
Yes. All countries that have adopted routine screening mammography have experienced a significant reduction in breast cancer mortality, including the United States. While mammography is imperfect and does not detect all cancers at an early stage, it does reduce breast cancer mortality by at least 25%.
Improving Mammography: A Look Ahead
This and other studies have raised a good point, however. We do need to screen smarter. As we better understand breast cancer and breast cancer risk factors, we should work to tailor screening to an individual woman’s risk. Women who are low risk, or at risk for low-grade disease, could be screened less frequently. Women who are at higher risk or at risk for aggressive disease could be screened more frequently with tools other than mammography, such as ultrasound or MRI.
We are not there yet. Current risk models are not very good at telling which women are going to develop breast cancer and which are not. At the UVA Breast Care Center we are currently developing a breast cancer risk model that includes breast density. We believe this will help women better understand their breast cancer risk and make decisions about screening based on that information.
What type of mammography is right for you?
Tina Tinsley’s dream was to be a mother, and her wish was granted after years of trying. But because of cystic fibrosis, she couldn’t do basic tasks that most moms take for granted. She couldn’t go to the grocery store or give her children baths. When she left the house, she had to take an oxygen tank along with her.
It wasn’t always this way. Tinsley, now 38, was a physically active child, but cystic fibrosis changed all that as she got older.
A hereditary condition that develops during childhood, cystic fibrosis primarily affects the respiratory system, pancreas and sweat glands. The body produces excess mucus that clogs the bronchi, which are the main passageway into the lungs. This leads to breathing difficulties and infections.
Infertility and IVF
Cystic fibrosis also causes infertility. Tinsley, who lives in Staunton, Va., was told she’d never have children, but she wasn’t one to take no for an answer. She and her husband, Phillip, kept trying. After numerous procedures and two in vitro fertilization (IVF) attempts over eight years, they were successful, and twins Cole and Sara were born in 2009.
Her faith in God kept her going through the long and often-disappointing process, she says. The twins were in the NICU for many weeks after their birth. “UVA took excellent care of them and made sure they were coming home,” she says.
After the birth of the babies, her cystic fibrosis symptoms worsened. “My husband says it really took a toll on my body,” she says. “But even if I knew that, if I had been warned, I don’t know if I would’ve listened. I really wanted to have kids.”
Family History of Cystic Fibrosis
Things took a turn for the worse in October 2013, when Tinsley was admitted to UVA with a lung infection and put on a ventilator and feeding tube. “I nearly left here. I almost died,” she says. For Tinsley, that was a very real possibility. Her brother died of cystic fibrosis three years ago at the age of 39. She also has two cousins with the condition, one of whom died from it.
Antibiotics controlled her infection, and eventually she was strong enough to be put on the lung transplant waiting list. Still, she wasn’t ready to admit she needed a transplant. She thought she might still get better and needed the convincing of her doctor, Max Weder, MD. “He said I wasn’t going to live if I didn’t have the transplant,” Tinsley says. “He’s by far the best physician I’ve ever had. We make a good team. The whole transplant team is just phenomenal.”
Tinsley also got support from other members of the transplant team at UVA, including social worker Bill Potts and pre-transplant coordinator Heidi Flanagan, RN.
“Heidi knew how nervous I was, and she was so compassionate. She told me to look ahead a year to what my life was going to be like.”
Potts, she says, asked her what she wanted from the rest of her life. “I told him I just wanted to be a mama to my babies. He said, ‘Transplant can give you that.’”
Lung Transplant and Recovery
While Tinsley was in the hospital, Phillip, Tinsley’s husband of 18 years, would drive 40 miles from Staunton to Charlottesville to be with her and then drive home to be with their children.
Christine Lau, MD, performed Tinsley’s lung transplant, which lasted almost 10 hours. Tinsley was removed from the ventilator the first day after her surgery. “I was up sitting in a chair the next day and walking in the hallways the day after that.”
She stayed in the MICU (medical intensive care unit) for two weeks following the surgery and worked with a respiratory therapist, physical therapist and nutritionist to regain normal function. Tinsley also takes immunosuppressants, drugs that prevent her body from rejecting her new lungs. Transplant recipients take anti-rejection medications for the rest of their lives.
Weder says Tinsley’s case is a special one. It’s not often that patients go from being near death to walking out of the hospital several weeks later. “She is a unique case and serves as a great example of how everyone on our MICU and transplant teams work together in difficult transplant cases.”
Along the way, the Tinsley family received lots of help. People in their Staunton community raised funds to help cover some of their transplant medical expenses. Another group made sure the children had presents under the tree this past Christmas when neither parent had the time or resources to go shopping. The Tinsleys’ church community donated weeks of meals during her hospitalization. The Tinsleys also received a grant from a nonprofit that paid for one round of their IVF procedure.
Tinsley, whose motto is “Live to fight another day,” says she feels better now than she’s felt since she was a child. She can give her children those baths, she goes to the grocery store and the oxygen tank is gone. She hopes to share her story with local churches and maybe write a book someday. Her new goals also include running a marathon. “I know I can do it,” she says.
More Transplant Information
Meet Dr. Weder
To many women, having a baby at 37 weeks may seem about the same as having the baby at 39 weeks. Why endure another two weeks of backaches and swelling when you could induce labor?
Does it really make a difference for your child?
UVA obstetricians sometimes see expecting parents who want to schedule an induction at 37 or 38 weeks for logistical reasons. And that used to be considered OK.
But now doctors know that there’s a big difference between 37 and 39 weeks. Babies do best if delivered at 39 weeks or later.
The “Magical Gestational Age” of 39 Weeks
At 39 weeks, babies have better developed organs, including the brain and lungs, and:
- Maintain temperature better
- Eat better
- Have a lower risk of breathing problems
- Are less likely to need extensive medical care and interventions, including the neonatal intensive care unit
“It’s important to mention that most babies born spontaneously or due to medical necessity between 37-39 weeks do well,” says obstetrician Vanessa Gregg, MD. “But statistically, 39 weeks or beyond is best for babies.”
That’s why UVA does not schedule expecting moms for elective early deliveries, which is induction or Cesarean section before 39 weeks. The March of Dimes recently recognized UVA and just 12 other hospitals in Virginia for low elective early delivery rates and for implementing a delivery policy.
UVA had no elective early deliveries in 2012 and the first half of 2013 (numbers are not yet in for the second half of last year), compared to a national mean of almost 8 percent of all births.
“When we explain to women and their families that babies are better off if born after 39 weeks, they’re receptive to waiting until that magical gestational age for delivery,” Gregg says.
However, deliveries before 39 weeks can still happen if the mother goes into labor on her own. There are also medical reasons to induce, including:
- Maternal high blood pressure
- Maternal diabetes
- Twins or other multiples
- Fetal anomalies that need special care outside the womb
- Abnormal placental development
- Prior uterine surgeries that make the uterus too fragile to wait
- Growth restrictions due to the fetus getting too big
Are you pregnant or thinking about having a baby? Find out more about our:
In August 1982, Thomas P. Loughran Jr., MD, was working in Seattle when a woman with a mysterious blood illness was transferred to his hospital. That patient and her condition changed the path of Loughran’s research forever.
Loughran and his research are featured in the Spring 2014 issue of UVA’s family health magazine, Vim & Vigor. Check it out for stories about:
- Angelina Jolie’s double mastectomy and BRCA1 and BRCA2 genetic testing
- Controlling diabetes without drugs
- How much to hover when your kids are playing
- The jobs that are hardest on your heart
Live in Virginia? Sign up to get Vim & Vigor in the mail for free.
In this final installment of our Fad Diets Q&A series, UVA nutritionists Carole Havrila and Katherine Basbaum explain how sleep and belly fat relate and give us their best advice for sticking to a diet plan.
Q: Tell me about how sleep and belly fat relate to weight-loss.
Havrila: There is science that validates that elevated cortisol levels (a stress hormone) happen when we lack enough sleep or are consistently stressed out. While these states are correlated with higher cortisol levels and more belly fat, the only way to get that off is to care for the whole body. You must reduce calories and exercise to lose total body weight.
Basbaum: The stomach or abdominal area is indeed one of the more dangerous places on the body to carry excess weight: As fat accumulates and “pads” the spaces between the abdominal organs (“visceral fat”), you have increased risk of metabolic disturbances, cardiovascular disease and type 2 diabetes.
Regarding lack of sleep, that can indeed lead to weight gain; there are specific hunger and satiety hormones (ghrelin and leptin) that can get thrown off if you’re consistently not getting a good night’s sleep. This means that not only will you be likely to consume more calories throughout the day, you will also have more trouble burning them off.
Q. Best tips for sticking to a diet or weight-loss plan?
Havrila: Accountability is a very powerful thing, so if you are really worried you will gain weight then keep a daily log of what you are eating/drinking (you can do this online with apps like MyFitnessPal or Sparkpeople). These keep a tally of your calories and can be helpful to keep you on track when you are considering that extra cookie.
Fad Diets: Final Thoughts
Fad diet advertisements often distort key facts about the body in order to sell their products.
Here are 5 things from this series to remember the next time you’re tempted to believe otherwise:
- Detox-diets, cleanses and any plan that removes a food group entirely could put you at risk of missing nutrients you need. If you have health issues, fasts and cleanses can even hurt you.
- Diets that focus on eating large amounts of saturated fat found in many meats, butter, full-fat dairy, etc., can be bad for your heart, and that hurts your overall health.
- Extreme diets are often so hard they backfire.
- You don’t need to cleanse; your body detoxifies itself.
- Every weight-loss plan requires diet and exercise to be successful.
What do YOU think?
Was this series helpful? What surprised you? What diet will you try — or try to avoid — next? Tell us below.
Which are worth trying, which will prove a wash?
In this fourth installment of our Fad Diet Q&A series, UVA nutritionists Carole Havrila and Katherine Basbaum make their picks for best and worst diets on the popular market.
Q. What about the diets that got top ratings in a recent US News & World Report article: DASH, TLC diet, Mayo Clinic, Weight Watchers, Flexitarian, Volumetrics, Biggest Loser, Ornish, Engine 2, Flat Belly diet, Abs diet?
Havrila: I believe that these diets mentioned do work and can work if followed, and the calories are not severely limited (below 1200 calories for women and 1500 for men). The DASH diet, Mayo Clinic, Weight Watchers, Flexitarian, Volumetrics and vegan/vegetarian diets are all reasonable diets that work successfully when followed. Vegan diets require planning to make sure that important nutrients are included but are healthy diets in general.
Basbaum: For the fourth year in a row — when taking into consideration ease of use, nutrition, safety, effectiveness for weight loss and protection against diabetes and heart disease — US News & World Report has named the DASH diet as the best overall diet for 2014. Why? Because it’s smart, balanced, realistic, tried and true.
Q. What fad diet makes you cringe the most?
Havrila: Detox diets that advocate large amounts of dietary supplements in addition to restrictive diets and enemas or other detoxification methods. These could potentially be dangerous to those on prescription medications and/or having cancer treatment.
Basbaum: Definitely the gluten-free craze that has been happening for the past couple of years. If you have a genuine, medically diagnosed intolerance to gluten, or if you have celiac disease, then a gluten-free diet is warranted. But as a weight-loss tool, it’s potentially dangerous and may even cause weight gain if you don’t do it right.
Next Up: Sleep, Belly Fat, and Making Weight-Loss Last, Fad Diets Q&A Part 5
It’s one thing to experiment with fad diets when you’re relatively healthy. But people dealing with health issues, especially cancer and heart problems, need to be extra careful.
In this third installment of our Fad Diet Q&A series, UVA nutritionists Carole Havrila and Katherine Basbaum tell us what diet elements could be dangerous and which could help.
Q. If someone has a heart condition or is in cancer treatment, are there certain diets to avoid?
Havrila: For cancer, any diet that would be restrictive in total calories or protein or both would likely worsen the nutritional status of a patient receiving cancer treatment and would not be recommended. This includes:
- Fasts (juice or otherwise) that are prolonged
- Severe macrobiotic diets that eliminate many foods and are very low in total calories
- Any diet that would include the use of high amounts of dietary supplements, as they may interfere with medicines patients use or even interfere with cancer treatments
Basbaum: For heart disease, I’d say stay away from the Atkins-type diets, the ones that encourage large amounts of high-fat animal protein like steak and bacon. These foods are high in sodium and saturated fats, two of the things we recommend eating in moderation when eating for heart health.
Q. What kind of diets aid prevention of heart issues and cancer?
Havrila: In terms of cancer prevention, plant-based diets rich in legumes and beans, fruits and vegetables and whole grains. Meat is a “condiment” and not the centerpiece of the meal. Diets for cancer prevention are controlled in calories to help patients maintain or achieve a healthy weight. Processed meats are eaten sparingly, if at all, and red meat is limited to 18 ounces a week.
Basbaum: For heart health, your diet should focus on high-quality lean protein (both plant and animal-based), low-fat dairy, whole grains, low sodium (less than 2000 mg/day), and having the majority of dietary fat coming from either polyunsaturated or monounsaturated fat sources, i.e. olive oil, canola, nuts, seeds, avocado.
Next up: Detox, Gluten-Free, Vegan, Fad Diets Q&A Part 4
I know, I know: You can’t always trust an infomercial. But we live in a fast-food world, and those of us interested in losing weight would love to find a single magic ingredient to do the work for us.
In this second installment of our Fad Diet Q&A series, UVA nutritionists Carole Havrila and Katherine Basbaum offer a reality check.
Q. What about weight-loss claims for wonder ingredients? Recently, I’ve been curious to see magazines touting turmeric, coconut oil or garcinia cambogia. Can adding just one of these or other ingredients really make you lose weight all by themselves?
- Be skeptical if the product or diet promises a quick fix, if it recommends approaches based on limited, hard-to-find studies or a single study, if it lists good and bad foods or if it sounds too good to be true.
- Do some research on credible websites.
- Ask your dietitian, doctor or pharmacist to help.
- Understand that diet pills and dietary supplements are not regulated as drugs are. Therefore there is a risk of contamination or a risk that products marketed and sold with these ingredients may not even have these ingredients in them.
- Remember, some weight loss or diet pills have been associated with liver failure and even death.
Basbaum: When it comes to specific foods or herbs that are touted in the press as miracle weight-loss foods, remember a couple things:
- If it sounds too good to be true, it probably is.
- Even if there is some solid evidence that supports its weight-loss claims, you still have to do all the other things that are traditionally needed for weight loss if you want to see significant results, i.e., healthy diet and exercise.
Next up: Diet Dangers for Cancer & Heart Patients, Fad Diets Q&A Part 3