Several months ago, I had an interesting conversation with a new olah. She was 44, and confused as to why the gynecologist had told her that 1) he didn’t conduct clinical breast exams and 2) she was too young for a routine mammography anyway. “Aren’t I supposed to be in follow up with a mammogram?” she asked me. “I don’t want to ignore my responsibility to take care of myself.”
Welcome to emigrating to another country, and a whole different approach to screening.
Around 35 years ago, the Israeli Ministry of Health came up with recommendations of mammography screening to detect breast cancer early. They based their screening plan on European data suggested that women’s highest risk of developing breast cancer occurred in the post-menopausal years; prior to this age, successful mammography imaging is compromised by active breast tissue, suggesting that routine screening is not an effective enough tool to identify early-stage breast cancer.
This is how screening healthy populations work. You do an overall analysis of the overall harms, overall benefits, and then make system-wide choices to benefit the largest number of your population. It is not an individual decision-making tool.
Despite several large scale studies in the last decade about the efficacy of mammography, it is still considered the gold standard for diagnosing breast cancer before it metastasizes. The best years to use this tool is from 50-74. Although most practitioners in the United States start routine mammography at age 40, the Agency for Healthcare Research and Quality (AHRQ) has concluded that:
- Women ages 50 to 74 benefit the most from screening mammograms. The best balance of benefits and harms occurs when screening is done every 2 years.
- Mammograms also reduce breast cancer deaths in women ages 40 to 49 years. As such, women in their 40s can also benefit from screening mammograms, but the benefits are lower than for older women because their risk of developing breast cancer is lower.
- The risk of potential harms is also higher for women in their 40s because they are more likely to have false-positive results and follow-up procedures, such as breast biopsies that do not result in a diagnosis of breast cancer.
- The balance of benefits and harms is likely to improve as women move from their early to late 40s.
- Women in this age group who have a mother, sister, or daughter with breast cancer are at increased risk of developing breast cancer. These women may benefit more from beginning screening in their 40s than women who have no close relatives with breast cancer.
This is how screening healthy populations work. You do an overall analysis of the overall harms, overall benefits, and then make system-wide choices to benefit the largest number of your population. It is not an individual decision-making tool. When screening for cancer, this means that we have no proven methods to prevent the disease, but we can detect it early, when it is small and localized, known factors to reduce cancer death.
In Israel, cancer is still the leading cause of death for anyone over age 15. Lung cancer is currently the leading cause of death among Jewish men in Israel (although prostate cancer is the most frequently occurring). Breast cancer is still the leading cause of death among Jewish women, followed by colon, and then lung, cancer. Until now, there were no national screening programs to detect lung cancer in its early stages, the gold standard to reduce cancer mortality.
In last week’s Jerusalem Post, we read about the Ministry of Health’s new 3 year pilot program to introduce routine use of CT screening for lung cancer. Specifics have not been released as to who and how participants will be screened, but it suggests that in the near future, routine lung cancer screening may be part of the national plan.
Meanwhile, the current standards for screening healthy adults for the early detection of various cancers are listed below:
Current Ministry of Health Recommendations for screenings of healthy populations ( written in 2011 and still valid as of January 2020)
|Target Cancer||Target Population||Frequency||Means||Needed paperwork|
|Breast||Women ages 50-74||Every 2 years||Mammography (x-ray of the breast tissue)||Referral from family dr/gynecologist/breast surgeon (and hitchayvut if received in a non kupah clinic, e.g. hospital)|
|Colon||Men and Women over age 50||Once a year||FOBT * ( Fetal Occult Blood Test)||Acquire the kit from the kupah nurse|
|Cervical||Women after age 21||Every 2 years||Pap smear||Exam performed by gynecologist during routine visit|
* Those with first degree relatives with a colon cancer diagnosis are allowed routine colonoscopy every 5 years. All others need to get a referral/hitchayvut from a gastroenterologist if you choose a colonoscopy as a screening method.