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Breast cancer screening guidelines based on flawed Canadian study, new paper says – CBC.ca

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A new paper calls into question a decades-old Canadian study that has informed breast cancer screening guidelines for women in their 40s around the world, which generally do not recommend a yearly mammogram.

The commentary — co-written by researchers at The Ottawa Hospital, Sunnybrook Research Institute in Toronto, the University of British Columbia, the University of Alberta and Harvard Medical School — will be published in the Journal of Medical Screening this week.

It specifically points to randomization issues with the Canadian National Breast Screening Study (CNBSS), originally conducted in the 1980s, which involved tens of thousands of women and eventually took place in 15 different urban centres across the country.

The randomized trials set out to determine whether or not screening helped save women’s lives. In the first study, women aged 40 to 49 were randomly assigned to receive mammograms or placed in a control group where they had a single physical exam, with all participants followed up with for several years.

Over the course of the study, there were 38 deaths from breast cancer in the mammography group and 28 among those who didn’t receive mammogram screenings.

As a result, Canadian researchers concluded that annual screening in women aged 40 to 49 at average risk does not reduce breast cancer mortality any more than a physical exam.

The study has gone on to inform guidelines both here and around the world. The most recent guidelines issued by the Canadian Task Force on Preventive Health Care still do not recommend screenings for women in that age group.

A key issue of earlier screening is the risk of false positives and over-diagnosis. There are lumps that aren’t cancerous or harmful to women, but if discovered, would require a biopsy.

Experts have warned any kind of breast cancer treatment — whether it be radiation, chemotherapy or surgery — may carry harm.

New evidence 

But the CNBSS had several problems, according to Dr. Jean Seely, co-author of the new paper and a professor of radiology at the University of Ottawa and head of breast imaging at The Ottawa Hospital.

She and her co-authors are calling for mammograms for women aged 40 or older, should they want them.

Seely said there is now “conclusive confirmation” the CNBSS was conducted — particularly in some trial locations — with women who weren’t randomly assigned.

When interviewing 28 staff members who worked on the original study, some confirmed there were multiple instances in which women with detectable lumps, who were pre-screened by a nurse, were in fact purposefully placed in the mammography group, she said.

“I was astonished. I did not expect to find such clear, clear evidence of what was going on,” Seely said. “Then I think my next reaction was anger. How could this have been allowed?”

Dr. Jean Seely is a professor of radiology at the University of Ottawa and head of breast imaging at The Ottawa Hospital. She is also the author of the paper recently published in the Journal of Breast Imaging. (Michel Aspirot/CBC)

The paper adds to the long-standing debate over the quality of the studies since they were first published and whether women in their 40s should be regularly screened.

Since the ’90s, radiologists and researchers have raised concerns about the inclusion of women with advanced cancers in the study, the quality of the screening and the factors used to determine if mammographies were beneficial for that age group.

Experts have mostly suspected issues with the randomization, which they say would’ve skewed the findings.

An investigation into these suspicions was done by external experts in the 1990s after the first results of the CNBSS were published.

The resulting paper said it “failed to uncover credible evidence” that the randomization was subverted in any way. Its authors further said that even if there had been acts of subversion, they would have been “few in number” and “alterations could have had only a trivial effect on the study findings.”

Results would be different, experts argue

Still, some experts aren’t convinced; the new paper concludes that results of the trial would have changed with the seven instances of women with lumps from the mammography group sent to the usual care group.

Seely said she’s hopeful this new evidence will lead to change

“I think probably the most personal challenging moments that I have in my practice are when I see a woman in her 40s who presents with an advanced breast cancer,” she said.

More often than not, Seely said, those women were told by their family doctors they shouldn’t be screened because of their age. “On a personal level, as a professional, I find this very, very difficult,” she said.

According to the Canadian Cancer Society, while women aged 50 and older have higher rates of breast cancer diagnosis, there’s a higher rate of mortality for women between 30 and 49.

Women in that age range consist of 17 per cent of all cancer deaths in Canada. That’s compared to women aged 50-69, who represent just eight per cent of cancer deaths.

Lead investigator defends study

Many other experts, including the principle investigators of the CNBSS, continue to defend the study.

“We had a great deal of understanding of what could go wrong with randomization and we took a great deal of care to ensure it didn’t apply in the National Breast Screening Study,” said Dr. Anthony Miller, a professor emeritus at the Dalla Lana School of Public Health at the University of Toronto, who led the study.

Miller, who has seen a copy of the new paper, denies the possibility that any women were not placed randomly within the trials. There were extensive quality-control measures in place to maintain the integrity of the study, he said.

One of the primary reasons it is not recommended women that in their 40s undergo regular mammograms is the risk of over-diagnosis. (CBC)

Nurses were only in place to inform participants about the study and get their consent, he said, and any examinations happened after a woman had been randomized.

At that point, Miller said, excluding women who may have had palpable lumps “would indeed falsify the results of the study.”

CNBSS considered gold standard

Miller is not alone in his defence of the CBNSS. While its authors say their work has been under attack for decades, the CBNSS has withstood years of skepticism and challenges.

The study has been hailed by many around the world as the gold standard in breast cancer screening research. In 2019, a 25-year followup to the study was named one of the British Medical Journal’s Top 5 research papers of the last decade.

Compared to a number of other breast cancer screening trials, it would be difficult to find one as well documented and well run as the CNBSS, according to Dr. Karsten Jørgensen, acting director of the Nordic Cochrane Centre, which reviews medical trials, including those on breast cancer screening.

Canada’s trial results also align with other reputable studies around the world, which show no benefit to early screening, Jørgensen said.

“There’s always room for interpretation. There’s also always pitfalls. There’s always limitations with the trials — but that’s why we do systematic reviews and these types of meta-analysis,” said Jørgensen.

“Much of this is down to interpretation and which results should you trust.” 

New findings being considered

Seely and her fellow researchers have raised their concerns about the CNBSS to the University of Toronto and the Canadian Medical Association Journal, both of which were involved in the original study.

In a statement, the university’s office in charge of research, oversight and compliance said it “places a high value on research integrity” and is “reviewing the concerns raised by a group of individuals and has been in touch with them.”

The university did not specify the scope or timeline of its review, only that it will “get back to them with our next steps.”

“CMAJ will co-operate with the university office’s process fully and will await the office’s report on the outcome of the review before deciding if any further action is needed,” Dr. Kirsten Patrick, interim editor-in-chief of the journal, wrote in her own statement.

She did not provide any further comment.

Unlikely guidelines will change

The Canadian Task Force on Preventive Health Care says it is unlikely it will consider changing the country’s current guidelines on breast cancer screening to include women in their 40s.

In a written response to CBC, the task force defended its guidelines, saying it “conducts rigorous, detailed evidence reviews” when formulating them.

“Our guidelines, including those on breast cancer screening, have been recognized as the best in the world,” said Dr. Brenda Wilson, co-chair of the task force.

Wilson wrote “the best available evidence” is used to inform the guidelines. When there are changes to that evidence, she said the task force “updates a full review of the body of evidence, including any new evidence.”

The task force doesn’t comment on individual studies or opinion pieces without doing that review, she said.

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What’s the greatest holiday gift: lips, hair, skin? Give the gift of great skin this holiday season

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Give the gift of great skin this holiday season

Skinstitut Holiday Gift Kits take the stress out of gifting

Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.

In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.

“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.

There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.

Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.

Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.

In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.

 

Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

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Here is how to prepare your online accounts for when you die

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LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?

It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.

Here’s how you can prepare your digital life for your survivors:

Apple

The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.

For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.

You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.

Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.

Google

Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.

When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.

You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.

There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.

Facebook and Instagram

Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.

When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.

The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.

You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.

TikTok

The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.

Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.

X

It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.

Passwords

Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?

Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.

But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.

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Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.

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Pediatric group says doctors should regularly screen kids for reading difficulties

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The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.

New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.

The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.

Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.

Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.

“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.

“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”

McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.

But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.

The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.

He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.

“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.

“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.

McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”

McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.

He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.

“Early identification of reading difficulty can truly change the trajectory of a child’s life.”

This report by The Canadian Press was first published Oct. 23, 2024.

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