Recommendations for Screening Mammography; What Has Changed?The U.S. Preventive Services Task Force (USPSTF) is comprised of health care professionals and researchers who are experts in assessing preventive health services. USPSTF was established by Congress 25 years ago and has worked as an independent ‘think-tank’ that uses scientific criteria to make recommendations about screening tests and other preventive services. It does not dictate health insurance coverage policies or speak for the government, though it has been given a prominent advisory role in the current version of the Senate Health Care bill. The Task Force recently published a controversial set of guidelines regarding the use of screening mammograms, recommending against routine screening mammograms in women age 40-49 and recommending biennial (every two years) screening mammograms for women between the ages of 50-74.
In developing these guidelines, USPSTF reviewed research that had studied the effectiveness of mammography and other forms of breast cancer screening. Their primary goal in evaluating the research outcomes was to examine the effect of screening mammograms on mortality. In other words, how many lives were saved by mammograms? They cited research findings that for women ages 40-49, about 1900 screening mammograms were needed to save one woman from death due to breast cancer, as opposed to 1339 mammograms for women ages 50-59 years, and only 377 mammograms for women ages 60-69. The research also showed that there are some risks involved with mammography, such as the risk of false positive results causing the need for additional tests (mammograms, ultrasounds, or biopsies) and the potential psychological stress that produces. The task force thus concluded that the risks of screening mammograms for women ages 40-49 likely outweighed the benefits. They did note that the decision to use mammograms to screen for breast cancer prior to age 50 should be made between each individual and her health care provider, who can explore and discuss that woman’s personal risks and health status.
At this time, other health agencies including the American Cancer Society, the American Medical Association, the American College of Obstetrics and Gynecology have not changed their recommendations for screening mammograms. Mayo Clinic also continues to offer annual screening mammograms for women beginning at age 40.
Further, there are several ways in which the data is interpreted and communicated, which can be confusing. For example, the research showed that it takes about 1900 screening mammograms to save one 40-49 year old woman from cancer death. The same research describes this finding by reporting that mammography screening reduces breast cancer deaths by 15% for women aged 39-49 years. One out of 1900 seems trivial but the number 15% does not! This is still a significant finding.
Additionally, there is criticism that the task force does not consider the impact to morbidity; that is, the effect to the overall health and quality of life of the patient. Breast cancer screening has two aims: 1) to reduce breast cancer deaths, and 2) to improve treatment options. If the cancer is found early, patients have a higher likelihood of having a breast preservation surgery rather than mastectomy, and fewer women need axillary lymph node dissection, both of which are directly related to quality of life issues. There is a strong association between screening and more conservative treatments and while mortality rates are important, preserving quality of life should be of paramount concern as well.
Another shortcoming of the research is that no studies which included newer technologies, such as digital mammography, were reviewed. Digital mammography more accurately detects cancers in younger women and those with dense breast tissue. While it’s not yet known if that would have altered the research results, evidence to that effect is compelling.
Finally, the USPSTF acknowledges that “breast cancer mortality has been decreasing since 1990 by 2.3% per year overall and by 3.3% for women aged 40-50 years. This decrease is largely attibuted to the combination of mammography screening with improved treatment ”. This same publication recommends that individuals should consider routine screening mammography based on their health and risk factors, yet it is well known that approximately 80% of breast cancers are diagnosed in women without a family history of breast cancers.
Breast cancer is the most common cancer in women in the United States, with more than 190,000 women receiving a diagnosis of invasive disease annually and more than 40,000 dying of breast cancer each year. The updated USPSTF recommendations have sparked substantial controversy resulting in confusion, fear, and anger among patients, their families, and various women's health advocates.
While we may disagree with USPSTF’s newly updated recommendations, we can appreciate the attention it has brought to breast cancer and to the need to improve our screening and early cancer detection processes. Mammography is still the best screening tool we have available to us today. We, at Join the Journey, will continue to encourage women to be aware of their breasts and to see their health care provider promptly if there are any changes, to have annual clinical breast exams and screening mammograms. Women are encouraged to discuss their concerns with their health care providers and learn more about the risks and benefits, as well as the limitations of mammography. We continue to support breast cancer research to advance the science and technology and hopefully, one day, we will be better able to individualize screening and medical care for our patients.
JTJ appreciates the editing assistance of Dr. Sandhya Pruthi, Mayo Clinic Breast Clinic
Check out the Susan Komen organizational response to the USPSTF recommendations on the web-site www.susankomen.com under research, then news.
