The United States Prevention Services Task Force is the government agency officially charged with recommending which medical procedures should be routine, and for whom. In 2009, the USPSTF ruled that—contrary to previous standard medical practice—women under the age of 50 should not get annual mammograms.

This abrupt change of policy made many women uneasy—not the least of them the physicians and surgeons on the front lines of breast cancer research and treatment. Now, three years into the new policy, WVFC asked Elisa Rush Port, MD, FACS—co-director of the Dubin Breast Center of the Tisch Cancer Institute and Chief of Breast Surgery at Mount Sinai School of Medicine in New York City—for her thoughts on mammograms and their effectiveness as a cancer screening tool for women 40 and older. We also welcome Dr. Port as the newest member of the Medical Advisory Board of Women’s Voices for Change.

Patricia Yarberry Allen, MD

Editor, Medical Mondays

 


Mammogram Controversy Continues

 By Elisa Rush Port, MD, FACS

There have been six major clinical trials and multiple others evaluating the efficacy of mammography and its role in the early detection of breast cancer. Cumulatively, these trials have demonstrated a clear-cut survival benefit across all age groups beginning at 40 years old. As a result, in 2002 recommendations were established for yearly screening mammography for women beginning at age 40 in the United States

In 2009, this recommendation was questioned when the United States Prevention Services Task Force (USPSTF) revisited the issue and published its findings in the Annals of Internal Medicine. Although the same data was analyzed and the survival benefit across all age groups (beginning at age 40) was demonstrated to be 15 percent or greater, the USPSTF’s recommendations changed substantially. Instead of a “B” recommendation (“The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial”), screening mammography was downgraded to a “D” (“The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits”)

So what happened?

Essentially, there was a shift in thinking toward the “harms” and “costs” of mammography: unnecessary callbacks and biopsies, anxiety, and dollars. According to the USPSTF, the harms of yearly mammography outweighed the benefits for most age groups. According to the study published in the Annals of Internal Medicine that was everywhere in the press in 2009, the main reason for demoting mammography for women under the age of 50 was that for women 39 to 49, 1,904 mammograms were needed to be done to detect one cancer, compared with 1,339 mammograms for women 50 to 59.  An arbitrary line was drawn in the sand by the USPSTF: 1 cancer detected in 1,339 mammograms was acceptable, but 1 cancer in 1,904 was not.

Thus the recommendation for yearly mammography in patients from 40 to 49 was rescinded. The study recommended forgoing mammography for this younger age group despite acknowledging that the survival benefit for the younger group was the same.

On top of that, a recent editorial in The British Medical Journal (BMJ) criticizing the Komen Foundation for its promotion of mammography suggested that Komen was overselling the benefits of mammography while saying nothing of the potential harms that screening mammography can engender.

There is no perfect screening test. Chest computerized tomography (known as CT scans) for lung cancer, for example, can lead to multiple follow-up exams that involve significant amounts of radiation. And if something suspicious is found on a chest CT, biopsy may be recommended, which could lead to major interventions such as lung surgery or complications such as collapse of the lung.  Colonoscopy, too—widely accepted as a life-saving screening test—can lead to bleeding, infection, and perforation, all of which are potentially life-threatening. There is no accurate screening test for ovarian cancer, which is why the majority of ovarian cancers are detected in Stage III or IV.  We are dissatisfied when there is no good screening test, yet there are those who severely criticize the use of the effective ones that we have.  What gives?

Mammography has withstood the tests of time, randomized clinical trials, and the introduction of other competing technologies, none of which have proven to be as effective for screening for breast cancer in the general population. The potential “harms” of mammography (follow-up exams, biopsies, and anxiety) that are constantly harped on by its critics are nowhere near as dangerous as those associated with other screening tests, and none of the potential harms is even close to being life-threatening. There is no question that with health care costs exploding, any test that results in downstreaming costs (which is basically all tests) must be scrutinized for the overall benefits.

But we have been there and done that with mammography. Neither the Annals of Internal Medicine study nor the recent editorial in BMJ factored into the discussion, in a full-fledged way, the potential harms related to failing to detect breast cancer as early as possible—which is sure to be a consequence from recommending against routine screening mammography. The BMJ editorial harshly criticized the Komen advertisement, implying that it numerically misrepresented the survival benefit of screening mammography. But here are the facts: There is a survival benefit, across all age groups, among those who develop breast cancer and have been screened with mammography. And while survival has always been the gold standard for evaluating the efficacy of a screening test, there are other, almost equally as important, endpoints that demonstrate significant benefits of mammography, including reduction in harm, anxiety, and cost.

For example, the development and widespread use of mammography in the 1970s and 1980s was the single most influential factor leading to the development of breast-conserving surgery, or lumpectomy: a smaller procedure with no overnight hospital stay, and with an equal survival rate, that allows patients to return to work, family, and activity much more quickly than a mastectomy. In the United States in 2012, the majority of women who are eligible for lumpectomy surgery choose this option.

Critics talk about the anxiety and stress related to getting mammograms. What about the anxiety and stress related to not getting mammograms?  For the woman who isn’t getting yearly mammograms, isn’t it stressful to know that if one day she feels a lump, and that lump is found to be cancer, it is likely to be larger and require more extensive surgery and chemotherapy than if she had been screened?

While anecdotes and personal experience are not criteria for making recommendations for the general population, those of us who take care of breast cancer patients on a daily basis and make it our life’s work see cases every day exemplifying why mammography works. Yes, there are cancers that are missed on mammogram. And yes, there are patients who do not get mammograms who develop breast cancers that are completely curable and survivable. But for the vast majority of women, the data clearly shows that mammograms save lives and result in less invasive and extensive treatment for many women. The harms related to mammography are exaggerated and need to be kept in perspective as mostly tolerable and completely non-life-threatening.  When it comes to recommending yearly mammograms and affirming that mammograms save lives, let’s stop getting hung up on technicalities. Let’s stop re-crunching the numbers until they give us a different answer, and accept what the data demonstrates: From age 40—not age 50—yearly mammograms save lives.