On Monday evening, the way that we are supposed to recommend breast cancer screening to women was radically shaken to the core and has left many physicians and their patients angered and confused.

Mammograms have been one of our great triumphs in the early detection of cancer, resulting in fewer deaths from breast cancer in women over the age of 40. On Monday, a panel of medical experts released their conclusions from a re-analysis of mammogram data, which has been analyzed multiple times before and resulted in our current screening recommendations of yearly mammography for women 40 and over.

This panel has now recommended that for women who are not deemed to be at elevated risk for the disease, screening begin at the age of 50, and then only every two years thereafter. They cite unnecessary anxiety in women undergoing mammography and false positive results leading to negative biopsies as problems with screening women under the age of 50. Many women and their physicians are having emotional and visceral reactions to these new recommendations. My husband, who is a prominent academic breast surgeon in Manhattan, told me bluntly on Monday: “I could fill a room with hundreds of women whose lives were saved by a mammogram under the age of 50.”

It is important to take a step back and really analyze this recommendation and the potential motivating factors behind it, question why we are spending energy reanalyzing old data, and solicit and review reactions from leaders in breast cancer screening and management. Thomas M. Kolb, M.D., who opens our discussion below, is widely regarded as a leader in the field of women’s health care and imaging.

Dr. Kolb has been on the faculty of numerous medical educational meetings, and he has lectured throughout the U.S. and internationally on the topic of breast cancer detection and diagnosis, including at the New York Academy of Sciences and the Radiological Society of North America. In 1998, Dr. Kolb published the first contemporary study detailing the use of breast ultrasound to detect cancers, and in 2002 his  publication describing the performance characteristics of mammography, clinical breast examination and ultrasound was awarded the Scientific Paper of the year by the American Medical Association. Dr. Kolb is currently a principal investigator of the North American Digital Breast Tomosynthesis project, which is analyzing a novel mammographic technology that acquires multiplanar images of the breasts.

We at WVFC will keep providing you with the best information possible on matters so urgent to all of us.

Elizabeth Poyner, M.D.

Co-Chair, Medical Advisory Board, Women’s Voices For Change

The Folly of Limited Screening for Breast Cancer: Why the U.S. Preventive Services Task Force Recommendation is Dangerous.

The following addresses the U.S. Preventive Services Task Force (USPSTF) recommendation statement, including the supporting and evidence update articles, published in the Annals of Internal Medicine November 17, 2009 and as reported by the NY Times.

Their recommendations: The USPSTF “recommends against routine screening mammography in women aged 40–49 years. The decision to start regular, biennial screening before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. The USPSTF recommends biennial (once every two years) screening mammography for women aged 50 to 74 years.”

Analyzing the recommendations: It is important to analyze how and why the USPSTF arrived at its recommendations to limit screening to understand how it will affect you as a patient.

The current USPSTF recommendation is based on a patchwork of information including patient trials and mathematical models. It is not made on the basis of any new clinical information that contradicts previously accepted screening schedules. Reading the actual publications should give pause to anyone who has decided to forgo mammographic screening from ages 40–49 and to go to biennial screening from ages 50–74.

The Facts: Results of patient trials, including large randomized controlled trials performed in the 1960s through the 1980s,  showed a 15 percent decrease in the death rate from breast cancer in women 40–49 years and approximately 30 percent in women aged 50–69 years who had annual screening mammograms. That means fewer deaths from breast cancer in women who were regularly screening with mammograms.

However, there were limitations in these studies that contributed to controversy as to the exact benefit in younger women, because the numbers of younger women screened were not as large as those who were older and these trials were not meant to stratify women by age. Still, most investigators, including the most recent previous USPSTF review in 2002, concluded that the benefit in younger women existed. The current review updates all relevant studies from 2001 through 2008, and concludes, “Trials of mammography screening for women aged 39 to 49 years indicate a statistically significant 15 percent reduction in breast cancer mortality for women randomly assigned to screening vs. those assigned to controls.” This re-affirms that screening younger women saves lives.

While this would seem to confirm the importance of screening younger women, the USPSTF took it one step further. Citing problems in design, conduct and interpretation of previous studies used to arrive at the current recommendation to screen younger women (which are well known and have been debated for over 20 years), the USPSTF decided to look at mathematical models to predict how well mammograms worked.

While these models themselves contain inherent limitations, it was found that all models predicted a decrease in the death rate, even in younger women. In fact, if the criteria were life-years gained (and not just change in death rate), the benefits of screening mammography would be greater in younger women than screening women older than 74 years. Further, the models predicted that 20 percent of the benefit of screening annually would be lost by screening once every twp years instead of annually.

The Controversy: So how did the USPSTF conclude that it is not worth screening younger women and is better to screen women 50–69 only once every two years? The answer lies in the word “efficiency.”

The Task Force took all the data that pointed toward a positive benefit for screening younger and more often and stated it was not “efficient,” meaning that it was not worth expending the energy and resources to save the smaller numbers of younger women who would not die from breast cancer if they had been screened.

Moreover, USPSTF uses the potential harms of screening mammography to enhance its recommendation of limited screening. These include false positive results, anxiety, and “needless” biopsy in younger women and in those screened annually. They admit that “harms of mammography screening have been identified, but their magnitude and effects are hard to measure,” and that “our meta-analysis of mammography screening trials indicated breast cancer mortality benefit (lives saved) for all age groups from 39 to 69 years, with sufficient data for older women…. Mammography screening at any age is a trade-off of a continuum of benefits and harms. The ages at which this trade-off becomes acceptable to individuals and society are not clearly resolved by available evidence.”

The USPSTF is clearly saying the following:

  • Screening with mammograms saves lives for all age groups.
  • More lives would be saved by screening earlier.
  • More lives would be saved by screening annually.
  • In order to improve “efficiency” less should be done at the cost of fewer lives saved.

Within the confines of available scientific information, there exist gray areas. Yet, in spite of their own conclusions as to the scientific evidence, the USPSTF has decided on drawing a line that would adversely affect women of all ages. Hopefully, it is not a decision influenced by the current health care debate.

Patient beware.

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