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The Raging Debate on Mammography Guidelines

In November last year, a series of “bombshell” recommendations about screening mammography was made by the U.S. Preventative Services Task Force , an independent panel that makes health care recommendations. Their recommendations were published in the Annals of Internal Medicine..(2009;151:716-726). (www.annals.org) and are summarized below:

Recommendations: The U.S. Preventative Services Task Force (USPSTF) recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation)
The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement)
The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation)
The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

While their recommendations are indeed provocative, I strongly believe they are not valid and they should NOT be adopted. For example, when mammography screening was introduced in Sweden, the death rate from breast cancer was reduced by about 40%. In the U.S., the breast cancer death rate has decreased by 30% since 1990, when screening mammography began to be widely used. Before that, the breast cancer death rate had been unchanged for the preceding 50 years. Of course, my worry is the insurance carriers will use these USPTF recommendations as a “cover” for denying coverage for the costs of breast screening and further, that the public will be unnecessarily confused by the conflicting opinions and not seek regular screening. That would be a major setback, for breast cancer will get a longer headstart prior to detection (if these guidelines would be followed) and more women with breast cancer will require more radical (and expensive) treatments, more debilitating symptoms, and a lower probability of living a normal life span.

The USPSTF recommendations have been endorsed by the following organizations: American Academy of Family Physicians, American College of Medicine, American College of Preventative Medicine, National Association of County and City Health Officials, and the American Public Health Association.

On the other hand, virtually all the national organizations whose physician members are directly responsible for the screening and management of breast cancer are strongly opposed to these recommendations, including the American Cancer Society, the American College of Radiology, the American College of Surgeons, American Society of Breast Surgeons, the Society of Breast imaging, and the National Comprehensive Cancer Network. Indeed, many of their leaders have made very strong statements lamblasting the conclusions of the USPSTF.

“The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women, beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgements about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions” Otis W. Brawley, MD Chief medical Officer, American Cancer Society.

The American College of Obstetricians and Gynecologists (ACOG) also maintains its current advice that women in their 40s continue mammographic screening every 1 to 2 years and women age 50 or older continue annual screening, stating: “ All women, along with their physicians, should individually assess the benefits as well as the risks of mammographic screening”.

The American College of Surgeons (ACS) also affirmed the the American Cancer Society Guidelines have resulted in an effective approach toward dealinig with brest cancer and that women should continue to follow them in consultation with their physicians. Dr Lemar S. McGinnis, MD, President of the ACS, stated: “ While recognizing that mammography is not perfect and supporting continuing research for improved methods, the surgical community believes that the American Cancer Society’s screening guidelines offer an optimal approach to detecting breast cancer early, when it can be most successfully treated.”

The American Society of Breast Surgeons is strongly opposed to the recommendations released November 16, 2009 by the USPSTF. “We believe there is sufficient data to support annual mammography screening for women age 40 and older… these recommendations effectively turn back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam. Mammography screening reduces breast cancer mortality and saves lives.”

Read the withering criticism that leaders in the field have made, and their recommendations that current guidelines be maintained:

“For women age 40 and over, the benfits of annual breast screening continue to outweigh the risks…age should not be an absolute when determining who should receive mammorgraphy screening. It is imperative to consider the patient’s individual risk factors when considering an appropriate screening routine. Therese B. Beavers, MD, Chair, Guidelines Panel for Breast Cancer Screening and Diagnosis, National Comprehensive Cancer Network.

“The UTPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at age 40 is shocking. At least 40% of the lives saved by mammographic screening are of women aged 40-40. These recommendations are inconsistent with curtrent science and apparently have been developed in an attempt to reduce costs. Unfortuneately, many women may pay for this unsound approach with their lives!” W. Phil Evans, MD, President, Society of Breast Imaging. Oncology, 23:1214, November, 2009

The U.S. Preventative Services Task Force recommendations “have taken a tremendous toll, and I believe they set us back”. “After all we’ve done to urge people to get screened, now they hear maybe they shouldn’t bother. That’s dangerous”. Nancy Brinker, the Founder of Koman Foundation and a breast Cancer Survivor was quoted in the Washington Post (November 24th,2009) stated at the National Press Club

“These unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against over the past 20 years. …The new recommendations seem to reflect a conscious decision to ration care……it could have deadly effects on women.” Carol H. Lee, MD Chair of the American College of Radiology Breast Imaging Commission. Oncology, 23:1214, November, 2009

“I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives”. James H. Thrall, MD Chair of the American College of Radiology Board of Chancellors. Oncology, 23:1214, November, 2009.

There is no new data to support these guidelines –they are completely insane..as a women, I find the rhetoric about anxiety and unnecessary testing offensive and patronizing.”. Dr Elsie Levin, Medical Director, The Boston Breast Diagnostic Center (General Surgery News, December, 2009)

“The net effect of the recommendations is that screening would begin too late and would be too little. We would save money but we would lose lives,” Stephen A. Feig,MD, President-elect of the American Society of Breast Disease, (Elsevier Global Medical News. 2009 Dec 3,2009)

The fastest-growing cancers, and thus the ones likely to be missed with screening every two years occur in younger women. Thus, the implied suggestion that screening mammography be delayed until the age of 50 and then undertaken every two years, makes no sense… I wonder if the recommendations would have been the same had there been greater representation on the Task Force of physicians involved in the detection and treatment of breast cancer.” Dr Carol Fabian, Director, Breast cancer Prevention Center, University of Kansas Medical Center. (General Surgery News, December, 2009)

“What does this tell women in their 40s? It tells them basically that they can go back to the 1950s, when they waited until a cancer was too large to ignore any more and then bring it to their doctor’s attention,… They’re basically saying ignore your breasts until there’s an obvious cancer.” Daniel B. Kopans,MD, Breast Imaging Division, Massachusetts General Hospital and Professor of Radiology at Harvard Medical School. (Elsevier Global Medical News. 2009 Dec 3,2009)

“Recommendations as important as these should not be decided on narrow evidence that is not widely supported by the breast cancer and provider community,” Robert Rifkin, M.D., Chair, Patient Advocacy Foundation Scientific Advisory Board. Until there is much more conclusive evidence, we continue to join our non-profit colleagues, including the American Cancer Society, Susan G. Komen Foundation, National Comprehensive Cancer Network, and the American Medical Association, in recommending that women over the age of 40 continue regular, annual mammography screening.

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