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U.S. Preventive Services Task Force Recommendations for Mammography
3/29/2010 12:00:00 AM
Since the November 2009 announcement of the controversial United States Preventive Services Task Force (USPSTF) recommendations for mammography, Baptist M&S Imaging has noticed a significant drop in the number of women receiving screening mammograms. Other practices throughout the country are reporting the same phenomenon. This supports the findings from the recent Annals of Internal Medicine survey that 67% of physician respondents plan to follow the USPSTF guidelines by ceasing to recommend mammography for women in their 40’s. In addition, 62% will now advise women 50-74 years of age to get mammograms every other year instead of annually.
The breast imagers at Baptist M & S Imaging are very concerned. The USPSTF panel’s recommendations are flawed and have caused much confusion. The panel members had no expertise in the diagnosis or management of breast cancer. Their recommendations are contrary to the guidelines from the American Cancer Society and the American College of Radiology advising annual mammography for all women beginning at age 40.
The recent editorial suggests that breast imagers and cancer care specialists who dispute these findings are too emotionally involved to be objective; however, different, legitimate conclusions can be drawn from the same data. There is unequivocal evidence that the mortality of breast cancer has decreased by 30% since 1990, the time at which regular mammography became widespread. In fact, recent updates from the Swedish trials have shown greater than 40% reduction in mortality in the 40-49 year age group. The USPSTF agrees that there is mortality reduction related to mammography. They estimate that the mortality reduction is approximately 15% for the 40-49 age group as well as for the 50-59 age group. The problem is that more women in the younger age group would have to be screened (1900 patients) to save one life than in the older age group (1300 patients). The USPSTF determined that it was not worthwhile screening the younger women.
Advances in breast cancer treatment do contribute to the lower mortality rate, but the majority of the decrease since 1990 is attributable to mammography, because it allows detection and treatment of smaller cancers. Smaller cancers are more easily cured, thus decreasing morbidity. Morbidity and cost of treating more advanced cancers were not included in the USPSTF evaluation.
The recommendations artificially divide women into groups when the risk of developing breast cancer increases gradually over the 40’s and 50’s. There is no evidence that the usefulness of mammography changes abruptly at age 50. In fact, cancers in pre-menopausal women tend to be more aggressive, arguing for more frequent imaging in the 40-49 age group. We are risking the health of a whole group of young women, by failing to screen them for early, curable cancer. In addition, the USPSTF report advocates that women discuss their risk of breast cancer with their physician in deciding whether to undergo mammography, but 75%-90% of women have no risk factor other than their gender, which would leave a huge number of women unscreened.
Another concern of the task force was over-treatment. Certainly some breast cancers are indolent, and might not harm the women in her lifetime, but we can not predict the behavior of an individual breast cancer at this time or tell which low grade tumors will de-differentiate and metastasize. We will not find the aggressive cancers unless we look for them, and currently, mammography is the best method for screening. USPSTF was concerned about the number of false positive mammograms and the resultant anxiety produced, but studies have shown that women would rather suffer the anxiety of having to return for additional imaging or percutaneous biopsy, in order to detect cancer early.
On a final note, a recent analysis of breast cancer mortality in Massachusetts, presented at the American Society of Clinical Oncology 2009 Breast Cancer Symposium, showed that 75% of the patients who died had not been regularly screened with mammography. Seventy percent had never had a mammogram before diagnosis. Another 5 % had not had a mammogram within two years of diagnosis. Only 16% of the deaths occurred in patients who had regular screening. This confirms that patients who do not undergo mammography have more advanced cancers at the time of diagnosis and are more likely to die from their disease.
The following links contain more detailed information regarding the risks and benefits of mammography and analysis of the USPSTF decision.
http://www.sbi-online.org/associations/8199/files/Detailed_Response_to_USPSTF_Guidelines-12-11-09-Berg.pdf
http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp
http://www.sbi-online.org/associations/8199/files/THE%20FACTS%20ABOUT%20MAMMOGRAPHY%20SCREENING-Kopans.pdf