New Recommendations for Breast Cancer Screening Meet Resistance

< Nov. 18, 2009 > -- In a move that surprised many, including physicians and other healthcare providers, the US Preventive Services Task Force (USPSTF) has announced new guidelines for breast cancer screening.

The new guidelines suggest that women do not need to start having mammograms to screen for breast cancer until they are 50 year old, and they only need to have those exams every other year.

In addition, breast self-exams, which women have been urged to do routinely, have not helped lower the death rate from breast cancer, according to the USPSTF.

Benefits vs. Risks Considered

A spokeswoman for the task force that put together the new recommendations says the guidelines are the result of an analysis that compared benefits and risks - early detection and reduced breast cancer deaths, for instance, vs. false positive results (indication of breast cancer when none is actually present), which can cause anxiety and make more testing necessary.

Specifically, the guidelines:

• recommend against routine screening mammography in women aged 40 to 49. Though other groups strongly recommend annual mammography beginning at age 40 for women at average risk for breast cancer, the guidelines suggest that when women reach 40 they should talk to their doctor about the best time to start regular, every-other-year mammography.
• recommend that women aged 50 to 74 years old have screening mammograms every other year rather than annually.
• say that not enough data exist to make a recommendation based on benefits vs. harms for women 75 and older.
• recommend against teaching women breast self-examination because the evidence does not show it reduces deaths from breast cancer.
• say that not enough evidence exists to assess the value of clinical breast exams done by a health-care provider for women aged 40 and older.

Guideline Changes Result of Routine Review

"Every topic [of preventive health] comes up for re-review every five years," says Dr. Diana Petitti, vice chairwoman of the task force and associate director of the Center for Health Information and Research at Arizona State University, Phoenix. "The task force issued its last recommendation about breast cancer screening in 2002."

She says the task force reviewed published evidence of five screening modalities in reducing breast cancer death: traditional film mammography, clinical breast exam, breast self-exams, digital mammography, and MRI. The task force also commissioned two studies related to breast cancer screening, Dr. Petitti says.

The results of the review are published in the Annals of Internal Medicine, and do not include a recommendation favoring one form of mammography or MRI over another.

Many Clinicians Disagree

The new guidelines are sparking debate and disagreement among breast cancer experts.

The American Cancer Society (ACS) and the American College of Radiology (ACR) have indicated strong disagreement with the new guidelines.

Dr. Otis W. Brawley, chief medical officer of the ACS, said in a statement that the organization "continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40."

Dr. Brawley notes that before the cancer society made that recommendation, its experts considered "virtually all the same data reviewed by the [task force], but also additional data that [it] did not consider."

Dr. Carol Lee, chief of the breast imaging commission for the ACR, says that "the universal reaction among breast imagers I have spoken to across the country since we learned of these revised recommendations ... has been one of outrage."

"Screening mammography saves lives," Dr. Lee says. "It saves lives of women in their 40s."

Dr. Lee states that the ACR also stands by its recommendation that women of average risk for breast cancer should begin routine mammography screening at age 40 and do it every year.

Was Cost-Cutting Considered?

Dr. Lee wonders if the new recommendations by the task force were motivated by a desire to cut costs.

Absolutely not, says Dr. Petitti. "The task force does not deal with issues of coverage and insurance," she says. "The decision, the recommendation, had no discussion of costs."

Dr. Petitti also says that she worries that some of the recommendations will be misunderstood. The new recommendation for women aged 40 to 49, she said, is for them to talk to their doctor about the best time to start biennial screening. "At 50, the balance of benefits and harm [from mammography] become better," she says.

Always consult your physician for more information.

More from ACS and NCI

In response to the new breast cancer screening guidelines released earlier this week by the US Preventive Services Task Force (USPSTF), the American Cancer Society (ACS) released a statement which may be found in its entirety at http://www.cancer.org.

In the statement, Dr. Otis W. Brawley, chief medical office of the ACS, says: “In 2003, an expert panel convened by the American Cancer Society conducted an extensive review of the data available at the time, which was not substantially different from the data included in the current USPSTF review. Like the USPSTF, the Society’s panel found convincing evidence that screening with mammography reduces breast cancer mortality in women ages 40-74, with age-specific benefits varying depending on the results of individual trials and which trials were combined in meta-analyses. And like the USPSTF, the American Cancer Society panel also found that mammography has limitations - some women who are screened will have false alarms; some cancers will be missed; and some women will undergo unnecessary treatment. These limitations are somewhat greater in women in their forties compared with women in their fifties, and somewhat greater in women in their fifties compared with women in their sixties. We specifically noted that the overall effectiveness of mammography increases with increasing age. But the limitations do not change the fact that breast cancer screening using mammography starting at age 40 saves lives. As someone who has long been a critic of those overstating the benefits of screening, I use these words advisedly: this is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member."

In its conclusion, the ACS states: “The American Cancer Society acknowledges the limitations of mammography, and we remain committed to finding better tests, and currently are funding a large study to improve the accuracy of mammography. In fact, data show the technology used today is better than that used in the studies in this review, and more modern studies show that mammography is achieving better results than those achieved in these early experimental studies that go back as far as the mid-60’s. And as scientists work to make mammography even more effective, the American Cancer Society’s medical staff and volunteer experts overwhelmingly believe the benefits of screening women aged 40 to 49 outweigh its limitations.”

The National Cancer Institute (NCI) issued the following statement in response to the USPSTF guidelines:

"NCI appreciates the US Preventive Services Task Force's careful review and analysis of the evidence regarding breast cancer screening for women at average risk. The take-away message is that each woman needs to consider her individual benefits and risks and discuss them with her health care provider before making a decision on when to start screening mammography and how often to get one. The Task Force report concludes that screening mammography remains an important, effective tool for early detection of breast cancer. It also indicates, however, that the evidence of benefit might vary, according to age and individual risk factors.

"NCI has had screening mammography recommendations for many years, and we need to evaluate them in light of the Task Force's recommendations - for all women, not only for those of average risk. It's too early for us to make any decisions right now. NCI's primary role as a biomedical research agency is to generate scientific knowledge that can be used by the Task Force and other organizations in their deliberations and recommendations. Today's report reflects the fact that more questions need to be answered, and that will be NCI's central focus going forward."

Always consult your physician for more information.