According to a government task force, 50 is the new 40 — at least where yearly mammography for women is concerned. In what many women deemed a shocking departure from current protocol, the U.S. Preventive Services Task Force has called for an overhaul of mammography guidelines. The group, founded in 1984, is comprised of independent, private sector experts in prevention and primary care.
The panel’s November 2009 Recommendation Statement touched off a war of words, pitting the independent group of medical personnel and scientists against women, many physicians and respected organizations, including the American College of Obstetrics and Gynecology, the American Cancer Society, and the Susan G. Komen Foundation.
Proponents of existing guidelines — a baseline mammogram beginning at age 40, and yearly thereafter — were quick to respond. Dr. Daniel Kopans, one of the world’s top experts in the field of breast imaging, blasted its critics in the December 2009 medical journal Diagnostic Imaging, accusing the task force of using unscientific data analysis or misusing data to support its findings.
Kopans points out that, prior to 1990, breast cancer death rates held steady for 50 years, but have dropped 30 percent since then — at least two-thirds of which is attributable to screening. Additionally, Kopans argues that since 75 percent to 80 percent of breast cancers occur in women whose risk is not elevated, screening based on risk would miss most of them.
The rationale for change
The U.S. Preventive Services Task Force is charged with evaluating the benefits of individual medical services based on age, gender and risk factors for disease. It acknowledges that breast cancer, the second leading cause of cancer death among women, has been significantly reduced through widespread screening. However, it maintains that screening is most cost effective, and yields the best results, beginning at age 50, when breast cancer risk markedly increases, and says re-screening is indicated every other year until age 74.
The panel’s rationale is that screening women in their 40s yields too many false positives, leading to unnecessary biopsies and other testing without greatly improving survival odds, while at the same time, causing women unnecessary anxiety. According to the task force, for women 40 to 49 years old, only one cancer death is prevented for every 1,904 women screened. In women 50 to 59, one death is prevented for every 1,339 women screened, and it’s one death for every 377 women 60 to 69.
Why the outcry?
The counterargument is that statistics are everyone, not anyone. What if the life saved is your mother, sister, daughter, friend — or you?
Additionally troublesome to women is the task force’s position that breast self-exams and clinical breast exams (meaning by a doctor in an office setting) are problematic.
Again, the task force points to false-positive test results, which cause undue stress, repeat visits, and unwarranted imaging and biopsies. Despite these drawbacks, many women say they prefer the cost, inconvenience and temporary anxiety in order to get peace of mind, or a jump start on treatment if cancer is found. As one woman quipped, “I can bear a little anxiety, I can’t bear a little death.”
The government weighs in
The panel’s recommendations have intensified women’s fears and confusion on an already worrisome subject. To add to their uncertainty, U.S. Health and Human Services Secretary Kathleen Sebilius, whose department appoints the panel, appeared to distance herself from the controversial new guidelines.
Acutely aware of the public’s mounting fear that the findings will be adopted by the government and eventually by private insurers, she promptly released a statement calling the panel “an independent team of doctors and scientists that doesn’t set federal policy or determine the services covered by the federal government.” Task force members, who call the public’s response “unexpected,” state that their work predates the health-care debate.
Despite the outcry from many women, physicians and organizations, the Preventive Services Task Force is not alone in its recommendation that baseline screenings begin at age 50 and be repeated biennially thereafter.
Internationally, the World Health Organization agrees. Across Europe, screening begins at age 50 with re-screening every other year — yielding detection rates similar to those in the U.S.
Closer to home, according to the women’s advocacy group Our Bodies Ourselves, it along with the National Women’s Health Network, Breast Cancer Action and The American College of Physicians agree that screening beginning at age 50 yields the best risk/benefit ratio.
Renowned breast expert Dr. Susan Love, author of “Dr. Susan Love’s Breast Book,” considered one of the bibles of breast health since its publication in 1990, adds that the new guidelines “align us with the rest of the world and current research.”
According to Our Bodies Ourselves, 37 million mammograms are performed each year, and even though they’re low dose, health professionals are concerned about the cumulative effect of radiation over time. Additionally, mammography is an imperfect science complicated by breast density, a factor affecting 50 percent of pre-menopausal women and 30 percent of post-menopausal women.
According to the National Breast Cancer Coalition, after 10 mammograms, the cumulative risk for a false-positive result is nearly 50 percent. The risk for unnecessary biopsies is almost 20 percent.
The task force also recommends discontinuing mammograms after age 74 because of the same cost/benefit concerns.
The task force calls the public’s fierce reaction a surprise. Since the backlash, it has sought to explain its positions, noting that it never intended to imply that women in their 40s shouldn’t get mammograms or that they should stop monthly self-examinations. Diana Petitti, vice chair of the task force, admitted in the Wall Street Journal that the panel could have stated its positions more clearly.
For the U.S. Preventive Services Task Force, the bottom line is that each woman should confer with her doctor to make the best, most informed decision about when mammography is most appropriate for her.