Mammography Screening Guidelines
Newton-Wellesley Hospital Responds to Recent Government Task Force Mammography Recommendations
On November 16, 2009, the US Preventive Services Task Force (USPSTF) reversed decades of previous recommendations regarding breast cancer screening guidelines.
What did the USPSTF recommend?
Newton-Wellesley's Alan Semine, MD, Chief of Breast Imaging and Medical Director of the Auerbach Breast Center, responds to the Task Force's new guidelines.
Read Dr. Semine's Guest Column in the Newton TAB
Hear from a local breast cancer survivor treated at Newton-Wellesley about how a routine mammogram saved her life (YouTube clip)
Op-Ed for Newton TAB | November 23, 2009
By Alan Semine, MD, Chief of Breast Imaging, Newton-Wellesley Hospital; President, Massachusetts Radiologic Society; and Clinical Professor of Radiology, Tufts University School of Medicine
Why the New Mammography Recommendations Are Wrong
The screening mammography recommendations of the United States Preventive Services Task Force, (USPSTF) published recently in the Annals of Internal Medicine and widely reported by the press, were poorly stated and misleading. In addition, the media proceeded to amplify the confusion by reporting the guidelines as if absolute and based on new information. In fact, the USPSTF based its dubious conclusions on existing data that it reinterpreted. The recommendations have been challenged by a chorus of organizations including the American Cancer Society, the American College of Radiology, the American Society of Breast Surgeons, the Society of Breast Imaging, the American Society of Clinical Oncology and many others.
The USPSTF recommended against routine screening for women 40 to 49 years of age. Yet the task force acknowledged that mammography in this age group does save lives. This fact is not disputable based on extensive long term studies. Its recommendation was based on its own conservative risk benefit valuation.
The USPSTF rendered a verdict that screening 1339 women in their 50s to save one life makes screening worthwhile in that age group. But because it is necessary to screen 1904 women in their 40s to save one life, then screening is not worthwhile. Such valuation in the face of relatively comparable numbers is not justified. In fact, there is excellent data demonstrating even better survival with mammography screening. The task force suggested that perhaps only women at high risk should be screened in their 40s. That strategy ignored the fact that 70% of breast cancers develop in women without family history.
Also, many women at high risk do not become aware of their risk factors until they are diagnosed. It is cruel to dismiss the tremendous suffering, grief and disfigurement associated with advanced breast cancer as well as its devastating impact on young families. The financial cost of treatment for advanced breast cancer is also far greater than for early stage cancer. In addition, if financial considerations must be the focus, they fail to attribute value to the greater total number of life years saved when a younger woman survives breast cancer.
The next recommendation of the task force was to screen women over fifty every other year rather than annually. They acknowledged the obvious: that the cancers detected, on average, would be more advanced but they emphasized that the total number of cancers detected would be the same with fewer questionable findings. This position represents a serious lack of understanding that the most important objective of screening mammography is to detect breast cancer at the earliest possible stage to get the best chance of cure. Meanwhile, the task force also suggested that screening can be stopped after age 74. Yet, it is well established that the incidence of breast cancer continues to increase with age. It is wiser to continue screening and detect cancer in its earlier stages in order to offer the elderly less aggressive effective treatment. Otherwise we have to struggle with the challenge of treating advanced stage breast cancer in the elderly.
The task force also indicated that physical examination by health care providers is not effective for detection of early breast cancer. Then they proceeded to discourage teaching of self-examination because large clinical trials have demonstrated that teaching self-examination is not helpful and does not result in earlier detection. In fact, teaching self-examination as a formal exercise may not be helpful, but it is very important to encourage women to be familiar with their body as well as their breasts, and to seek medical attention when they notice a change. A significant number of early curable breast cancers are self-detected.
The recommendations of the USPSTF are not based on new data but rather on a reinterpretation of selected studies. They reached a conclusion that differs markedly from the position of national organizations as well as prior recommendations of the USPSTF. The members of the task force do not represent a new standard in medical wisdom. The publicity they have received threatens to undermine decades of effort educating women about the importance of early detection to combat breast cancer.
Mammography does have limitations and it is essential that we pursue every opportunity to improve its effectiveness as well as explore alternative methods of detection and treatment. However, mammography remains the single most effective tool we have to detect breast cancer early. We must continue to urge women to begin screening mammography at age 40 and encourage them to talk with their doctors to ask any questions they have about mammography and self-examination.
This material is intended to provide general educational information and to help users arrange more easily for health care services. This site is not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment. Nor should users rely upon this information if they need emergency medical treatment. We strongly encourage users to consult with a qualified health care professional for answers to personal questions.
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