The Mammography Controversy

http://www.cometawellnesscenter.com/The most recent recommendation from the U.S. Preventative Services Task Force which came out in November 2009 stating that women under 50 should not undergo routine mammography has created a flurry of controversy. For many women, doctors and more, this drastic statement from the USPSTF feels like a slap in the face. This is not an unreasonable response because the new screening recommendation lays to rest the “brainwash” style message women have been receiving for two decades that they should have yearly screening starting at age 40. It is naturally difficult for the American public to have faith in any system put in place which has so much control over their lives and well being, if it appears that the rules can so dramatically change overnight. Almost as a de je vu from the WHI study in the late 90s, when women were told overnight that they must stop their HRT because it may kill them or do them more harm than good, the women of this country feel duped again. Is this such a surprise?

The USPSTF is responsible for providing evidence-based recommendations and treatment guidelines for clinicians. In reality, the task force members were quite thorough in the research which established the proposed guidelines for breast cancer screening. In order to formulate its guidelines, the task force used new data from mammography studies in England and Sweden and also commissioned six groups to make statistical models to analyze the aggregate data. Models were considered the way to answer questions like: “how much extra benefit do women get if they are screened every year?” The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 59, and one death for every 377 women age 60 to 69. Furthermore, the risk of false-positive results in mammography is significantly higher in women aged 40-49. Additionally, for the same reason that women in this age group can be falsely suspected of having breast cancer, mammography is less likely to be able to detect cancer. This is due to the fact that women in their 40s have dense breasts and this reality makes true cancer detection more challenging as well as false cancer detection more likely.

While many women do not think a screening test can be harmful the risks are real. Potential risks of mammography include radiation exposure, false-positive results that can lead to unnecessary anxiety and potential surgery, such as breast biopsy or more, false reassurance and over diagnosis. In the case of “over-diagnosis”, the concern is that mammography is more likely to inaccurately detect areas in the breast between ages 40-49 that would never progress to cancer or may disappear on their own. These women end up with unnecessary surgery and stress.

For these reasons and more completely cited in the Annals of Internal Medicine article dated November 17, 2009, the USPSTF recommends against routine screening mammography in women aged 40-49 years, but instead in women age 40 to 49 years of age, clinicians should periodically perform individualized assessment of risk for breast cancer to help guide decisions about screening mammography before age. 50.

The formal USPSTF conclusions are as follows:

For biennial screening mammography in women aged
40 to 49 years, there is moderate certainty that the net
benefit is small. Although the USPSTF recognizes that the
benefit of screening seems equivalent for women aged 40
to 49 years and 50 to 59 years, the incidence of breast
cancer and the consequences differ. The USPSTF emphasizes
the adverse consequences for most women—who will
not develop breast cancer—and therefore use the number
needed to screen to save 1 life as it’s metric. By this metric,
the USPSTF concludes that there is moderate evidence
that the net benefit is small for women aged 40 to 49 years.
For biennial screening mammography in women aged
50 to 74 years, there is moderate certainty that the net
benefit is moderate.
For screening mammography in women 75 years or
older, evidence is lacking and the balance of benefits and
harms cannot be determined.

Although many view the task force as an independent body of experts whose job is to take an objective look at the data and are the people we should be listening to when it comes to public health messages, others such as the American College of Radiology consider the USPSTF recommendations “unfounded”, “incredibly flawed”, “seem to reflect a conscious decision to ration care” and if adopted, they will “result in many needless deaths”. But, a morsel of truth to consider is the estimate of 3.3 billion dollars spent on mammography alone in the last year. This figure was given by the American College of Radiology itself, giving them a good reason to worry about the long-term effects of the most recent recommendations since the guidelines should initially make health plans less likely to aggressively prompt women in their 40s to have mammograms as well as older women to have the test annually. In addition to the American College of Radiology, the American Cancer Society and the National Cancer Institute are strongly opposed to the new screening for breast cancer recommendations set forth by the USPTF under the premise that the guidelines are created for the government s so that it may justify rationing health care. But with careful scrutiny, the studies clearly demonstrate the various harms of mammography are nearly cut in half when women have mammograms every other year instead of every year and yet the benefits are almost unchanged.

I believe that mammography is overrated and the risk/benefit ratio is definitely skewed towards risk in women between 40-49 years of age. This is well substantiated throughout the international medical research and the USPSTF has frankly further re-enforced this fact. As I could not more accurately nor eloquently state the present reality brought to face the American public most recently by the new USPSTF breast cancer screening guideline recommendations, I would like to quote Naomi Freundlich, free lance writer and Health Program writer at The Century Foundation:

“In the end, the Preventative Task Force mammography recommendations are supported by strong data and good science. The study authors do not have conflicts of interest and despite charges from some critics, they are not connected to the government and did not have rationing of health care resources as their underlying mission. Therefore it seems short-sighted and counter-productive for groups like the American Cancer Society to so forcefully dismiss the recommendations out of hand. Instead, why not use them as the first step in advancing a changing view of breast cancer screening and the real risks and benefits involved. It’s only by accepting these shortcomings that we can truly focus on developing better methods for detecting early tumors, better methods for distinguishing lesions that will progress from those that won’t, and eventually, giving women a better “safety belt” to use against the threat of breast cancer.”

The practice of medicine in this country is slowly coming around to the fact that there is no one-size-fits all approach or treatment program in the practice of medicine. As the medical paradigm has always been very slow to shift in this country, the USPSTF studies have forced the medical community and patients alike to consider that there is quite likely an “oversell” so to speak going on right now with the routine use of mammography for screening breast cancer. In fact is it not possible that as we have become so entrenched in the diagnosis of cancer, we may well be impeding the development and acceptance of better tests that more accurately distinguish between aggressive tumors and tumors that are unlikely ever to lead to cancer? In my opinion, this is where the crux of the problem exists with mammography as the “gold standard” breast cancer screening tool. It is often not possible for mammography to distinguish between the nonmalignant or low malignancy tumor and the aggressive tumors. The good news but much misunderstood or unknown fact is that such an accurate breast screening test exists in this country and all over the world. It is called Thermography. To learn more about this incredibly important, noninvasive and highly accurate screening tool check out the Themography Center on our website. More will be posted about Thermography in future posts.