New Mammography Guidelines Hit the Wall of Public Opinion

The new recommendation from the U.S. Preventative Services Task Force that women under 50 should not undergo routine mammography is generating a lot of controversy—it is a direct challenge to the strong message women have been receiving for two decades that they should have yearly screening starting at age 40. The task force also recommends that women age 50-74 have a mammogram every two years (rather than yearly) and finds that there is little benefit in screening women over 74 at all.

To the experts who have been questioning the benefits of mammography for several years, these recommendations are no surprise—and they are welcome. The World Health Organization, and many European countries where the government pays for routine mammography screening, already follow these guidelines. But how is this news playing in Peoria?



The initial reaction from many health professionals, breast cancer survivors and advocates has been outrage and anger, with many insisting that women’s health will be compromised if these recommendations are implemented. Still others see the new guidelines as evidence that the government is using comparative-effectiveness studies to justify rationing care. Leading this onslaught are some key members of the cancer establishment: The American Cancer Society, The American College of Radiology and the National Cancer Institute.

Dr. Otis W. Brawley, chief medical officer of the ACS, released this statement in response to the Preventative Task Force report:

 “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.”

Dr. Carol H. Lee, chair of the American College of Radiology Breast Imaging Commission, launched a blistering attack on the Preventative Services Task Force recommendations, calling them  “unfounded” “incredibly flawed” and if adopted, they will “result in many needless deaths.” Furthermore, says Lee, they “seem to reflect a conscious decision to ration care.” Lee’s organization, of course, has reason to worry about the long-term effects of this report; the American College of Radiology estimates that $3.3 billion was spent on mammograms in the last year alone.

In reality, the mission of the Preventative Services task force is to provide evidence-based recommendations and treatment guidelines for clinicians—they are not charged with rationing care. Appointed by the Department of Health and Human Services, they are an independent group of 16 experts who specialize in prevention and primary care. True to their mission, the task force members were quite thorough in their research. According to the New York Times, “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.”

These six independent groups—located at academic medical centers—were comprised of researchers from CISNET, the National Cancer Institute-funded Cancer Intervention and Surveillance Modeling Network. Each group used their own model to examine 20 screening strategies with different starting and stopping ages and intervals. Modeling estimates the lifetime impact (outcomes including benefits and harms) of breast cancer screening mammography.

Their findings were remarkably consistent. In the Times article,  Donald A. Berry, a statistician at the University of Texas M. D. Anderson Cancer Center and head of one of the modeling groups says, “The models were the only way to answer questions like how much extra benefit do women get if they are screened every year.”

‘We said, essentially with one voice, very little,’ Dr. Berry said. ‘So little as to make the harms of additional screening come screaming to the top.’”

In fact, the CISNET analysis showed that screening every other year in women over 50 maintains almost all of the benefit of annual screening with only half the number of false-positives.

To summarize their other findings, the task force panel determined that the “harms” or risks of yearly mammography screening for women under 50 outweighed its benefits. These risks include anxiety, false positives that lead to surgical biopsies and over-diagnosis (and over-treatment) of precancerous lesions that would never progress or might disappear on their own. The group found that in women 40-49, 1,904 women must be screened for 10 years before one cancer death is prevented. That ratio drops to 1 death prevented for 1,300 women age 50-59 screened, and 1 for 377 for women 60 to 69 years old. 

I’ve written about the overuse of mammography and the many studies that back up the task force’s recommendations here and here in previous HealthBeat posts. It’s an issue that has gained traction in recent months, and despite rejection of the new recommendations by some prominent cancer groups, there are others, like the National Breast Cancer Coalition, who support them—or at least see the guidelines as important tools for helping women make informed decisions about their care. They are too important to be shrugged off as outliers.

The massive campaign to screen early and screen regularly has become so much a part of our culture that it is very difficult to accept an alternative view. Change will not come easily—and by necessity, it must be gradual. Women have been told for the last 20 years that they should have yearly mammograms starting at age 40. They have been told by countless magazine articles and public health campaigns to conduct self-exams in the shower—another screening technique the Preventative Task Force no longer recommends.

Through all of these entreaties—along with the powerful anecdotes from survivors who credit mammography with saving their lives—women have been made to believe that screening is the same as prevention. Those ideas are hard to dislodge, says Nancy Berlinger, a research scholar at The Hastings Center who has written about comparative effectiveness studies and cancer treatment. “Apart from not smoking, there are not a lot of things you can do to prevent cancer. The idea of a test like mammography as a kind of safety belt, something that provides personal protection against cancer, is very strong.” The worry, she says, is that if you take away mammograms, “you leave nothing but fear in its place.”

For now, it is unlikely that women will lose insurance coverage for mammography screening anytime soon. The Centers for Medicare and Medicaid Services announced that the new guidelines will not change how the agency covers mammograms for Medicare patients. And the Wall Street Journal, reports that Susan Pisano, spokeswoman for America's Health Insurance Plan, an industry trade group, “anticipates mammogram coverage will continue even for those who fall outside the new guidelines' target age range. What may change, she says, are insurers' aggressive outreach efforts to get women to get their screening, such as the reminder postcards they used to receive about getting their annual mammogram.”

There is a larger concern here that goes beyond mammography. As evidence has grown that the benefits of some screening tests have been oversold and that there are significant risks involved in widespread use of the techniques, the response from the cancer establishment has been to forcefully dismiss the findings. Could it be that entrenched interests—in screening, surgery, chemotherapy and other treatments associated with diagnosing more and more cancers—are impeding scientific evidence? Will we see this same dismissal of comparative effectiveness data when it comes to prostate cancer screening and treatment, cholesterol-lowering drugs, diabetes treatments or other high-cost, high-profit health interventions?

It will take some time for t
he public and practitioners to really digest the Preventative Task Force’s mammography recommendations. The Mayo Clinic, for example, an organization that prides itself on using comparative effectiveness studies to drive clinical practice, characterized the new guidelines as “interesting” but Dr. Sandhya Pruthi, director of the Mayo Clinic Breast Clinic, said “the current practice is to continue with annual screening mammography for women over age 40.”

Some practitioners say that the recommendations should be used as a starting point for deeper conversations between women and their doctors about what makes the most sense for them personally. Screening, like treatment for breast cancer, is not a one-size-fits all endeavor. If a woman has a genetic propensity for breast cancer, has close family members who have been diagnosed with the disease or has already had a bout with cancer, she will probably want to receive regular screening, even in her 40’s. But for the rest of us, our risks and benefits need to be carefully reconsidered depending on age, lifestyle and comfort level with the stress of false positives, for example.

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.

29 thoughts on “New Mammography Guidelines Hit the Wall of Public Opinion

  1. The fact that there are these differences in recommendations as to when screening is appropriate opens up a venue for discussion with patients about the pros and cons of such screening. Aside from the cost issues, women need to know that mammograms can find alot of things that will be benign and all too often detect early cancers that may be clinically insignificant. If time is taken to present both sides of the argument for and against screeening before age 50, then patients should be left to decide for themselves, in consultation with their physicians, what is the appropriate course to take. Until now, most guidelines have recommeded screening starting at 40 which gives us clinicians little to stand on when suggesting there might be a downside to screening before 50.
    This is where we need those comparitive research studies to more definitively answer these questions. It is interesting that the studies examined were done in Europe where the medical establishment has less of an economic interest in continuing the status quo. We don’t see our radiologists doing similar research that might result in a reduction of mammograms, and thus of revenue to the radiologist in our fee for service driven medical system.

  2. The missing part of the mammography story is that all of the protagonists (the medical groups) generally agree on how effective mammography is at reducing breast cancer deaths (about 1,900 women age 40 would need to be screened regularly for 10 years to save one woman’s life from breast cancer). They also generally agree on the harms of screening. The difference that leads to the controversy is the way difference groups value those differences, and how they think about harms. The evidence of effectiveness has generally been hidden from view, with advocates for screening worried that transparency on the issue would lead more women to choose not to be screened.
    After decades of professional groups’ promoting a simplistic message about screening – that more is always better, and that it is always a good thing – it is not surprising that advancing a more balanced and nuanced message generates friction. I am hopeful that this controversy helps us move to a model of shared decision making around screening issues based not on fear and advocacy, but instead on accurate, balanced and complete information that lets patients decide whether or not to be screened based on their own values.

  3. The cancer industry’s hostile reaction to the new evidence-based guidelines for screening mammography is disheartening, but perhaps not unexpected. Whenever independent research about the harms of screening mammography emerges, it is vigorously attacked and dismissed by those whose livelihood depends on women falling victim to breast cancer. They have the most to lose, after all. For an excellent discussion of the resistance of the scientific/medical community to information that runs counter to current beliefs see:
    http://www.bmj.com/cgi/eletters/339/jul09_1/b2587 – toward the end of the page see:
    It is time for a new paradigm for overdiagnosis with screening mammography
    Karsten J Jørgensen, Peter C. Gøtzsche (20 August 2009)
    In the current case, I believe the average woman does not understand enough about the harms of screening, and this is not explicit in the new guidelines. It should be made clear that if 2000 women are screened for 10 years, one woman will avoid a breast cancer death. BUT 10 women will be harmed by unnecessary cancer treatment; another 200 women will have a false alarm and be subject to additional radiation and biopsy. THEN women may stop and think – is it worth subjecting 10 women to mutilation, irridation, chemical poisioning, side effects like lymphedema, negative effects on insurance eligibility and on and on in order that one may avoid a breast cancer death? Which one do you think you will be – the one treated for nothing or the one whose life is saved? You are literally 10 times more likely to be treated for nothing. It would appear that very few US women understand this. We have been lied to for too long…

  4. Having been aware of the international health community’s stance on Mammography screening guidelines (start at age 50), I delayed getting my first one until I was in mid-40’s despite rcv’g a few form letters from my PCP, whom I do not really know.
    Since then, I’ve put off getting an “annual” f/up Mammogram but have had occasional thoughts that it might be giving my PCP a “bad score” on something. Now I can let go of that, thankfully.

  5. Ann,
    The CMS or insurance companies’ “quality” indicators haven’t changed. Docs will get penalized if we don’t assure yearly mammograms for women. There’s a disconnect for you.

  6. Docs cannot spend time “talking with patients” now. They are paid on a fee for service basis and that does not include discussions with patients! Every female patient is to decide on mammography after talking with her doc? … I don’t think so!

  7. Well, the rubber meets the road on cost containment and the car veers into the ditch doesn’t it? It certainly didn’t help that the “suggestion” of overscreening was on such a sensitive topic for the largest protected group in our society.
    Yet, this is what will happen, and it happened before when the HMO movement trie to rein in costs from overtreatment.
    To credit some of the supporters of the new report, they stated that the money might be better used for breast cancer research rather than breast cancer screening, but does it really stop there?
    Is it more or less palatable to the masses if we trade one form of investment vs. another for a single disease or is it more reasonable to ask “which is more beneficial, breast cancer screening or childhood immunization, breast cancer screening vs. colonoscopy screening?”
    Is this a zero sum game in total or a zero sum game after a divvying up resources between diseases? And who then decides the allocation of money to different disease categories?
    I don’t have the answers, and they are not easy, but it seems to me that the individual needs to decide what they want more, this or that. I guess if each person had an “allowance” for screening, they could choose how to spend it. Or they could give it back and say “use the resources for something or someone else.” Another alternative might be for the whole system to get an allowance and to let the doctors sort out who gets what.
    The way it is though, with administrators possibly being the fall people for disallowing things isn’t feasible because they a) aren’t qualified, b) have no skin in the game, c) will be forever lambasted for favoring saving money over providing treatment.
    The way things are, the gate watchers will reduce what they can get away with and approve that which they can’t get away with. That game is much more about public relations and court rooms than scientific analysis.
    I did feel bad for the folks on TV trying to justify the reduced screening recommendation in the face of breast cancer survivors. As much as they tried though, the defenses they put up didn’t work well.
    And the timing, it couldn’t be worse to raise the specter of things possibly to come before passage of the final bill. For sure, it shows Americans don’t trust anything that smacks of being political — lots of folks on the news said so, as if the group made the reduced recommendation under some sort of influence by the Obama Administration.
    If the administration was “behind” this, then they are really dumb, so I figure this isnt a stunt of Obama. Coincidence is unlikely, so the question is, were opponents of health care reform, specifically the public option opponents, behind this changed stance being released and publicized now?
    Gosh is that paranoid? Do we really trust no one?

  8. The Task Force recommendations reflect a reasoned conclusion from available evidence.
    The current furor revolves around advice from the Task Force regarding screening for the 40-49 age group. However, contrary to some media reports, this independent panel did not advise against screening for this age group, but only against making this a routine practice rather than a matter of individual choice. The debate also took on political overtones, based on accusations that the altered recommendations were motivated by a desire to save money at the cost of women’s health. Further fueling the intensity of debate were testimonials from many women whose cancers were detected by mammography and who are now cancer-free, claiming that mammography saved their lives. Since it is impossible to know how any of these women would have fared in the absence of mammography, their anecdotal evidence is uninformative and need not be addressed here further.
    Does mammography save lives? It is striking how greatly the certainty of expressed opinions exceeds the certainty of evidence, but enough evidence exists to justify tentative conclusions. A number of randomized, controlled studies have shown modest reductions in death from breast cancer among women screened by mammography, with the reductions (typically about 20 percent) greatest within the 50-74 age bracket. Even within this group, however, the benefits are not dramatic – typically, more than one thousand women must be screened over 10 years to avert one breast cancer death. This benefit, which appears to be real, must be balanced against the downside risks. These include unnecessary anxiety among large numbers of women from the experience of being tested, the additional anxiety from repeat exams when an initial exam is inconclusive, and still further stress from false positives. In addition, false positives lead to unnecessary surgery or radiation, and even some mammographically detected breast cancers that are correctly diagnosed can result in unnecessary treatment, because a fraction of these appear to regress spontaneously and would never have surfaced in the absence of a mammogram. Finally, mammography itself exposes women to radiation, although at a danger level too low to offset the gain resulting from cancer detection.
    Although the above evidence tells us that mammography reduces a woman’s risk of dying from breast cancer, it does not answer a larger question – if a woman routinely receives mammography screening, is she likely to live longer than if she doesn’t?
    Death from breast cancer in a screened population is known as “disease specific mortality”. Death rates overall are referred to as “all cause mortality”. Do reductions in disease-specific mortality translate into reductions in all-cause mortality?
    The evidence is conflicting, but in aggregate suggests that over the entire age span contemplated for screening, the answer is no – women who are screened will not live longer, on a statistical average, than comparable women who are not screened. In contrast, within the 50-69 year old age bracket, reductions in breast cancer disease-specific mortality do appear to be accompanied by small reductions in all-cause mortality as well. Outside of that age range, the lack of a discernible reduction in overall mortality despite reduced breast cancer-specific mortality might signify (a) errors in attributing deaths to breast cancer, (b) offsetting mortality increases due to screening (e.g., from radiation, stress, unnecessary surgery), or (c) a diluting out of a small disease-specific mortality reduction by deaths from other causes to the point where it is no longer statistically discernible.
    The overall benefit for women age 50 to 69, combined with a lack of clear evidence for an overall mortality reduction outside of that age bracket, supports the panel advice recommending routine screening starting only at age 50, with younger women encouraged to consult with their physicians before making a choice.
    A relevant study quantifying some of these conclusions can be found at
    http://findarticles.com/p/articles/mi_m0689/is_6_51/ai_87914467/

  9. We need to go down these evidence based paths.
    But by far the biggest challenge will be the continuation of already seriously eroded trust in our “experts” and our federal health agencies.
    Trust will take decades to rebuild- if ever
    Patients are VERY confused and freightened. We need to recognize that.
    Dr. Rick Lippin
    Southampton,Pa

  10. What needs to happen is that the heads of each of the societies that makes recommendations needs to be locked in a room – with no food and water – until they come out with a uniform recommendation.
    Seriously, the presence of different recommendations doesn’t help patients or the physicians that are supposed to be guiding them.
    And if a physician doesn’t recommend mammography to a women in her 40s and she one gets cancer, there are still plenty of expert witnesses who will testify to a violation of the standard of care.

  11. I agree Legacy if you want these issues to be much easier for the public to handle you need uniform standards and safeharbor. As far as the task force, I agree none of them have a conflict of interest, but with that none of them are an oncologist that have real world knowledge of taking care of these women either.

  12. Dear Naomi:
    This is another great review. The commentaries were also refreshing and intelligent. The only problematic information came from the link to the ACR and Dr. Carol Lee, who is an accomplished researcher but does not speak for me as a radiologist or physician. I saw the question “Does mammography save lives?”, let me offer a link to our paper that analyzes this question. As a reader pointed out, most women with screen-detected cancer think that the mammogram saved her or her sister’s or mother’s life. How and why this myth continues is frustrating to me as a proponent of consumer oriented informed decision-making. The myth continues to be perpetuated on TV and all the articles and blogs since the USPSTF made their recommendation. So remember, it takes about 25 screen detected cancers to save one life (or less than 5% chance). And yes, about 1000 women need regular screening over 10 years to save one life (and about 10 will receive harmful treatment through overdiagnosis) with the additional drawback of anxiety and false-positives, as your readers have pointed out. This last sentence summarizes the decision to screen or not. Here is the link:http://www.biomedcentral.com/1472-6947/9/18
    Thank you.

  13. The outcry and immediate politization of this seemingly evidence-based recommendation is pretty discouraging for future health care policy.
    My Pastor posted this about hunger:
    “Opulence and waste are no longer acceptable when the tragedy of hunger is assuming ever greater proportions.’’ Benedict XVI -World Food Summit.
    What if we excise “hunger” and replace it with “those without access to health care? ”
    Perhaps other diseases will generate less emotion and be easier to set reasonable standards of treatment.

  14. Ginger,
    I do think the issue of mammography is particularly fraught with emotion; being diagnosed with breast cancer is a deeply-seated fear for many women and we all know someone who has been affected by the disease. Also,
    the dichotomy of these recommendations coming at a time when the message from most breast cancer organizations and advocates has been that
    mammography unequivocally saves lives, makes them seem more controversial.
    The government made it clear yesterday that these recommendations will not be used to justify reducing benefits for mammography—this is clearly a
    case where comparative-effectiveness data is no match for public opinion.
    Naomi

  15. John,
    Thanks for your comments–it’s good to know that Carol Lee doesn’t speak for all radiologists. When women tell us that mammography saved their lives, their mothers life or the life of a sister or close friend, it’s very difficult to provide an argument against routine screening in younger women, or yearly screening for those over 50. As a non-physician or researcher, I have been stymied in this endeavor–as was the nurse from USPSTF when
    interviewed by Sanjay Gupta–it’s hard to fight deep-seated beliefs with impersonal statistics. I think the task for the next several years will be to find ways to communicate the findings from the task force (and all the
    other research that questions the benefits of mammography) in ways that resonate better with women–and the practitioners who treat them.
    Naomi

  16. Will we see this same dismissal of comparative effectiveness data when it comes to ovarian cancer screening and treatment?
    Results from a large, continuing (through at least 2014) ovarian cancer trial, published in The Lancet Oncology, indicate that postmenopausal women who are screened for ovarian cancer are more likely to have their cancers detected at early stages. But the researchers warned that the benefits were still far from clear.
    Many of the women in the trial had false positive results on screening tests that led to unnecessary surgeries and complications, especially among those who had ultrasound scans alone. And the researchers said there is still no evidence that screening reduces the death rate from ovarian cancer.

  17. Legacy Flyer, Jenga,,
    I agree that until there are uniform recommendations,
    women and their practitioners will remain very confused and conflicted about routine screening mammography. Based on the strong and sustained reaction to
    the task force recommendations, this clearly is not the time to put everyone in a room without food and water and expect them to come out with those uniform guidelines–they’d probably resort to cannibalism before coming to a conclusion. I think the status quo will continue for the near future, and some physicians will likely still worry that if they don’t recommend yearly
    screening they will be penalized by payers or subject to liability.
    Naomi

  18. Ed,
    The goal of comparative effectiveness studies is first, to identify the best treatments/tests and to reduce ineffective or harmful ones. Adding cost factors into the equation veers into cost-effectiveness studies, a term that is less palatable to the public. The USPSTF recommendations were not of the cost-effectiveness ilk and were never meant to be. Experts have been
    questioning the benefits of routine mammography
    screening for years (actually, as far back as 1997) and as noted in the article, European policies for government-paid mammography screening already follow guidelines very much like those that appeared in the recent report.
    And yes, I do think it is paranoid to imagine that reform opponents had a hand in releasing these recommendations now. They only seem like they are from left field because mainstream cancer groups have failed to consider these findings over the years and have consistently told women that all evidence points to the life-saving qualities of mammography.
    Naomi

  19. Naomi
    It’s not very difficult to provide an argument against routine screening in younger women. What if it were your spouse that was diagnosed with ductal carcinoma in situ, a dormant cancer which does not spread and may never have caused problems, and doctors advised her to have a mastectomy in case it might spread?
    The reality had been two wide excisions, one partial mutilation, one reconstruction, five weeks’ radiotherapy, chronic infection, four bouts of cellulitis, several general anaesthetics and more than a year off work. All because of an earlier-than-advisable screening process?
    And yes, experts have been questioning the benefits of routine mammography screening for years. One retired medical oncologist noted that many years ago, the NCI tried to convince everyone not to screen women younger than 50 but were given such a tongue lashing by Congress that they went home, licking their wounds and withdrew their recommendation.
    Congress didn’t want to upset constituents. I think that could include the Office of the President. Health and Human Services Secretary Kathleen Sebelius told American women that they have nothing to learn from the science that led to the USPSTF guidelines on mammography.

  20. MediaCurves.com conducted a study among 600 about the new guidelines released by the Preventive Services Task Force of the Department of Health and Human Services recommending against regular mammography tests for women under 50 years old. Results found that the majority of physicians (78%) reported that they do not agree with the new guidelines. Furthermore, the majority of physicians (78%) also reported that the advice they give to patients will not change based on the new Preventive Services Task Force of the Department of Health and Human Services guidelines.
    More in depth results can be seen at:
    https://www.mediacurves.com/HealthCare/J7646-MammogramGuidelines/Index.cfm
    Thanks,
    Ben

  21. Thanks for covering this in a rational way. The fact is that the evidence on mammograms for women in their 40s has been weak at best for years. This announcement came as no surprise to physicians who pay attention to the evidence-based guidelines proffered by agencies that have no interest in overdiagnosing and overtreating. This has been the recommendation in the UK for years.
    The truth is that breast cancer survivors have created a strong lobbying movement, along with the american cancer society, breast surgeons, breast radiologists, and oncologists. The more abnormalities found, the more biopsies, surgeries, and rounds of chemo, all of which lead to more funding for more research, and so on. I’m not suggesting nefarious motives, but every specialty always advocates for itself.
    I really don’t blame women who were screened in their 40s and believe they are alive today because of it; how can I know if they were one of the ten who was overtreated instead of the one in 2,000 who was saved? And how can I expect anyone closely affected by breast cancer to understand?
    I hope that once people stop assuming that this has something to do with the current health care debate that we will come to the understanding that perhaps we would be better off investing in better ways to find earlier cancers and better ways to tell which tumors are benign, rather than giving people false reassurances that their mammograms will keep them safe.
    What will I tell my patients? The same thing I’ve been telling them for years. I recommend mammograms for women between the ages of 50 and 70 (though I may now advise they be done every other year), and that the evidence is not strong for women under 50, and that, in fact, in many countries screening doesn’t start until age 50. When I counsel this way, about half my patients decide they want to be screened, about half decide they will wait until they’re 50. One of the great things about being a primary care doctor is that I’m able to have these conversations with women whom I know and who trust me.
    More information is always good. More studies will be done, and perhaps we’ll find that the newer digital mammograms are more effective, but for now this is what we have, and we need to help women to make decisions for themselves. Given that so many professional organizations continue to recommend yearly mammograms at age 40, I highly doubt the exams will no longer be reimbursed by insurance companies.
    I hope that more people will see this as the introduction to a conversation with their patients rather than an affront to women’s health, and that we can refocus our efforts towards finding screening methods that work better. I also hope that the current health reform bills will give more people access to primary care providers who have time to get to know their patients and can have these conversations with them.

  22. My wife is a 44 year-old family physician who has stubbornly refused to get a screening mammogram. A woman ahead of her time.
    I am a 49 year-old family physician who will not be getting a PSA next year, although I will be getting a screening colonoscopy.
    The new breast cancer recommendations are tough on patients, who, after all, are not generally trained in epidemiology. The radiologists’ response was completely predictable, as was that of the politicians, but I’m surprised and disappointed by the ACS and the NCI. Those guys have epidemiologists, don’t they? What gives? Prediction: Remember the dust-up a while back when estrogen replacement therapy fell by the wayside? Now it’s a done deal. Give America 5 years and the new breast cancer screening regime will be accepted–unless of course we have new recommendations by then.

  23. The other side of the coin, presented to me from an oncologist friend, is radiation risk imposed by mammography, is not simply of negligible value in younger women, but may have a net harm effect, if women who have mammograms at age 40 start having higher rates of cancer in irradiated breasts 25 or 35 years later.
    The recommendation not to begin mammography until age 50 has to do with medical issues, more than cost effectiveness issues. Mammography is not harmless. You are subjecting women to annual doses of ionizing radiation to the breasts, with some unavoidable scatter to chest wall and lungs. We do not know how many women who are irradiated by mammography in their 40s will develop radiation-induced breast cancer (or even lung cancer) in their 60s, 70s, and 80s.
    The other problem is that women in their 40s tend to have very dense breasts, making it more difficult to get an accurate exam. These women often are called back for additional views, giving them even more radiation. There are more false positives, leading to breast biopsies and sometimes unnecessary lumpectomies, in cases where the biopsies are technically suboptimal.
    In contrast, in older women, their breasts are less dense, making the examination more accurate, with fewer false positives, and there are fewer years of remaining life to develop a radiation-induced malignancy.
    The fact is that we have no truly long term follow up studies to determine very long term risks of carcinogenesis from radiation exposure in mammography.
    1. J Radiol Prot. 2009 Jun;29(2A):A123-32. Epub 2009 May 19.
    Mammography-oncogenecity at low doses.
    Heyes GJ, Mill AJ, Charles MW.
    Department of Medical Physics, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
    Controversy exists regarding the biological effectiveness of low energy x-rays used for mammography breast screening. Recent radiobiology studies have provided compelling evidence that these low energy x-rays may be 4.42 +/- 2.02 times more effective in causing mutational damage than higher energy x-rays.
    The risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer. In vitro radiobiological data are generally acquired at high doses, and there are different extrapolation mechanisms to the low doses seen clinically. Recent low dose in vitro data have indicated a potential suppressive effect at very low dose rates and doses. Whilst mammography is a low dose exposure, it is not a low dose rate examination, and protraction of dose should not be confused with fractionation. Although there is potential for a suppressive effect at low doses, recent epidemiological data, and several international radiation riskassessments, continue to promote the linear no-threshold (LNT) model.

  24. Here is a response to the JAMA article (October 14) regarding the use of mastectomy for early stage breast cancer.
    Soft descriptors in the JAMA report obscure the fact that there is a problem and sheds some light (inadvertently) on the risks of screening.
    To the Editor: Surgeon Recommendations and Receipt of Mastectomy…
    Based on a survey of early stage breast cancer patients, Morrow et al., report that breast conserving surgery (BCS) is recommended and attempted “in a majority of patients.” Recommendations for mastectomy were “largely” based on contraindications to BCS and “only” 6.2% of patients who did not report a contraindication received a surgeon recommendation for mastectomy.
    Another way to look at this: at least 6.2% of the time a newly diagnosed breast cancer patient received an inappropriate recommendation from her surgeon. Since there may be 180,000 cases of breast cancer diagnosed per year in this country, this alone will result in 10,800 inappropriate mastectomies.
    Furthermore, 16.7% of surveyed patients reported that their initial surgeon did not recommend one procedure over another. Since BCS has been the standard of care since 1991, the reported lack of physician guidance is a disheartening finding and surely contributes to the mastectomy rate.
    Altogether, 8.8% of patients reported making a patient-directed decision for initial mastectomy. Does this reflect informed decision-making?
    Why?
    As Gershon Locker, MD, noted a few years ago at the San Antonio Breast Cancer Symposium, while discussing the variability in mastectomy rates in different countries and the relatively high rate in the US, “When a doctor recommends mastectomy, you have to ask, ‘Why?’ ”
    Morrow et al., properly note that their findings suggest the need for “a combined approach of education for patients and health care professionals.” But this is old news. The answer must (always) involve money.
    We rarely discuss the various incentives that encourage mastectomy in one way or another. No need for expensive radiation therapy (insurance company benefit); an inpatient surgical stay (surgeon admit rate benefit); no angst due to lumpectomy deformity (liability benefit); extended follow-up office visits with the surgeon (surgeon practice benefit).
    Mastectomy rates remain high, at least in part, because we condone and accept the status quo. The authors’ choice of soft descriptors to downplay a departure from an evidence-based standard of care does a disservice to the cause of appropriate healthcare.

  25. America is not ready to control health care costs.
    The backlash response to the USPSTF mammography recommendations is evidence of our ingrained “more is better” approach to health care. We will see similar responses when we learn of the lack of evidence to support many of our interventions that are promoted before there is data to back them up.
    Interestingly, cost was not an issue addressed by the USPSTF. Yet, cost control follows when evidence is used to make a recommendation.
    We need strong leadership to reorient us to evidence basis. Where will this leadership come from? Katherine Sebelius showed no leadership at all when she quickly backed away from the USPSTF recommendations. I expected more from the Obama administration.
    As a member of the American Academy of Family Physicians I will lobby for leadership from our organization. As family doctors we should be experts in the science as well as the communication of the science to our patients.

  26. Dear Naomi,
    I just love this blog. It is well researched and beautifully articulates the limitations this country faces when we MUST FACE a paradigm shift in medicine. I hope that you can visit my website someday (available through the blog site posted) and would love your opinion of my new blog site, established this very morning!
    Thanks,
    Ariane Cometa MD, the holistic doc

    • Michael–

      Thank you for the kinds words. I’d be interested in your comment on the reasoning behind our choices.