Experts Debate New Mammogram Guidelines
November 17, 2009 7:12 AM
A government panel is updating its guidelines on who should be screened for breast cancer and how often. Dr. Ashton consults experts on both sides of the contested issue about what the recommendations mean for millions of women.
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2) This is just the beginning of Healthcare rationing. Policy groups will choose cost effective medicines, procedures and work-ups. Cost effectiveness will be the first "medical question" that will need to be answered. Just as Dr. Spock said,"In any case, were I to invoke logic, logic clearly dictates that the needs of the many outweigh the needs of the few." -- Spock
"Or the one." -- Kirk (Star Trek II)
1. "The data really is not clear that doing mammography screening under 50 makes a major difference in womens lives"
The USPSTF that released the recommendations did not find that screening mammography in women aged 40 to 50 had no benefit. In fact, in the supporting evidence article that can be found on their website they cite two new studies (since 2002) that give more evidence that screening in the age group 40 to 50 reduced breast cancer mortality. In the cited studies from europe, one found a 15% reduction in breast cancer mortality (a United Kingdom study), the second found a 30% reduction (a Swedish study). The reason the USPSTF changed its recommendation from 2002 is because of the number calculated from a computer model, and the subjective valuation of harm from false positive mammogram results and false positive biopsies (in 2002, the USPSTF did not attempt to place a value on those adverse events, leaving that decision to the individual). One expert flatly states there is no proof of benefit in screening women aged 40 to 50, that we do it for 'hope'. The USPSTF states that we have to screen 1900 women (aged 40 to 50) to save one life from breast cancer. If there are 22 million women aged 40 to 50 in the United States, we would only save 1,150 lives. The USPSTF decided that it not sufficient to justify the discomfort, anxiety, and potential complications from surgery or chemotherapy.
2.".. not because we want to deprive women of their right to be radiated."
This is an unprofessional statement, derogatory to those who choose to undergo screening.
The USPSTF does cite evidence about the risk of radiation. The risk of radiation is higher in those with some breast cancer gene mutations, and for those that receive radiation therapy. The risk of radiation from the screening mammogram is low ( an English study suggested that over 70 lives are saved by screening for every life lost due to radiation effects).
3. "..we are finally catching up to the rest of the world!"
A study published in Lancet/Oncology in 2008 compared Cancer survival statistics between several countries. You cannot access this article from Lancet without paying for it. However, a summary of the article can be found on WebMD. Search for the article titled, "Cancer survival rates vary by country". The quote from the WebMD article is, "The highest survival rates were found in the U.S. for breast and prostate cancer,...". With this recommendation, we will not be catching up, but rather, we will be giving up our leading efforts.
4. "Young women have dense breasts..."
Anybody that does mammography knows that this is not a blanket statement. Somewhere between 10 and 20 percent of women aged 40 to 50 have breasts that are not classified as "heterogeneously dense" or "dense". There are also 10 to 20% of women over age 65 that have denser breasts. While it is true that mammography does not work as well with denser breasts, are you going to deny all women in that age group a screening mammogram because most have dense breasts?
Mammomography in numerous trials, and in national databases has been shown to reduce breast cancer mortality, even in the age group of 40 - 50. That is the benefit. Do the harms outweigh the benefit?
In my training, we were taught that value judgements should be left to the patient. The decision to undergo screening mammography should be made by the individual based on their own values. Only a small number will benefit (but those few will gain 40 to 50 years of life). The individual must decide how much harm there is to the discomfort, anxiety, and potential overtreatment of breast cancers that might not have ever injured the health of the patient.
To the credit of the USPSTF, they do imply that the decision should be made by the woman after discussion with their doctor. It was only because of the desire to make a simple blanket recommendation that they settled on their new guidelines. I just hope that doctors counseling patients on the limited benefits versus the potential harms will exhibit less bias than your expert welcoming the new recommendations.
By the way, mammographic screening stategies dictated by the NHS in the United Kingdom would not pass MQSA standards in the United States (Sweden's would).