USPSTF Recommendations Ignore Realities of Breast Cancer

USPSTF Recommendations Ignore Realities of Breast Cancer

Annual mammogram screening beginning at age 40 saves lives. U.S. Preventive Services Task Force (USPSTF) recommends less frequent screening at a later age, not because screening will not save lives, but because it will not save sufficient numbers of lives when started before age 50.

The guidelines are based on outdated, blemished data and do not evaluate cost-effectiveness or any other benefits of early detection. In fact, USPSTF states, “Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.”[1]

Women need to empower themselves with accurate information about screening to benefit from early detection.

The Reality of Breast Cancer in Younger Women

Women younger than 50 are diagnosed with and die from breast cancer. Research proves that mammogram screening can prevent breast cancer deaths in these women.

Nearly 65,000 women younger than 50 were diagnosed with breast cancer in 2013, according to the American Cancer Society. Nearly 5,000 women in this age group died from breast cancer.[2] Within its own recommendations, even USPSTF recognizes that mammogram screening contributed to a 15 percent decrease in breast cancer mortality among women aged 39 to 49.[3]

Decreasing mortality is not the only benefit from early detection with screening mammography – it is simply the most important benefit. There are many other potential benefits to identifying and treating cancer in its earliest stages:

1. Prevent chemotherapy

2. Prevent lymphedema

3. Limit surgery

4. Minimize radiation therapy

5. Decrease psychosocial impact

6. Maximize number of treatment options available

Mammogram is superior to clinical breast exam or self-exam at identifying small tumors. Tumors detected under 1cm in size, regardless of their biology, can almost always be treated without chemotherapy. About 20-30% of these tumors will have aggressive biology and if left to grow for one to two years, they would certainly require more aggressive treatment. USPSTF has failed to acknowledge the harms of chemotherapy needed for more advanced tumors.

Identifying tumors that have not spread to lymph nodes can minimize surgical and radiation treatments. Breast conservation and partial breast irradiation are options with early stage breast cancers. Surgical complications decrease when radiation can be avoided in the setting of mastectomy with reconstruction. Avoiding lymph node dissections also decreases the incidence of lymphedema. USPSTF has failed to acknowledge the burden of lymphedema when disease has spread to lymph nodes.

Aggressive treatments also represent a cost burden to individuals and to society. The total cost of treating all cancers exceeded $216 billion in 2009, according to the National Institutes of Health.[4] Breast cancer accounts for a significant portion of this. By detecting cancer at its earliest stages, the cost of cancer care can be greatly diminished. This cost burden inevitably has a direct psychosocial and economic impact to cancer patients, their families and society as a whole. The “harms” of a false-positive mammogram are almost trivial in comparison to the burden of advanced cancer care. USPSTF has failed to acknowledge the emotional and cost burden of delaying breast cancer diagnosis.

Due to significant advances in adjuvant therapies, death from breast cancer has improved even at advanced stages of diagnosis. However, USPSTF has failed to acknowledge 10 years’ worth of advancements in breast cancer treatment focused on minimizing surgery and radiation treatment when cancer is detected at early stage.

These advancements have helped to decrease morbidity while improving quality of life for cancer survivors. These benefits depend on early detection enabled by annual mammogram screening.

It is irresponsible for USPSTF to describe harms of false-positives and anxiety of testing without discussing the benefits of avoiding aggressive treatment. Women should be empowered to make their own decisions about their health care. Failure to provide this information and limiting access to mammogram screening does not help to accomplish this.

Furthermore, these “recommendations” made by USPSTF can be inappropriately used to limit insurance coverage for annual screening, prevent primary care providers and OB/GYNs from ordering screening, and discourage women from obtaining routine mammograms. By recommending annual screening beginning at age 40, women are encouraged to begin thinking about their breast cancer risk and breast health.

The Argument Against Mammogram Screening

USPSTF recommendations suggest women should begin screening at the age of 50 and continue screening every two years until the age of 74. This decision was made in 2009, reversing an earlier stance for annual screening beginning at age 40. A recent review of the 2009 decision upheld the reversal. These recommendations are based heavily on data provided by flawed research studies:

Canadian National Breast Screening Study

The Canadian National Breast Screening Study is one of the studies used to support current USPSTF recommendation.[5] Multiple independent researchers who reviewed this study noted multiple problems.[6]

1. Outdated mammogram technology from the 1970s.

2. Women included in the study were not appropriately placed in the screening and control groups.

3. Technicians performing exams did not receive special training in mammogram screening.

4. Radiologists interpreting mammograms were not trained specifically in breast imaging.

USPSTF recommendations also consider harms and risks like patient anxiety, false-positive results, recalls and overdiagnosis. These are important concerns to recognize, but are sometimes overstated. The Swedish Two-County Trial found that two lives are saved for every instance of overdiagnosis.[7] This trial also showed that recalls affected less than 1 in 20 women.

While it is necessary to talk about the harms and risks, physicians should discuss them with patients rather than denying them access to mammogram screening.

The Benefits of Mammogram Screening

The American Cancer Society, Society of Breast Imaging and American College of Radiology all recommend women receive mammogram screening once every year for as long as they are healthy. Numerous studies and data support this position.

National Cancer Institute SEER Data

While cancer treatments have improved, early detection enabled by mammogram has helped to reduce the mortality rate. Data collected by the National Cancer Institute over the last several decades supports this.

Over a similar period of time, mammogram screening rates skyrocketed while breast cancer mortality rates decreased by one-third.[8][9]

University of Michigan Comprehensive Cancer Center

The ability of mammogram screen to aid early diagnosis is also evident in research published May 2014 in Cancer. Researchers compared data collected from 1977 to 1979 with data collected from 2007 to 2009. While incidences of early-stage breast cancer rose by one-half based on projected rates, incidences of late-stage breast cancer would have dropped 37 percent.[10]

Analysis of Mammogram Screening in Women Aged 40 to 49

Prior to its 2009 reversal, USPSTF recommended annual screening beginning at age 40. These recommendations relied on an analysis of eight randomized clinical trials, published 1997 in Journal of the National Cancer Institute.

Results from this analysis showed that women aged 40 to 49 benefitted from mammogram screening. Incidences of breast cancer and breast cancer deaths were lower among women aged 40 to 49 than for women aged 50 or older. A mortality reduction of 23 percent was noticed in this study when screening in women aged 40 to 49.[11]

More Deaths in Unscreened Women

A failure analysis published September 2013 in Cancer determined that most breast cancer deaths occur in women who do not receive routine breast cancer screening. Unscreened women accounted for 71 percent of breast cancer deaths. Additionally, approximately one-half of these deaths were in women younger than 50.[12]

RadNet Position | Mammogram Screening

In summary, we agree with the USPSTF that screening mammography saves lives. We also agree with the American Cancer Society and many others that mammography screening should begin at age 40 for average risk women and should occur annually while women are healthy. We believe this will maximize the benefit of early detection by not only saving lives, but also by reducing the need for more aggressive treatments.

[1] U.S. Preventive Services Task Force. “Draft Recommendation Statement: Breast Cancer: Screening.” April 2015.

[2] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[3] U.S. Preventive Services Task Force. “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.” Annals of Internal Medicine. November 2009.

[4] National Heart, Lung, and Blood Institute. “NHLBI Fact Book, Fiscal Year 2012.” 2013.

[5] Miller et al. “Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial.” The BMJ. February 2014.

[6] Daniel B. Kopans. “Arguments Against Mammography Screening Continue to be Based on Faulty Science.” The Oncologist. February 2014.

[7] Tabár et al. “Swedish Two-County Trial: Impact of Mammographic Screening on Breast Cancer Mortality during 3 Decades.” Radiology. September 2011.

[8] National Center for Health Statistics. “Health, United States, 2013: With Special Feature on Prescription Drugs.” 2014.

[9] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[10] Helvie et al. “Reduction in late-stage breast cancer incidence in the mammography era: Implications for overdiagnosis of invasive cancer.” Cancer. September 2014.

[11] Hendrick et al. “Benefit of Screening Mammography in Women Aged 40-49: A New Meta-Analysis of Randomized Controlled Trials.” Journal of the National Cancer Institute. January 1997.

[12] Webb et al. “A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened.” Cancer. September 2014.