Mammographic screening: More heat than light


Age of Diagnosis/Frequency graph

The saga of the new breast cancer screening guidelines issued by the US Health Preventive Services Task Force continues to evolve and has now polarized the public as well as professional fields. Many radiologists and surgeons, along with their patients and the public, feel betrayed by what they perceive as a reversal in public policy and a denial of service. Some sense a plot by the government to ration health care (the USPST denies that cost was entered into their analysis and they are in fact an independent body even though appointed by the Department of Health and Human Services). The other side of the argument (and one that the USPST is now maintaining as they have slightly backpedaled) is that the recommendations all along were for women ages 40-50 to have an individualized decision about the pros and cons of screening, and not to abandon screening altogether. They did sneak in the every 2 years recommendation based on the fact that numerous trials looking at either yearly or every other year screening show about the same impact on lowering mortality due to breast cancer.OK, so where is the reasoning in this heated debate? Is it possible that there is one truth, but just divergent interpretations of the data, in part driven by emotion? I propose that the answer to this is yes. Most experts agree that screening does lead to early detection for some but not all breast cancers. They also agree that most positive finding in mammograms are in fact benign and in many cases lead to unnecessary additional imaging, biopsy, and even surgery. They also agree that many cancers that are picked up would never have affected the patient over their lifetime. Finally, false positive results and unneeded tests are more common in the 40-50 year old group. So in fact, these dramatic guideline "changes" are essentially nothing new. In my opinion, most women who are 40-50 should be offered screening because even though mammograms are not as effective in this in this group, the age distribution of breast cancer indicates that this age group is clearly susceptible (data from Surveillance Research Program, Cancer Statistics Branch, 2007. ). However, this age group needs to be clearly informed of the consequences of screening, including going to surgery for a false positive result, and also how their risk of dying of breast cancer is being impacted (essentially going from about 1 in 28 to 1 in 37 based on the 25% reduction in breast cancer mortality). The USPST estimates that in the 40-49 year old range, about 1900 women have to be screened for 10 years to save one life, but at the risk of over 100 false positives that require additional imaging with some going on to biopsy. For age 50-59, 1300 women have to be screened, but this number is only 380 for women aged 60-69. Americans are accustomed to saving life at all cost and sparing no expense for a medical beneficial procedure. In fact, many states have legislated coverage for mammograms for women beginning at age 40. At the current time, policy by the FDA, Medicare and most insurance companies is set based on benefit traded off against health risk but not cost. Since women do not die from false positive results, it would seem logical that beginning at age 40, women should be screened provided they are informed, in a numerical sense) about the risks.However, stay tuned for my next blog as I discuss what may be in store for the new realities of health care reform where cost does enter into the picture, and what this may mean in the cancer field. But I will tell you in advance that there should not be cause for alarm – especially when one looks at the alternative of continuing to do business as usual.

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