In 2009, the U.S. Preventative Services Task Force (USPSTF), organized to try to curb health care expenses, called for these dramatic changes to mammogram breast cancer screening guidelines:
- Routine mammograms for average-risk women starting at age 50 instead of 40.
- Routine screening to end at age 70.
- Screening mammograms every two years instead of one.
The American Cancer Society (ACS) initially argued that delaying mammograms would lead to more deaths and since age is the biggest risk factor for breast cancer, it makes no sense to stop screening relatively healthy women at 70. The ACS also argued that the task force guidelines would lead to insurance changes and increase economic disparity in breast cancer screening. But yesterday, while reaffirming in their update review in JAMA that regular mammograms in women aged 40 to 69 did reduce the number of breast cancer deaths, the ACS backed down somewhat and issued new mammogram guidelines:
- Women should undergo regular screening mammography starting at age 45.
- Women 45 to 54 years of age should be screened annually.
- Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually.
- Women should have the opportunity to begin annual screening between the ages of 40 and 44 years.
- Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
“The society picked age 45 as the start date for screening because that’s when a woman’s risk of breast cancer begins to spike,” said Richard Wender, ACS chief cancer control officer. (The USPSTF apparently didn’t consider this spike with their choice of 50.) The last two ACS guidelines appear to battle against “death panel” type policies which might actually deny women the opportunity to screen at certain ages.
So, how do you sell increasing the risk of ‘death’ to American women? With rhetoric and politics. Here’s some of the rhetoric. Screening is “harmful” because false positives could lead to additional testing with “more radiation exposure” causing “anxiety” and “unnecessary biopsies.” Also, push an “anti-shame” message. Thirty years ago the ACS had an advertisement, “If you haven’t had a mammogram, you need more than your breasts examined.” Today’s rhetoric emphasizes a woman’s right to choose not to get a mammogram without being considered “irresponsible.”
Honestly, this rhetoric by itself would probably stop many women from getting mammograms because mammograms are not comfortable. I delayed mine a couple times until my first “positive” result. Sure I was anxious, but I did not mind getting additional tests and a biopsy to confirm that I did not have cancer. Because if I had had cancer, it was tiny and detected early enough to most likely cure it! And early detection not only saves lives, but can prevent the need for a major operation, radiation therapy, or chemotherapy. That’s why screening is so important! I know women diagnosed in their 40’s alive today because of a mammogram. Unfortunately, rhetoric will scare many away from this lifesaving screening test.
Now about the politics. No woman was ever forced to get a mammogram at 40, but at least insurance paid for it. The new guidelines will change insurance reimbursement. The “old” guidelines, those recommended by the American Cancer Society until yesterday, were intended to save the most lives. The USPSTF guidelines are intended to save the most money. By starting mammogram screening at 50 instead of 40, more young women will die from breast cancer, but the numbers will be small compared to the 40,300 expected to die this year. Also, some women might be lucky enough to find the lump in time and some who don’t will survive until 50 and not need to be counted in the new statistics. So the task force will dodge a PR bullet.
If you think this is cynical, look at the wording for the over 70 women. The task force noted that “breast cancer is a leading cause of death in older women, which might suggest that the benefits of screening could be important at this age.” However, the USPSTF also concluded that the benefits of screening are probably not as great for older women because they tend to have breast cancers that respond well to treatment and have a higher risk of dying from other causes. Again, the government is counting on some women surviving even after finding the lump much later than a mammogram would. And that those dying (from/with) breast cancer will have other age related causes to which their deaths can be attributed instead of the breast cancer. Sort of a death panel, but you can imagine that as long as the death numbers are held in check, they can spin this.
In the JAMA article, the authors mourn “the contentious nature of debates surrounding breast cancer screening” and advise that “given the weight of the evidence that mammography screening is associated with a significant reduction in the risk of dying from breast cancer after age 40 years, a more productive discussion would be focused on how to improve the performance of mammography screening.” Decisions based on subjective differences in perception of “harm” including that for some women, being recalled for additional imaging could result in “persistent adverse effects” could be decreased by more education about false positives and improved testing to decrease false positives, rather than avoiding screening.
In the news, you will see lots of confusing quotes. Like in USA Today: “Mammograms reduce the risk of dying from breast cancer by as little as 15% to as much as 40%” and “Although mammograms can save lives, their benefits are much more modest than many women assume. They also carry risks.” (The risks of further tests, biopsies, and treating a cancer that might not have been fatal.) The American College of Radiology’s breast imaging commission still recommends women get annual mammograms beginning at 40 saying that if you want to save the most lives, that’s the recommendation that will do it.
I conclude from all that I have read that mammograms save the lives of women and should continue to be done starting at 40. Unfortunately, soon you will likely have to pay for your own mammogram possibly until age 50 and after 70. Unless the anti-mammogram rhetoric convinces you to avoid the cost…
http://jama.jamanetwork.com/article.aspx?articleid=2463262#Discussion
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