The Doctors Next Door

The New Breast Cancer Screening Guidelines--Now What?

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Sorry, I've been keeping you waiting but this is a BIG DEAL.  I'm sure you feel the same. It was really important to me to think it through. First a recap of the controversial new breast cancer screening guidelines released by the United States Preventive Services Task Force (USPSTF) earlier this week--the USPSTF (say that 6 times fast):

 

  1. recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms
  2. recommends biennial [every other year] screening mammography for women aged 50 to 74 years.
  3. concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  4. recommends against teaching breast self-examination (BSE).
  5. concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  6. concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

Who are these people?!?

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No, they're not ogres.  They're actually pretty decent folks.  I've met a few of them myself.  So let's talk about where they're coming from. The USPSTF has as its mission to:

...evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.

They go on to say that...

The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.

I especially like that "impartial" part. Bottom line, with all the pharmaceutical companies and other special interests that have been revealed to have stuck their greedy little fingers into our medical studies, the USPSTF may just be the best thing going as a resource for unbiased medical guidance.  They came out with these recommendations knowing full well that they would create a firestorm of controversy. The group is not attached to big business and their role is not one of advocacy.  The individuals who serve make up a group of really smart people that spend hours and hours pouring over the scientific literature, discussing it for even more hours and hours and finally carefully choosing each and every word in their recommendation statements. 

I do know something about this process, having sat on a few guideline panels myself.  You try to keep your butt in your seat while the people around you all straight-faced and articulate-like spend half the day arguing over the definition of cerumen impaction (a goomba of earwax plugging up your ear)

To contrast the USPSTF with other organizations that express opinions on the topic of breast cancer screening, the American Cancer Society, the American Society of Clinical Oncology, the American College of Radiology, the Susan G. Komen--all have biases based upon their particular view of the world of cancer or their advocacy position.  Advocacy = dollars. Those with an express advocacy role are competing for funding dollars as their primary driver.  Sometimes that means the very vocal advocacy groups crowd out the quieter voices even though those quieter voices are speaking for a more common problem. (i.e. Jerry's Kids versus neurofibromatosis).

So now lets take a few of these USPSTF statements one at a time.

 

Number 1:

The task force recommends AGAINST routine screening mammograms in women age 40-49 years of age.

 

In this statement they're saying weigh the decision based on more information than just age.  Things that should factor into your decision include risk factors (family history, genetics, lifestyle) and personal preferences.  The benefits to screening in this age group exist but they are small.  Studies have shown that 1900 women would need to be screened with yearly mammograms for 10 years to save just one life.  Among those 1900 women many benign biopsies would have been done. 

 

This first statement is what they call a "Grade C" recommendation which indicates that doctors should:

Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. (I know they spent a lot of time on this sentance but I can help but think the grammer is really bad)

 

Nonetheless, that's our loophole, ladies!

 

Number 2

The Task Force recommends every other year screening for women age 50-75. 

 

This is in contrast to prior recommendations for annual mammography.  At this interval, the risks and costs of screening balance nicely with the benefit.

 

Numbers 3, 4, and 5

 

The USPSTF then tells us that there are three things they're can't be sure about.  These are:

  • The benefit of mammograms over the age of 75
  • A doctor's examination of your breasts
  • Digital mammograms or MRI of the breasts

I will tell you that when my 90-year old grandmother (who I believe was 88 or 89 at the time) told me she had just had her mammogram, my response was, "don't ever do that again, please".  At her stage of life, treatment of a breast cancer is worse than the disease itself and would not extend her life.  But where's the line?  It seems easy to tell this to my 88 year old grandmother but what about a 77-year old aunt who swims every day, reads books to the children at the library on Saturday mornings and has recently taken up oil painting?  Here again, go with risk factors and personal preferences with eyes wide open as to the uncertainty in benefit versus harm. 

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Number 6

Finally--the USPSTF recommends AGAINST teaching women breast self-exam (BSE).  There's actually a fair degree of consensus on the lack of value in breast self-exam.  The studies have found that women that found their own cancer didn't find it while performing a BSE. It was an incidental finding while getting dressed, showering, etc.  So we should continue to be aware of our bodies.  But breast tissue is by it's very nature pretty lumpy.  The tissue changes due to hormonal fluctuations and doing a BSE has definitely led to a lot of unnecessary biopsies. 

 

Other organizations like the American Cancer Society (an advocacy organization) stand by their recommendation for yearly mammograms beginning at age 40The American College of Radiology (ACR) is outraged at the USPSTF guidelines and have stated that if guidelines were "incorporated into reimbursement policies by government insurers and payers, many avoidable breast cancer deaths will occur."

 

Maybe they're right.  Maybe they're biased.

 

The thing that is most bothersome to me is that we now appear to have

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Is this where the researchers have left us?

nothing left for pre-menopausal early detection of breast cancer.  No breast-self exam, maybe your doctor shouldn't even check you for lumps, mammograms might hurt more than they help.

 

Well...there's always prayer. 

 

And we really FEAR breast cancer. Despite the fact that we women have a much greater risk of dying from heart disease, we don't obsess about a heart attack like we do about breast lumps. 

 

Perhaps the best thing the USPSTF has done for us is to uncover the ugly truth. The fact is we don't have any very good tests for early diagnosis of breast cancer. Mammograms and breast exams have subjected us to many unnecessary biopsies.  These have harms--physical, psychological and economic. 

 

So go to it you researchers--that's what we need most--an innovation for early breast cancer diagnosis that has a low risk of harm and great potential benefit.  In the meantime, I think insurers need to continue to cover mammograms for women who choose to have them done earlier and/or more often than the USPSTF has advised.  It's all we have.  It's a personal decision that each of us must weigh for ourselves with all the facts in front of us. 

 

 

 


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1 Comment

180Degrees said:

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I can't believe no one has commented on this here. It is such a hot topic. I must say I am heartened by your responsethat there is merit to these new guidelines as there seems to be a firestorm that these guidelines are going to kill women. As a breast cancer survivor, I have become obsessesed with learning as much as I can and one of the things that I feel needs to be looked at is thermography vs. mammography. There is proof that it is just as beneficial at detecting cancer but doctors still do not back it. WHY??? We are so brainwashed by those who would push mammograms on us that they are saving our lives when in fact, the compression and radiation actually causes cancer. After having been through fighting the status quo in regards to my cancer treatment, all I can say is there has to be a better way. The whole BUSINESS of cancer is killing us. Doctors need to be more proactive in doing tests that might show deficiences that could lead to cancer such as hormone inbalace, tyroid issues, vit D levels, iodine levels, etc. Instead, we are told we are just getting older and this is what happens to us. All the signs were there that my system was out of whack, leaving me suseptible for cancer to grow. Yet , my doctors continued to ignore me in my allotted 15 min. exams and did not do the proper tests. So now I am bitter and fed up with the quality of medical care. Why can't they make a better effort to keep us well, instead of just giving us some drug to cover up underlying issues? Why won't doctors have a more integrative approach to medicine, encouraging things besides just drugs to heal what ails us. Are you the kind of doctor who will think outside the box, or are you like most doctors, and brainwashed by Big Pharma and so constricted by fear of lawsuits that you continue to just treat diseases and not people?

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