In November 2009, the U.S. Preventive Services Task Force issued new guidelines for breast cancer screening that have caused significant controversy among the medical community, women's advocacy groups, the worldwide media, and others. They have also caused significant confusion for millions of women. This article summarizes the guidelines and controversy surrounding them. Bottom line: women need to talk to their doctors to develop an appropriate breast cancer screening regimen based on their individual medical situations. While the new guidelines may be appropriate for some women, in other women, following the new guidelines may not be the most effective means of detecting breast cancer in early stages.
Summary of New Guidelines
- Recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial (every 2 years) 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.
- Recommends biennial screening mammography for women aged 50 to 74 years.
- Concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
- Recommends against teaching breast self-examination.
- Concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older.
- 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.
The U.S. Preventive Services Task Force is mandated by federal law to conduct scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support. The Task Force was first convened by the U.S. Public Health Service in 1984, and since 1998 has been sponsored by the Agency for Healthcare Research and Quality. It describes itself as leading independent panel of private-sector experts in prevention and primary care.
Differences between New and Old Guidelines
The new U.S. Preventive Services Task Force guidelines are controversial because they recommend less screening for younger women. While guidelines have varied slightly by organization, the U.S. National Cancer Institute recommends has recommended screening mammography every one to two years for women once they reach 40 years of age and every year once they reach 50 years of age. In some instances, physicians may recommend beginning screening mammography before age 40 (i.e. if the woman has a strong family history of breast cancer).
In recent years, organizations such as the American Cancer Society have changed their positions regarding breast self exams, no longer recommending that women perform self exams on a monthly basis. This decision was made after several studies revealed that the exams do not increase the chances that women will survive breast cancer. Despite the change in position, the American Cancer Society and other organizations suggest that self exams can be performed to help detect changes in the breasts to call to a physician's attention. Women who perform self exams should consult a healthcare professional to determine how to correctly perform the exam. In addition, organizations have generally recommended that women aged 20 and over receive regular clinical breast exams by a health care professional.
Other screening tests, such as ultrasound or MRI, have been recommended as screening methods for certain women depending on medical circumstances. These tests are also often used as diagnostic tools if an abnormality is first detected with mammography, a breast exam, or other method.
Reactions to the New Guidelines
The U.S. Preventive Services Task Force caused an firestorm of controversy immediately after their issuance. Medical professionals, advocacy groups, and individuals have had mixed reactions to the recommendations that women receive less screening and begin screening at a later age than previously recommended. A sample of the reactions from reputable U.S. organizations follows:
- U.S. Health and Human Services Secretary Kathleen Sebelius, November 18, 2009: "There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration but our policies remain unchanged. What is clear is that there is a great need for more evidence, more research and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women. My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you." http://www.hhs.gov/
- Otis W. Brawley, M.D., Chief Medical Officer, American Cancer Society, November 16, 2009. The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the U.S Preventive Services Task Force, but also additional data that the [Task Force] did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions... Breast cancer is a serious health problem facing adult women, and mammography is part of our solution beginning at age 40 for average risk women. http://www.cancer.org/
- Statement of the American College of Radiology, November 16, 2009. Mammography screening for women ages 40 and above is one of the major health care advances of the past 40 years. With the onset of mammography screening, the death rate from advanced breast cancer, that had been unchanged for the preceding 50 years, has decreased by 30 percent since 1990. Moreover, early mammography screening means cancers can be caught sooner, often allowing women to choose less invasive treatments that help to preserve the quality of women's lives as well. Newly revised U.S. Preventive Services Task Force recommendations could reverse this decline in breast cancer morbidity and mortality, causing undue suffering to women facing breast cancer and their families. http://www.acr.org/
- Press Statement of the National Breast Cancer Coalition, November 16, 2009. For over a decade, National Breast Cancer Coalition has held the position that over-emphasis on the importance of breast cancer screening, despite a lack of strong evidence, has been elevated to such a degree that some even equate screening with prevention. NBCC hopes that today's release of the U.S. Preventive Services Task Force revised recommendations will put screening and its limitations into proper perspective. We hope that policy makers, the public and the health care community will take the time to carefully analyze the basis of the revised recommendations. Women have been given different messages for years, but unfortunately those messages were not based on strong evidence," said NBCC president, Fran Visco. "Women deserve the truth even when it is complicated. They can accept it." http://www.stopbreastcancer.org/
- Susan Love, M.D., Breast Cancer Surgeon and founder of the Dr. Susan Love Research Foundation, November 18, 2009. These [U.S. Preventive Services Task Force] guidelines are just that-guidelines. The guidelines aren't saying that women between 40-50 should never have a mammogram...What they are saying is that a careful review of the scientific evidence shows that in younger women of average risk the risks outweigh the benefits of routine screening. Understandably, this is a shocking statement to hear, as it completely contradicts the "women should get an annual mammogram starting at age 40" recommendation that we've been hearing for the past decade. What many people don't know is that this recommendation to extend screening to women under 50 was fraught with controversy. The problem with mammography in women under 50 is that it doesn't work very well. Breast tissue is dense in young women and appears white on a mammogram. Cancer also appears white on a mammogram. This means that trying to find cancer on a young woman's mammogram it is like looking for a polar bear in the snow. As a result, mammography misses many cancers in young women. And not only does it miss many cancers- giving a false sense of security-it also finds many things that are NOT cancer but need to be checked out through biopsies or other tests. In addition, the risk of the radiation is higher in younger women and cumulative so that the additional cancers caused by the radiation have to be weighed against the ones found by the test. It is not as simple as we would like to believe... What I hope these guidelines will do is push doctors to have a conversation with their patients about the risks and benefits of mammography so that women can make a decision that is right for them. http://www.dslrf.org/
Editorial note: Given the controversial nature and questioning of the new breast cancer screening guidelines by the U.S. Health and Human Services Secretary and several reputable U.S. health organizations, the Imaginis.com Medical Advisory Board has decided, at present, not to change the existing breast cancer screening information contained within our web site. Our goal is to provide women with detailed information to make fully informed decisions about cancer screening with their doctors. We highly encourage women to talk about these new screening guidelines with their health care providers to determine the best course of action given their individual medical circumstances.
