A recently released study from Sweden is fostering debate over what age women should get mammograms.
This most recent study suggests that mammograms, a breast cancer screening test, can lower the risk of dying of the disease by 26 percent or more for women in their 40s. These findings conflict with the U.S. panel that recommended against routine screening before the age of 50.
Its timely to post an abbreviated article by Alan Semine, MD, Chief of Breast Imaging, Shields MRI, and Chief of Breast Imaging for Newton-Wellesley Hospital; and Clincila Professor of Radiology, Tufts University School of Medicine, on the issue.
Why the U.S. Preventive Services Task Force is Wrong
The screening mammography recommendations of the United States Preventive Services Task Force, (USPSTF) published recently in the Annals of Internal Medicine and widely reported by the press, were poorly stated and misleading. In fact, the USPSTF based its dubious conclusions on existing data that it reinterpreted. The recommendations have been challenged by organizations including the American Cancer Society, the American College of Radiology, the American Society of Breast Surgeons, the Society of Breast Imaging, the American Society of Clinical Oncology and many others.
The USPSTF recommended against routine screening for women 40 to 49 years of age. Yet the task force acknowledged that mammography in this age group does save lives. This fact is not disputable based on extensive long term studies. Its recommendation was based on its own conservative risk benefit valuation.
The USPSTF rendered a verdict that screening 1339 women in their 50s to save one life makes screening worthwhile in that age group. But because it is necessary to screen 1904 women in their 40s to save one life, then screening is not worthwhile. Such valuation in the face of relatively comparable numbers is not justified. In fact, there is excellent data demonstrating even better survival with mammography screening. The task force recommended screening for those of high risk yet ignored the fact that 70% of breast cancers develop in women without family history. The financial cost of treatment for advanced breast cancer is also far greater than for early stage cancer.
The next recommendation of the task force was to screen women over fifty every other year rather than annually. They acknowledged the obvious: that the cancers detected, on average, would be more advanced but they emphasized that the total number of cancers detected would be the same with fewer questionable findings. This position represents a serious lack of understanding that the most important objective of screening mammography is to detect breast cancer at the earliest possible stage to get the best chance of cure. Meanwhile, the task force also suggested that screening can be stopped after age 74. Yet, it is well established that the incidence of breast cancer continues to increase with age.
The recommendations of the USPSTF are not based on new data but rather on a reinterpretation of selected studies. They reached a conclusion that differs markedly from the position of national organizations as well as prior recommendations of the USPSTF. The members of the task force do not represent a new standard in medical wisdom. The publicity they have received threatens to undermine decades of effort educating women about the importance of early detection to combat breast cancer.
Mammography does have limitations and it is essential that we pursue every opportunity to improve its effectiveness as well as explore alternative methods of detection and treatment.
We must continue to urge women to begin screening mammography at age 40 and encourage them to talk with their doctors to ask any questions they have about mammography and self-examination. Alan Semine, MD
