Revised breast cancer screening guidelines spark uproar, confusion

For years, Christine Laine, MD, MPH, has recommended annual mammograms for her Philadelphia-area female patients ages 50 to 70.

But now the internist plans to follow the revised breast cancer screening recommendations issued Nov. 16 by the U.S. Preventive Services Task Force.

The guidelines, published in the Nov. 17 Annals of Internal Medicine, say women younger than 50 do not need routine mammography screening and women 50 to 74 should get a mammogram every two years. The guidelines also recommend against teaching women to do breast self-examination.

The revisions mark a shift from the task force's previous guidelines, issued in 2002, that recommended screening mammography every one to two years for all women older than 40.

"The new recommendations differ in a relatively nuanced way from the previous recommendations in that they're evidence-based," Dr. Laine said. "I think that all clinical guidelines should be based on evidence. ... We should be screening to maximize benefits and decrease harms."

For years, medical experts have debated the age at which routine screening mammograms should begin and how often they should be given. The latest guideline changes have sparked an uproar, leaving physicians unsure of which recommendations to follow and patients uncertain of when they should be screened.

Among the health organizations that oppose the new guidelines is the American Cancer Society, which will continue to recommend annual mammograms and clinical breast examinations beginning at age 40.

Taking its concern a step further, the American College of Radiology asked that the recommendations be rescinded to prevent the possibility of the new guidelines influencing policymakers as they shape health system reform legislation.

The National Cancer Institute and the American College of Obstetricians and Gynecologists plan to continue following their current screening guidelines, but are reviewing their recommendations in light of the task force's revisions.

The American Medical Association did not issue a statement on the guidelines, but it has existing policy calling for annual mammograms starting at age 40.

HHS policy unchanged

The task force recommendations have caused so much concern that Dept. of Health and Human Services Secretary Kathleen Sebelius stepped in. She assured physicians and patients that the task force -- an outside panel of doctors and scientists -- makes recommendations, but does not set federal policy.

Sebelius said the panel does not determine what services are covered by Medicare and Medicaid, adding, "our policies remain unchanged."

But many physicians are still concerned that the guidelines will lead to a growing number of breast cancer deaths that could have been avoided with early detection.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives, just not enough of them," said Otis W. Brawley, MD, chief medical officer of the American Cancer Society.

But Diana Petitti, MD, MPH, vice chair of the task force, said she doesn't understand the vocal disapproval.

"This is not a recommendation against screening anyone in their 40s. It's a recommendation against routine screening," Dr. Petitti said, adding that the recommendations do not apply to women at high risk of breast cancer.

"We're simply saying the benefits [of regular mammograms for women in their 40s] are small in relation to the harms and that as women get older, that benefit-risk equation becomes more favorable," she said.

Potential harms include false-positive results, patient anxiety due to screening, unnecessary biopsies, discomfort during mammograms and radiation exposure. False-positives tend to decrease as women age, Dr. Petitti said.

Washington, D.C., radiologist Rachel Brem, MD, however, dismissed the potential harm when compared with the value of detecting cancer. "Virtually all of my patients would prefer the small anxiety of a false-positive with the possibility to diagnose an early breast cancer."

The revisions are based on clinical evidence, Dr. Petitti stressed, including two studies commissioned by the task force that were published in the Nov. 17 Annals of Internal Medicine.

Researchers of one study found that annual mammography screening for women age 50 to 79 resulted in a 8% median increase in breast cancer mortality reduction. For screening every two years, the figure was 7%.

For screening that begins at age 40 and continues to 69, researchers found a 3% median breast cancer mortality reduction with either annual or biennial screening.

Researchers concluded that greater mortality reductions could be achieved by stopping screening at an older age than by initiating screening at an earlier age. No recommendations were made for women 75 and older because, the task force said, there is insufficient evidence to assess the additional benefits and harms.

But early detection is partially credited for the steadily falling breast cancer death rate among women younger than 50, according to the ACS. Since 1990, the death rate has decreased by 3.2% annually.

"There are very few physicians who think these recommendations make any sense at all. The take we have on it is it's a financially driven motivation," Dr. Brem said.

Susan Pisano, a spokeswoman for America's Health Insurance Plans, said mammography screening coverage by insurers would remain the same, regardless of the updated recommendations. "We're hearing that when a physician orders a mammogram for a woman younger than 49, it's typically going to be covered," she said.

Dr. Petitti, of the task force, said doctors should never discourage a woman in her 40s from getting a mammogram. Instead, she urged physicians to talk to patients about the benefits and risks of mammography.

"I only hope the message is clear," Dr. Petitti said, "and that those who are putting out counter messages attacking the task force have read carefully what we said and have considered the process by which we came up with the recommendations."