Task Force Makes Controversial Change to Mammogram Guidelines

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The U.S. Preventive Services Task Force issued new guidelines Monday for basic preventative screening for breast cancer for women over the age of 40. Among the changes include an increasing of the age for baseline mammograms to age 50, and to change the recommendation for annual screenings to having the exams every other year.

The guidelines are published in the Nov. 17 issue of the Annals of Internal Medicine.

The USPSTF is an independent panel of 16 government appointed healthcare experts that reviews medical research every five years and recommends ways to reduce the risk of illness and death. It is sponsored and funded by the Agency for Healthcare Quality and Research, part of the Department of Health and Human Services.

The new guidelines were based on a comprehensive analysis of the medical literature, including data from more than 600,000 women from the U.S. Breast Cancer Surveillance Consortium. In addition, the task force commissioned a study funded by the National Cancer Institute that involved six independent teams of researchers conducting mathematical modeling studies of the risks and benefits of 20 different screening strategies, including the modalities of traditional film mammography, clinical breast exam, breast self-exams, digital mammography, and MRI.

The new guidelines state:
• Recommend against teaching women breast self-examination because the evidence does not show it reduces deaths from breast cancer.
• Not enough evidence exists to assess the value of clinical breast exams done by a health-care provider for women aged 40 and older.
• Recommend against routine screening mammography in women aged 40 to 49. The guidelines suggest that when women of average risk reach 40 they should talk to their doctor about the best time to start regular, every-other-year mammography. The guidelines do not apply to high risk women, such as those with a family history of breast cancer or those who test positive for the BRCA1 or BRCA2 gene.
• Recommend that women aged 50 to 74 years old have screening mammograms every other year rather than annually, because in most women, the tumors are slow-growing. Even for the minority of women with aggressive, fast-growing tumors, annual screening will make little difference in survival, according to the task force findings.
• There is not enough evidence to recommend digital mammography or MRI over traditional film mammography.
• Not enough data exist to make a recommendation based on benefits vs. harms for women 75 and older.

The changes may eventually affect insurance coverage for the preventative screenings for breast cancer. Private insurance plans typically base their coverage on recommendations from private groups, such as the American Cancer Society, except for the state of West Virginia, which ties its recommendations to the USPSTF guidelines. Medicare is required by law to cover one screening for women ages 35 to 29, and yearly mammograms after that. However, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) gives the Secretary of Health and Human Services the ability to change coverage after consulting with the National Cancer Institute.

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Several patient advocacy groups praised the recommendation change, saying it represented a growing recognition that more tests, exams and treatments are not always beneficial and can harm patients. Mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes-disfiguring biopsies, and unneeded treatment, including surgery, radiation and chemotherapy.

But most breast cancer experts, including the American Cancer Society and the American College of Radiology, disagree with the Task Force recommendations. Since regular mammography screenings were recommended in 1990, the mortality rate from breast cancer has decreased by 30%.

"Not screening all women in their 40s and every other year in their 50s is an opportunity to miss some cancer and miss saving lives," said Dr. Elizabeth Fontham, dean of the Louisiana School of Public Health and the national volunteer president for the American Cancer Society. "I certainly think it is going to confuse women, and that's unfortunate."

Dr. Otis W. Brawley, chief medical officer of the American Cancer Society, said in a statement that the organization "continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40."

The American College of Radiology called the guidelines "a step backward," and added that they "represent a significant harm to women's health." “Screening mammography saves lives”, said Dr. Carol Lee, chair of the Breast Imaging Commission for the American College of Radiology. Her organization, she said, also stands by its recommendation that women of average risk for breast cancer should begin routine mammography screening at age 40 and do it every year.

All experts tend to agree that more research is necessary to more accurately capture an individual woman’s risk of breast cancer. Most acknowledge that mammography is imperfect and that women do not always have accurate information about the procedures. "We have oversimplified the message in a way that misrepresents the biology of the disease," says Barbara Brenner, executive director of Breast Cancer Action, a San Francisco-based advocacy group that has long questioned the emphasis on mammography.

About 39 million women undergo mammograms each year in the United States. Breast cancer is the most common cancer and the second leading cause of cancer deaths in American women. More than 192,000 new cases and 40,000 deaths from the disease are expected in the U.S. this year.

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