January 2010

Uproar — Imaging Community Greets New USPSTF Mammography Screening With Scorn
By Kathy Hardy
Radiology Today
Vol. 11 No. 1 P. 24

Reaction (noun): a response to some treatment, situation, or stimulus

Merriam-Webster might have to come up with a stronger definition for the breast imaging community’s response to the U.S. Preventive Services Task Force’s (USPSTF) recommendations regarding breast cancer screening. Within 24 hours of publishing its statement in the November 2009 issue of the Annals of Internal Medicine, Health and Human Services, the American Cancer Society, the ACR, and the Society of Breast Imaging spoke out in opposition to the recommendations.

Robin B. Shermis, MD, MPH, medical director of Toledo Hospital Breast Care Center in Ohio, calls the debate a socially focused issue that has raised the level of public awareness.

“If this is meant as a way to begin rationing, they picked the wrong area to start,” he says. “Breast cancer is a high-profile disease. The backlash clearly shows that women are saying they are so off base with these recommendations.”

Respondents are focusing on the USPSTF’s recommendation against routine screening mammography for women aged 40 to 49, a reversal of the task force’s 2002 recommendations for breast cancer screening. The task force also concluded in the most recent recommendations that the decision to start regular biennial screening mammography before the age of 50 should be an individual one, taking into consideration specific benefits and harms. The benefits of early breast cancer detection need to be weighed against the potential harm of a false-positive finding or the increased exposure to radiation, according to the task force.

Breast imaging specialists are responding to the recommendations in a variety of ways. For the most part, they agree that mammography has its issues. However, this modality remains the “gold standard” for breast cancer screening for women beginning at the age of 40.

“We tried so hard to get the word out that women need to get regular mammograms and now this recommendation damages that,” says Carol H. Lee, MD, a diagnostic radiologist at Memorial Sloan-Kettering Cancer Center in New York and chair of the ACR’s Breast Imaging Commission. “As breast imagers, we’re used to having what we do attacked. Every few years, issues come up regarding guidelines in breast imaging.”

To clarify its message, Ned Calonge, MD, MPH, USPSTF chair, and Diana Petitti, MD, MPH, USPSTF vice chair, said in testimony before the U.S. House of Representatives Committee on Energy and Commerce Health Subcommittee that the decision of whether a woman in her 40s has a mammogram should be based on a discussion between her and her doctor.

“Many doctors and many women—perhaps even most women—will decide to have mammography screening starting at age 40,” Calonge says. “The task force supports those decisions.”

With the flood of information muddying the breast cancer screening waters, women have much to discuss with their physicians. Lee says doctors will need to sort out the women who need mammograms from among all their patients. According to Shermis, radiologists can help clear up discrepancies by spreading the word about the benefits of early breast cancer screening. Statistics show that mammography screening for women aged 40 and older is a major healthcare advance of the past 40 years. With mammography screening, the death rate from advanced breast cancer, which remained unchanged for the preceding 50 years, has decreased by 30% since 1990.

“We need to do a lot of public relations, either through ads that clarify the recommendations or word of mouth,” he says.

Lee is more cautious about radiologists’ role as public advocates for mammography, saying there can be negative feedback when speaking out about anything that could result in reduced imaging.

“The problem is we’re seen as having a vested interest if we speak out,” she says. “The message would be stronger coming from nonradiologists, from people like the former NIH [National Institutes of Health] director and leaders of other medical organizations.”

One diagnostic radiologist who will be speaking with women on the topic is Sara Anschuetz, MD, of Adventist Midwest Health in suburban Chicago. Having spent the past 10 years in breast imaging, Anschuetz says she continually deals with the controversy of when to begin screening mammography. Despite the USPSTF recommendations, she says she will still recommend that women begin their screening mammograms at the age of 40, adding that other radiologists aren’t changing their beliefs on the topic.

“No one will disagree that mammography is far from perfect,” Anschuetz says. “But it’s the only modality to show a reduction in mortality rates. The data shows the efficacy of screening mammography for women between the ages of 40 and 49. Until something better comes along, it’s what we have.”

In its search for answers, the USPSTF researchers examined the efficiency of five breast screening modalities in reducing breast cancer mortality: film mammography, clinical breast examination, breast self-exam, digital mammography, and breast MRI. An evidence review for each modality included questions related to the harms and benefits of breast cancer screening. In addition, the task force performed a decision analysis using population modeling to compare the expected health outcomes and resource requirements of starting and ending mammography at different ages, as well as using annual and biennial screening intervals.

While the USPSTF acknowledges evidence that screening with film mammography reduces breast cancer mortality, the evidence is strongest for women between the ages of 50 and 74, with the strongest evidence for women aged 60 to 69. The task force found no evidence of a benefit to screening for women older than 75.

The task force also found no evidence to support clinical breast examination beyond mammography and recommends against physicians teaching women how to perform breast self-examinations.

“The biggest mistake among these recommendations is the one telling physicians to not instruct women on how to perform breast self-exams,” Shermis says. “Women find lumps and can then undergo treatment sooner than if they waited until their annual exams. It goes against all grains of common sense that doctors shouldn’t teach women how to perform self-exams.”

The USPSTF noted that early screening also involves unnecessary imaging tests, inconvenience, worry, and biopsies in women without cancer due to false-positive findings.

Regarding the false-positive issue, Anschuetz and fellow staff members don’t see this as quite the issue it’s made out to be in the task force’s recommendation. Certainly, they see the risks, but their experiences with patients show that the benefits outweigh any potential detriments.

“Having a positive finding that turns out to be false is better than knowing nothing at all,” Anschuetz says. “The risks are small, but at least there will be an answer.”
Shermis contends that if the goal is to reduce the number of breast biopsies, the way to go about that is with tort reform.

“Some level of the decision-making process on whether or not to biopsy is based on a fear of being sued if something is missed in the screening process,” he says. “I don’t practice that way, but it is a consideration.”

Lee speaks to the numbers cited by the task force in regard to false positives. While the recommendations show a 50% reduction in false positives by eliminating screening mammography for women aged 40 to 49, that number does not take into consideration the reduced mortality rate from that age group, she says.

“We understand the science,” Lee says. “We object to the statistics they referred to. They came to a very different conclusion than we have. You save one life for every 1,000 mammograms you do. How can you argue with that? They’re just looking at the numbers. It’s like using a math equation to determine if it’s raining rather than looking out the window.”

Part of the reason behind the discrepancy in beliefs may stem from the task force members’ backgrounds. The 16 task force members include primary care clinicians with individual interests in areas such as decision modeling and evaluation, effectiveness in clinical preventive medicine, clinical epidemiology, the prevention of high-risk behaviors in adolescents, geriatrics, and the prevention of disability in the elderly.

“There are no radiologists, no oncologists, no radiology oncologists, and no gynecologists,” he says. “The task force is devoid of the people who have the knowledge in this area. They are totally out of touch.”

During clarification testimony, the USPSTF noted that the timing of these recommendations during debate over national healthcare reform was purely coincidental. Regardless, when addressing the issue of medical costs, there are those who may look at limiting screening mammography for women between the ages of 40 and 49 as a cost-saving measure. However, Shermis points out that proponents of narrowing the window of women undergoing screening mammography need to weigh monetary savings against lives saved.

“What they failed to look at are the years saved per person for breast cancer detected by mammography during that age range,” he says. “They also didn’t consider the financial ramifications of undetected breast cancer. The cost to treat an advanced cancer is greater than if you treat it earlier.”

What remains to be seen is the long-term effect of the USPSTF’s latest recommendations on breast cancer detection and mortality rates. Lee notes that the initial fervor will die down, but what will remain is the message for many women indicating they don’t need to have mammograms until they reach the age of 50.

“My nondoctor girlfriends are telling me that they didn’t realize that they didn’t need all those mammograms in their 40s,” she says. “Now that they’ve heard about these recommendations, they think they don’t need mammograms until age 50. It makes me wonder what the impact of this will be on imaging down the road.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pa., and a frequent contributor to Radiology Today.