New breast cancer screening guidelines confuse womens experts disagree | Breast Cancer Screening
The US Preventive Services Task Force (USPSTF) has issued new breast cancer screening guidelines, which are published in the November 17 issue of the Annals of Internal Medicine. The task force now recommends against routine mammography screening for women before age 50 years and suggests that screening end at age 74 years.
The new USPSTF recommendations are in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society and the American College of Radiology, which have both criticized the new document. Several agencies and organizations, such as the Seattle Cancer Care Alliance, have said they will continue to follow the American Cancer Society guidelines. However, according to an article in the New York Times, advocacy groups like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network “welcomed the new guidelines.”
The panel noted that screening women between ages 40 and 50 for ten years prevents one cancer death for roughly 2,000 women screened and that mammography in that age range can cause unnecessary stress and anxiety and lead to overtreatment. But Carolyn Runowicz, director of the Neag Comprehensive Cancer Center at the University of Connecticut, said, “My patients tell me they can live with a little anxiety and distress but they can’t live with a little cancer.” Still, many doctors said they would inform their patients about the recommendations, as well as the fact that several medical groups, such as the American Cancer Society and the American College of Obstetricians and Gynecologists, have chosen not to adopt the new guidelines .According to the Los Angeles Times, President Obama and congressional Democrats who support health care reform hope to expand the use of independent government institutions similar to the Preventive Services Task Force to recommend which treatments and practices work best. But the outcry surrounding the task force’s mammography recommendations underscores the challenges health reform advocates face in achieving that goal. The reaction to the new guidelines also shows how a “potentially revolutionary improvement in the medical system would almost certainly bring controversy, confusion and uncertainty along with it,The new guidelines also highlight a debate in the medical community about the benefits and drawbacks of breast cancer screening that has continued for decades. For example, although an NIH panel in 1997 said that routine mammograms for women in their 40s might not be justified based on the risks of the procedure, the Senate then voted 98-0 to urge the National Cancer Advisory Board to endorse routine screenings for women in that age group.
Specific Recommendations
Specific recommendations of the USPSTF, and the accompanying strength of recommendations, were as follows:
1. The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. Based on patient context, including patient values concerning specific benefits and harms, individual decisions should be made regarding starting regular, biennial screening mammography before age 50 years (grade C recommendation).
2. Women aged 50 to 74 years should undergo biennial screening mammography (grade B recommendation).
3. Current evidence is insufficient to determine additional benefits and harms of screening mammography in women 75 years or older (I statement).
4. In women 40 years or older, current evidence is insufficient to determine the additional benefits and harms of CBE beyond screening mammography (I statement).
5. The USPSTF recommends against clinicians teaching women the technique of BSE (grade D recommendation).
6.Current evidence is insufficient to determine additional benefits and harms of either digital mammography or MRI vs film mammography as screening modalities for breast cancer (I statement).
Evidence-Based Findings
The accompanying updated evidence review on breast cancer screening looked at published studies identified from a search of Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through the fourth quarter of 2008, MEDLINE January 2001 to December 2008, and bibliographies of identified articles. Also reviewed were Web of Science searches and Breast Cancer Surveillance Consortium for screening mammography data.
“Mammography screening reduces breast cancer mortality for women aged 39 to 69 years; data are insufficient for older women,” write Heidi D. Nelson, MD, MPH, from Oregon Health & Science University in Portland, and colleagues. “False-positive mammography results and additional imaging are common. No benefit has been shown for CBE or BSE.”
Inclusion criteria for studies were randomized controlled trials with breast cancer mortality outcomes for screening effectiveness and studies of varying designs and multiple data sources regarding harms. The reviewers found that for women aged 39 to 49 years, mammography screening was associated with a 15% decrease in breast cancer mortality rates (relative risk, 0.85; 95% credible interval, 0.75 – 0.96; 8 trials). However, data are lacking for women 70 years or older.
Radiation exposure from mammography is low, and adverse experiences are common but transient and do not alter screening practices. The estimated rate of overdiagnosis from screening ranges from 1% to 10%. Compared with older women, younger women have more false-positive mammography results and additional imaging but fewer biopsies. Trials of CBE are ongoing. In trials of BSE, benign biopsy results increased, and there were no decreases in mortality rates.
breast cancer screening guidelines confuse women as experts disagree
If the experts can’t agree on guidelines for breast cancer screening, then how are women supposed to decide? At the end of the day, the new guidelines from the U.S. Preventive Services Task Force, a panel of independent experts, have left women quite confused. Several other expert sources, including the American Cancer Society, have criticized the new guidelines and disagree with them.
the new guidelines which do not apply to higher-risk of womens :
* Women between the ages of 40 and 49 should not be routinely screened.
* Women between the ages of 50 and 74 should be screened every two years.
* Screenings are unnecessary for women 75 and older.
* Women should not be taught how to perform breast self-examinations.
* There is no additional benefit to clinical breast examination by doctors, nor are there added benefits to digital mammography or magnetic resonance imaging over film mammography.
And here are the old guidelines, from a study only seven years old which relied mostly on the same data:
* Women should start getting annual mammograms at age 40.
* Doctors should perform clinical breast examinations and teach breast self-examinations.
So which is it? It has been hammered into women for two decades that early detection through regular screening can save lives. And while mammograms are no fun, the fear of breast cancer has sent nearly two-thirds of all women in their 40s to be tested the last two years, and 72% of women age 50 to 65.
What is the panel’s reasoning? While screenings definitely reduce breast cancer mortality, they can also result in psychological harm, unnecessary tests and biopsies due to overdiagnosis and false-positive results. In contrast to a false positive, the detection of a possible cancer which turns out not to be one overdiagnosis is the detection of a cancer that would never have become clinically apparent, and is often followed by unnecessary overtreatment, which can be harmful to the patient.False positive results were more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups. Therefore, the benefit of screening for women 40 to 49 years was found to be small. For the 50 to 74 group, the biennial screening maintains almost all of the benefit of annual screening (81%) with almost half the number of false positives.
