The US Preventive Services Task Force is an ad hoc voluntary group of medical experts periodically assigned by the US Department of Health & Human Services to offer advice and guidelines on best practices on some topic in preventive medicine and public health.
They are known for their willingness to bring science to discussion tables where emotions have hitherto held sway. Such appears to be the case with new guidelines which they have announced with regard to the age of onset and frequency of routine mammography.
These guidelines, published and discussed in the most recent Annals of Internal Medicine, (cited below under US Preventive Services Task Force, 2009, and accompanying commentaries, and the many citations within all this material, basically say the following:
1. The prior recommendation (US Preventive Services Task Force, 2002) of annual mammographies starting at age 40 as a means of screening for breast cancer was somewhat ambivalent in terms of the concreteness of its statistical basis and its science, and that the doubters about starting them too soon and having them too often, were probably right all along. In their collective, and necessarily hindsight opinion, those millions of unnecessary mammographies did more harm to more patients that did not have breast cancer than they did good for the statistically far fewer patients whose breast cancers were detected.
2. The principal harms that occurred were fourfold. First, there were many more unnecessary follow-up mammographies that disclosed no new cancers. Second, there were vastly more breast biopsies (and repeat breast biopsies) , painful and expensive procedures that turned out not to have identified an any malignancy. Third, many marginally malignant, or extremely slow-growing cancers, and even altogether non-malignant growths were mistakenly and/or over-aggressively treated. These treatments, along with the biopsies, opened the door to surgical misadventures, infections, and ironically, unintended initiation of new tumors through some of the paradoxical side-effects of radiation and chemotherapeutics. Fourth, a great many women were needlessly worried about having a life-threatening disease, when, in fact, they did not.
3. Routine breast self examinations for lumps, and even the administration of examinations by trained doctors and nurses in office settings, while not of themselves having side-effects other than inducing worry, have led to too many biopsies with a potential for adverse side-effects, while disclosing few genuine tumors in individuals relative to the harm collectively caused by teaching and encouraging this procedure. Inevitably, many patients, nurses, and physicians, will, in fact, find lumps, which almost inevitably leads to subsequent, and overwhelmingly unnecessary, biopsies.
4. There is now more scientifically reliable, statistical evidence that mammograms starting at age fifty, and repeated every other year, will likely detect, more predictably, lumps and cancers that are actually serious enough actually to warrant biopsy and appropriately aggressive treatment. The risks of false-positives are significantly reduced by waiting until this age range, and the every other year interval further reduces that risk.
5. This advisory of waiting to age 50, and having every other year intervals, is in no way intended for those with a strong personal case history of breast pathology, or who have predisposing factors such as known familial breast cancer genetic markers.
There is no evidence that these medical and scientific advisors of the 2009 US Preventive Services Task Force, which included nine men and seven women at the time the recommendation was finalized, were in the pay of insurance companies that wanted to deny coverage for annual mammograms, or, as has been alleged, they were part of some scheme, inevitable under current proposals for health care reform, to ration health care.
Nonetheless, they, and their recommendations have been thoroughly pilloried.
And the Secretary of Health & Human Services, Kathleen Sibelius, whose agency requested this very analysis, has beaten a hasty retreat, giving the appearance of leaving her honest analysts out there hanging defenselessly (See Sack & Kolata, cited below).
Nonetheless, some gutsy support for the new recommendations can be found in the press. See Controversy over mammograms (2009), Fink (2009) and Rifkin (2009) cited below.
And at least one breast cancer survivor (Collins, 2009) finds this and other blue-ribbon panel medical advisory flip-flops oddly amusing, once one has gotten past the uglier parts of chemotherapy or radiation.
Who Disagrees with Their Expert Opinion? Other Expert Bodies & A Lot Of Breast Cancer Survivors
· The American Cancer Society (see American Cancer Society, 2009, cited below)
· The American Society of Breast Disease (see Lebovic, 2009, cited below)
· The American College of Obstetricians and Gynecologists (see American College of Obstetricians and Gynecologists, 2009, cited below)
· The American College of Radiology (see American College of Radiology, 2009, cited below).
· The American Society of Clinical Oncology is less stark in its disagreement, but it clearly thinks that the new recommendations are throwing the baby out with the bath water (see American Society of Clinical Oncology, 2009, cited below).
· So do a great many women whose lives have been saved by early mammography and breast self-examinations. See the following cited below: Kearns, (2009); Leveen (2009); Sperber (2009), Swersky (2009).
Is Past Experience with Older Diagnostic Technology & Means of Image & Biopsy Interpretation Necessarily the Best Guideline for a Forward-Looking Recommendation?
A key question that is not being asked today, is: Whether our retrospective statistical look at false positives caused by the mammographic equipment and older biopsy methods used in the recent past, and the ways of interpreting the resulting mammograms and tissues excised, will continue to lead to false positives, needless follow-up biopsies, and overtreatment in the years to come?
The advisory as it stands now seems to rule out significant changes in the technology and interpretation of mammograms and biopsies, but any biomedical librarian worth his or her salt will be able to identify a substantial number of papers dealing with new pieces of medical imaging equipment, new combinations of medical imaging equipment and means of taking biopsies, and new algorithms for scanning and interpreting the resulting mammograms and biopsies, that have been tested and shown to reduce significantly, false positives (Chan et al, 2008; Chawla et al, 2009; Eliahou et al, 2009; Freixenet et al, 2009; Leff et al, 2008; Llado et al, 2009; Peters et al, 2009; Pfleiderer et al, 2009; Potente et al, 2009; Rojas Dominguez & Nandi, 2008; Salem et al, 2009 ).
It might be a good idea to rule out their promise of something better and far more accurate, before ruling out routine annual mammograms for women at 40, with biopsies as needed in the judgment of the physician and patient.
Tony Stankus, FSLA, tstankus@uark.edu Life Sciences Librarian, Science Coordinator & Professor,
University of Arkansas Libraries MULN 223 E
365 North McIlroy Avenue
Fayetteville, AR 72701-4002
Voice: 479-575-4301
Fax: 479-575-4592
American Cancer Society. (2009). The American Cancer Society responds to USPSTF Mammography Guidelines. The American Cancer Society guidelines will not change; annual mammography recommended for women 40 and over. http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp
American College of Obstetrics and Gynecology. 2009. Response of the American College Of Obstetricians And Gynecologists to new breast cancer screening recommendations from the U.S. Preventive Services Task Force , 2009) http://www.acog.org/from_home/Misc/uspstfResponse.cfm
American College of Radiology. (2009). USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year. http://www.acr.org/HomePageCategories/News/ACRNewsCenter/USPSTFMammoRecs.aspx
American Society of Clinical Oncology. (2009). Expert Perspective from ASCO on Mammography Screening for Breast Cancer. http://www.cancer.net/patient/Cancer+News+and+Meetings/Expert+Perspective+on+Cancer+News/Expert+Perspective+from+ASCO+on+Mammography+Screening+for+Breast+Cancer
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