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, email@example.com Life Sciences Librarian, Science Coordinator & Professor,
University of Arkansas Libraries MULN 223 E
365 North McIlroy Avenue
Fayetteville, AR 72701-4002
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
Belluck, P. (Wednesday, November 18, 2009.) Responding to new mammogram guidelines: Many physicians aren’t ready to recommend change. New York Times, 159, (54,863), p.A1, continued on p.A22.
Berg, W. A., Blume, J. D., Cormack, J. B., Mendelson, E. B., Lehrer, D., Böhm-Vélez, M., et al. (2008). Combined screening with ultrasound and mammography vs. mammography alone in women at elevated risk of breast cancer. JAMA: The Journal of the American Medical Association, 299(18), 2151-2163.
Brett, J., Bankhead, C., Henderson, B., Watson, E. & Austoker, J. (2005). The psychological impact of mammographic screening. A sustematic review. Psychooncology, 14: 917-938.
Brewer, N.YT., Salz, T., & Lillie, S.E. (2007). Systemastic review: Long term effects of false-positive mammograms. Annals of Internal Medicine, 146, 502-510.
Chan, H., Wei, J., Zhang, Y., Helvie, M. A., Moore, R. H., Sahiner, B., et al. (2008). Computer-aided detection of masses in digital tomosynthesis mammography: Comparison of three approaches. Medical Physics, 35(9), 4087-4095.
Chawla, A. S., Saunders, R. S., Singh, S., Lo, J. Y., & Samei, E. (2009). Towards optimized acquisition scheme for multiprojection correlation imaging of breast cancer. Academic Radiology, 16(4), 456-463.
Collins, G. (November 19, 2009). The breast brouhaha. New York Times, 159, (54, 864), p. A27.
Controversy over mammograms. (Friday, November 20, 2009). New York Times, 159, (54, 865), p. A30.
Day, N.E. (2005). Overdiagnosis and breast cancer screening. Breast Cancer Research, 7, 228-229.
De Koning, H.J., Draisma, G., Fracheboud, J. & De Bruijn, A. (2006). Overdiagnosis and over treatment of breast cancer: Microsimulation modelling estimates based on observed screen and clinical data. Breast Cancer Research, 7, 285-265.
Duffy, S.W., Agbaje, O., Tabar, L., Vitak, B., Bjurstam, N., Bjorneld, L. et al. (2005). Overdiagnosis and overtreatment of breast cancer: Estimates of overdiagnosis from two tirals of ammographic screening for breast cancer. Breast Cancer Research, 7, 258-265.
Eliahou, R., Sella, T., Allweis, T., Samet, Y., Libson, E., & Sklair-Levy, M. (2009). Magnetic resonance-guided interventional procedures of the breast: Initial experience. The Israel Medical Association Journal: IMAJ, 11(5), 275-279.
Fink, R. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Freixenet, J., Oliver, A., Martí, R., Lladó, X., Pont, J., Pérez, E., et al. (2008). Eigendetection of masses considering false positive reduction and breast density information. Medical Physics, 35(5), 1840-1853.
John, E.M.. Phipps, A.I., Knight, J.A., Milne, R.L., Dite, G.S. Hopper, J.L., et al. (2005). Medical radiation exposure of mammographic screening: Findings from the Breast Cancer Family Registry. International Journal of Cancer, 121, 386-394.
Kearns, J.M. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Kelikowske, K. (2009). Evidence-based breast cancer prevention: The importance of individual risk. Annals of Internal Medicine, 151, 750-752.
Kirschner, E. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Kolata, G. (Tuesday, November 17, 2009). New guidelines suggest fewer mammograms. New York Times, 159, (54,862), p.A1, continued on p.A17.
Kolata, G. (Friday, Novemebr 20, 2009). Mammogram debate took group off guard. New York Times, 159, p.A22.
Kosters, J.P., & Gotzsche, P.C. (2003). Regular self-examination or clinical examination for early detection of breast cancer? Cochrane Databse Systematic Reviews, CD003373.
Lam, W. W. M., Chan, C. P., Chan, C. F., Mak, C. C. C., Chan, C. F., Chong, K. W. H., et al. (2008). Factors affecting the palpability of breast lesion by self-examination. Singapore Medical Journal, 49(3), 228-232.
Lebovic, G. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Leff, D. R., Warren, O. J., Enfield, L. C., Gibson, A., Athanasiou, T., Patten, D. K., et al. (2008). Diffuse optical imaging of the healthy and diseased breast: A systematic review. Breast Cancer Research and Treatment, 108(1), 9-22.
Leung, G. M., Woo, P. P. S., Cowling, B. J., Tsang, C. S. H., Cheung, A. N. Y., Ngan, H. Y. S., et al. (2008). Who receives, benefits from, and is harmed, by cervical and breast cancer screening among Hong Kong Chinese? Journal of Public Health (Oxford, England), 30(3), 282-292.
Leveen, A. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Lladó, X., Oliver, A., Freixenet, J., Martí, R., & Martí, J. (2009). A textural approach for mass false positive reduction in mammography. Computerized Medical Imaging and Graphics: The Official Journal of the Computerized Medical Imaging Society, 33(6), 415-422.
Mandelblatt, J.S. et al. (2009). Clinical guidelines: Effects of ammography screening under different screening schedules: Model estimates of potential benefits and harms. Annals of Internal Medicine, 151, 738-747.
Moss, S. (2005). Overdiagnosis and overtreatment of breast cancer: Overdiagnosis in randomized control trials of breast cancer screening. Breast Cancer Research, 7, 230-234.
Nelson, H.D., Tyne, K., Naik, A., Bougatsos, C., Chan, B. & Humphrey, L. (2009). Screening for for breast cancer: An Update for the US Preventive Services Task Fioorce. Annals of Internal Medicine, 151, (10), 727-737.
Olsen, A.H., Agbaje, O.F., Myles, J.P., Lynge, E. & Duffy, S.W. (2006). Overdiagnosis, sojourn time, and sensititivity in the Copenhagen mammography screening program. Breast Journal, 12,338-342.
Paci, E., Miccenesi, G., Puliti, D., Baldazzi, P., DeLisi, V., Falcini, F., et al. (2006). Estimate of overdiagnosis of breast cancer due to mammography after adjustment for lead time. A service screening study in Italy. Breast Cancer Research, 8, R68.
Peters, N. H. G. M., Meeuwis, C., Bakker, C. J. G., Mali, W. P. T. M., Fernandez-Gallardo, A., van Hillegersberg, R., et al. (2009). Feasibility of MRI-guided large-core-needle biopsy of suspiscious breast lesions at 3 T. European Radiology, 19(7), 1639-1644.
Pfleiderer, S. O. R., Brunzlow, H., Schulz-Wendtland, R., Pamilo, M., Vag, T., Camara, O., et al. (2009). Two-year follow-up of stereotactically guided 9-G breast biopsy: A multicenter evaluation of a self-contained vacuum-assisted device. Clinical Imaging, 33(5), 343-347.
Potente, G., Messineo, D., Maggi, C., & Savelli, S. (2009). Practical application of contrast-enhanced magnetic resonance mammography [CE-MRM] by an algorithm combining morphological and enhancement patterns. Computerized Medical Imaging and Graphics: The Official Journal of the Computerized Medical Imaging Society, 33(2), 83-90.
Rabin, R.C. (Tuesday, November 17, 2009). New guidelines on breast cancer draw opposition. New York Times, 159, (54,862), p.D5.
Rakha, E. A., El-Sayed, M., Reed, J., Lee, A. H. S., Evans, A. J., & Ellis, I. O. (2009). Screen-detected breast lesions with malignant needle core biopsy diagnoses and no malignancy identified in subsequent surgical excision specimens (potential false-positive diagnosis). European Journal of Cancer (Oxford, England: 1990), 45(7), 1162-1167.
Rifkin, W. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Rojas Domínguez, A., & Nandi, A. K. (2008). Detection of masses in mammograms via statistically based enhancement, multilevel-thresholding segmentation, and region selection. Computerized Medical Imaging and Graphics: The Official Journal of the Computerized Medical Imaging Society, 32(4), 304-315.
Sack, K. (Friday, November 20, 2009). A medical culture clash. New York Times, 159, (54, 865), p.A1, continued on p.A22.
Sack, K. & Kolata, G. (Thursday, November 19, 2009). Breast cancer screening policy won’t change, US officials say. New York Times, 159, (54, 864), p. A1, continued on p.A3.
Salem, C., Sakr, R., Chopier, J., Marsault, C., Uzan, S., & Daraï, E. (2009). Accuracy of stereotactic vacuum-assisted breast biopsy with a 10-gauge hand-held system. Breast (Edinburgh, Scotland), 18(3), 178-182.
Seifi, A., Axelrod, H., Nascimento, T., Salam, Z., Karimi, S., Avestimehr, S., et al. (2009). Migration of guidewire after surgical breast biopsy: An unusual case report. Cardiovascular and Interventional Radiology, 32(5), 1087-1090.
Sergentanis, T. N., Zagouri, F., Domeyer, P., Giannakopoulou, G., Tsigris, C., Bramis, J., et al. (2009). Biopsy method: A major predictor of adherence after benign breast biopsy? AJR.American Journal of Roentgenology, 193(5), W452-7.
Sperber, R. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Steinhauer, J. (Wednesday, November 18, 2009). Responding to new mammogram guidelines: Women’s general approach to personal health prevails. New York Times, 159, (54.863), p.A1, continued on p.A22.
Swersky, B. (Wednesday, November 18, 2009). The controversy over mammograms: Letter to the editor. New York Times, 159, (54,863), p.A30.
Tu, S.P., Reisch, L.M., Taplin, S.H., Kreuter, W. & Elmore, J.G. (2006). Breast self-examination: Self-reported frequency, quality, and associated outcomes. Journal of Cancer Education, 21, 175-181.
US Preventive Services Task Force. (2009). Screening for breast cancer: US Preventive Task Force Recommendation Statement. Annals of Internal Medicine, 151, (10), 716-726.
Yen, M.F., Tabar, L., Vitak, B., Smith, R.A., Chen, H.H. & Duffy, S.W. (2003). Quantifying the potentialproblem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. European Journal of Cancer, 39, 1746-1754.
Zackrisson, S., Andersson, I., Janzon, L., Manjer, J. & Garne, J.P. (2006). Rate of overdaignosis of breast cancer 15 years after [the] end of Malmo mammographic screening tiral: Follow-up study. BMJ (British Medical Journal) , 332, 689-692.