New mammography screening recommendations from the U.S. Preventive Services Task Force will cost women's lives and essentially take the breast cancer death rate back to 1950s levels, a panel of mammography experts said at the annual meeting of the Radiological Society of North America.
The net effect of the recommendations is that “screening would begin too late and would be too little. We would save money but we would lose lives,” said Dr. Stephen A. Feig, a professor of radiology at the University of California, Irvine, and president-elect of the American Society of Breast Disease.
The task force now recommends that women aged 50–74 years need only get biennial exams instead of annual screenings and that routine mammographic screening is not necessary for women aged 40–49 years.
“What does this tell women in their 40s? It tells them basically that they can go back to the 1950s, when they waited until a cancer was too large to ignore any more and then bring it to their doctor's attention,” said Dr. Daniel B. Kopans, who is senior radiologist in the breast imaging division at Massachusetts General Hospital and a professor of radiology at Harvard Medical School, both in Boston. “They're basically saying, 'Ignore your breasts until there's an obvious cancer.'”
The recommendations—released in November (Ann. Intern. Med. 2009;151:716–26)—triggered a controversy among physicians, patients, and politicians. The recommendations were the subject of a Dec. 1 hearing before the Health subcommittee of the House Energy and Commerce Committee, at which task force members were put on the defensive.
The USPSTF guidelines were updated using evidence from two studies commissioned by the task force. One study, funded by the Agency for Healthcare Research and Quality, is an updated systematic review of screening mammography randomized, controlled trials (Ann. Intern. Med. 2009;151: 727–37). It concludes that mammography screening reduces breast cancer mortality by 15% for women aged 39–69 years and that both false-positive results and additional imaging are common.
The other study, by the Cancer Intervention and Surveillance Modeling Network, used estimates of screening outcomes for a range of screening strategies at different frequencies and ages of initiation and cessation (Ann. Intern. Med. 2009;151:738–47). This study concluded that “biennial intervals are more efficient and provide a better balance of benefits and harms than annual intervals.”
The use of these studies as the basis of the new recommendations angered experts on the RSNA panel. “They used selective science and they also used computer modeling as the major new analysis that they put forth,” Dr. Kopans said. “There were direct studies that were actually ignored by the task force.” These studies show that most of the decrease in breast cancer deaths is because of screening and not therapy.
Dr. Feig agreed and cited several randomized studies. “We know from these studies that women who are screened may have their risk of death from breast cancer reduced by as much as 40%–50%.”
In the Swedish Two-County trial (Lancet 1985;1:829–32), a 31% reduction in mortality was seen in women aged 40–74 years who were offered screening. “These randomized trials underestimate the benefits of screening” because the results include all women who were offered screening, not just those who underwent screening, Dr. Feig said.
In the Swedish seven-county service screening study (Cancer 2002;95:458–69), there was a 44% reduction in mortality among women who were screened.
“In the United States—where many women are being screened—the average woman with invasive breast cancer today is almost 40% less likely to die from her disease, compared with her counterpart in the 1980s,” Dr. Feig said (Cancer 2002;95:451–7).
“About 20% of all breast cancer deaths in our country are found in women in their 40s. Because they're younger, they have longer life expectancies. About 40% of the years of life lost to breast cancer are linked to those that are found in their 40s,” he said. The new recommendations would put these younger women at risk.
The RSNA panelists also expressed concern that the recommendations could prompt insurers to stop paying for screening mammography not recommended by the task force.
Disclosures: Dr. Feig and Dr. Kopans reported that they have no relevant conflicts of interest.