In the 50 years since mammography became a vigorous part of diagnostic radiology, it has contributed to the early detection of breast cancer; it has shown surgeons where to find and remove lesions without the need for radical mastectomy; it has helped increase the survival rate of breast cancer patients; and it has become a generally acceptable screening procedure for asymptomatic women.
In the same half-century, mammography—particularly screening mammography—has remained the most politically controversial element of diagnostic radiology. The American College of Radiology, the American Cancer Society, the American Medical Association, and the National Cancer Institute, among many others, have supported breast screening. In 1992, the US Congress passed the Mammography Quality Standards Act defining policy for all mammography facilities. The Medicare program pays for screening mammography for women younger than age 65, when all Americans qualify for Medicare coverage. In the same years, other medical groups including the American College of Physicians, some federal employees and, at times, other elements of the National Institutes of Health have opposed breast screening and even challenged the clinical value of mammograms for symptomatic and high-risk patients.
The most recent salvo of assaults on screening came last 16 November, when a quasi-government advisory panel, the US Preventive Services Task Force (USPSTF), issued a statement disagreeing with the positions of the Cancer Society, the ACR and even the task force’s own prior assertions in 2002.
Recommending against routine screening mammography in women ages 40–49 years. “The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.”
Recommending biennial screening mammography for women between the ages of 50 and 74 years.
“Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years and older.”
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…the harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis) as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
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Studying cancer deaths among women in their 40s reveals some important trends. Death rates were dropping slightly in the 1970s, thanks to better awareness and better treatments. While some of that drop is due to improvements in treatment, conservative estimates are that about half is due to mammography. Without mammography, many women would not be candidates for breast-conserving therapy. You cannot treat a tumor until you find it, and we know that mammography has led to finding tumors when they’re smaller and far more treatable.
We think the task force may underestimate mammography’s lifesaving value. In 2003, an expert panel convened by the American Cancer Society conducted an extensive review of the data available then. Our panel reviewed data similar to that examined by the federal task force as well as recent and large population-based studies of modern mammography. Those studies show much stronger benefits from screening compared with the limited data examined by the task force. The task force also restricted its analysis to a certain kind of trial. While those trials are the strongest type, their use meant the panel was limited to reviewing an older body of evidence that underestimates the benefit of modern mammography. The task force took a step backward in the fight against breast cancer.
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Why have the recommendations . . . created such a firestorm? We think it is because the statements were poorly worded, covered a controversial, touchstone issue and were released at a time when everything is examined through the prism of health-care reform and partisan politics.
We think women should ignore the political furor surrounding these recommendations. This is not a government plot to save money. No one wants insurance companies to deny coverage for mammograms. The task force is saying that the greatest benefit from screening mammography occurs for women ages 50 to 74. The task force is not against women getting mammograms in their 40s. The panel simply wants women in that age group and older women to discuss the risks and benefits with their doctors before they get tested. No one should be against that.
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