New breast cancer screening guidelines are wrong
| Saturday, Nov 21 2009 10:45 PM
Last Updated Saturday, Nov 21 2009 10:45 PM
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Almost everyone knows of someone who has had breast cancer. As a radiologist who has promoted and practiced mammography for the last 30 years, I have extensively studied the benefits of mammography. Nothing gives more pleasure than to see a life saved because we detected the cancer in its early stage, and it was then successfully treated.
Mammography screening for women ages 40 and above is one of the major health care advances of the past 40 years. With the onset of mammography screening, the death rate from advanced breast cancer -- which had been unchanged for the preceding 50 years -- has decreased by 30 percent since 1990. Moreover, early mammography screening means cancers can be caught sooner, often allowing women to choose less invasive treatments that help to preserve the quality of women's lives as well.
In a recent article in Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) published several revisions in its previous recommendations about screening for breast cancer. These revisions are likely to reverse this decline in breast cancer death rates, causing undue suffering to women facing the disease and their families.
The task force now recommends:
* Against routine screening mammography in women age 40-49;
* Against teaching breast self examinations;
* Against clinical breast examinations;
* Against previously recommended routine screening for women 75 years or older;
* Against annual screening mammograms for women age 50-74 (recommending screening every other year versus the currently recommended annual screening).
In other words, the USPSTF is now recommending against all commonly accepted routine screening methods for women in their 40's, and rescinding its prior recommendation of screening of women 74 years and older, "because it is more likely she will die of other causes."
The task force recommendations are based on the implausible presumption that the "harms" of screening: The discomfort of squeezing the breast, the anxiety associated with an abnormal result, the chance of a false positive result requiring additional exams, e.g., additional mammography views, ultrasound, etc., or biopsy, and the chance for over-diagnosis (detecting a cancer that would never have become life threatening) outweighing the benefit of lives saved.
Huh?
This is an utterly irresponsible position by a governmental agency, which was concerned just six months ago that there was a decline in screening mammography by 1 percent. In taking this position, the task force totally disregarded a number of well established, peer reviewed studies from Sweden, Netherlands and elsewhere showing that mammography screening is responsible for most of the decrease in death rates by breast cancer over the last 20 years. The task force ignored an almost universal agreement by clinicians that the breast cancer treatment is far more successful when the cancer is found at a smaller size and earlier stage by mammography.
While ignoring all this evidence and a large number of respected journal articles, they gave full weight to another trial that had been translated from Russian to English. That, in my mind, makes the entire literature review suspect.
Further, the task force relied on its own computer models without allowing for public input or involving anyone with expertise in breast cancer detection or treatment. There are no oncologists or radiologists on the panel.
The USPSTF is a government-sponsored body making recommendations that will be published and recognized by the federal government.
The Agency for Healthcare Research and Quality (AHRQ) funded the project, selected the USPSTF members, provided staff support to the task force, provided project oversight, developed key questions in conjunction with the task force, assisted with internal and external review of the draft manuscript, and will be posting the recommendations on its website. The bibliography even cites journal articles written by AHRQ staff.
A firestorm of protest against this report has erupted from the medical community, the American Cancer Society, related organizations and breast cancer patients. The administration immediately began backtracking. While Health Secretary Kathleen Sebelius is saying that these recommendations will have no bearing on the policy, the White House Deputy Communications director Daniel Pfeiffer wrote on the White House blog that "their recommendations will be used in health reform to identify effective clinical preventive services."
Regardless of what the politicians contend, those of us in practice know for fact that the payers, including Medicare and other plans, will use this report as a shield for denials for these services. The task force must retract this dubious report and its recommendations.
I have previously written about much better outcomes in treatment of breast cancer in the U.S. compared to the U.K., Canada and other countries. Unfortunately, the actions of this task force will set back 30 years of progress in detection and treatment of a deadly disease.
Welcome to government-sponsored studies and cost controls in the land of universal health care.
Dr. Girish Patel is founder and director of Truxtun Radiology Medical Group.
