Wednesday, November 18, 2009

New breast cancer screening guidelines create confusion and controversy.

The U.S. Preventive Services Task Force (USPSTF) has updated their 2002 recommendation statement on screening for breast cancer in the general population, and the new statement has created a loud controversy among physicians, cancer survivors, women's health advocates and, inevitably, politicians. Making its debut in the midst of a hotly debated healthcare reform bill the timing could hardly be worse.

About the USPSTF:

The USPSTF was established in 1984 to "evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care." The USPSTF is an independent, voluntary body, and "...recommendations made by the USPSTF are independent of the U.S. government, and they should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services."

Here is the outline of the new recommendations:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  • The USPSTF recommends against teaching breast self-examination (BSE).
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

The primary controversy revolves around the statements against routine screening in women through their 40's, and biennial (rather than annual) screening between 50 to 74 as well as the recommendation against teaching breast self-examination.
The position of the Task Force is that the routine annual screening for breast cancer can cause "...psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results." They also note the overdiagnosis of cancer that would not become clinically apparent during a woman's lifetime, and unnecessary early treatment of breast cancer that may become clinically apparent but would not actually shorten a woman's life. Although "...false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." They also state that there is adequate evidence that teaching breast self examination (BSE) is associated with harms that are "at least small."

However, The American Cancer Society "...continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider."
Many physicians and women's health advocates are also either confused or seem to be  misinterpreting the recommendations to insinuate that women shouldn't -or won't be allowed to- have a screening at all until they're 40; Dr. John Larrinaga, Medical Director at the Ross Breast Center states: "It doesn't make sense on any level for any person to put their heads in the sand like an ostrich and say we shouldn't be checking ourselves or shouldn't be vigilant about the disease...This is just wrong, this is not scientifically supported." Dr. Ann Marie Shorter, a radiologist with a specialty in breast care says "The statistics are meaningless when it comes to breast cancer deaths if it's your wife, your best friend; these guidelines are a travesty. They don't make sense."
And Rep. Debbie Wasserman Schultz (D-Fla.) "blasted" the report, saying "We can't turn literally 20 years of recommendations ...upside down, and discourage women from becoming familiar with the look and feel of their breasts," and "We can't allow the insurance industry to continue to drive healthcare decisions"

Given the current climate of political diversity on the healthcare bill, the controversy isn't likely to die soon. Meanwhile, breast cancer continues to be the most common form of cancer among women in the US, with about 192,370 new cases of invasive breast cancer expected to be diagnosed in 2009. In our opinion, the best guideline is the old adage: If in doubt, check it out.

Signs and symptoms of breast cancer may include:

  • A breast lump or thickening that feels different from the surrounding tissue
  • Bloody discharge from the nipple
  • Change in the size or shape of a breast
  • Changes to the skin over the breast, such as dimpling
  • Inverted nipple
  • Peeling or flaking of the nipple skin
  • Redness or pitting of the skin over your breast, like the skin of an orange

When to see a doctor:
If you find a lump or other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor.

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