Picture imperfect: Interpreting the new recommendations for breast-cancer screening

Breast cancer advocacy starts with a tear. It gathers strength in solidarity and marches to the drumbeat of awareness in torrents of pink ribbons. No other medical condition, with the possible exception of HIV, has rallied more support for screening and prevention. Now, USPSTF recommendations are questioning the effectiveness of some breast-cancer screening and stirring up a political and emotional storm.
Dr. Michael LeFevre and his colleagues are an island in a swirling stream of controversy. Much has been generated by the media, said the professor and associate chair of Family Medicine at the University of Missouri, but he’s willing to take part of the blame. LeFevre serves on the U.S. Preventive Services Task Force and is one of 16 medical and public health professionals from across the country responsible for the new recommendations for breast-cancer screening.
“The recommendations could not have come out at a worse time,” LeFevre said. “The notion that this was part of somebody’s health reform package or was politically motivated or was a cost-savings reduction is unequivocally false. It couldn’t be more untrue.”
Back in the summer of 2008, the USPSTF voted on the recommendations without knowing when they would be published. Fifteen months later, in the midst of a debate on health care reform, they appeared in the Annals of Internal Medicine. (See “To Screen or not to Screen.”) The recommendations, some of which were meant to encourage discussion between patient and doctor, have set off a divisive national dialogue.
Three recommendations sparked controversy: eliminating routine mammograms for patients 40 to 49; biennial rather than yearly mammograms for ages 50 to 74; and eliminating a systematic program of breast self-exam. The departure from the 2002 recommendations advising routine mammograms beginning at 40 has polarized the breast-cancer community. Responses from organizations such as the American Cancer Society, the National Cancer Institute and the American Congress of Obstetricians and Gynecologists range from outright rejection to full acceptance, which leaves many women in no man’s land.
LeFevre said that, ironically, the recommendations were meant to empower women. “We’re not saying women shouldn’t have mammograms in their 40s,” he said. “We are saying that the net benefit is small and that a woman and her physician should make that decision together based on her individual circumstances and her own values. We didn’t think turning 40 should trigger a mammogram. It should trigger a discussion.”
The USPSTF concluded that the biggest drawback to mammography for women in their 40s is the relatively high incidence of false positives, which can result in unneeded biopsies, tests or unnecessary treatment. These figures range from 1 percent to as high as one-third, said LeFevre. But he doubts the resulting recommendations will change access to mammograms. “It’s a political football,” he said. “I’d be very surprised if health reform and insurance will deny mammograms to women in their 40s if they want them.”
Regarding recommendations for women 50 to 74, the USPSTF found that biennial mammograms garnered a greater net benefit than yearly tests. Reducing mammograms by one-half resulted in a slightly lower detection rate, but it was offset by the fact that fewer screenings overall resulted in fewer negatives.
The job of the task force was to come up with recommendations that would give patients the greatest chance of benefiting from breast-cancer screening while reducing the drawbacks. In short, the USPSTF measured potential benefits against human costs, which they called harms. This resulted in a net benefit, which they graded according to magnitude and level of certainty.
“It’s something that’s fairly unique about the USPSTF,” LeFevre said. “Most people choose to look mainly at the benefit side. When you do look at the harms, it becomes a qualitative judgment rather than quantitative.”
Applying science to qualitative information can be a challenge, and LeFevre said that personally, he has never been engaged in a more rigorous scientific process. “This was really about when to start, how often to screen and when to stop.”
In the end, the task force didn’t answer the question of when to stop. There were no trials of women older than 70, so evidence didn’t allow a fair comparison of benefits and harms. What researchers do know is that though the ability for mammography to make a difference increases with age, it takes 10 to 12 years for a woman to benefit. When breast cancer is detected in this age group, there’s a good chance something else will take a woman’s life.
These sobering conclusions challenge the belief that early detection and technology always improve health and prolong lives. They might even suggest that screening as the solution to breast cancer has been oversold.
“The notion that early detection is the answer to cancer has almost become a faith,” LeFevre said. “We need better prevention and better and less toxic treatment. Understanding which diseases need to be treated and which don’t is an important piece of that.”
As a family physician, LeFevre advises his patients against obsessing over breast cancer. “If you’re trying to stay healthy, there are bigger fish to fry,” he said. “Heart disease is a far bigger killer of women than breast cancer.”
LeFevre said he believes that women are best served when members of the breast-cancer community look for areas of agreement. One area might be the recommendation against breast self-exam, which was targeted at health care workers teaching rote monthly exams. When all is said and done, the USPSTF supports the spirit of the exam: Women should be aware of their bodies and report any lumps or changes. Nearly everyone agrees. And where there’s common ground, there’s a beginning.
Radiologist Terry Elwing, M.D., wants her patients to know that along with the twinkling promise of research and technology, some things are better left unchanged. As director of Women’s Imaging at Boone Hospital’s Harris Breast Center, Elwing takes issue with the new USPSTF recommendations for breast-cancer screening. Some replace early detection with what she and others might consider a shot in the dark.
“The way they looked at the data is very questionable,” Elwing said. Some of the best data, they didn’t use; some of the worst data, they did use. So their statistics are flawed, and I think they’re blowing out of proportion these potential risks.”
Elwing said the task force excluded data from an important study in Sweden while including trials in which patients weren’t rigorously screened. The Swedish study reported a 40 percent reduction in mortality when mammograms were introduced to women in their 40s. In comparison, the USPSTF estimates a 15 percent mortality reduction in the same age group.
The disparity raises questions because the USPSTF recommends against routine mammograms for women in their 40s. (See “To Screen or not to Screen.”) These younger patients develop fewer but more aggressive cancers that can also be tricky to diagnose. They tend to have dense breasts, which increases potential harms such as false positives, biopsies, anxiety and over-treatment.
“I think in a good breast center, the harms can be minimized significantly,” Elwing said. “We minimize harms by talking to patients and being very diligent on the technologist side, finding the problems so we don’t have to recall the patient. A radiologist always talks to a patient when they have a problem. Most patients come and go without any concern. When we do find something, we’re going to take care of you.”
Elwing believes that for all its diligence, what’s lacking on the highly credentialed task force is practicality. Its members include academicians and public-health professionals but no radiologists or oncologists, who deal with breast-cancer patients on a daily basis. This perhaps explains what she sees as a disconnect between some of the recommendations and their implementation. For example, the USPSTF suggests that women in their 40s make individual decisions about screening based on “patient context,” or risk. But 75 percent of the people who get breast cancer aren’t high-risk.
“I thought this was over and done with,” Elwing said. After much debate back in 2002, the panel came out in favor of annual mammograms for all women older than 40. “We should go on to studying digital mammography, tomosynthesis or MRI — or how we stratify risk. There are so many things we could look at besides who should get a mammogram. Oncologists will tell you that it’s not new drugs or radiation that are the forces behind decreased mortality. It’s early detection. It’s finding the cancer when it’s still small and contained in the breast so we can remove it.”
Dr. Paul Dale, chief of Surgical Oncology at Ellis Fischel Cancer Center, said new technology offers hope in detecting increasingly smaller cancers. Because mammographic images are getting clearer due to digital technology, physicians have more confidence in what they deem benign. One of the most promising technologies is tomosynthesis, which is like a CAT scan of the breast without the additional radiation, time or cost. Once approved by the FDA, it will allow doctors to view multiple slices of the breast and see through dense breast tissue.
For now, most doctors rely on mammography. Although it’s imperfect, it has been responsible for a steady decline in breast-cancer deaths since it was introduced in the 1980s. “A mammogram is uncomfortable for some women,’” Dale said, “but most of them get through it just fine. It does provoke anxiety if there’s an abnormality — as does a test of any type. But it’s better if it’s found early.”
Dale believes the USPSTF recommendations could influence the future of health care legislation. Women outside the recommended parameters might have to pay out-of-pocket for breast-cancer screening, which could create a chilling effect on early detection. Breast cancer in otherwise healthy older women can become life-threatening, he said.
“If a woman is healthy and has a good chance of living five years or longer, she should continue getting mammograms,” Dale said. “It’s very treatable. In this age group, they often do exceptionally well. Two of the biggest risk factors for breast cancer are being a woman and getting older.”
Dr. Mary Muscato, a hematologist medical oncologist and Susan G. Komen board member, views the recommendations from two perspectives. “It’s a tough problem,” she wrote in a recent e-mail. “But just thinking of this as a population problem (need many tested to find one positive) rather than a personal problem (I have many patients in their 30s and 40s with breast cancer), it’s doomed to be rejected by people, even if accepted by public health officials.” Muscato’s remarks illustrate some of what’s fueling the controversy. Although research might tell us what’s best for the general population, personal and anecdotal stories can be more powerful.
Elwing said that when it comes to the general population, about two-thirds of patients who should get mammograms do. She would like these figures to increase. Lately she’s noticed that in the wake of the USPSTF recommendations, women are asking if they really need to come in.
“Our response is, ‘Yes,’” Elwing said. “We have not changed our position about breast-cancer screening. When you put out something like this, it gives people on the fence more ammunition not to do their screening.”
Once cancers become palpable, their prognoses worsen, which costs patients and society, she said. “I’m all for cost containment — as long as it doesn’t cost someone their life.”

To Screen or Not to Screen: USPSTF recommendations for breast-cancer screening

• 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 into account patient context including the patient’s values regarding specific benefits and harms. (Grade C recommendation)
• The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)
• 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. (I statement)
• The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation)
• The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement)

Ratings grade the magnitude of net benefit, with B representing moderate; C representing small; D representing zero or negative; I representing insufficient evidence. Annals of Internal Medicine, Nov. 17, 2009.