In case you missed it during last night’s newscasts or this morning’s talk shows, the U.S. Preventive Services Task Force has made a huge about-face with its breast cancer screening recommendations.
Based on the latest string of studies (which I’ve posted about frequently, for example, here), this independent panel of prevention and primary-care experts now recommends the following:
- Women should start having screening mammograms at age 50 rather than at age 40.
- Women between the ages of 50 and 74 should have mammograms every two years rather than once a year. (The task force says current evidence is insufficient to determine whether the benefits of screening mammography outweigh the potential harms for women aged 75 and older.)
- Doctors should stop instructing women to conduct regular breast self-exams. (The task force said that there’s insufficient evidence to know whether clinical breast exams — those done by doctors — were beneficial.)
(These recommendations are not, however, for high-risk women — those with a strong family history of the disease, for example.)
Writes the New York Times:
Dr. Diana Petitti, vice chairwoman of the task force and a professor of biomedical informatics at Arizona State University, said the guidelines were based on new data and analyses and were aimed at reducing the potential harm from overscreening.
While many women do not think a screening test can be harmful, medical experts say the risks are real. A test can trigger unnecessary further tests, like biopsies, that can create extreme anxiety. And mammograms can find cancers that grow so slowly that they never would be noticed in a woman’s lifetime, resulting in unnecessary treatment.
Dr. Petitti also told the Times that although she knew the new guidelines would be a shock for many women, “we have to say what we see based on the science and the data.”
According to the Times, the National Cancer Institute is now considering revising its breast-cancer screening guidelines as well. But the American Cancer Society, the American College of Radiology, and (according to Bloomberg News), the American College of Obstetricians and Gynecologists have announced their intention to continue to recommend annual mammograms starting at age 40.
UPDATE: On Tuesday, the Mayo Clinic in Rochester announced that it will not be changing its screening recommendations, but will be sticking with its current ones, which encourage women to get annual mammograms starting at age 40. Mayo also intends to continue to promote both breast self exams and annual clinical exams.
Right now, it’s unclear how these new guidelines will affect insurance reimbursements for mammograms. Some people (I heard it being discussed on MSNBC this morning) are already charging that this change in recommendations is being done more to control health care costs than to improve health.
Those people, I politely suggest, haven’t really examined the research. Nor, I think, have they considered that all the money spent on unnecessary mammograms (and the often resulting unnecessary biopsies and treatment) could be much better allocated. As the women’s health advocate (and long-time believer in a more evidence-based approach to mammography) Dr. Susan Love blogged yesterday: “We need to help women understand what mammography can and cannot do, and focus on finding the cause of breast cancer and preventing it altogether.”
The new guidelines were published in the Annals of Internal Medicine, which you can read in full here.
I believe that if the ACS, Medicare and the insurers do not change their positions based on this, which appears likely, it doesn’t bode well for plans to transition our health care system towards evidence based medicine. As it stands now, we endorse and pay for treatments based largely on cultural factors that are impervious to contradictory evidence, and that will continue to bankrupt the system until matters change.
I would think that 21st century technology would make more sense, such as digital imaging thermograpy! We have a link for a provider on our website.
Yes, that’s it, 21st century technology. Because more imaging technology for even earlier detection, not to mention the new costs, is precisely what’s missing in our health care system.
Susan Love has it right. We need to stop focusing so much on early detection and start asking about why breast cancer occurs in the first place.
Michael:
There’s no good evidence to support digital imaging thermography for breast cancer screening.
Claims that it can detect tumors early are simply not backed up with any good science.
New technologies need to be proven before they become recommended.
Susan
Are mammograms really that expensive? I have known several women with breast cancer in their late 30s and early 40s. Why would we back off from early detection. Is this one of those public health, mathematical deals where “on average” it doesn’t pay? It pays if it’s my wife or daughter whose life is saved?
Medicine is still fascinated with keeping the dying alive and does less for the common cold and obesity than it does for some obscure chemotherapy for a disease that kills 1,000 people a year.
The issue is not about the cost of mammograms. The panel specifically did not take that into comparison. For every action there is a reaction. Testing may spot something in one person but find things that turn out to be nothing in 40 others, and that can have negative health implications for those 40 others if they undergo medical procedures based on the misinformation. This notion that “you would want tevery last step taken if it was your wife or daughter” gets us in trouble, wives and daughters included. I think we need to ask how much the “early detection saves lives” message is really constructed to protect those industries that cause cancer, and to keep our eyes focused on the medical companies that take our money to provide early detection services, and to make ourselves feel better that we so often can do so little about cancer. Cancer is cellular, and quite often by the time you can see it it has had the potential to metastasize.
I would reccomend starting mammograms at age 40 from personal experience. My wife turned 40 in 2006, and later in the year got her reccomended mammogram. It indeed showed and lump.
There was anxiety, yes, as at each step of the way, there was greater confirmation that the lump was cancerous – we had it removed (it was small) and the biopsy showed not only that it was cancerous, but that it had started to spread to the lymph system.
It was agonizing, with both chemo and radiation necessary, but in the end worth it – she is a survivor with no signs of reoccurance though we are watching it very closely.
I have long been skeptical about frequent, universal screening tests of all kinds simply because the profit motive is so powerful. I go with the flow and do the mammography thing, but I have often wondered whether it’s really necessary (or harmless) for all women to irradiate their breasts annually for half their lifetimes. These tests may have benefits, but there’s no denying that they are also licenses to print money for the providers, a factor that cannot be overlooked.
And, while I’m on the subject, I’d like to see someone take a similar look at the (relatively) new medical cash cow: colonoscopies. Everything I’ve read indicates that these tests do indeed greatly reduce the risk of colon cancer, and I’ve also gone through this mandatory middle-age rite of passage, but they’re expensive, invasive, and require a 2-3 day prep period and a missed day of work. They are also hugely lucrative. I saw an article about medical incomes in the Wall Street Journal not long ago that showed skyrocketing income for gastroenterologists since the advent of universal colonoscopy screenings.
I hate to sound cynical, but medical folks are human, after all, and we can’t expect them to be completely indifferent to the monetary considerations that drive the rest of society.
Paul and Ann,
I hope you’re not doctors. If you are, I’m glad you’re not mine.
Jeremy:
No, I’m not a doctor, but I do have them in my family. Nor do I doubt that early detection saves lives. I was simply suggesting that there is a strong economic incentive for universal screening tests of various kinds and I am not sure to what extent that economic incentive discourages any questioning of the status quo. As consumers of medical services and citizens of a country that spends a huge amount of money on health care yet achieves mediocre outcomes, we have a right to ask these questions.
Not all doctors embrace the current recommendations for screening of asymptomatic people. In particular, Dr. Norton Handler’s book The Last Well Person takes a pretty dim view of a number of routine screening tests, including mammograms.
I’m not a doctor. But I live with and work among and am married into them. And I think that helps me understand how my doctor is not my mommy, and how every test isn’t a magic potion that came from a magic cabinet sprinkled with sparkly magic doctor dust. Now I suppose you REALLY don’t want me to be your doctor. Darn!
One angle I found interesting is that two of the members of the USPSTF (the body that made the recommendations) appear to be medical professionals from right here in the Twin Cities, yet I have found no reference (not to say there hasn’t been some someplace I have not seen) to this nor any attempts to interview these doctors by any of the “hyper local” media.
They are:
Dr. Geogre Isham (M.D., M.S.)
Medial Director and Chief Health Officer of Health partners
and
Dr. Timothy Wilt (M.S., M.P.H.)
Professor Department of Medicine
U of M
and on the Staff of VA Medical Center, Minneapolis
Let’s have somebody interview these guys for their take on:
1. The facts of their recommendations
2. How they think the matter has been handled by the news media, both locally and nationally.
Paul L:
I’m working on it.
Susan
Susan:
Good….I look forward to your reporting. I did just see a replay of Dr. Sanjay Gupta (CNN’s med guru) interviewing/grilling a member of the USPSTF who was an R.N, and Ph.D., but I didn’t catch her name. It was fairly nasty, with him berating her for using the term “small value” when she spoke of the under 40 screenings…..with him implying that she was inferring that the lives saved were of “small value”. Methinks this whole thing is taking on the air of last summer’s wholly uninformative and uninformed “death panels” diatribes.