The new guidelines for mammograms (the ones that don't necessarily recommend screening at age 40) have drawn fire. What do you all think - do they make sense?

They make sense for a government that is trying to rein in the high costs of healthcare. According to H.R. 3962, the USPSTF will be renamed and given a pivotal role in determining what the "essential benefits package" will include. This is rationing, folks.

http://covertrationingblog.com/general-rationing-issues/sebilius_is_wrong_uspstf_is_setting_policy

All I gotta say is that I voted for McCain................

Ya' damn right its rationing and what they're really saying is that we're OK with say 5000 women needlessly dying from breast cancer every year in an attempt to contain costs.

And I'll bet my ass they won't change the reccomendations for prostate screening! URGH!!!!!!

I read the followiong story on another website and it rings true to me.

Daughter A complains about her breasts but insurance wont' cover mammogram because she's under age 30. When she's finally Dxed, she has stage III breast cancer. At age 34 she dies from her disease. Cost to the system, over 2 MILLION dollars.

Scared from Daugther A's situation, Daugher B sister of daughter A, insists on having a mammogram at age 26. Doctor's find a stage 1 breast cancer and she's cancer free at age 40. Cost to the system, 35 thousand dollars.

Any questions?

With all due respect pathdr2b, the scenarios you describe above have nothing to do with breast cancer screening. Daughter A potentially needs a diagnostic mammogram to work up a complaint. However, that is even debatable as at least one study examining the usefulness of mammography in evaluating breast complaints in 1,908 women aged 35 years or younger found that of the 23 women found to have palpable cancers, none of the 1,908 mammograms contributed any information that affected patient management. Nor is she even eligible for screening mammography under the new guidelines or old ones because she is under 40 ( in fact she is under 30) for which no screening guidelines exist. Daughter B also is not eligible for routine screening due to age ( she is 26). However, based on her family history she should be undergoing screening due to her recognized increased risk, which is very different than screening an entire population based on age alone.

I know this is a dicey area, and so I would compel all of you to try to educate yourselves on this topic. The NCI (National Cancer Institute) has a very good webpage on this topic: http://www.cancer.gov/cancertopics/pdq/screening/breast/HealthProfessional/page2

Here is a quote from one section regarding the benefit of screening in different age groups:


A way to view the potential benefit of breast cancer screening is to estimate the number of lives extended because of early breast cancer detection.[19,20] Harris [21] estimated the outcomes of 10,000 women aged 50 to 70 years who undergo a single screen. Mammograms will be normal (true negatives and false negatives) in 9,500 women. Of the 500 abnormal screens, between 466 and 479 will be false-positives, and 100 to 200 of these women will undergo invasive procedures. The remaining 21 to 34 abnormal screens will be true positives, indicating breast cancer. Some of these women will die of breast cancer in spite of mammographic detection and optimal therapy, and some may live long enough to die of other causes even if the cancer has not been screen detected. The number of extended lives attributable to mammographic detection is between two and six. Another expression of this analysis is that one life may be extended per 1,700 to 5,000 women screened and followed for 15 years. The same analysis for 10,000 women aged 40 to 49 years, assuming the same 500 abnormal examinations, results in an estimate that 488 of these will be false-positives, and 12 will be breast cancer. Of these 12, there will probably be only one to two lives extended. Thus, for women aged 40 to 49 years, it is estimated that one to two lives may be extended per 5,000 to 10,000 mammograms.

I for one believe the benefit of across the board screening in the 40-49 year old age group is quite small and may indeed by outweighed by the risks of unnecessary procedures due to false positives, false sense of security due false negatives, etc. A more rational approach would be to offer screening to women at higher risk - those with first degree family members with breast cancer or ovarian, history of chest irradiation before age 16, family history of Li Fraumeni, known family member with BRCA 1 or 2 mutation, etc.

As doctors it is incumbent upon us to understand the uses and limits of our technology and in all cases utilize them wisely and to the fullest benefit to our patients.

I'm a trained former NCI Cancer Epidemiologist, breast cancer researcher (bench work), and current Advisory Board member for the Komen foundation. In other words, I didn't pull these comments out my rear end! The idea of completly dismissing ANY type of yearly detalied analysis of breast tissue ( ie ultrasound, MRI's for high risk folks, digital mammograms) is ridiculous. One reason it's so idiotic to me is because Black/Hispanic/Native American women are diagnosed at later stages. So the medically prudent thing to do in this situation would have been to qualify the recommendations since it makes NO SENSE for the groups I just named.

The fact is billions of dollars are being made in this country from people DYING so as far as I can see, there's really no impetus to save 5000 thousands lives a year, when people can get paid tens of millions of dollars to treat their illness.

Perhaps because I'm a black woman, from a BRCA1 family, and have had two tumors removed from each breast before the age of 40, are my reason for being so passionate about this. What I do know is that if I had not insisted on a mammogram at age 32, that the atypical ductal hyperplasia I was diagnosed with and was NOT palpable, many very well have become cancer and that I probably wouldn't be around now to have this little debate with you.

And I feel the same about the cervical cancer reccs. Young girls of color have high higher rates of HPV infection which is one of the causative agents in cervical cancer, so if you eliminate the screening, these women will die at higher rates that white women and at younger ages.

So maybe that's what this is all about. Further proof that medical speaking, no one really cares what happens to women of color.

This statement is totally irrevelant to the case I mentioned. Why? Because Daugther A complained for MONTHS about her breasts, but was repeadly told by doctors that she was too young to have breast cancer. I met a 16 year old stage III breast cancer patient a few years ago at the Race For The Cure who had the same story except in her case, she went back and forth to the ER (had no insurance) for almost a year before getting a mammogram. She's dead now.

As for Daughter B, I'd hedge my bets that this was a BRCA 1 family, and if I were her Dcotor, I would have treated her accordingly. She wouldn't have had to go to a few doctors before she could find one that would order a mammogram for her so she could get her insurance would pay for it, thus finding her stage I cancer early.

But then this is why I think in general medicine needs more Scientist/Physicans on board.

I totally get that preventative medicine can sometimes lead to false positives, and appear to be unnecessary. But it seems like common sense to me, it costs MORE to treat cancer at a later stage than it does catch it early when care won't be so costly.

Finally as a published former cancer researcher, I can tell you that you can't single out ONE paper, shout "Ah Hah", and think you've found the "holy grail" of medicine, LOL!!!

Yeah, I think I'd better rethink my timeline for pursuing med school......................

"A more rational approach would be to offer screening to women at higher risk - those with first degree family members with breast cancer or ovarian, history of chest irradiation before age 16, family history of Li Fraumeni, known family member with BRCA 1 or 2 mutation, etc."

It may be more "rational" but I had followed typical "guidlines", I might very well not be here now.

I didn't inhert the prepensity for breast tumors from my Mother, I inherited it from my Dad, but how many Physicans know that's possible? Very, Very few when I was a cancer epedemiologist. I'm Black, but I am a decendant of Ashkenazi Jews, which also puts me at higher risk. How many Doctors would have guessed that by looking at me? How many would have thought to ask if I had Jewish ancestors? NONE!!!

In the absence of compelling evidence to the contrary, women need to continue to be their own best health advocates! And we also need more doctors of color, but I'll save that speech for another thread!

pathdr2b - first let me say I respect your experience both as a patient and a researcher in this field. I would ask that you respect mine as board certified medical oncologist that has personally taken care of more breast cancer patients than I can count and seen far too many of them die. Second, let me say that I think we are really more in agreement than disagreement.

Now here’s my novel.

The recent USPSTF recommendation changes are as follows:

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.

This is not a blanket statement saying mammograms should not be done in any woman under 50, just not routine, universal screening mammograms offered to asymptomatic, average risk patients.

There is nothing in this statement that recommends avoiding mammograms in women at a higher risk of breast cancer such as yourself and the women described in your scenarios. Again, these women are out of the average risk pool either because they are symptomatic or because of their personal or family histories. Thus the "typical guidelines" either the revised ones of this year or the 2002 ones do not apply to them.


There is also nothing in this statement that says even an average risk woman in this age group should not get a mammogram, just that she and her physician should discuss the risks and benefits of screening.


This committee by the way is comprised of 16 individuals, all with at least an MD, PhD, MPH, RN, many with 2 or more degrees. 8 of these individuals are women, and at least 2 of those 8 women are minorities.


Now then, the study I cited regarding mammograms failure to aide in management of women with palpable tumors is, yes, just one study, but it is telling. New, palpable breast masses are breast cancer until proven otherwise and a mammogram cannot and does not substitute for a biopsy. Furthermore, there are imaging modalities for palpable breast masses – sono and MRI that in my opinion give more useful information. As a practicing oncologist (until recently) I can tell you I have seen at least half a dozen women who had palpable masses that looked "benign" on mammogram and therefore no further diagnostic workup was pursued until months or years later when palpable axillary nodes appeared, or worse, signs of metastatic disease.

I can also recall at least a few patients who suffered near fatal pulmonary emboli from tamoxifen ( yes, prescribed by me, in accordance with NCCN guidelines) used to treat mammographically detected DCIS to decrease their future breast cancer risk. The DCIS would not have been detected without a mammogram and as you know the best estimate is that only 30% - 40% of DCIS becomes invasive and thus potentially life threatening ( and we are not even sure over what the time period that occurs – 5, 10, 15 years? ) And those patients may not have ever had another breast cancer episode, even without tamoxifen, but almost died because they were treated with tamoxifen. I won’t even go into the the literature on chemotherapy induced heart failure, myelodysplasia, leukemia, radiation induced heart disease and sarcomas, etc due to treatment of even the earliest stage invasive cancers, again sanctioned by the NCCN guidelines, that may have less than a 10% chance of recurrence. Every test result has repercussions and can take you down roads you never imagined. Are the lives of these women any less important than the lives of the women whose breast cancer may be missed if we abandon universal screening in this age group (though I would contend that the women who develop breast cancer in this age group likely do have identifiable risk factors that support cancer screening, and would continue to get screened even under these new guidelines)

Also, don't forget that while many doctors make money off of treating breast cancer, just as many if not more make money doing screening mammograms and breast biopsies, many of which are benign.

The USPSTF revision in their recommendations for universal mammographic screening in women age 40-49 was largely due to the growing body of evidence revealing the risk of harm that can be done to these patients, which is not limited to false positives leading to unnecessary tests or false negatives leading to false sense of security, but also the possibility of mammogram oncogenicity, and adverse outcomes due to overtreatment. Treatment guidelines in fact have changed considerably since the last USPSTF statement on screening. Mammographically detected tumors have a better prognosis than interval tumors, therefore may not require as much treatment, and maybe, just maybe, especially in SOME cases of DCIS, don’t even need to be detected because they are not life threatening and won’t ever be. It also reflects the growing evidence that MRI may be a superior screening tool, particularly in women that are higher risk, so why should a 44 year old with an increased risk of breast cancer due to family or social history (say, BRCA 1 carrier and age at first live birth over 30) be subjected to a test that is probably inferior to other diagnostic modalities, like MRI ( though many radiologists would say she needs both)


A one size fits all approach to patient care can indeed be quite harmful.


I would like to see more resources put into patient education, and primary care provider education so that both patient and doctor can recognize who is at risk for breast cancer and needs screening. I would furthermore like to see primary care doctors’ reimbursement increase so that they can take the time needed to get an adequate family/ social history to determine individual breast cancer risk, instead of working at the dizzying pace they do now. I would like to see more time and effort put into emphasizing preventive strategies– adequate Vit D intake, exercise, breastfeeding, avoidance of HRT. Mammograms don’t prevent breast cancer. I would like to see more research into determining individual prognosis based on tumor specimens (like the Oncotype Dx test) so we know which patient, diagnosed with cancer, non-invasive and invasive, needs chemo or any treatment for that matter, and which doesn’t.

It is my hope that the latest guidelines will spur just this kind of dialogue among doctors and patients that will lead to increased awareness and more rational use of this modality, thereby improving outcomes for everyone. A 46 year old woman who has had 6 children, 3 of them before the age of 30, with no family history of breast or ovarian cancer, who does not belong to a racial/ethnic group with a high risk of breast cancer probably has a higher risk of having a false positive mammogram than breast cancer, and thus probably shouldn’t be screened. This woman was my mother 20 years ago, and whether or not she was screened, has now reached the age of 66 and has never been diagnosed with breast cancer, so did not need screening at age 40-49. I on the other hand had my first child at age 33, and have a paternal grandmother and aunt who were diagnosed with breast cancer, so I should highly consider continuing screening because my risk is greater than hers. Because of the revised statement, both women in my opinion can now have a greater role in assuring that they are receiving care that is most appropriate to them.

It is my understanding that some of the data on screening vs. not screening is a little old. After screening 40-49yo women became standard, it then would have been unethical to have a control group of women who were not screened during that decade.

But now there are conflicting guidelines, and some experts believe that that age group should be screened and some experts do not. Would this be an opportune time to test the hypothesis again? It might be ethical to test screening vs. not screening, with today's incidence of cancer and today's diagnostic and therapeutic standards. Would that be a good idea?