Sunday, March 28, 2010

FAQ's About New Guidelines for Breast Screening in Women under age 50

I was pleased to give a talk recently to the Wellness Council of greater Cleveland about the new guidelines for breast screening issued by the US Preventive Services Task Force.

Many women were understandably confused by conflicting news reports when the guidelines were issued last fall.  Fortunately, National Breast Cancer Coalition developed an excellent list of  frequently asked questions to help women understand the new guidelines and discuss them with their physician.  Following is a sample of just a few of the questions and answers. You can read the rest at this link.

What does the Task Force say about breast cancer screening?

On November 16, 2009, the Task Force released the following new guidelines for healthcare providers:

•    The Task Force does not recommend that women automatically begin mammography screening at the age of 40.  Instead the Task Force recommends that 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.
•    The Task Force recommends every other year screening mammography for women aged 50 to 74 years.
•    The Task Force concludes that there is not enough evidence to determine the harms and benefits of screening mammography in women over 74.
•    The Task Force recommends against healthcare providers teaching breast self-examination.
•    There was not enough evidence for the Task Force to make a recommendation on clinical breast examinations, digital mammography, or MRI

Does this mean that women in their 40s will not be able to get mammograms?

NO.  That is a misrepresentation of what the Task Force said.  The Task Force said that the decision to start regular mammography before age 50 should not be automatic but should be an individual decision and take into account the patient’s values regarding specific benefits and harms. It gives women more control over their health care decisions.

Has breast cancer screening had a significant impact on mortality from breast cancer?

No, over 40,000 women continue to die of breast cancer each year, despite the emphasis on breast cancer screening in our country.  To change this, we must address the facts about breast cancer and not simply accept what we want to believe.  The fact is that all breast cancers are not equal and that we don’t currently have tools for “early detection” that are good enough for the life-threatening breast cancers.

But doesn’t early detection save lives?

Not necessarily. Some breast cancers are slow-growing and have a good prognosis, whenever they are found, whether small or large.  Other breast cancers are aggressive and fast growing, and we don’t have the tools to catch them early enough or treatments that will work.

Why doesn’t mammography work as well for women in their 40s?

Younger women have more dense breast tissue, making mammography less accurate.  Also, mammography is better at detecting slower growing tumors more common in older women, than the fast-growing, aggressive tumors more often found in younger women.  And the balance of benefit vs. harm changes as women get older since the likelihood of breast cancer increases with age.  The disease is relatively rare in younger women.

But shouldn’t a woman in her 40s have a mammogram if she feels a lump?

Certainly. The Task Force recommendations are meant to be guidelines for broad public health policy for healthy women with no symptoms, and an average risk for breast cancer.  These guidelines are not meant for any woman with an increased risk or for any woman who feels a lump or change in her breast.  Women who have any concerns need to visit their doctors and may need diagnostic mammograms.  Mammograms taken to assess a problem are not the kind of mammograms we are talking about with these guidelines.

What’s the harm in trying to detect breast cancer early, even if our methods don’t work that well?

The harms from screening too early or too often include increased false positives, leading to increased imaging and radiation exposure, biopsies and scarring that can affect the accuracy of future mammograms, and anxiety.  There is also the harm of overdiagnosis of breast cancer.  This would involve treatment of cancers that would never be life threatening, and treatment of cancers that may regress, or go away on their own.  The treatments for breast cancer are not aspirin, they are toxic and can be life threatening; the scenario of overdiagnosis should not be taken lightly.

A mammogram/self examination found my breast cancer and I am alive today so these methods clearly work, right?

It is understandable that many people would think that they are alive today because their breast cancer was discovered through screening. But this makes many assumptions that just can’t be known, such as how life-threatening the cancer would have been, if the cancer may have regressed on its own, and whether the cancer would have been discovered in other ways and would have had the same prognosis. The point is, individual stories are not evidence of effectiveness.  Detection, screening, breast cancer…these are all very complicated issues.

Look at bone marrow transplant for breast cancer.  It seemed to make sense: if chemotherapy works, maybe even more chemotherapy would work better.  Bone marrow transplant is a method of giving patients lethal doses of chemotherapy, then replacing their bone marrow.  It was believed that level of dosing would kill all the cancer.  And in some cancers, usually blood based, it worked.  So women with breast cancer received this incredibly toxic treatment outside of clinical trials.  When the trials were actually performed and we had the scientific evidence, it showed that not only was bone marrow transplant not more effective than standard treatment, but it actually resulted in deaths from the treatment itself.  Health care should always be based on the highest level of scientific evidence or well designed studies to get that evidence.

Isn’t it better to give women a simple public health message?

These issues are complex. We would like it to be a simple message, but we also want it to be truthful. Women deserve the truth and are capable of understanding the facts and making their own decisions.

Aren’t these guidelines really about saving money?

These recommendations are not about saving money or about the current health care debate.  The Task Force began their review of breast cancer screening well over two years ago.  The recommendations and accompanying scientific literature were published in the Nov. 17 issue of Annals of Internal Medicine.  The recommendations were made by scientists and physicians based on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit.  There were no economists involved and the recommendations were not based on considerations of cost. 

The full list of FAQ's is very helpful and informative, so please make sure to read all of them. You can download your own copy at NBCC's site and share it with your friends and family.  Here's the link.

Please also take a moment to review NBCC's detailed analysis of the USPSTF recommendations and learn more about the importance of high quality scientific evidence in  developing health guidelines for breast screening.  Link to NBCC analysis

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