A letter from Dr. Jerome Schroeder, Medical Director of Imaging for the Exempla Saint Joseph Hospital Breast Care Center. Should you wish to speak with him he directly, he can be reached at 303.318.3416.
As you might have heard, in mid-November 2009, the United States Preventative Services Task Force (USPSTF) released new guidelines regarding screening mammography, eliminating the recommendation for screening altogether in averaged-risk women in their 40s and changing their recommendations to every-other-year screening in average-risk women aged 50-70.
The USPSTF cited research data indicating that, because it takes over 1900 women in their 40s invited to be screened in order to save one life, the costs were not worth it, despite acknowledging data that prove that the benefit of screening women in their 40s is equivalent to screening women in their 50s. They also pointed out that too many costly procedures overall are being performed and too many ‘non-killer’ cancers are being diagnosed, leading to unacceptable anxiety and ‘inconvenience’ to women subjected to these procedures.
What the USPSTF is ignoring, however, is robust data collected over the last 20+ years which actually put the decrease in the death rate for women screened from age 40 and older at over 40% and, in some populations, closer to 50%. The data are clear that, more than any other intervention, screening mammography is primarily responsible for the decrease in the death rate that we have witnessed since 1990. Furthermore, the decline in death for women in their 40s has been 3.3% per year since 1990, a full percentage higher than the 2.3% annual decline seen in the population as a whole. Although only 15% of breast cancers occur in women in their 40s, over 41% of life years lost to this disease are lost in this same patient population.
In terms of ‘undue anxiety’ or the ‘inconvenience’ of performing additional tests and biopsies, to claim that adult women are incapable of handling this is an insult at best and, at least, very paternalistic. Studies have consistently shown that, even with additional anxiety over having to have additional tests and/or biopsies, most women are grateful for what they perceive as ‘thoroughness’ and few, if any, say that their experience will keep them from returning for screening the following year.
Some feel that this report is the ‘opening salvo’ in the government’s attempt to reign in runaway health care costs. In this light, this may not be an attempt at ‘rationing’ as some claim, but rather to seriously look at what we have dogmatically done in medicine and ask the question ‘why?’ Personally, I think that there are other places to look rather than at a program with a proven track record of saving lives. Nevertheless, proponents of mammography have never claimed it to be perfect and it is well known that, in dense breasted women, it can miss up to 30% of cancers. Instead of ‘throwing the baby out with the bath water,’ though, perhaps we should refine for whom we recommend screening mammography based on risk and breast density, instead of arbitrary age groups, and come up with a better screening test for the rest. Breast MRI exam speeds and costs are approaching those of digital mammography. Could this replace mammography in certain women as a yearly screening exam? Its sensitivity for invasive cancers approaches 100% with no radiation to the breasts.
As we have become more sophisticated in understanding the genetics and biology of breast cancer, we are now able to accurately predict whether certain cancers need or do not need chemotherapy. As this research continues, it is a very realistic possibility that, when any cancer is diagnosed, tests will be able to tell us who does and does not need any treatment at all. Until we can accurately predict type, grade and stage of a cancer with imaging alone, however, we will still likely need to continue to perform biopsies to make the most accurate diagnosis. This will require the continued screening of women of all defined age groups.
If anything, these new guidelines have re-opened the debate and dialogue between patients, their providers and mammography specialists. Hopefully, in the end, this debate will result in more accurate screening and treatment approaches for this most common female cancer which do not arbitrarily exclude a population of women, ignoring the clear benefits to finding breast cancers at their earliest, curable stages. In the meantime, the policy and recommendation for yearly screening for all women aged 40 and older will remain those of the Breast Care Center at Exempla Saint Joseph Hospital.
Sincerely,
Jerome Schroeder, MD
