[Fredslist] The Folly of Limited Screening for Breast Cancer

[Adrian Miller]

Hi...thought this might be of interest to some:

The Folly of Limited Screening for Breast Cancer
November 18, 2009 by Women's Voices for Change Medical Advisory Board
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Monday evening, the way that we are supposed to recommend breast  
cancer screening to women was radically shaken to the core and has  
left many physicians and their patients angered and confused.
Mammograms have been one of our great triumphs in the early detection  
of cancer, resulting in fewer deaths from breast cancer in women over  
the age of 40 years. On Monday, a panel of medical experts released  
their conclusions from a re-analysis of mammogram data, which has been  
analyzed multiple times before and resulted in our current screening  
recommendations of yearly mammography for women 40 years and above.
This panel has now recommended that for women who are not deemed to be  
at elevated risk for the disease, screening begin at the age of 50  
years and then only every two years thereafter. They cite unnecessary  
anxiety in women undergoing mammography and false positive results  
leading to negative biopsies as problems with screening women under  
the age of 50. Many women and their physicians are having emotional  
and visceral reactions to these new recommendations. My husband, who  
is a prominent academic breast surgeon in Manhattan, told me bluntly  
on Monday: “I could fill a room with hundreds of women whose lives  
were saved by a mammogram under the age of 50 years.”
It is important to take a step back and really analyze this  
recommendation, the potential motivating factors behind it, question  
why we are spending energy reanalyzing old data, and to solicit and  
review reactions from leaders in breast cancer screening and  
management. Thomas M. Kolb, M.D., who opens our discussion below, is  
widely regarded as a leader in the field of women’s health care and  
imaging.
Dr. Kolb has been on the faculty of numerous medical educational  
meetings, and he has lectured throughout the U.S. and internationally  
on the topic of breast cancer detection and diagnosis, including at  
the New York Academy of Sciences and the Radiological Society of North  
America. In 1998, Dr. Kolb published the first contemporary study  
detailing the use of breast ultrasound to detect cancers, and in 2002  
his  publication describing the performance characteristics of  
mammography, clinical breast examination and ultrasound was awarded  
the Scientific Paper of the year by the American Medical Association.  
Dr. Kolb currently a principal investigator of the North American  
Digital Breast Tomosynthesis project, which is analyzing a novel  
mammographic technology that acquires multiplanar images of the breasts.
We at WVFC will keep providing you with the best information possible  
on matters so urgent to all of us.
Elizabeth Poyner, M.D.
Co-Chair, Medical Advisory Board, Women’s Voices For Change
The Folly of Limited Screening for Breast Cancer: Why the US  
Preventive Services Task Force Recommendation is Dangerous.
The following addresses the US Preventive Services Task Force (USPSTF)  
recommendation statement, including the supporting and evidence update  
articles, published in the Annals of Internal Medicine November 17,  
2009 and as reported by the NY Times.
Their recommendations: The USPSTF “recommends against routine  
screening mammography in women aged 40-49 years. The decision to start  
regular, biennial screening 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. The USPSTF  
recommends biennial (once every 2 years) screening mammography for  
women aged 50 to 74 years.”
Analyzing the recommendations: It is important to analyze how and why  
the USPSTF arrived at its recommendations to limit screening to  
understand how it will affect you as a patient.
The current USPSTF recommendation is based on a patchwork of  
information including patient trials and mathematical models. It is  
not made on the basis of any new clinical information that contradicts  
previously accepted screening schedules. Reading the actual  
publications should give pause to anyone who has decided to forgo  
mammographic screening from ages 40-49 and to go to biennial screening  
from ages 50-74.
The Facts: Results of patient trials, including large randomized  
controlled trials performed in the 1960’s through the 1980’s,  showed  
a 15% decrease in the death rate from breast cancer in women 40-49  
years and approximately 30% in women aged 50-69 years who had annual  
screening mammograms. That means fewer deaths from breast cancer in  
women who were regularly screening with mammograms.
However, there were limitations in these studies that contributed to  
controversy as to the exact benefit in younger women, because the  
numbers of younger women screened were not as large as those who were  
older and these trials were not meant to stratify women by age. Still,  
most investigators, including the most recent previous USPSTF review  
in 2002, concluded that the benefit in younger women existed. The  
current review updates all relevant studies from 2001 through 2008,  
and concluded that, “Trials of mammography screening for women aged 39  
to 49 years indicate a statistically significant 15% reduction in  
breast cancer mortality for women randomly assigned to screening vs.  
those assigned to controls.” This re-affirms that screening younger  
women saves lives.
While this would seem to confirm the importance of screening younger  
women, the USPSTF took it one step further. Citing problems in design,  
conduct and interpretation of previous studies used to arrive at the  
current recommendation to screen younger women (which are well known  
and have been debated for over 20 years) the USPSTF decided to look at  
mathematical models to predict how well mammograms worked.
While these models themselves contain inherent limitations, it was  
found that all models predicted a decrease in the death rate, even in  
younger women. In fact, if the criteria were life-years gained (and  
not just change in death rate) the benefits of screening mammography  
would be greater in younger women than screening women older than 74  
years. Further, the models predicted that 20% of the benefit of  
screening annually would be lost by screening once every 2 years  
instead of annually.
The Controversy: So how did the USPSTF conclude that it is not worth  
screening younger women and better to screen women 50-69 only once  
every 2 years? The answer lies in the word “efficiency.”
The Task Force took all the data that pointed towards a positive  
benefit for screening younger and more often and stated it was not  
“efficient,” meaning that it was not worth expending the energy and  
resources to save the smaller numbers of younger women who would not  
die from breast cancer if they had been screened.
Moreover. USPSTF uses the potential harms of screening mammography to  
enhance its recommendation of limited screening. These include false  
positive results, anxiety and “needless” biopsy in younger women and  
in those screened annually. They admit that “harms of mammography  
screening have been identified, but their magnitude and effects are  
hard to measure,” and that “our meta-analysis of mammography screening  
trials indicated breast cancer mortality benefit (lives saved) for all  
age groups from 39 to 69 years, with sufficient data for older  
women…..Mammography screening at any age is a trade-off of a continuum  
of benefits and harms. The ages at which this trade-off becomes  
acceptable to individuals and society are not clearly resolved by  
available evidence.”
The USPSTF is clearly saying the following:
Screening with mammograms saves lives for all age groups.
More lives would be saved by screening earlier.
More lives would be saved by screening annually.
In order to improve “efficiency” less should be done at the cost of  
fewer lives saved.
Within the confines of available scientific information, there exist  
gray areas. Yet, in spite of their own conclusions as to the  
scientific evidence, the USPSTF has decided on drawing a line that  
would adversely affect women of all ages. Hopefully, it is not a  
decision influenced by the current health care debate.
Patient beware.



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Adrian Miller
Adrian Miller Sales Training
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516-445-1135 (cell)
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