Breast cancer is the most commonly diagnosed type of cancer in women. An estimated 192,370 new cases of invasive breast cancer in women and 1,910 cases in men will occur in 2009. Some 40,170 breast cancer deaths will have also occurred during 2009. The risk factors for breast cancer include age, high breast tissue density, confirmed hyperplasia, long menstrual cycles, use of oral contraceptives, having first child after the age of 30, never having children, inherited genetic mutations (BRCA 1 and BRCA 2), personal or family history of breast cancer, and having received high-dose radiation therapy to the chest for medical treatment. We do know that breast cancer occurring before age 50, especially before age 40, carries a more dire prognosis for survival.
So the, what is a woman to believe? In 2002 the same government body, with different members, came to a different set of conclusions. Now the same the same federal agency with new members on it’s committee, comes to a very different point of view, although the actual data is not that different than it was 7 years ago. It is undeniable that early detection reduces the risk of death from breast cancer. It is also true, that we do not have definitive tests for almost any cancer when it comes to determining which patients will progress and which ones will not. Additionally, we know that open screening, rather than informed, focused early detection, has lower yield overall when it comes to early detection and subsequent impact on lives saved from breast cancer death. It is also not new that there are risks with all medical test and procedures, including mammography. These include pain during the procedure, false positive results, possibly unnecessary biopsies based on those results and longer term effects of repeated low dose radiation exposure.
As such, we cannot oppose the new recommendations per se, though later it’s flaws will be exposed. What needs to be said is that this reversal will change dramatically, and quickly, health insurance coverage decisions by both private carriers and Medicare. It also means that one MUST question if this data, not that different than previous data, is being viewed through a prism of fiscal priorities. Did economics play a role in the promolgation of these guidelines? If so to what extent? If so, what was the calculus use to divine these recommendations from this board of all primary care based and oriented physicians? Why does the Agency for Healthcare Research and Quality not include in its review panel, breast surgeons, oncologists, radiologists and others who deal with the actual disease and the effects of early versus late detection?
While learned men and women can debate the statistics from the various studies in England and Scandinavia (nations with socialized health systems) that were primarily used as the data base for these guidelines, we must question openly two recommendations.
First, what is the rationale for urging doctors to STOP teaching women breast self examination techniques? Should not ANY patient who notices a change in their body – a lump, a mass – report that to their physician? If they are to notice these things, should they not be aware of the proper techniques for self physical examination? One would think so.
Second, what is the rationale for urging women to cease monthly self examination? Or examination on any regular basis? As noted above, early detection of lumps and masses, by a woman, should be the LEAST form of early detection we should expect. So why the decision to pass on this? Again, one must ask for the details of the “statistical models” that were used based on the data from Britain and Scandinavia, and wonder what economic modeling factors played a role.
The task force also seemed to feel that saving one woman’s life prior to age 50, did not warrant the added “risk” (or cost?). The task force concluded that 1 cancer death is prevented for every 1,904 women age 40-49 who are screened for 10 years, compared with 1 death for every 1,339 women age 50-74, and 1 death for every 377 women age 60-69. Yet, that calculus yields that a woman, say age 40, who misses early detection and dies from breast cancer before age 50, based on today’s actuarial survival tables, will have lost perhaps another 40+ years of survival by missing her “window of curability”.
So, this new set of recommendations raises many questions. Many of those questions go beyond the actual scientific data, go beyond the death rates and side effects, go to issues of the role of economics, financing and money. Perhaps this is the new model to be expected as the proposed Comparative Effectiveness Commissions come into full operation. While we welcome all advances in understanding of disease and its treatment, these guidelines take essentially similar data and rework the findings to meet a sensibility that appears to be in vogue within the federal health establishment. Sadly, this argument has been used before, against recommendations to carry out more aggressive early detection. The public, and worried women in this case, are caught in the middle of the confusion. Most sadly, the actual determinant of payment for these tests may well be health insurers and federal health programs, as they will look at these new guidelines and match their payment policies to them. This means that women will be facing more out of pocket expenses, insurers and Medicare will save money, but no one’s health insurance premiums will go down, that you can be sure of.
The Task Force grades the strength of the evidence from “A” (strongly recommends), “B” (recommends), “C” (no recommendation for or against), “D” (recommends against), or “I” (insufficient evidence to recommend for or against). When one looks at their actual recommendations, and the grades THEY themselves assigned it gets more confusing. Lets review them one at a time:
(1) 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 into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation). This means NO RECOMMENDATION FOR OR AGAINST
(2) The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation) This means RECOMMENDED
(3) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement) This means INSUFFICIENT EVIDENCE TO RECOMMEND FOR OR AGAINST)
(4) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement) This means INSUFFICIENT EVIDENCE TO RECOMMEND FOR OR AGAINST
(5) The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation) This means NOT RECOMMENDED
(6) The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement) This means INSUFFICIENT EVIDENCE TO RECOMMEND FOR OR AGAINST
So WHAT actually did this group come up with. Apparently only TWO real things: first, they believe women age 50-74 should have mammograms every two years; second, they recommended against doctors and nurses teaching women how to perform breast self examination. IN EVERY OTHER RESPECT, THEY EITHER COULD NOT MAKE A RECOMMENDATION FOR OR AGAINST, OR THEY ADMITTED THE EVIDENCE WAS INSUFFICIENT TO RECOMMEND FOR OR AGAINST.
In the final analysis, this report from a medical perspective is very much open to criticism for its form, data collection sources and most notably for its supposed recommendations, which are really not there. If our tax dollars are going to be used in this way, we will have expect much more from panels such as this. This report does not clarify, it muddles. Most worrisome, it opens a financial cans of worms for women of all ages as they deal with health insurers who are already looking for any way possible not to pay . . . ben kazie md
In Reversal, Panel Urges Mammograms at 50, Not 40 – http://www.nytimes.com/2009/11/17/health/17cancer.html?_r=1&hp
New Guidelines on Breast Cancer Draw Opposition – http://www.nytimes.com/2009/11/17/health/17scre.html?ref=health
US Dept of HHS: Agency for Healthcare Research and Quality – http://www.ahrq.gov/clinic/uspstfab.htm
Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement – http://www.annals.org/content/151/10/716.full
American Cancer Society Responds to Changes to USPSTF Mammography Guidelines – http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Respo
National Breast Cancer Coalition – http://www.stopbreastcancer.org/index.php?option=com_content&task=view&id=134&It
UCSF Helen Diller Family Comprehensive Cancer Center: KARLA KERLIKOWSKE, MD – http://cancer.ucsf.edu/people/kerlikowske_karla.php
Life expectancy at birth, at 65 years of age, and at 75 years of age, by race and sex: United States, selected years 1900–2005 – http://www.cdc.gov/nchs/data/hus/hus08.pdf#026
Clinical Trials by Cancer Site:Breast Cancer – http://bethesdatrials.cancer.gov/breast_cancer/index.aspx
Breast cancer in the United States: Recent trends – http://www.ajho.com/breast-cancer-in-the-united-states-recent-trends/article/157