New guidelines on mammograms a matter of dispute

Murray Rebner

The U.S. Preventive Services Task Force (USPSTF) has issued its final breast cancer screening recommendations. Similar to the group’s draft guidelines, as well as those issued in 2009, they continue to recommend that only women aged 50-74 get mammograms, and then only every other year. Multiple medical organizations and societies such as the National Comprehensive Cancer Network, the American Congress of Obstetrics and Gynecology, the Society of Surgical Oncologists, the American College of Radiology and the Society of Breast Imaging recommend annual screening mammography starting at age 40. Unlike the panel members of the task force, members of these organizations have clinical experience. They diagnose and treat patients with breast cancer. If these flawed guidelines are implemented, they will result in thousands of unnecessary breast cancer deaths.

The previous and current USPSTF recommendations as well as the new American Cancer Society guidelines actually state that annual screening mammography beginning at age 40 saves the most lives. The delayed and less frequent screening that the USPSTF promotes would not only result in thousands of unnecessary breast cancer deaths each year, it would also cause thousands more women to endure extensive and expensive treatment than if their cancer was found earlier by an annual mammogram. The task force made a subjective value judgment when it determined that the so-called harms of screening (being called back from a screening mammogram and its associated short-term anxiety, plus the very small risk of diagnosing a cancer that might not progress) outweigh its potential life-saving and morbidity-reducing benefits.

The Affordable Care Act only requires insurance coverage for exams given a grade of “B” or higher by the task force. As the USPSTF recommendations are written, women 40-49 who want a mammogram, those 50-74 who want an annual mammogram and those 75 and older who want a mammogram at all might not be guaranteed coverage. The USPSTF recommendations could effectively prevent a woman from receiving a test of her own choosing.

Anticipating these recommendations, Congress passed legislation that delays for two years any changes to insurance coverage based on these USPSTF recommendations. This moratorium will allow for a thorough analysis of the evidence as well as a thorough review of how the task force is staffed and operates. It will also continue to provide full insurance coverage to women 40 years and older.

Since mammography screening became widespread in America in the mid-1980s, the U.S. breast cancer death rate, unchanged for the previous 50 years, has dropped 36 percent. Scientifically speaking, the USPSTF appears to have used only a small selection of studies, many of them involving outdated mammogram machines. By Institute of Medicine standards, the USPSTF recommendations may not even be considered “trustworthy.”

Congress was right to call for a pause. Mammography is not a perfect test. However, until we develop improved tests or, better yet, find a cure it remains the basis for diagnosing early treatable breast cancer. As a radiologist I have seen many women saved by a mammogram because it led to early, successful treatment of breast cancer. I believe we should save the most lives possible while we work to improve the technologies related to both diagnosis and treatment.

Murray Rebner, M.D., is director of breast imaging at Beaumont Hospital.