Breast Cancer: New Recommendations Reflect Poorly

Mammography screening is one of the major health care advances of the past 40 years. With the onset of routine mammography screening, the death rate from breast cancer has decreased by 30 percent since 1990, even though it was unchanged for the preceding 50 years. Mammography screening means that cancers can be detected sooner, allowing women to choose less invasive treatments that help to preserve the quality of their lives as well.

Newly revised U.S. Prevention Services Task Force (USPSTF) recommendations could reverse this decline in breast cancer morbidity and mortality, causing undue suffering to women facing breast cancer. In a decision that dismisses many scientific studies and data analyses, the Task Force ignores the physical and psychological harms of more aggressive treatments required for advanced cancers, and is not prioritizing saving lives.

The federally supported U.S. Preventive Services now recommends against the following routinely accepted procedures:

• Routine screening mammography in women age 40-49;

• Teaching breast self-examinations;

• Clinical breast examinations;

• Screening for women 75 years or older; and

• Annual screening mammograms for women age 50-74 (recommending screening every other year).

USPSTF is recommending against all commonly accepted routine breast cancer screening methods for women in their 40s despite its statement that the 10-year risk for breast cancer in a 40-year-old-woman is 1 in 69. It also rescinds its previous recommendation providing for screening beyond 74 because "the shortened life among women 75 and older" makes it more likely that she could die from another cause before the cancer kills her.

As acknowledged in the research of the task force, if regular mammography screening does not begin until 50, more women will die of breast cancer. The task force also acknowledges that more lives will be lost if screening is not performed annually after 50. What then is the value of human life?

The USPSTF estimates that the mortality reduction for screened women aged 40-49 is 15 percent and for women 50-59 is also 15 percent. However, according to the USPSTF, approximately 1,900 women need to be screened to save one woman in her 40s, 1,300 women need to be screened to save one woman in her 50s, and 600 women need to be screened to save one woman in her 60s. They reason that because more screenings for women age 40-49 are needed to save one life than in the other age groups, the harms of screening mammography are too great to justify screening beginning at 40, despite a similar mortality reduction. The impact of screening-detected cancer on a younger patient's life and her family by saving her from dying from breast cancer cannot be overstated.

USPSTF selectively reviewed the literature and used computer models, ignoring hundreds of well-regarded scientific studies on the subject. This is not based on direct data or a new clinical trial.

The scientific basis for the value of screening mammography has been proven previously in numerous evidence-based clinical trials that clearly show a major benefit for all populations who were screened, including the 40-49 year group.

Swedish clinical trials showed a decrease in mortality from breast cancer of greater than 40 percent for the 40-49 year group. In Malmo, Sweden, there was a 35 percent mortality reduction for women 40-49, and in the Gothenberg trial, a 44 percent reduction in breast cancer deaths in the screening group.

It is unscientific to compare a 40-49-year-old group to women who are 50-74, as done by the Task Force. Breast cancer incidence increases per decade and the incidence in women in their 40s is very similar to those in their 50s. In women in their 80s, breast cancer incidence is higher than in women in their 70s. As far as risk is concerned, only 10 percent to 25 percent of breast cancers occur in high-risk women. Not screening the others would miss 75 percent to 90 percent of breast cancers.

Other professional and scientific organizations, including the American Cancer Society, have not changed their guidelines -- which are to screen women with mammography yearly beginning at age 40.

The Ellen Shaw de Paredes Breast Cancer Foundation bases its recommendations on scientific data which have clearly shown that women's lives are saved by performing screening mammography annually beginning at age 40. Women at high risk may need earlier screening and screening with additional modalities, such as breast MRI.

We are strongly opposed to the proposed change in screening guidelines by the U.S. Preventive Services Task Force. Changing the guidelines would be a major setback in the advancement we have made in improving women's lives through early detection.

Ellen Shaw de Paredes, M.D., FACR, is a Richmond radiologist specializing in breast imaging. She lectures internationally on mammography, wrote the textbook "Atlas of Mammography," and is founder of the Ellen Shaw de Paredes Breast Cancer