November 20, 2009
Dear Sibley Physician:
The United States Preventive Services Task Force (USPSTF) recently submitted guidelines for screening mammography that are interpreted as rejecting "routine screening mammography" for women 40-49 who are not at high risk, biennial screening for women 50-74 and withdrawal of support for breast self-examination, breast self-examination instruction, clinical breast examination and routine screening for women 75 and over.
The Task Force acknowledges that there is a decrease in mortality from breast cancer for women screened with mammography in their 40's though uses what experience and randomized control trials have shown to be a very conservative number (15% mortality decrease for women screened with mammography) allowing them to assert that there is a benefit but that "harms" outweigh benefits.
The "harms" they cite are anxiety, additional procedures and costs. Studies have shown women who present for mammography screening understand and accept the anxiety. And they accept the possibility of additional procedures to avoid dying from breast cancer. Rightly, most women are not focused on the cost of screening.
The Task Force tried to clarify their position that they were not against screening mammography, only "routine screening mammography" prompted by reminder letters and that a patient should have a mammogram after a discussion with her doctor.
We believe that this position creates a confusion and inefficiency in itself.
The following points are provided should your patient wish to have a discussion with you about screening mammography:
1. There is universal agreement that mammography saves lives.
2. 75% of breast cancers occur in women who are not at high risk for breast cancer.
3. 25% of breast cancers occur in women in their forties.
4. The most number of years of life lost to breast cancer are for women who develop breast cancer in their forties.
5. Mammography does decrease breast cancer deaths for all age groups screened, including women in their forties on the order of 30% based on real experience in the US and Europe as well as based on the majority of randomized control trials.
6. Mammography finds cancers at an earlier more curable stage.
7. Most (75%) women who die from breast cancer do not have mammographic screening.
8. There is agreement that more women will die of breast cancer if the screening interval for women 50-74 is extended from annual to biennial intervals. Allowing a cancer to grow for an additional year will result in more aggressive and morbid treatments. Earlier cancers are more favorable and can be treated with less cost.
9. Women and physicians should rely on American Cancer Society Guidelines to inform them of the best screening options available.
Why 2009 USPSTF recommendations are flawed or suspect:
1. There were no breast cancer experts on the 16 member panel. Three members are associated with insurance companies including the Medical Director of Group Health Cooperative, Medical Director/CEO of Health Partners, and a member of the Blue Cross Blue Shield Medical Advisory Group.
2. The panel is a government sponsored body, not independent.
3. The panel ignored actual experience and randomized control trials and relied on mathematical models to draw conclusions.
4. The panel commissioned its own computer models, not subjected to critical peer review. They ignored hundreds of respected journal articles and rejected both randomized control trials and already existing modeling studies.
5. The panel disregarded evidence that digital mammography is more accurate in women in their forties. Data are based on film screen mammography which is being used less and less in this country. Sibley uses all digital mammography.
6. The cost to screen and diagnose breast cancer for women in their forties should not be considered a "harm."
7. Actual harms are minimal and acceptable. The additional biopsies generated by screening mammography do not affect women in their forties as much as other age groups.
8. Although this panel cites the use of evidence based medicine their recommendations are not based on evidence. Despite documented decreased deaths from breast cancer for women in their forties they withdraw support for screening mammography. Despite admitting there will be more deaths from breast cancer for women screened biennially ages 50-74 they withdraw support for annual screening. Despite having no evidence for or against screening women 75 and older they withdraw support. Despite having no scientific evidence that screening only high risk women (who account for only 10-25% of breast cancer cases) will decrease breast cancer mortality they support screening this population.
9. Health and Human Services has so far rejected plans to modify their recommendations for screening based on this panel’s recommendations.
Rebecca A. Zuurbier, MD
Director of Breast Imaging
Irene Gage, MD
Director of Radiation Oncology
Colette M. Magnant, MD
Director of the Breast Cancer Program
The Sullivan Center for Breast Health
Sibley Memorial Hospital