The unscientific approach to the latest USPSTF mammography guidelines

With its new breast cancer screening guidelines, the United States Preventive Services Task Force (USPSTF) is taking a significant step backwards for women’s health by ignoring the proven benefits of early detection through mammography.

In the Annals of Internal Medicine, USPSTF recommends biennial screening mammography for women ages 50 to 74 years and holds that individual circumstances should dictate mammography screenings for women ages 40 to 49 years. While their grading system is confusing in and of itself, the real world implications of the guidelines are heartbreaking. Under the Affordable Care Act (ACA), insurance will no longer be required to cover mammography. In practical terms, the recommendations will severely limit patient access to a screening tool proven to detect breast cancer early, when it can be treated more easily.

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Experts agree the new USPSTF guidelines seem to stray from the science. The American College of Radiology (ACR), the Society of Breast Imaging (SBI) and the National Comprehensive Cancer Network (NCCN) continue to recommend annual mammograms for women beginning at age 40. It’s no wonder patients are confused. So how did USPSTF arrive at its conclusion?

To determine the grades for mammography screening recommendations, USPSTF weighed the benefits of screening for breast cancer against the possible harms. The primary benefit that USPSTF evaluated is reduction in deaths from the disease. It is irrefutable that mammography plays an important role in saving lives. Thanks to early detection through screening mammography, 98 percent of breast cancer patients survive.

The harms that USPSTF has highlighted in its screening guidelines include the anxiety caused by false positives as well as the invasive biopsies and other procedures that may follow. But any short-term anxiety induced by a false positive could not outweigh the thousands of lives saved each year by mammography. Moreover, in one study, most patients who experienced a false positive test result still said they support screening.

Breast cancer screening is not a zero sum game. Looking at death rates alone only tells half the story. The Task Force failed to concern itself with the role that mammography plays in early detection, which is essential to preventing diseases from progressing and maximizing treatment options. Detecting a cancer early can mean saving a life but it can also mean saving a patient from disfiguring surgery and toxic chemotherapy. It means more time at home and less time in a hospital. It gives a woman and her doctor more options for treatment and the opportunity to determine the best path forward. The Task Force failed to take any of this into account.

Ultimately, there is no reason to mandate a limited approach to breast cancer screening. Advances in medical imaging mean that, with today’s mammography, more abnormalities are found early, fewer patients have to undergo follow-up screening, time and money are saved and needless worry can be avoided.

Fortunately, Congress placed a two-year moratorium on the final USPSTF recommendations as part of its year-end omnibus spending bill.  While this is a noteworthy victory, it does not change the fact that women in the United States will be profoundly affected by the USPSTF guidelines after 2017. The guidelines will be especially detrimental for low-income women if insurance companies choose not to cover mammography and impose burdensome cost sharing for the exam.

Like all screening tools, mammography is not perfect, but the objective evidence shows that early detection not only saves lives, but improves the quality of life. It is truly disappointing the USPSTF decided to ignore these undeniable facts.  

Monticciolo is chair of the American College of Radiology (ACR) Breast Imaging Commission.

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