November 17, 2009 — Most women should begin routine mammograms to screen for breast cancer at age 50, not 40 as previously recommended, according to new guidelines from the U.S. Preventive Services Task Force that aim to reduce harm from overtreatment, the New York Times reports. According to the Times, the new guidelines differ significantly from the task force's last recommendations and from those of other groups. The changes "are likely to touch off yet another round of controversy over the benefits of screening for breast cancer," the Times reports (Kolata, New York Times, 11/17).
The task force -- an independent panel of primary care and prevention experts appointed by HHS -- also said that women ages 50 through 74 should receive mammograms every other year, not annually, because biannual exams offer nearly the same benefits but are about 50% less likely to do harm. The task force does not recommend breast self-examinations, which it said have not been shown to reduce breast cancer death rates. In addition, the panel found insufficient data concerning the benefits of screening after age 74, as well as on whether newer types of mammography are superior to regular film mammograms (Wilson, "All Things Considered," NPR, 11/17). The guidelines do not apply to women who have a high risk of breast cancer based on family history or genetic mutations, such as the BRCA1 or BRCA2 genes.
Harms Outweigh Benefits, Task Force Says
The task force reviewed research published since it last issued breast cancer screening guidelines in 2002 and considered new analyses of the data (Wang, Wall Street Journal, 11/17). In setting the new guidelines, the experts weighed the benefits of early screening against the risks -- namely the high chance that a mammogram could result in a "false positive" for women, prompting unnecessary treatments and stress. Women in their 40s are 60% more likely to face harm from mammography than women older than age 50 but are much less likely to have breast cancer (Kolata, New York Times, 11/17). For women ages 40 through 49 screened every year, one cancer death is prevented for every 1,904 women screened. For women ages 50 through 74, that ratio drops to one death prevented for every 1,339 women screened, and from ages 60 through 69, it drops to one death prevented for every 377 women screened (Kolata, New York Times, 11/17). According to Diana Petitti, vice chair of the task force, "We're not saying women shouldn't get screened. Screening does save lives. But we are recommending against routine screening." She added, "There are important and serious negatives or harms that need to be considered carefully." Among those harms is the fact that "there are some breast cancers detected that grow very slowly and would never have killed you," Petitti notes (Stein, Washington Post, 11/17).
The task force also stressed that decisions on when to undergo mammography should be made in consultation between doctors and patients ("All Things Considered," NPR, 11/17). In the last two years, nearly two-thirds of women in their 40s and 72% of women ages 50 through 65 had mammograms, according to an accompanying editorial by Karla Kerlikowske, a professor in the University of California-San Francisco's Department of Medicine, Epidemiology and Biostatics (Kolata, New York Times, 11/17). Petitti said, "The task force isn't saying there isn't a benefit" to screening women in their 40s, but "we're saying the benefit is small. The change really is a change between do it routinely and don't do it routinely" (Wall Street Journal, 11/17).
New Guidelines Draw Praise, Ire From Groups
The new guidelines were well received by some advocacy groups, such as the National Breast Cancer Coalition, Breast Cancer Action and the National Women's Health Network. The National Cancer Institute announced Monday that it would reconsider its own guidelines due to the new research (Kolata, New York Times, 11/17). CMS said that the new guidelines will not alter how those programs cover mammograms (Wall Street Journal, 11/17). Congress currently requires Medicare to cover annual mammograms. The effect of the new guidelines on private insurers is less clear. According to the Times, "The guidelines are not expected to have an immediate effect on insurance coverage" in the private market. Every state except Utah currently mandates that private insurers pay for mammograms for women in their 40s. But Margaret O'Kane, president of the National Committee for Quality Assurance, said that her organization would change the way it grades private insurers, based on the release of the new guidelines. Grades are now partially based on the percentage of patients enrolled in a plan who receive mammograms every year or two years after age 40. That measure will now consider women ages 50 and older (Kolata, New York Times, 11/17).
While some advocacy groups were receptive to the new guidelines, other experts considered them misguided and potentially dangerous. Marisa Weiss, an oncologist at Lankenau Hospital and the founder of Breastcancer.org, said, "I'm riled up; this is a giant step backward and a terrible mistake. We know mammography over-performs and finds things that will never be life-threatening, and we know it under-performs in some women. But it has no chance to perform in women who don't get it" (Rabin, New York Times, 11/17).
Some groups that issue guidelines on screening and cancer prevention criticized the task force's recommendations. The American Cancer Society and the American College of Obstetricians and Gynecologists said their guidelines would remain intact despite the new research, although ACS reviews its recommendations each January (Graham/Maugh, Los Angeles Times, 11/17).