On the front page of this morning’s USA Today, the headline reads “Report: Mammograms may not be needed until age 50.” The story covers the recent findings of the U.S. Preventive Services Task Force (USPSTF), published this month in Annals of Internal Medicine. In it, the “independent panel of experts” makes some rather startling recommendations. I’ll list three here with the preliminary note that I disagree with each of them. The USPSTF concluded that:
- Women under the age of 50 should not undergo routine screening (mammograms). Exceptions are women with a family history of breast cancer or known risk-elevating mutations.
- Women aged 50-74 should undergo mammograms every two years, rather than every year.
- Clinicians should not teach women to perform breast self-exams.
I’m just shocked at these recommendations. I’d like to give them my own sarcastic headlines, starting with…
Saving A Few Lives: Inconvenient
To justify the first of them, that women under 50 shouldn’t get mammograms, they conclude “For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small.” In other words, they’re somewhat certain that only a few lives will be saved. “The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results,” they wrote. It seems that a little anxiety and inconvenience outweigh the 1 out of every 1,904 women who will die each year because of this guideline (their numbers).
Give Cancer Another Year
The second recommendation, that women aged 50-74 should have mammograms every 2 years instead of every year, has a similarly ridiculous justification. “A decision analysis performed for the USPSTF projected that biennial screening produced 70% to 99% of the benefit of annual screening, with a significant reduction in the number of mammograms required and therefore a decreased risk for harms.” So, a computer model that the authors themselves didn’t even perform told them that screening every 2 years was at least 70% as effective as screening every year. I’m not an oncologist, but I do know one thing that’s universally agreed-upon by cancer clinicians: early detection is the best protection. This recommendation might save some women the “harms” of anxiety and inconvenience. It might prevent the “harm” of insurance companies paying for more mammograms. It will also give cancer one more year to appear and do its work, 1 more year to grow and metastasize to other parts of the body.
Why Should We Teach Anything?
The third recommendation that I list seems the most inane of all. Apparently, clinicians should not teach women to perform breast exams because “Adequate evidence suggests that teaching BSE does not reduce breast cancer mortality.” Great idea, guys, let’s tell the clinicians to go ahead and withold information that might save a woman’s life. Why? Because the woman who finds a lump during her self-exam is just going to die anyway. Never mind that encouraging women to self-exam, and teaching them how to do so correctly, is one of the most important exercises in breast cancer awareness, an intangible thing that probably encourages numerous women to take care of their bodies and live healthier lives.
If You Ever Want to Screw Something Up, Just Form A Task Force
As you might guess, I’m very upset by this report, by the fact that the press is picking it up, and the detrimental effect it will almost certainly have in our war against breast cancer. This is not science, it’s pseudoscience. The general recommendation of this so-called task force: let’s do less screening, because it might save some anxiety, money, and inconvenience. Seriously? Now might be a good time for a congressman to form another task force – one that would look for connections between the USPSTF and the insurance industry. Because now, you know what’s going to happen? Insurance companies are going to balk at paying for annual mammograms, refuse to cover tests for women under 50. And if a woman tell them she wants the test, because she has a family history of breast cancer, you know they’ll take that new, private information and use it to raise her rates or drop her coverage altogether.
Maybe I’m overreacting. But personally, for my friends and family, I would recommend mammograms annually for any woman over the age of 35. Because I’m happy to comfort said women in case they get anxious. I’m happy to talk to them, in the event that they’re stressed. I’m not too worried about the inconvenience of what might be unnecessary testing. Why? Because it just might save their life.
References
U.S. Preventive Services Task Force (2009). Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement Annals of Internal medicine, 151 (10), 716-726
anon says
You do realize the false positive rate of screening is 95%, right? The performance of self-examination is even worse. The fact that these techniques were put into large-scale practice at all is amazing.
source: Screening for breast cancer. JAMA. 2005 Mar 9;293(10):1245-56.
Sally says
I’m not in the medical field but I am an outraged and stunned woman of 55 who can hardly believe the blatant stupidity of this task force. From what I have read not one of the panel is practicing in oncology. The Seattle Times newspaper this morning said that the task force advises the current administration. Is this the begining of health care rationing or are these people in the pockets of the insurance companys?? Either way it really scares me. How much influence does this group really have? Are they political appointees? And thank you for putting things in perspective wtih regards to the rational behind this. Yes, I too am happy to talk and comfort those who are stressed by this life saving procedure. It’s time for us ladies to stick together in this and say enough is enough.
Matt says
Statistics are so tricksy. The same statistical result can often be re-worded to seemingly support two opposing views! I’d encourage you to read this article in the Atlantic Monthly:
http://www.theatlantic.com/doc/200911u/mammograms
…which reports this interpretation of the data:
“Dr. Donald Berry, head of biostatistics at the M.D. Anderson Cancer Center in Houston, points out that…the benefit for women 40-50 is really only 9 percent, which is not statistically significant — meaning it could represent the play of chance and not a real advantage…. Berry, who co-authored a companion paper to the task force report, calculates that a decade of mammograms in a woman’s 40s increases her lifespan by an average of 5 days .”
Dan Koboldt says
Thanks to all of you who commented or e-mailed me in response to this post. There were some who agreed with me, but the overwhelming consensus is that I overreacted, and for that I do apologize.
My initial gut reaction to the USA Today article was one of surprise and anger. That, no doubt, is exactly what the journalists intended. “Everyone wishes and thinks it has to be that early detection and screening is the solution but the data says it helps so very little,” dcgent@gmail.com commented.
Another reader, Thanatos Savehn, was more direct: “Don’t get freaked out by Bayesian approaches to decision-making,” he told me.
“Our doctors are routinely trained to evaluate clinical tests by balancing the specificity (i.e. what percentage of cancers it reveals) in addition to the sensitivity (what percentage are false alarms),” remarked crazytrainmatt@hotmail.com “New studies change this equation for well-established tests all the time.”
What many of you reminded me (some more gently than others) is that this was in fact a scientific study, and the conclusions of the panel were drawn from the best evidence available. As shocking and perhaps disconcerting as the data may be, they are what they are. I still may not agree with all of their recommendations, but I sincerely hope that these surprising steps will take us closer to defeating the terrible, resourceful, enigmantic enemy that is cancer.