Do you still need that annual mammogram?

For decades, the annual or biannual mammogram as a routine screening tool for the detection of early breast cancer has been a largely unquestioned event on a woman’s health calendar as soon as she turned 40.

The assumption was and continues to be that early and regular breast cancer screenings would detect cancer at its earliest, most treatable stage, and that more lives would be saved. According to the National Cancer Institute, breast cancer mortality has dropped by 35% since screening mammography became widespread in the mid-1980s. The NCI’s cancer statistics database (SEER) reports that the breast cancer death rate fell from 26.6 deaths per 100,000 women to 21.9 deaths per 100,000 women from 2000 to 2010 -- a decline of 18% (almost 2% per year).

Recently, the yearly screening mammogram has again come into question by the United States Preventive Services Task Force (USPSTF), a panel of independent experts who issue reports to the government regarding preventive care and evidence based medicine.  In April, the USPSTF came out with revised recommendations for breast cancer screening. The panel based its recommendations on its conclusion that the benefit of mammography screening increases with age, benefitting women ages 50 to 74 the most. As a result, the new recommendations call for screening mammograms to start at 50, instead of at 40, and to be conducted every other year instead of annually.

USPSTF also does not recommend that yearly screening mammograms begin automatically for women in their 40s, but instead that “the decision to start screening should be an informed, individual one, recognizing the potential benefits as well as the potential harms of mammography and based on a woman’s values, preferences, and health history.”

The task force also cited the incidence of false negative results, resulting in a cancer not being identified, and false positive results, resulting in overdiagnosis and overtreatment and accompanying psychological distress to the woman.

In 2009, when USPSTF first made these same recommendations, all major breast health organizations—American College of Radiology, the American Cancer Society, the American College of Surgeons—came forward and spoke out against them. Consequently, the recommendations were disregarded. An amendment to include coverage for annual screening mammograms was added to the Affordable Care Act.

Letters registering opposition to the revised recommendations have been sent to President Obama by the American College of Radiology, and to the Department of Health and Human Services by members of Congress. Across the country, breast cancer professionals have given their feedback to the USPSTF including the breast cancer team at Marin General Hospital. In our letter, we said:

• Adoption of USPSTF breast cancer screening recommendations would result in thousands of additional and unnecessary breast cancer deaths each year. If women ages 40-49 go unscreened and those 50-74 are screened biennially, approximately 6,500 additional women would die each year in the U.S. 
• The USPSTF guidelines deprive women of their right to choose when or if to be screened for breast cancer. The new recommendations may mean that insurance companies will no longer be required to offer screening mammography without a copay, which was previously guaranteed by the Affordable Care Act. Estimates say 17 million women could lose insurance coverage for mammography, saving corporations money, but at what price?  Women deserve the freedom to consider the risks and benefits of mammographic screening in consultation with their doctors.
• The USPSTF guidance should include a discussion of the benefits of reduced morbidity as a result of the detection and treatment of earlier stage disease. Earlier detection of breast cancer allows women more treatment options, reduced surgeries, better cosmetic outcomes, and may eliminate the need for chemotherapy.
• The current USPSTF report overstates the potential harms of annual mammography. The potential for false positives is inherent in any screening process. Past research shows, and our experience supports, that the majority of women who experience a false-positive exam support screening and feel that the benefits far outweigh this risk. Reducing access to screening should not be used as a method to decrease these presumed potential harms.

USPSTF recommendations are currently in draft form, but will come out in final form soon. We hope that they will revise these recommendations based on input from us and others.

Bottom line, to preserve women’s access to routine mammography, we believe the USPSTF should revise their recommendations to allow coverage for annual screening mammography beginning at the age of 40.

Given these reports, my colleagues and I know that women will have questions and concerns about breast cancer screening in the future. We invite you to study this issue carefully, consult with your physician, and together plan the breast cancer prevention strategy that is right for you.