New government-sponsored guidelines for mammograms disclosed last month by the U.S. Preventive Services Task Force have sparked debate with consumers, health care providers, advocacy groups and politicians.
The new guidelines now call for women to start getting their mammograms at age 50, rather than at the previously recommended age of 40 years, and repeating the test every two years rather than yearly, as was previously recommended. The panel also recommends against teaching breast self-examination because the harms from excessive testing for benign problems outweigh the benefits of picking up cancers. The guidelines state that screening before the age of 50 should be an individual choice based on family history and general health.
To start with, let's dispel one misconception. The task force was comprised of doctors and scientists from academic medical centers and health care organizations from around the United States, and was not composed of a group of government employees or insurance executives sitting around trying to figure out how to cut costs. (In the spirit of full disclosure, my colleague, Kimberly D. Gregory, MD, MPH, Director of Women's Reproductive Health Services at Cedars-Sinai Medical Center, was a member of the U.S. Preventive Services Task Force.)
The changes in the recommendations from those made by the task force in 2002 are based upon new information that became available from clinical studies carried out over the last decade. This is how medicine moves forward -- as new information becomes available, it should be disseminated to physicians and the public and incorporated into our decision making. Our decisions should be based upon the most current, best available data, and then applied to individual patients in a personalized manner that takes into account their own variables that include genetic predisposition to a disease, their medical history and their degree of psychological comfort with the recommendations.
I agree with the panel's recommendation to begin screening later and to screen every two years rather than every year for women at low risk for developing breast cancer. Like all medical interventions, mammograms have benefits and risks. Based on data analysis, which was thoroughly described in a series of articles published in the Nov. 17, 2009 issue of the Annals of Internal Medicine (available to the public online), the panel determined that getting screened for breast cancer early and often leads to false alarms. The highest rate of false-positive mammograms are among women aged 40 to 49 years, who have a cumulative risk up to 56 percent of having a false-positive result over the 10 years if they receive annual mammograms. This may result in psychological distress, unnecessary additional imaging tests and biopsies in women without cancer without substantially improving women's odds of survival.
Women, with appropriate input from their physicians, need to weigh their own personal risk factors for the disease to determine when screening should begin for them. As noted, I think that recommendations, whether they are government-sponsored or sponsored by medical societies, should be data driven based on the best evidence available. And, the data we are seeing here shows that waiting is an acceptable general choice. High-risk groups should be screened earlier and more frequently, while those that are low-risk may not need it until later. Women who do not have a family history or other risk factors, but are worried or anxious to be tested, should go ahead and get tested if it gives them peace of mind.
In most women, breast tumors are slow growing. So there is little risk in extending the time between mammograms, and, in fact, there were no differences in breast cancer mortality between women who were screened annually compared to those undergoing mammography every two years. In the rare cases of women with aggressive, fast-growing tumors, they likely will not see a significant difference in survival odds with annual screening.
So how did this all end up in the middle of a political discussion? It was the timing, of course. The conclusions were immediately plunged into a partisan, political dispute. Republicans and Democrats both pounced on the recommendations as a part of the larger, acrimonious health care discussion, alleging that the opposing side's proposed reforms would lead to reduced care for patients. A House health subcommittee even held hearings about the findings.
It is entirely inappropriate for mammography recommendations to be caught up in politics. Breast cancer screening should not be used by politicians as a way to say they support women's issues, nor should it be a battle ground as they craft health care policies.
The medical community wants patients to be informed and make good decisions about their health care. That is what these guidelines should do and where they should stay -- with doctors and their patients. The House and Senate have a huge undertaking in managing our long-overdue health care policy reforms. They need to keep their focus on the big picture and develop appropriate policies, and leave care to the doctors working with their individual patients.
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