Major Cancer Agencies Respond to USPSTF’s New Mammography Guidelines

On November 16, 2009, the US Preventive Services Task Force (USPSTF) announced that it is changing its guidelines for mammography and no longer recommends routine screening for women between the ages of 40 and 49. The new guidelines were published in the November 17th issue of Annals of Internal Medicine. In the days that followed, many cancer organizations issued statements on the revised guidelines, a few of which are summarized below.

On December 4, the USPSTF unanimously voted to update the language of their recommendation regarding women under 50 years of age to clarify their intent that women in their 40s should speak with their physicians to make an informed decision about whether mammography is appropriate for them based on family history, general health, and personal values.

American Society of Clinical Oncology
In response to the USPSTF recommendations, the American Society of Clinical Oncology (ASCO) emphasized the following points:

"There has been a longstanding debate over the most appropriate age and frequency of mammography screening for breast cancer. There is no debate, however, over the fact that mammography reduces the risk of dying from breast cancer. As stated in the USPSTF recommendations, extensive scientific evidence shows that mammography reduces breast cancer mortality both among women aged 50 and older, as well as among women aged 40 to 49.

"While mammography is not a perfect screening tool, it is the best method currently available for detecting breast cancer in the general population.

"Today’s recommendations from the USPSTF recognize the value of mammography in reducing breast cancer deaths, affirm the importance of mammography among women aged 50 and older, and emphasize that mammography should be seriously considered in women 40 to 49 after assessment of the risks and benefits. It is therefore of concern that at present more than a third of women who are now recommended for screening are not getting regular mammograms. While the optimal scheduling of regular mammograms is being discussed by experts in the field, ASCO would not want to see any impediments to mammography screening for any woman age 40 and above.

"From ASCO’s perspective, the critical message is that all women-beginning at age 40-should speak with their doctors about mammography to understand the benefits and potential risks, and determine what is best for them."

American Cancer Society
Otis W. Brawley, MD, chief medical officer of the American Cancer Society (ACS), made the following remarks:

"The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions. . .

"[T]he overall effectiveness of mammography increases with increasing age. But the limitations do not change the fact that breast cancer screening using mammography starting at age 40 saves lives. As someone who has long been a critic of those overstating the benefits of screening, I use these words advisedly: this is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member."

National Cancer Institute
The National Cancer Institute (NCI) issued the following statement:

"NCI appreciates the US Preventive Services Task Force’s careful review and analysis of the evidence regarding breast cancer screening for women at average risk. The take-away message is that each woman needs to consider her individual benefits and risks and discuss them with her health care provider before making a decision on when to start screening mammography and how often to get one. The Task Force report concludes that screening mammography remains an important, effective tool for early detection of breast cancer. It also indicates, however, that the evidence of benefit might vary, according to age and individual risk factors.

"NCI has had screening mammography recommendations for many years, and we need to evaluate them in light of the Task Force’s recommendations -for all women, not only for those of average risk. It’s too early for us to make any decisions right now. NCI’s primary role as a biomedical research agency is to generate scientific knowledge that can be used by the Task Force and other organizations in their deliberations and recommendations. Today’s report reflects the fact that more questions need to be answered, and that will be NCI’s central focus going forward."

American College of Obstetricians and Gynecologists
The American College of Obstetricians and Gynecologists (ACOG) maintained its current advice that women in their 40s continue mammography screening every 1 to 2 years and women age 50 or older continue annual screening, stating:

"As the organization representing the nation’s ob-gyns who provide health care exclusively for women, ACOG welcomes these new review data on breast cancer screening. However, the implications of the USPSTF’s recommendations for both women and physicians are not insignificant and require that ACOG evaluate both the data and the USPSTF’s interpretations in greater detail. All women, along with their physicians, should individually assess the benefits and as well as the risks of mammography screening.

"The USPSTF also recommends against clinicians teaching women how to perform breast self-exams (BSE). At this time, ACOG’s position is that ob-gyns should continue to counsel women that BSE has the potential to detect palpable breast cancer and can be performed.

"ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential."

National Comprehensive Cancer Network
The National Comprehensive Cancer Network (NCCN) recently updated the NCCN Clinical Practice Guidelines in Oncology for Breast Cancer Screening and Diagnosis and continues to recommend annual clinical breast examinations and mammography for women 40 years and older at normal risk. Therese B. Bevers, MD, of the University of Texas M. D. Anderson Cancer Center and chair of the NCCN Guidelines Panel for Breast Cancer Screening and Diagnosis, remarked:

"For women age 40 and over, the benefits of annual breast screening continue to outweigh the risks. . . . Age should not be an absolute when determining who should receive mammography screening. It is imperative to consider the patient’s individual risk factors when considering an appropriate screening routine."

American College of Surgeons
The American College of Surgeons (ACoS) released comments strongly supporting current ACS screening mammography guidelines that recommend women get a mammogram every year, starting at age 40. The College affirmed that the ACS guidelines have resulted in an effective approach toward dealing with the possibility of breast cancer and that women should continue to follow them in consultation with their physicians.

Lamar S. McGinnis, Jr, MD, FACS, President of the ACoS and former president of the ACS, said:

"While recognizing that mammography is not perfect and supporting continuing research for improved methods, the surgical community believes that the American Cancer Society’s screening mammography guidelines offer an optimal approach to detecting breast cancer early, when it can be most successfully treated. . . Mammography is a good and safe tool, which we will continue to improve. In the meantime,” he added, “let’s save lives as best we can. . . Let us not confuse our patients and the public with mixed messages.”

American College of Radiology
Carol H. Lee, MD, chair of the American College of Radiology Breast Imaging Commission, stated:

"These unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against over the past 20 years. Mammography is not a perfect test, but it has unquestionably been shown to save lives-including in women aged 40-49. These new recommendations seem to reflect a conscious decision to ration care. If Medicare and private insurers adopt these incredibly flawed USPSTF recommendations as a rationale for refusing women coverage of these life-saving exams, it could have deadly effects for American women."

James H. Thrall, MD, FACR, chair of the American College of Radiology Board of Chancellors, noted:

"I am deeply concerned about the actions of the USPSTF in severely limiting screening for breast cancer. These recommendations, in combination with recent CMS imaging cuts, jeopardize access to both long proven and cutting-edge diagnostic imaging technologies. Government policy makers need to consider the consequences of such decisions. I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives."

Society of Breast Imaging
W. Phil Evans, MD, FACR, president of the Society of Breast Imaging, commented:

"The USPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at 40 when this approach has overwhelmingly been shown to save lives is shocking. At least 40% of the lives saved by mammographic screening are of women aged 40-49. These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives."

11 Other Health and Prevention Organizations
Eleven of the nation’s leading health and prevention organizations sent a letter to Congress that defended the USPSTF recommendations regarding breast cancer screening, in an effort to “set the record straight” about public misstatements regarding the recommendations.

In their letter to Rep. Henry Waxman, D-Calif, and Rep. Joe Barton, R-Tex, chairman and ranking Republican of a House subcommittee that held a Dec. 2 hearing on the USPSTF recommendations, the organization leaders said:

"The US Preventive Services Task Force was established as an independent body to apply rigor and objectivity to the analysis of clinical preventive care-even on issues that arouse passions and political posturing. The misstatements we have noted are evidence of both of these dangers, and the Task Force is our best defense against both.

"Our common goal is for preventive services to improve the health of all Americans. . . . We believe the Task Force is the best way to ensure we’re guided toward that goal by recommendations of experts who are guided by science, and only by science."

The letter was signed by leaders of the following organizations: American Academy of Family Physicians, American Academy of Nurse Practitioners, American Academy of Physician Assistants, American College of Physicians, American College of Preventive Medicine, American Journal of Preventive Medicine, American Public Health Association, National Association of County and City Health Officials, Partnership for Prevention, Public Health Institute, and Trust for America’s Health.