USPSTF Breast Cancer Screening Guidelines Further Criticized

USPSTF Breast Cancer Screening Guidelines

Patrick Borgen, MD

In January 2016, the US Preventive Services Task Force (USPSTF) released a final version of its guidelines that closely adhered to its initial, albeit controversial, assessment of breast cancer screenings in women.

The guidelines state that women with an average breast cancer risk should not start routine screenings until age 50 and should undergo testing every 2 years subsequent to turning 50. The task force said at the time that although screening mammography is effective in reducing breast cancer mortalities among women between ages 40 and 75, the benefits do not sufficiently outweigh the risks for the broader screening programs previously recommended.

Initial outcry by medical professionals across the United States was immediate and critical, though some medical professionals feel the guidelines are justified. Now, in an interview withTargeted Oncology, Patrick Borgen, MD, chair of the Department of Surgery, head of the Brooklyn Cancer Center, Maimonides Medical Center, joins the former with a unique perspective on the decision.

"I am vehemently opposed to these recommendations. I believe they are based on 2 problems. One is that they incorporate trials that were deeply flawed, which really do not tell us what we need to know about screening," he said.

"The second problem with the recommendations is that they use survival as the endpoint, and there are other endpoints which are equally or more important. The fact that a woman can have a delay in diagnosis, but get chemotherapy, radiation, or a mastectomy, is not a consolation."

The new guidelines are as follows, separated into the appropriate age groups.

• 40-49 years:Recommends informed, individualized decision-making based on a woman’s values, preferences, and health history. (C recommendation)
• 50-74 years:Recommends mammography every 2 years. (B recommendation)
• 75 years and older:More research needed. Current science inadequate to recommend for or against. (I statement for insufficient evidence)

The US Department of Health and Human Services said the recommendations will not affect insurance coverage for mammography because of federal legislation signed in December 2015 that keeps benefits the same through 2017.

Borgen says these guidelines would likely affect the 40-49 years old age group, as breast tissue would be the most dense.

"The group in this argument with the most dense breast tissue is the 40 to 49 age group. We are not talking about whether mammograms find breast cancers in those women, which they do, but we have to remember that 50% of the life years lost to breast cancer happens in women aged 40 to 49," he said.

"We are not going to be screening those women at all. While there are challenges with digital mammography and dense breasts, it is way better to face those challenges than to simply not screen these women. The solution for the future is likely to be 3D mammography, or tomosynthesis. This sees through breast density a lot better than current digital mammography does, and my guess is that it will become the standard in the future."

The initial announcement for the guidelines came in a recnet issue of the Annals of Internal Medicine¹, alongside an editorial saying it was “time to douse the firestorm” concerning screening. The guidelines guidelines apply to asymptomatic women who either do not have preexisting breast cancer or a previously diagnosed high-risk lesion, as well as those who do not exhibit a higher risk level due to genetic mutations, family history, or a history of chest radiation at a young age.

Borgen says in regards to the pullback of screening, women will see this as a way to avoid mammograms.

"Make no mistake about it, women are not looking forward to their next mammogram. They are uncomfortable, they involve compression of the breast, and they’re anxiety provoking. Therefore, if a woman reads from the government, 'you don’t need a mammogram at 40, 45, or 47,' many women will say, 'Oh, thank goodness.' That’s a natural thing to do. We will see a decline in the utilization of mammography. Also, the stage at diagnosis will go up and we will lose more lives," he said.

At the time, Albert L. Siu, MD, MSPH, who chaired the panel examining the guidelines, said the American Cancer Society (ACS) also has recognized that the benefits of mammography increase with age. In October 2015, ACS updated its breast cancer screening guideline²to recommend women at an average risk of breast cancer should wait to undergo annual screening mammographies until they reach age 45. Additionally, after age 55, the guideline recommends shifting the schedule of undergoing a mammography to every other year.

Prior ACS recommendations, which were formulated in 2003, recommended that annual screening should begin at age 40.

"In terms of the latest iteration of the Task Force’s guidelines, I wish that this would stop. I wish calmer and cooler heads would prevail, that the data would be viewed in a constructive way, and that the big picture would be looked at," said Borgen.

"It is not just about survival, it’s about avoiding big operations that I do, or avoiding chemotherapy and radiation therapy, fertility issues after chemotherapy, and the possibility of leukemia. We want to minimize the treatment burden on the patient. The best way to do that is by finding the disease early."

In creating the final version of the recommendations, the USPSTF conducted a review of the science since its 2009 recommendation. The draft recommendation was available for public comment from April 21 to May 18, 2015.

References

1. Siu AL on behalf of the US Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement [published online January 11, 2015].Ann Intern Med. doi:10.7326/M15-2886.
2. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society.JAMA. 2015;314(15):1599-1614.