Originally published in MedPage Today
by Kristina Fiore, MedPage Today Staff Writer
Radiologists have rejected revised mammography guidelines from the U.S. Preventive Services Task Force (USPSTF), arguing that they are not backed by scientific evidence and will lead to unnecessary deaths.
Under the revised guidelines, “screening will begin too late and its effects will be too little,” said Stephen A. Feig, MD, of the University of California Irvine and president-elect of the American Society of Breast Disease. “We will save money but lose lives.”
The USPSTF recommended an end to routine mammograms for women in their 40s and suggested that women in their 50s be screened every two years, instead of every year.
The recommendations drew a storm of criticism from politicians, women’s rights advocates, and many doctors — particularly those who perform mammograms.
The radiologists expressed their discontent today at a special press briefing at the Radiological Society of North America meeting here.
Critics said the guidelines represent a major setback to progress derived from increased breast cancer screening over the last decades.
Daniel B. Kopans, MD, of Massachusetts General Hospital, said screening has resulted in a 30% decrease in breast cancer deaths since the early 1990s, when mammography began gaining popularity.
“Current American Cancer Society guidelines [recommending annual mammography for women starting at age 40] have been shown to save lives,” Kopans said. “The Task Force, by its own admission, said women will lose their lives. That doesn’t seem to be much of a choice.”
Feig said substantial evidence supports the use of mammography in women ages 40 to 49, citing several U.S. and international studies that have found significant benefit for the screening tool.
He said the U.S. Preventive Services Task Force relied on studies with significant methodology flaws that underestimated the benefits of mammography.
Task Force panelists “don’t know those studies underestimated the benefits,” Kopans said. “It’s a very subtle distinction.”
Radiologists say the Task Force’s decision was largely influenced by concerns about the harms of false positives.
But Feig said “you’re going to have some false positives to detect breast cancer very early,” when it is most curable.
He said alternative technologies are being investigated — such as ultrasound elastography — to minimize the need for biopsies, and if one is needed, the technology has evolved to perform it with a needle under a local anesthetic.
Feig also said that the radiation dose from mammography is extremely low and continues to fall. He said a mammogram exposes a woman to 0.3 mSv of radiation — a tenth of the dose humans receive each year from normal cosmic background radiation.
“The risk is negligible compared with the benefits of screening,” he said.
W. Phil Evans, MD, of the University of Texas Southwestern Medical Center and president of the Society of Breast Imaging, said the USPSTF panel is highly qualified, with 12 out of 16 members having multiple graduate degrees.
However, there was no breast cancer screening expert on the panel, he said.
That arose today in Washington at a House Energy and Commerce Subcommittee on Health hearing on the revised guidelines, which was attended by two members of the Task Force.
Rep. Michael Burgess (R-Texas), an Ob/Gyn, asked Task Force vice chair Diana Petitti, MD, MPH, whether there were any radiologists on the panel.
She said no, and then added that “the expertise of this panel has been called into question.”
She said radiologists were “consulted and reviewed the recommendations and provided input.”
Petitti and another member of the Task Force said at the hearing that they communicated their message poorly and didn’t mean to say women under 50 shouldn’t have mammograms.
They only wanted to emphasize that there is limited clinical evidence that the benefits of mammography outweigh the risks in younger women.
The task force, they said, wanted to convey the impression that women should still talk with their doctors, but they conceded that the guidelines failed to convey that.
This hearing is the first of two planned congressional hearings on the revised guidelines.
Radiologists also took issue with the age of 50 being the starting point for screening mammography. Kopans said no data support the use of age 50 as a threshold.
“The numbers don’t change there,” he said. “Nothing happens at 50, there’s no biological or scientific reason for this recommendation.”
Evans noted that several groups, including the American Cancer Society, the American College of Obstetricians and Gynecologists, the Mayo Clinic, the American Society of Breast Disease, and the American College of Radiology oppose the new guidelines.
Only two organizations – the National Breast Cancer Coalition and the Dr. Susan Love Research Fund — are in favor of them.
Radiologists say they aren’t clear on the motivation of the Task Force recommendations, but they may have something to do with cost. A lack of education about screening efficacy likely played a role as well, Kopans said.
“The panelists had good intentions,” he said. “But they don’t understand mammography screening.”
Feig warned that the decision will be a “disincentive for insurance groups to provide coverage for groups not included in Task Force recommendations.”
He added that technology has evolved over the years and is now better than it was when screening began.
“We are very worried that all of that progress is going to be lost,” Evans said.
The consensus among radiologists here is that physicians should continue to follow American Cancer Society guidelines to begin annual mammography screening for women at age 40.
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