Breast Cancer Screening USPSTF

As many of you know the United States Preventive Services Task Force (USPSTF) recently came out with new recommendations for mammogram screening for breast cancer that included the recommendation that women 40-49 not be screened routinely despite approximately 35,000 breast cancers are detected in this age group each year and that each year there are over 4,000 deaths in women in their 40's. USPSTF is not a government agency but it is funded by the federal government so although the recommendations are not official US policy they are pretty close to being so in actual practice. The American Cancer Society has been very active in refuting this recommendation.

I indicated before that I thought this recommendation was entirely based upon desire for cost control with the sense that women in their 40's could go ahead and die with breast cancer as the number of cases detected by mammograms each year was not enough to justify routine screening according to USPSTF. We were assured that this was not primarily a cost saving recommendation but already USPSTF recommendations are being used to deny screening to poor women. Most states have been providing free mammogram and Pap smear screenings for the uninsured poor. But already less than a month after the USPSTF recommendations the state of New York has changed it's policy. Women less than 50 are no longer eligible for free screening unless they have a "serious" family cancer history. We will have to see how soon other states follow New York's lead.

Thought for the day

"Let justice roll down like waters and righteousness like an ever flowing stream".

USPSTF Breast Cancer Epidemiology Nonsense, Part 3

Yesterday Health and Human Services Director, Kathleen Sebelius, tried to do some damage control in regard to the the public response to the new United States Preventive Services Task Force guidelines regarding screening mammography. She said to women "keep doing what you've been doing for years" and indicated that the task force " does not set federal policy and they don't determine what services are covered by the federal government".

One of the task force members, Dr. Timothy Wilt, indicated that he stuck by the new recommendations.

I don't have anything new to say about this. I am just providing updates for those who are following this issue.

Thought for the day

Keep it simple.

USPSTF Breast Cancer Epidemiology Nonsense Part 2

Yesterday I briefly discussed the new breast cancer screening guidelines published by the United States Preventive Services Task Force (USPSTF). The USPSTF is not a government agency but is funded by the federal government and operates under a congressional mandate. The highlights and controversial aspects of the recommendations are:

Against self breast examination

Uncertainty about whether a doctor's clinical breast exam does more harm than good

and the main one- recommendations against routine mammography screening for women age 39-49

Both the American Cancer Society and the American College of Obstetrics and Gynecology have written responses challenging these new guidelines. Why the challenge? The USPSTF report indicates that screening mammography for women in their forties does more harm than good. The report indicates that 1339 women in their 50's need to be screened to save one life and that 1904 women in their 40's need to be screened to save one life. With 22,327,592 women age 40-49 in the United States as of July 1, 2008 the difference between 1339 and 1904 seems pretty small to me. 17% of all breast cancer deaths each year are in women diagnosed in their 40's. Over 45,000 deaths from breast cancer occur in women age 40-49 over a 10 year time span.

The USPSTF report acknowledges that the benefits of screening mammography for women in their forties are the same as for those in their 50's with a mortality risk of 0.85 from 39-49 and 0.86 for women in their 50's. But because of the total smaller number of diagnoses in the 40-49 age range and more false positives the USPSTF believes that due to "anxiety, distress and other psychosocial effects" the risks outweigh the benefits. I believe that the anxiety and distress caused by learning of a breast cancer that could have been diagnosed earlier far outweighs the anxiety of a false positive mammogram. The only psychosocial benefit in not screening women in their 40's is cost reduction.

I would welcome any thoughts or comments on this issue.

Thought for the day

One day at a time.

USPSTF Breast Cancer Epidemiology Nonsense

The United States Preventive Services Task Force (UPSTF) has published new breast cancer screening guidelines in the Annals of Internal Medicine. The USPSTF is not a government agency. It is an independent body financially supported by the Agency for Healthcare Research and Quality which is a federal agency. The new guidelines are a bit surprising and I am sure will generate a lot of controversy.

The new guideline recommendations are:

Against teaching breast self examination.

Against routine mammography screening for women age 40-49.

Women age 50-75 years old should have biannual rather than annual screening mammography.

Insufficient evidence to determine the benefits and harms for clinical breast exams

Insufficient evidence to determine the benefits and harms of screening mammography after age 75.

Insufficient evidence to determine the benefits and harms of digital mammography or MRI vs film mammography screening

How did they come up with this? This was determined after a meta analysis of all studies that were identified through the Cochrane Register of Controlled Trials, the Cochrane Database of Systematic Reviews, a MEDLINE search from January 2001 to December 2008, Web of Science searches, and the Breast Cancer Surveillance Consortium for screening mammography. The problem with such meta analysis studies is that they often miss the trees for the forests. They compile statistical data but do not take into account the great individual and even group differences that can be widely different and need different recommendations. The guidelines are made for everyone and that is how we end up with what I call epidemiological nonsense.

Women -don't do self breast examinations? Doctors - don't do clinical breast exams? It may do more harm than good? Don't do mammography screening for women ages 39-49 even though this analysis even shows that mammography screening in this age range results in a 15 % decrease in breast cancer mortality rates? This is nonsense . Our faith in and dependence upon large scale meta analyses has led to absurdities such as these USPSTF guidelines. These guidelines are not just absurd, they are dangerous. Women will be confused about what they should do and because of this confusion women will die who would not otherwise. These guidelines will encourage insurance companies to deny payment for mammograms until age 50. At least women can appeal these denials. Under a government run health care system there would be no recourse.

I am interested to see what other health organizations including the American Cancer Society will have to say.

Thought for the day

" Cast your anxieties upon the Lord as He cares for you"

St. Peter

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Alcohol, Breast Cancer, Million Women Study, UK

We all know that alcohol use is associated with a variety of health risks. We are also told however that low use of alcohol(one to two drinks per day) gives some cardiac protection and can lower the risk of heart disease. Recent findings from the Million Women Study in the United Kingdom show that there are other adverse effects that we need to be aware of.

1.3 million women, average age 55, have been followed for the past seven years and it is clear that alcohol use, even mild can increase the risk of cancer, particularly breast cancer. The study found that the risk exists even with one drink per day and increases with increasing use. It is estimated that 1 drink per day resulted in an increase of 15 cancers per 1000 women and that two drinks per day caused 30 more new cancer cases per 1000 women. This might not seem like a lot but translates into approximately 13% of all new cancer cases in women may be directly attributable to alcohol. In addition to breast cancer there was an increase in rectal and liver cancers and in women who smoked esophageal and oral cancers as well.

This is a reminder to me that sweeping recommendations such as drink a little to reduce heart disease have to be balanced by other factors and that we need to look at overall health in evaluating any forms of prevention and treatment.

Thought for the day

"Fools despise wisdom and instruction".

The book of Proverbs