Mammogram Guideline Reversal
by Jeffrey Dach MD
In a dramatic break from enshrined medical dogma, the US Preventive Task Force revised their guidelines for breast cancer screening with mammography. Published in the Annals of Internal Medicine, the age at which screening should start was revised up to age of 50. Previous guidelines started at age 40. The panel now advises against screening mammograms for the 40-50 age group because current science based medicine indicates more harm than benefit.
Another thing: The annual frequency of screening mammograms was revised to every second year for the over fifty age group, bringing the new guidelines into line with European Guidelines which screen women age 50-69 every two years.
Setting Back Evidence-Based-Medicine with Fear Mongering
The mainstream media, government and corporate medicine have opposed the revised guidelines with slick marketing techniques, using fear mongering with appeals to emotion rather than evidence based medicine. Kathleen Sebelius, for example, appeared on national television advising women to ignore her own Department's task force panel, and start your mammogram screening at 40. The opposing criticism has at times been bizarre and comical, with one author claiming the new revised guidelines will cause 47,000 deaths. This would be impossible, since this exceeds the 30,000 deaths annually before the screening era. All of these opposing views avoid discussing the real problem with screening mammography.
Is There a Mortality Benefit, Yes or No?
Suprisingly, this is still under debate because the 7 or 8 randomized trials of screening mammography found differing mortality benefits. The U.S. Preventive Services Task Force USPSTF reviewed eight randomized controlled trials (RCTs) of mammography screening. The mortality benefit depends on which of the seven or eight randomized trials you regard as valid. Two of the studies had no mortality benefit at all. That is ZERO reduction in mortality. One mammography screening study for 40-50 aged women found increased mortality in the screened group (the opposite of what is expected). The most optimistc trials reported mortality reductions of 32 %. The task force did their best to sort out the studies and finally compromised on a 16% mortality reduction as a "best guess".
The 2006 Cochrane report Screening for breast cancer with mammography reviewed the same 7 or 8 clinical trials and finally compromised on an estimated 15% reduction in mortality, same as the USPSTF task force. Considering the harms of screening mammography, overdiagnosis, overtreatment and radiation exposure, the Cochrane report concludes."It is thus not clear whether screening does more good than harm."
Screening Mammography was once thought beneficial in young women with the BRCA gene, which a carried a high risk of breast cancer. However, screening was abandoned because radiation induced cancer offset the benefits.
Instead of Mortality- Look at Local, Regional and Distant Disease Numbers
Since mortality benefits of screening mamography vary from zero to 30% depending on the study, let's take a diffent approach to the numbers by looking at 20 years of data on local vs. advanced breast cancer numbers. This is exactly what Laura Esserman did in JAMA.
She says, "there are several reasons that may help to explain why screening has not led to a more significant reduction in deaths from breast cancer in the United States. First, screening increases the detection of indolent cancers. Second, screening likely misses the most aggressive cancers. In other words, tumor biology dictates and trumps stage, so the basic assumption of these screening programs that finding and treating early stage disease will prevent late stage or metastatic disease may not always be correct."
She also says "Ductal carcinoma in situ, rare prior to widespread screening, now represents 25% to 30% of all breast cancer diagnoses (>60 000 new case-diagnoses annually)"..."Ductal carcinoma in situ is considered to be a precancerous lesion and standard of care is excision and adjuvant treatment. However, after 2 decades of detecting and treating DCIS, there is no convincing evidence of substantial reduction in invasive breast cancer incidence. The 2002 decrease in incidence leveled off in 2005 and is attributed to a reduction in postmenopausal hormone therapy use, not DCIS removal."
This point made by Dr Esserman in JAMA is important. Mammography screening is detecting large numbers of DCIS cases which are then treated with surgery and radiation with no real benefit in terms of reducing the numbers of invasive breast cancers.
The Basic Problem With Screening Mammography
Reservoir of Silent Disease
The basic underlying problem with screening for breast cancer with mammography is the "reservoir of silent disease". A series of autopsy studies show that indolent breast cancers are common in the population. These early cancers, called DCIS, are silent and rarely cause clinical disease. The most impressive study was from Denmark in 1987. The Danish group used specimen radiography on autopsy samples, which most closely approximates what screening mammography does, searching for and finding small clusters of calcifications. The Danish team found breast cancer in one out of five women, most of which was DCIS (ductal carcinoma in situ).
One out of 5 women show breast cancer at autopsy, yet only 2 to 3 women per 10,000 die from breast cancer annually. (20% vs .03%) This indicates a disconnect between the huge reservoir of silent and clinically insignificant disease, and the much smaller numbers of invasive breast cancer presenting clinically.
DCIS in 18% of the Population
Current screening mammography technology detects >60,000 cases of DCIS annually, and this is only a small fraction of total DCIS which is present in one out of five women in the population. DCIS is ductal carcinoma in situ, an early form of cancer with good prognosis, a 98% five year survival with no treatment. I expect future refinements in xray technology to allow detection of even greater numbers of DCIS cases which have small calcifications. Ultimately the technology will catch up and replicate the Danish autopsy findings.
Do we really want to be detecting DCIS in one out of five women, and submit all these women to biopsy and lumpectomy? This is exactly what is advocated by the corporate-government-media sponsored mammography screening programs.
Just Stop Calling It Cancer
Recently, an NIH panel has asked pathologists to stop calling DCIS (ductal carcinoma in situ). Here is the NIH Consensus statement: "Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS. "
Less is Better
I beg to offer a differing opinion more in line with the US Preventive Task Force revisions. The detection of massive numbers of cases of DCIS results in harmful over-treatment of the population with little benefit in terms of reduced mortality from breast cancer. This opinion is echoed by Dr Laura Esserman in a recent JAMA article on the limitations, and disappointing benefits of screening mammography.
The Solution, Cancer Prevention With Iodine Supplementation
The discovery of a large reservoir of silent disease is a wake-up call that something is dreadfully wrong. Rather than screen the population for small calcifications, called DCIS, generating massive numbers of lucrative procedures with biopsies and lumpectomies that have little impact on overall mortality, I suggest a better approach.
The evidence is overwhelming that Iodine deficiency causes breast cancer, and Iodine supplementation prevents and treats breast cancer. Iodine supplementation is a less expensive and more effective alternative to the corporate-government-media sponsored runaway train called mammogram screening. Iodine tablets are available OTC on the internet without a prescription.
Radiation Exposure Causes Breast Cancer
Another frequently overlooked problem with screening mammography is the radiation exposure. Radiation is a known carcinogen, and exposing breast tissue to radiation causes beast cancer. Dr Berrington's paper in the 2005 issue of BJC estimated that radiation exposure from screening mammography causes one death for every 2000 women screened. This number is virtually identical to the numbers cited by the US Task Force for lives saved. The US Preventive Task Force estimated that 1,900 women in their 40's would be exposed to 10 years of radiation from mammograms to save one life. This survival benefit equals the mortality from radiation exposure.
Harm From Over-Diagnosis and Unnecessary Biopsies
How do we measure the harm resulting from missed diagnosis, over-diagnosis and unnecessary treatment arising from screening mammography? In a BMJ editorial, Dr Gilbert Welch says the following:
One in 1,000 women annually screened for 10 years will avoid dying from breast cancer.
Two to 10 women will be over-diagnosed and treated needlessly.
Ten to 15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis.
One Hundred to 500 women will have at least one "false alarm" (about half of these women will undergo a biopsy).
So in conclusion, the revised guidelines which limit screening mammography to the post-menopausal over 50 age group every two years is a vast inprovement over the older guidelines, and deserves the support of health care professionals, government officials like Kathleen Sebelius, and the mainstream media.
More Articles of Related Interest:
Mammogram Awareness Month
Rethinking Screening Mammography
Screening Mammograms, a Closer Look at the Data
Links and References
http://www.newsday.com/opinion/oped/opinion-statistics-deny-that-early-screening-for-breast-cancer-saves-lives-1.1625438
OPINION: Statistics deny that early screening for breast cancer saves lives
November 27, 2009 By Barron H. Lerner, M.D., professor of medicine and public health at Columbia University Medical Center, is the author of "The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America."
How can some breast cancer survivors be absolutely sure that having a mammogram saved their lives and statisticians be equally positive that this cannot be the case? Studies analyzed by the task force compared thousands of women who received mammograms in their 40s with a matched group who did not and found that the scans rarely save lives in this age group. They miss many cancers due to dense breast tissue, while also leading to so-called false positives, nodules that look like cancer but are not. In such cases, women may undergo unnecessary biopsies and other invasive testing and experience anxiety.
http://www.latimes.com/news/nationworld/nation/chi-091116mammograms,0,1094957.story
Women in 40s advised against routine annual mammograms
In a highly controversial move, an influential government-sponsored organization is recommending against routine annual mammograms for healthy women in their 40s.
After re-evaluating scientific research on mammography's ability to reduce deaths from breast cancer, the U.S. Preventive Services Task Force says these women should consult a physician and make a decision reflecting their own preferences and values. The recommendation does not apply to women at high risk for the disease.
http://www.annals.org/content/151/10/716.full
Clinical Guidelines. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement U.S. Preventive Services Task Force*
However, the current USPSTF is now further informed by a new systematic review (7), which incorporates a new randomized, controlled trial that estimates the “number needed to invite for screening to extend one woman's life” as 1904 for women aged 40 to 49 years and 1339 for women aged 50 to 59 years. Although the relative risk reduction is nearly identical (15% and 14%) for these 2 age groups, the risk for breast cancer increases steeply with age starting at age 40 years. Thus, the absolute risk reduction from screening (as shown by the number needed to invite to screen) is greater for women aged 50 to 59 years than for those aged 40 to 49 years.
http://www.annals.org/content/151/10/I-44.full
Summaries for Patients. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendations , Screening mammography should not be done routinely for all women age 40 to 49 years.
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2009/11/18/MNLT1ALVJA.DTL
Radiation causes 1 death for every 2,000 women screened annually starting at age 40, according to a study published in 2005 in the British Journal of Cancer. Another study shows that each mammogram increases the risk of breast cancer by 2 percent. Mammography also saves women's lives, so that's why it's a trade-off.
http://www.nature.com/bjc/journal/v93/n5/full/6602683a.html
Epidemiology British Journal of Cancer (2005) 93, 590–596. doi:10.1038/sj.bjc.6602683 Published online 31 August 2005 . Mammographic screening before age 50 years in the UK: comparison of the radiation risks with the mortality benefits A Berrington de González1 and G Reeves1 1Cancer Research UK Epidemiology Unit, University of Oxford, Gibson Building, Radcliffe Infirmary, Oxford OX2 6HE, UK Accepted 30 May 2005.
Mammographic screening before age 50 years is less effective than at older ages and the associated radiation risks are higher. We estimated how many breast cancer deaths could be caused and how many could be prevented by a decade of annual two-view mammographic screening starting at ages 20, 30 and 40 years, respectively, in the UK;
In conclusion, our estimates suggest that a decade of annual two-view mammographic screening before age 40 years would result in a net increase in breast cancer deaths, and that starting at age 40 years could result in a material net decrease only if breast cancer mortality is reduced by about 20% or more in women screened.
http://www.huffingtonpost.com/lauren-cahn/a-mammogram-didnt-save-my_b_362257.html A Mammogram DIDN'T Save My Life
http://www.desmoinesregister.com/article/20091119/OPINION03/911190343/-1/debatedem/New-mammogram-guidelines-are-right-approach
Researchers weighed the risk and benefits of mammograms. It considered how many women would have to be screened to prevent a single cancer death in different age groups. (For example, 1,900 women in their 40s would be exposed to 10 years of radiation from mammograms to save one life.) The task force looked at how frequently a mammogram led to additional, unnecessary testing or biopsies. It considered the harms of false positives.
http://www.msnbc.msn.com/id/33973665/ns/health-womens_health/
New mammogram guidelines raise questions. Benefits of screening before age 50 don't outweigh risks, task force says
http://www.euref.org/
Mammography screening offered every two years to all women aged
50-69 This is in keeping with both International Agency for Research onCancer(IARC) recommendations and the European Council Recommendation onCancer.Screening..
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2009/11/18/MNLT1ALVJA.DTL
Radiation causes 1 death for every 2,000 women screened annually starting at age 40, according to a study published in 2005 in the British Journal of Cancer. Another study shows that each mammogram increases the risk of breast cancer by 2 percent. Mammography also saves women's lives, so that's why it's a trade-off.
http://www.nature.com/bjc/journal/v93/n5/full/6602683a.html
Epidemiology/ British Journal of Cancer (2005) 93, 590–596.
Mammographic screening before age 50 years in the UK: comparison of the radiation risks with the mortality benefits A Berrington de González1 and G Reeves1 1Cancer Research UK Epidemiology Unit, University of Oxford, Gibson Building, Radcliffe Infirmary, Oxford OX2 6HE, UK
Mammographic screening before age 50 years is less effective than at older ages and the associated radiation risks are higher. We estimated how many breast cancer deaths could be caused and how many could be prevented by a decade of annual two-view mammographic screening starting at ages 20, 30 and 40 years, respectively, in the UK; for all women, and for women with first-degree relatives affected with breast cancer. We extrapolated from a radiation risk model to estimate the number of radiation-induced breast cancer deaths, and used results from randomised trials, which suggest a reduction in breast cancer mortality of 10–20% in women invited to screening before age 50 years, to estimate the number of deaths that could be prevented. The net change in breast cancer deaths was defined as the number of radiation-induced deaths minus the number of prevented deaths. For all women, assuming a reduction in mortality from screening of 20%, a decade of annual screening was estimated to induce more deaths than it prevents if started at age 20 years and at age 30 years (net increase=0.86 and 0.37 breast cancer deaths, respectively, per 1000 women screened). The corresponding estimate for screening starting at age 40 years was a net decrease of 0.46 deaths/1000 women screened and a zero net change assuming a 10% mortality reduction. Results for women with first-degree relatives with breast cancer were generally in the same direction but, because their background incidence rates are higher, the net increases or decreases were greater. In conclusion, our estimates suggest that a decade of annual two-view mammographic screening before age 40 years would result in a net increase in breast cancer deaths, and that starting at age 40 years could result in a material net decrease only if breast cancer mortality is reduced by about 20% or more in women screened. Although these calculations were based on a number of uncertain parameters, in general, the conclusions were not altered when these parameters were varied within a feasible range.
http://www.huffingtonpost.com/lauren-cahn/a-mammogram-didnt-save-my_b_362257.html
A Mammogram DIDN'T Save My Life
http://www.desmoinesregister.com/article/20091119/OPINION03/911190343/-1/debatedem/New-mammogram-guidelines-are-right-approach
Researchers weighed the risk and benefits of mammograms. It considered how many women would have to be screened to prevent a single cancer death in different age groups. (For example, 1,900 women in their 40s would be exposed to 10 years of radiation from mammograms to save one life.) The task force looked at how frequently a mammogram led to additional, unnecessary testing or biopsies. It considered the harms of false positives.
http://www.msnbc.msn.com/id/33973665/ns/health-womens_health/
New mammogram guidelines raise questions
Benefits of screening before age 50 don't outweigh risks, task force says EUREF
Mammography screening every two years to all women aged 50-69
International Agency for Research on Cancer IARC.
European Council.Recommendation.on.Cancer.Screening..
http://www.medscape.com/viewarticle/712720
New Breast Cancer Screening Guidelines Opposed by Societies Laurie Barclay, MD
http://www.guardian.co.uk/society/2009/jul/10/breast-cancer-over-diagnosis
Breast cancer over-diagnosis results in unnecessary treatment for one in three
Screening for breast cancer is leading to over-diagnosis with many women undergoing unnecessary surgery and chemotherapy, scientists say Sarah Boseley, health editor guardian.co.uk, Friday 10 July 2009 08.00 BST Article history
http://www.huffingtonpost.com/dr-pete-klatsky/when-less-is-more-mammogr_b_367043.html
Dr. Peter Klatsky.Physician November 22, 2009 When Less Is More... Mammography and Paps
http://www.nytimes.com/2009/11/23/health/23cancer.html?hpw
Behind Cancer Guidelines, Quest for Data By GINA KOLATA Published: November 22, 2009
http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4194
Mammography and the Corporate Breast Medicine and Business Adriane Fugh-Berman and Alicia Bell, 11/24/2009
http://www.prospect.org/cs/articles?article=the_mammogram_mess
The Mammogram Mess Last week, new guidelines for breast cancer screening inspired a panic. Will we ever be able to discuss effective health care reasonably? Paul Waldman | November 24, 2009 |
http://blog.lib.umn.edu/schwitz/healthnews/2009/11/10-things-that.html
10 things that stand out from the mammography week to remember (forget?)
By Gary Schwitzer on November 23, 2009 8:08 AM
http://health.blogs.foxnews.com/2009/11/17/
confusion-outrage-over-new-mammogram-recommendations/
Confusion, Outrage Over New Mammogram Recommendations by Dr. Manny Alvarez
http://www.washingtonpost.com/wp-dyn/content/article/2009/11/19/AR2009111904053.html
Sebelius's cave-in on mammograms is a setback for health-care reform By Steven Pearlstein Friday, November 20, 2009
http://www.latimes.com/news/nation-and-world/la-na-mammogram19-2009nov19,0,6413481.story
Sebelius distances herself from new mammogram guidelines Her statement challenged the recommendations of the U.S. Preventive Services Task Force, made up of independent experts assembled by her department to address one of the most explosive issues in women's health.
http://www.presstelegram.com/news/ci_13815950?source=rss
Health chief says mammograms at 40 right call
MEDICINE: Sebelius says U.S. policy unchanged, despite panel's opinion.
By Randolph E. Schmid The Associated Press
Women should continue getting regular mammograms starting at age 40, Health and Human Services Secretary Kathleen Sebelius said Wednesday, moving to douse confusion caused by a task-force
recommendation two days earlier
http://www.foxnews.com/story/0,2933,575428,00.html
Doctors Divided Over New Mammogram Guidelines Tuesday, November 17, 2009
http://www.nytimes.com/2009/11/17/health/17scre.html
New Guidelines on Breast Cancer Draw Opposition By RONI CARYN RABIN Published: November 16, 2009
http://www.dotmed.com/news/story/10839
New Mammography Guidelines Could Have Deadly Effects for American Women November 24, 2009 Hologic
http://www.alternet.org/reproductivejustice/144177/
47,000_women_could_die_as_a_result_of_the_new_mammogram_guidelines
47,000 Women Could Die As a Result of the New Mammogram Guidelines By George Lakoff, AlterNet. Posted November 25, 2009.
http://www.washingtonpost.com/wp-dyn/content/article/2009/11/17/AR2009111704197.html
Mammograms and politics: Task force stirs up a tempest. search, recommendations for breast cancer screening have long been debated. Dan Eggen and Rob Stein Washington Post Staff Writer Wednesday, November 18, 2009
http://www.medscape.com/viewarticle/712473
USPSTF Issues New Breast Cancer Screening Guidelines Laurie Barclay, MD
The new USPSTF recommendations are in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society and the American College of Radiology, which have both criticized the new document. Several agencies and organizations, such as the Seattle Cancer Care Alliance, have said they will continue to follow the American Cancer Society guidelines. However, according to an article in the New York Times, advocacy groups like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network "welcomed the new guidelines."
Jeffrey Dach MD
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