The mammogram debate: the two sides

Mammogram guidelines questioned

Mammogram, the gold standard for breast cancer, is currently questioned just like what happened to prostate-specific antigen (PSA) s for prostate cancer. This was brought about by inconclusive research evidence that screening starting at 40 and beyond increases survival rates.

Last week, a heated debate started when the US Preventive Services Task Force (USPSTF) issued new federal guidelines on mammography which recommends that the starting age for mammograms to be raised to 50.

The previous US guidelines, with full backing from the American Cancer Society recommend that women should have the mammograms every 2 years starting at age 40. The recommendations applied to women with no family history of breast cancer and are therefore not considered to be high-risk. Those who have high risk profiles still need to continue regular screening tests.

The pros

The reasons for these new recommendations are quite similar in some ways to the reasons why many medical professionals (including the American Cancer Society) do not support routine prostate cancer screening with the PSA tests. Some of these reasons are:

Too many false positives that result in unnecessary but invasive biopsy
Overdiagnosis and overtreatment of a disease that is not necessarily fatal and may go away by itself.
Too many false alarms that lead into mental pressure, unnecessary fears and worries. Why worry 10 years earlier?
Mammograms present health risks, such as exposure to radiation
Upgrade to international standards.
Unnecessary healthcare costs

Indeed some of these points sound familiar in connection with the PSA test in 2008 and it was the same task force USPSTF that recommended the PSA 2008 guidelines. However, those guidelines were widely accepted, even embraced by the health community.

Regarding international standards, guidelines vary from country to country. Many developed countries, including the UK, Canada, set the age limit at age 50. I had my first mammogram 4 years ago in Germany. During my last gynecological check up here in Switzerland, I asked my doctor whether it’s time for the next one. But you are not yet 50, she told me.

Health care cost is another sore issue. Countries with universal health care system tend to cut down on screening methods that do not show conclusive benefits in order to allocate limited resources for what is necessary without compromising health care quality. Americans may dismiss this as “rationing” but it does have the upside of giving access to affordable health care to everybody.

The fact remains that there is no significant differences in breast cancer mortality between countries who start screening at 40 and those who start 10 years later.

The contras

Many health experts however, do not agree with the new guidelines

For one thing, women without family history of breast cancer can have the disease before the age 40. For these women, forewarned is forearmed. They’d rather take unnecessary anxiety than miss the chance of an early diagnosis and therefore early treatment.
Although the recommendations are not binding, there is danger that insurance companies might not cover mammogram expenses before the age of 50.

Some high profile health experts explicitly expressed their disagreement with the new guidelines.

American Cancer Society (ACS)

According to Dr. Otis W. Brawley Chief Medical Officer of ACS

“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.”

Health and Human Services Secretary Kathleen Sebelius

Secretary Kathleen Sebelius in an interview advises women to “keep doing what they have been doing” with regards to breast cancer screening.

“The task force has presented some new evidence for consideration but our policies remain unchanged.Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action. ..My message to women is simple. Mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions and make the decision that is right for you.”

Former head of the National Institute for Health Dr. Bernadine Healy

Ex-NIH director Dr. Bernadine Healy’s take is to ignore the new guidelines, which he believes, could save money but not lives.

Other resources:

Mammogram advice accurate but not ‘right’

Five Reasons to Welcome the New Mammogram Guidelines‎