Getting Some Clarity Around Screening Mammography
In these muddy waters, can we find and fight breast cancer?
Saving lives through mammography does not have to be expensive. In fact, an informed use of current technology allows breast cancer specialists to diagnose and treat the disease better than ever before. Yet recent updates to the United States Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) breast cancer screening guidelines have muddied the waters, leaving the public, patients, and providers searching for answers in the quest to catch and cure breast cancer.
In a society steered by economics and outcomes, both panels focused on cost effectiveness, overdiagnosis, and overtreatment. These panels hoped to decrease cost and patient anxiety while maximizing the lives saved — something we all aim for in screening. However, these panels moved forward without the advice of breast cancer experts and relied on data from outdated technology, from which they concluded that fewer mammograms would be better. As a result, they proposed changing the interval and age of initiation of screening mammography. The truth is, this approach costs more through increased morbidity and mortality. Using today’s advanced technology in a smart, targeted manner, coupled with subspecialist care and improved patient education, is the best way to drive down the costs of annual mammography and reduce mortality and morbidity.
The panels expounded on the cost of false positives from screening, which lead to extra imaging and interventions. In doing so, they failed to highlight two points. First, much of their data was based on screen film, an archaic technology long ago replaced by digital mammography which has, in turn been largely supplemented by 3-D mammography. The ACS acknowledged the difference between screen film and digital imaging but failed to take this into account in to its recommendations. Second, the false positives that so concerned both panels are well within the tightly dictated parameters of screening mammography. The Mammography Quality Standards Act's FDA regulations require that the mammography facilities perform an annual medical audit to assess follow up on the disposition of all positive mammograms and correlation of pathology results with the interpreting physician's mammography report. Breast imaging radiologists work within these standards, and with the advent of 3-D mammography, they have further improved upon their performance.
Numerous clinical studies demonstrate decreased return visits and increased detection rates of invasive breast cancers with 3-D mammography. Both panels missed the value of current technology and subspecialist care.
The ACS and USPSTF panels state that the reviewed literature strongly support starting screening for average risk females at age 45 and 50 respectively, resting in the belief that false positives increase with the higher breast densities often seen in younger women.
However, the screening panel numbers are hard to justify when you consider that an estimated 25 percent of post-menopausal women have dense breast tissue. Moreover, 3-D mammography improves the evaluation of dense tissue. The National Cancer Institute has shown that 1 in 5 women diagnosed with breast cancer are ages 40–49, while other data shows that 40 percent of all the years of life saved by mammography are for women in their 40s. The ACS panel felt that a 15 percent reduction in mortality for women 40–50 was not enough, though it is only 5 percent less than that for women older than 50.
The panels also concluded that biennial screening reduces mortality as effectively as annual screening. In this day and age, reduced mortality cannot be our only endpoint; our job as medical professionals is to preserve quality of life, as well as life itself. Reducing morbidity through early detection remains a key goal of mammography. Detecting smaller, lower-stage tumors can make all the difference between breast conservation and mastectomy or the need for radiation or chemotherapy. Reducing morbidity would not only help patients lead normal, meaningful lives, but it also decrease health care expenditures — things we all want.
Furthermore, the panels critiqued outcomes and perils of screening, such as patient anxiety after false positives, overdiagnosis, and overtreatment. However, limiting access to care does not translate into preventing these entities. Rather, we should work to increase patient and provider understanding; not every abnormal mammogram means cancer, nor does each cancer diagnosis warrant a mastectomy. These facts are often obscured by underlying fear of cancer and misconceptions about treatment, which patient education can help overcome. We should provide the facts, risks, benefits, and alternatives to our patients, not only to inform but also to empower them. Instead, the panels imply that women should bury their heads in the sand and succumb to their fears. Furthermore, research and testing can help determine which lesions require intervention, countering the overdiagnosis and overtreatment arguments.
Both panels also recommended a discussion between patients and providers on personal risk. While a conversation is important, the screening panels should have mandated not only the existence of a discussion but the topics that should be covered in it as well. Unfortunately, conversations on personal risk tend to focus on family history. Less than 5 percent of cancers are genetic and 75 percent of women diagnosed with breast cancer have no prior family history. However, in a population increasingly exposed to hormones through contraceptives, diet, delayed family planning, and fertility treatments, many females fall into the high-risk category without any family history of the disease. Appropriate risk-assessment models, continued patient education on risk factors, and screening at 40 can help these women avoid potentially devastating outcomes.
Though I may be biased as a breast imaging specialist, it is alarming that neither panel brought breast care experts on board, whether imaging, surgical, or clinical. Had they done so, their recommendations would have better captured the realities of fighting breast cancer. The panels’ focus on statistics, economics, and number-crunching caused it to miss the mark when it comes to caring for patients. Instead, the recommendations better serve the insurance companies, giving them a leg to stand on when denying claims.
Thankfully, Congress stepped in to delay a change to coverage, leaving us time to un-muddy these waters. One thing that is certainly clear is that it is our job to protect our patients and preserve public health. It is our duty to empower our patients with information, optimize our use of technology and subspecialist care, and start breast cancer screening at age 40.
By Anjali Malik, MD, breast imaging and intervention specialist at Eastern Radiologists Breast Imaging Center, in Greenville, N.C.