The federal government released new guidelines this week that recommend some startling changes in how women should be screened for breast cancer.
Current recommendations call for most women to get a baseline mammogram at the age of 40 and to get yearly screenings thereafter.
However, the 16 member panel of the United States Preventive Services Task Force (none of whom are oncologists or breast specialists) that made the recommendations now say that women who are of average risk of contracting breast cancer should, in consultation with their physicians, begin regular, routine mammograms at the age of 50 and that yearly mammograms are not necessary.
They are also recommending that women abandon the practice of self breast exams.
When considering these new guidelines it is important to understand that the vast majority of breast cancers present as a mammogram finding or as a palpable mass in the breast.
Should one infer then that if the panel is not recommending mammogram screening and not recommending self-exam, they are then not recommending any attempt at diagnosis of breast cancer before age 50?
After receiving several phone calls from women family members looking for guidance on what to do, this surgeon (who has not done an insignificant amount of breast surgery) is recommending these new recommendations go right where they belong – in the garbage.
And, it looks like I have some company in this position. Dr. Otis Brawley, the chief medical officer of the American Cancer Society, voiced his disagreement in the USA Today, saying “The task force is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.”
Let’s take a quick look at some numbers.
An estimated 1.5% of women will develop a breast cancer between age 40-49 and approximately 6300 women each year die of breast cancer that was diagnosed in their 40s.
Many thousands more women in their 40s each year who are diagnosed and treated for breast cancer survive.
In other words, there are tens of thousands of women each year who develop breast cancer while in their forties.
Everybody agrees (including the task force) that routine mammorgram screening cuts the risk of dying from breast cancer by 15% for women in the 40s and 50s.
The rationale given in part for the new recommendations is that the benefit of picking up the breast cancers in women age 40-49 is offset by the disadvantages of doing the procedure – the expense and physical discomfort of the test and the possibility of false positives causing ultimately unnecessary biopsies and the attendant anxiety of waiting for test results.
In addition, their argument is that it is not necessary to pick up breast cancers early when they are smaller in size as many breast cancers are slow growing and can be treated with equal outcomes at a larger size.
This is double garbage.
Mammograms are a non-invasive test and if done by an experienced mammogram radiology technologist take a few seconds of moderate pressure on the breast for two views of each breast. The discomfort is trivial. Breast ultrasounds and MRIs are completely painless.
Even the pain of breast biopsies has been reduced. Most biopsies are now done via a minimally invasive technique called stereotactic biopsy that uses one injection of local anesthestic and involve a needle only being placed into the breast.
The most disturbing and patronizing argument in this whole rationale is that doing mammograms (and possibly finding breast cancers at a smaller size) might cause women to worry unnecessarily. It is estimated that after ten yearly mammograms the risk of having a false positive is between one and ten percent.
So what? The task force wants to replace saved lives with less weekend biopsy anxiety in a single digit percentage of women getting mammograms?
“Don’t worry your sweet little head about getting that biopsy, honey. Never mind that it might save your life.”
All experts agree that prognosis in breast cancer is, in part, dependent on how large the tumor is when it is removed. And although some data exists that purports that breast cancers can actually regress, the natural history of this is not clear.
What is clear is that no experienced breast surgeon diagnoses a breast cancer and then “watches it.” Treatment is begun urgently as delay will likely result in an interval increase in tumor size, thus likely worsening the stage at resection (surgical removal).
I think that women in their 40s who were diagnosed and cured of their breast cancers would not trade their cures for a slightly longer “worry-free” time in their lives coupled with a subsequent diagnosis of a much larger, palpable mass.
How many women would trade the diagnosis of a 1 cm tumor with a 90% five year survival at age 46 for a 6 cm tumor with lymph node involvement with a 25% five year survival at age 50?
It also comes down to the money. I can’t help but think about the timing of this release in view of the likelihood of healthcare reform that will possibly allow 20 million new females to obtain full access to elective healthcare and the attendant costs to the system.
Breast MRIs are expensive at $1500-$2000 but are never performed as a first step in diagnosis. Charges for mammograms run in the $80-$120 range. Ultrasounds run about $150-$300.
Compared with the tens of thousands of dollars spent on patients with terminal illnesses in the last 30 days of life, these tests that everyone agrees saves lives of women raising families and in peak professional years seem like a bargain and well worth the money.
I wonder if any of the 6300 women who die each year after getting their diagnosis in their 40s would pay $80 or $300 or even $2000 for the opportunity to have had their cancers diagnosed even earlier.