In November 2009, the U.S. Preventive Services Task Force (USPSTF) updated its guidelines for breast-cancer screening (www.annals.org/content/151/10/716.full, accessed July 6, 2010). Although now well-known and the subject of much discussion and debate, the document took most clinicians and patients by surprise by scaling back the recommendations for women in their forties and fifties—essentially stating that in some cases, screening mammographies in this age group might cause more harm than good. The USPSTF said it revised its recommendations based on various reviews of the evidence, including one trial that estimated “the number neededto invite for screening to extend one woman’s life” to be 1,904 for women aged 40 to 49 years and 1,339 for women aged 50 to 59 years. The committee concluded that the benefits for earlier screening were “small,” whereas the potential harms for women resulting from false-positive tests (in terms of anxiety and unnecessary procedures, such as invasive surgeries and cancer treatments) were “moderate.”
Not every expert agrees. The American Cancer Society, the American College of Obstetricians and Gynecologists, and the American College of Physicians still advocate that a woman at average risk for breast cancer begin mammography at age 40 years and repeat it every one to two years (depending on the organization). The American College of Radiology (ACR) went so far as to warn that if the “cost-cutting” USPSTF recommendations are adopted as policy, “two decades of decline in breast cancer mortality could be reversed and countless American women may die needlessly from breast cancer each year” (www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/USPSTFMammoRecs.aspx, accessed July 9, 2010). The ACR deemed the USPSTF recommendations “unfounded,” and charged that they “ignore the valid scientific data” and “seem to reflect a conscious decision to ration care.”
Public reaction appears to be similarly negative. In a USA TODAY/Gallup Poll of 1,136 women conducted in November 2009, 76% believed that the USPSTF’s findings were based on cost considerations rather than scientific studies, and 84% aged 35 to 49 years said they planned to get mammograms before turning 50. The same survey, however, also indicated that women highly overestimate their risk of developing breast cancer.
One important point made by the USPSTF but largely ignored in the ensuing uproar was that clinicians need to better screen their patients and educate them about when best to begin obtaining routine mammograms. According to the USPSTF report, “The decision to start regular, biennial screening before the age of 50 years should be an individual one, and take into account patient context… .” One cannot determine patient context without talking with one’s patients. Taking a thorough family, menstrual, and reproductive history and determining genetic risk is one aspect of the conversation. This leads to education (pointing out the potential harms and limitations of mammography, which women may not understand as well as they do the potential benefits). Such knowledge empowers women to make an informed decision as to how they want to proceed.
In the end, if all the controversy has prompted more education and encouraged frank discussions between patient and provider, then it has all been worthwhile.
Judi Greif RN, MS, APNC, is a family nurse practitioner and medical writer currently residing in East Brunswick, N.J.