Radiologists who reacted with shock and outrage to the U.S. Preventive Services Task Force’s (USPSTF) revised guidelines recommending that women under age 50 not undergo annual mammography say the controversy shows no signs of waning.
“We are still outraged and this issue is not going away,” said Mary C. Mahoney, M.D., director of breast imaging at the University of Cincinnati Medical Center and chair of the RSNA Public Information Committee.
Issued in November, the recommendations advising against routine mammography screening for women 40-49 years of age and for every other year rather than annually for women between 50 and 74, unleashed a firestorm of opposition from organizations such as the American College of Radiology (ACR) and the Society of Breast Imaging (SBI), which said that the recommendations could result in countless unnecessary deaths each year. Both organizations urge adherence to American Cancer Society (ACS) guidelines recommending annual mammography for all healthy women beginning at age 40.
While not legally binding, the new guidelines could already be gaining a legislative foothold, radiologists fear.
For instance, citing budget restrictions, California’s Health and Human Services Agency in mid-December decided to temporarily halt enrollment in a state breast cancer screening program for low-income women and raise the eligibility age from 40 to 50.
That development disturbed Dr. Mahoney and colleagues. “Another radiologist who e-mailed me an article about this development summed it up perfectly in the subject line: ‘It’s starting,’” she said.
In December, more than 20 members of Congress signed a letter to California Gov. Arnold Schwarzenegger urging him to rescind the decision. Regardless of the outcome, radiologists fear this is just the beginning.
“If Medicare stops covering breast screenings for women under 50, most insurance companies will follow immediately,” said Dr. Mahoney.
RSNA Panel Condemns Guidelines
Along with concurring on the lack of scientific evidence used as a basis for the guidelines, a panel of breast imaging experts at RSNA 2009 criticized USPSTF for its lack of even one breast imaging specialist on its 16-member panel. “There were no radiologists, surgeons, oncologists—no one specializing in breast cancer,” said Dr. Mahoney, who moderated the RSNA panel discussion. “That’s a real problem.”
Nor was the USPSTF panel receptive to outside advice from imaging experts, according to Daniel B. Kopans, M.D., who said he e-mailed the task force with research outlining the effectiveness of mammography but received no response.
“It’s hard for me to believe the task force thought about the implications of these guidelines,” said Dr. Kopans, a senior radiologist in the Breast Imaging Division at Massachusetts General Hospital and a professor of radiology at Harvard Medical School, both in Boston. “If they had used the actual available data and not computer modeling, by their own estimates mammography screening would be appropriate for women in their 40s.”
Dr. Kopans pointed out that the age of 50—the threshold used by USPSTF in its analysis—has no basis in science. “It is meaningless with regard to screening since none of the parameters of screening change abruptly at age 50 or any other age,” he said. “It was only by grouping data together that USPSTF made it appear as if there was a sudden change at age 50 when no such change exists; rather the parameters of screening change gradually with increasing age.”
While acknowledging that mammography is not perfect, Stephen A. Feig, M.D., a professor of radiology at the University of California Irving School of Medicine in Irvine and president-elect of the American Society of Breast Disease, called it one of the greatest medical achievements of our time and shared statistics showing a 40-50 percent mortality reduction for women ages 40-75 screened in Sweden and British Columbia.
Although task force members insist that cost was not a factor in their recommendations, Dr. Feig said women who follow them could end up paying the price.
“The net effect of the new guidelines is that screening would begin too late and its effects would be too little,” said Dr. Feig. “We would save money, but lose lives.”
- An abstract of the Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation (USPSTF) Statement, in the November issue of the Annals of Internal Medicine, is available at annals.org/content/151/10/716.full. USPSTF recommendations are available at AHRQ.gov/CLINIC/uspstfix.htm.
- To listen to the RSNA 2009 Expert Panel Mammography discussion, go to RSNA.org/Media/rsna/view_mammo_panel_video.cfm?&streamer=1.
- An abstract of Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer, is available at jacr.org/article/S1546-1440(09)00480-3/abstract.
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