The U.S. Preventive Services Task Force has announced its updated recommendations for breast cancer screening, reiterating 2009 recommendations for fewer mammograms. Peter M. Jokich, MD, director of the Division of Breast Imaging at Rush, disagrees with the newer recommendations and believes women 40 and older should continue annual exams, as the task force recommended in 2002. Here, he explains why.
Breast cancer is the most common cancer in American women: It accounts for 29 percent of female cancers, affects one out of eight women in their lifetime, and killed an estimated 40,000 people in the U.S. last year alone. Of the breast cancers that occur each year in the U.S., approximately 75 percent will be invasive, potentially fatal, cancers. Until we can develop a screening blood test or assay that is sensitive for tiny or early breast cancers, screening breast imaging — mammography — is the best means of very early detection.
If breast cancer is detected small and early stage, the chance of successful treatment is extremely high, and the chance that a woman will require a mastectomy or chemotherapy is very small. Since 95 percent of breast cancers occur after the age of 40, starting annual screening mammography at 40 is the wisest thing a woman can do.
Unfortunately, the U.S. Preventive Services Task Force recommendations are putting the risks of anxiety due to false positive mammography results and the risk of over-treatment above the benefits of potentially finding a small cancer. Adding to this problem, the task force is basing its recommendations on old randomized controlled trials using outdated technology (film/screen or analog mammography as used in the 1970s and 1980s). There has never been a randomized controlled trial using modern digital mammography as practiced in the United States.
I believe that if such a study were to be conducted, it would show convincingly that screening mammography saves lives. I estimate we’ve achieved a very significant mortality reduction with annual screening at Rush, considering our audit statistics. We also would see a significant reduction in the number of women who would need chemotherapy or mastectomy.
Don’t wait, and don’t stop
For the time being, at least, the U.S. Congress has halted implementation of the new recommendations. The latest budget bill that passed Congress and was signed into law by President Obama late last year included a clause imposing a two-year moratorium on the screening recommendations, so that the issues it raises can be debated and clarified. Therefore, insurance companies, Medicare and Medicaid will be obligated to continue to cover screening mammography at the same level, removing a potential financial obstacle for women to receive annual screenings.
I agree that it doesn’t make sense to screen younger women, given that 95 percent of breast cancer cases occur in women past 40, and considering that younger breast tissue is more sensitive to the risks of radiation. However, women in their 40s who are told to make their own decision whether to undergo mammography, as the task force has recommended, should keep in mind that more than 75 percent of women who develop breast cancer have no family history of the disease, or other significant risk factors.
Also, breast cancer among women in their 40s tends to be more aggressive and faster-growing than cases in older women, because premenopausal women still have circulating estrogen, which can fuel breast cancer. Therefore, it’s more important for us to catch these cases, making women in their 40s the last group that I would want to stop receiving annual screening mammography.
As for older women, I worry that limiting screenings to every other year puts them at risk for more advanced, and harder-to-treat, breast cancers. While these types are the minority, and breast cancer typically develops at a slower pace in older women, two years is too much time to allow such cancers to go undetected for woman unlucky enough to develop them.
Given the increasing longevity of our population — a positive development achieved in part due to early detection and treatment of all cancers — I also recommend women to continue annual mammography well into old age, as long as they are in relatively good health and have reason to believe they have a further life expectancy of at least five to 10 years. The lead time for screening to save a life typically is 10 years, so if you believe you may live another decade, and screening is not burdensome due to other health issues, I recommend it whether you’re 75 or 85.
Fortunately, women do not need to worry about the new recommendations affecting their insurance coverage
I and my breast imaging colleagues nationwide see every day how breast cancer affects women. We also see how many lives we’ve saved and how many chemotherapies and mastectomies we’ve avoided with early detection due to regular mammography. It’s why we make the same recommendation to our patients that we do to our own family members: Get a mammogram every year after 40, and don’t quit until your last five to 10 years of life expectancy.