THE MAMMOGRAM CONTROVERSY

Reatha Williams, D.O.

• For women at average risk

• For women at higher than average risk

American Cancer Society

Updated Recommendations for Breast Cancer Screening

American Cancer Society New

Recommendations for women at average risk

• Women ages 40-44 should have the choice to start

breast cancer screening with mammograms if they wish

to do so. The risks of screening as well as the benefits

should be considered

• Women 45-54 should get mammograms every year

• Women age 55 and older should switch to

mammograms every 2 years, or have the choice to

continue yearly screening

American Cancer Society New

Recommendations for women at average risk

• Women ages 40-44 should have the choice to start

breast cancer screening with mammograms if they

wish to do so. The risks of screening as well as the

benefits should be considered

• Women 45-54 should get mammograms every year

• Women age 55 and older should switch to

mammograms every 2 years, or have the choice to

continue yearly screening

• Screening should continue as long as a woman

is in good health and is expected to live 10 more

years or longer

• All women should be familiar with the known

benefits, limitations, and potential harms

associated with breast cancer screening. They

should be familiar with how their breasts

normally look and feel and report any changes

to a health care provider right away.

Guideline's History

• 2001. Canadian Task Force-mammograms age 40, every 1-2 years

• 2003. ACS recommended screening mammograms starting at age

40 and annual CBE after age of 40

• 2002. AMA and 2006 NCCN. made similar recommendations

• 2009.USPSTF recommended that women 50-74 yrs of age are most

likely to benefit from biennial mammography screening and

evidence did not support mammography screening for women

aged 40-49.

• 2010. SBI recommended that women at average risk should begin

annual screening mammography at age. 40.

Current Guidelines Offer Conflicting Advice

• ACS, ASR, ASBS, USPSTF, NCCN, ACOG, etc all

offer different guidelines for breast cancer

screening.

• The contradictions have caused confusion

• Greater need for clarity

• Requiring physicians to adapt a more

comprehensive approach to determining risk

Current Guidelines Offer Conflicting Advice

Questions

• 1. What age should I begin screening mammograms?

• 2. How often should I be screened?

• 3. At what age should I stop?

• Guidelines advise people about what screenings they

should get and when they should get them

• Some screening tests find growths and they can be removed

before they have a chance to turn into cancer

• Other screening tests can find a cancer early when it's

easier to treat

• Guidelines also explain the limitations and risks of

screenings

• Help many people in the general public and health care

professionals, as well as policy makers and insurance

companies make important health decisions

Purpose of Guidelines

Benefits of routine screening mammography

• Earlier detection

• Cancer diagnosed at earlier stages

• Saves lives

• Less cost for treatment

• Less stress for patient and family

• Less morbidity

Risks for routine screening mammography

• False positives

• Increased procedures

• Increased cost

• Increased anxiety

• Over diagnosis

• Increased radiation

USPSTF U.S. Preventative Services Task Force

American College of Radiology

• Annual screening mammography for asymptomatic women age 40 and older

who are at average risk

• Women with a known genetic mutation with increased breast cancer risk-yearly

starting age 30

• Untested women with first-degree relative with known BRCA mutation-yearly

starting age 30

• Women with 20% or greater lifetime risk for breast cancer-yearly starting age

30, or 10 years earlier than the age at which the youngest first-degree relative

was diagnosed, whichever is later

• Women with history of chest radiation received between ages of 10 and 30-

yearly starting 8 years after the radiation therapy, but not before 25

• Women with bx-proven lobular neoplasia, ADH, DCIS, invasive breast ca, or

ovarian ca-yearly from time of diagnosis, regardless of age

American College of Radiologists

• There is no defined upper age limit at which

mammography may not be beneficial

• Screening mammography should be considered as

long as the patient is in good health and is willing

to undergo additional testing, including biopsy, if

an abnormally is detected

American Society of Breast Surgeons

Recommendations for Average Risk Women

• Discussion with her physician to consider screening

mammography at age 40-44 based on a balanced

discussion of risks and benefits

• Most studies show a decrease in breast cancer mortality

from screening starting at age 40 but in the group 40-49

there is a higher false positive rate

• Patients should discuss screening with their physician

including risk assessment to determine if they are average

risk

• Annual screening for women ages 45-54 as

indicated by the new ACS guidelines

• Biennial screening for women over the age of 75

if an estimated life expectancy is greater than 10

years

• Breast tomography may be considered for

screening because early data shows promise in

higher sensitivity and specificity rates with data

from large randomized clinical trials pending

MORATORIUM 2 YEAR

• Regarding changes to insurance coverage for

breast cancer screening, as outlined by the

USPSTF 2016 recommendations

• For private insurers, this means they will continue

to follow the task force's 2002 recommendations

• Women 40 years of age and older should undergo

screening mammograms every one to two year

• Keep the window open for more accessible

screening mammography

• If Insurance coverage for breast screening is

gone, many women may not have access to a

tool that could save their lives

Affordable Care Act

• Grading scale for private insurance coverage

• "A" or "B" by the USPSTF are covered with no copay

• Grade "C" assigned to routine screening of women ages

40-49

• Women less than 50 years of age who want to have a

mammogram may not be guaranteed coverage under the

ACA, if the 2016 USPSTF recommendations are adopted.

• The same is true for women ages 50 to 74 who prefer

annual screening

• Moving away from yearly screening in women 40

years of age and older endangers women, would

cause needless death, and would simply not be

good breast cancer screening policy

• If we look back at two of the purposes of

screening guidelines

• Some screening test find growths and they can

be removed before they have a chance to turn

into cancer

• Other screening tests can find a cancer early

when it's easier to treat

Protecting Access to Life

Saving Screening (PALS)

• Part of Consolidated Appropriations Act approved

at the end of 2015 to fund the government for one

year

• Designed to protect access to screening

mammographies for women 40-74 by posing a 2-

year moratorium on implementations of the latest

USPSTF breast cancer screening recommendations

False Positives

• USPSTF recommends biennial screening mammography for age 50-74 because women in this age range at average risk gain the most benefit from screening at this frequency

• Women 40-49 with a family history may benefit more than average-risk women from beginning screening at an earlier age

• While screening mammography in women 40-49 may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false positive results and unnecessary biopsies is larger

• Therefore the balances of benefits and harms is

likely to improve as women move from their

early to late 40's

Short Term Anxiety

• This can occur because of mammography results

with false positives

• This anxiety is short-lived and has no lasting effect

on women's health

• Short term anxiety from results and the

comparatively small numbers of mammogram false

positives do not outweigh the thousands of lives

saved each year by mammography.

• These mammograms can detect cancer

early, when it is most treatable and can be

treated less invasively

• Not only can this save lives but helps

preserve quality of lives

• False positives can cause women anxiety

but they would be more anxious if we didn't

find cancers early

Many women are afraid of their first mammogram, and

even if they have had them before, there is fear.

But there is no need to worry.

By taking a few minutes each day for a week preceding

the exam and doing the following practice exercises,

you will be totally prepared for the test, and best of all,

you can do these simple practice exercises right in

your home.

EXERCISE 1:

Open your refrigerator door, and insert one breast

between the door and the main box.

Have one of your strongest friends slam the door shut

as hard as possible and lean on the door for good

measure.

Hold that position for five seconds.

Repeat in case the first time wasn't effective.

EXERCISE 2: Visit your garage at 3 a.m.

when the temperature of the cement floor is just

perfect. Take off all your clothes and lie

comfortably on the floor sideways with one

breast wedged under the rear tire of the car.

Ask a friend to slowly back the car up until your

breast is sufficiently flattened and chilled.

Switch sides, and repeat for the other breast.

EXERCISE 3:

Freeze two metal bookends overnight. Strip to the waist.

Invite a stranger into the room. Have the stranger press

the bookends against either side of one of your breasts

and smash the bookends together as hard as he/she can.

Set an appointment with the stranger to meet next year to

do it again. You are now properly prepared!

Over Diagnosis

• All women undergoing regular screening

mammograms are at risk for the diagnosis and

treatment of noninvasive and invasive breast cancers

that would otherwise not have become a threat to their

health, or ever apparent, during their lifetime

• So beginning screening at a younger age and

screening more frequently may increase the risk for

over diagnosis and subsequent over treatment

Who Decides

• Women need a clear idea of what they're

choosing

• They shouldn't have that decision made

for them by a task force that is out of

touch

• There is no confusion among people who

understand the data

• The confusion is among people who want

to pick and choose isolated studies when

making their recommendations

• There are many criticisms of the USPSTF Study

• It relied on 30-40 year old data

• They ignored studies that show improvements in

technology over what was used 30 years ago

• We have more accurate technology now that

decreases recall rates and increases detection

3-D Mammography (Tomosynthesis)

• Able to find more invasive cancer which have the

potential to metastasize

• Up to 30% less call back rates

• Cancer detection rate in women 40-49 increased

and these cancers in younger women are usually

more aggressive and grow faster

Room for Improvement in USPSTF

• Made up of 15 members and none of which are

Radiologists or Oncologists

• These are the specialties that are experts in this area

• They are the ones who do the research, studies, and

publish the data

• Desire to eliminate the bias but this also eliminates the

knowledge by excluding the specialists who know the

field the best

• People on the task force don't fully understand the

literature on the benefits of early breast cancer screening

• Breast cancer screening is not perfect but it should be

made available to all women if they want it

“Mammography screening reduces breast cancer mortality by 15% for women aged 39–49

(RR 0.85, 95% CI 0.75–0.96); data are lacking for women 70 years and older.

Radiation exposure from mammography is low.

Adverse experiences are common and transient.

Estimates of over diagnosis vary from 1% to 10%.

Younger women have more false-positive results and additional imaging but fewer

biopsies than older women.”

• As primary care clinicians and researchers, I

hope that this lecture will facilitate greater

dialogue between women and their doctors

so they can make informed health care

decisions. I also hope that the health care

organizations will continue with additional

research addressing important evidence gaps

in the science of breast cancer screening.

Goal