When should women start routine screening for breast cancer?
The debate over when women should undergo screening mammograms has erupted into a controversy of almost epic proportion. The U.S. Preventive Services Task Force (USPSTF) recommendations, released in November 2009, evoked passionate reactions on both sides of the issue.
Even politicians jumped into the fray. The House Energy and Commerce Committee's health subcommittee held a hearing on December 2, 2009, to examine the USPSTF breast cancer screening guidelines, which resulted in Republicans and Democrats hurling accusations at one another.
"This has become politicized because of the health care reform bill," said Lucy N. Marion, dean of the School of Nursing at the Medical College of Georgia, who's also a member of the USPSTF expert panel. "We [the task force] voted on this in July of last year, under the previous administration. We hadn't even had the election yet, so it didn't have anything at all to do with health care reform. We're ethically responsible to objectively look at the data. We had new data and new studies, which led us to revise the screening recommendations."
Bernadette Mazurek Melnyk, dean of the College of Nursing and Health Innovation at Arizona State University and also a member of the USPSTF panel, added, "There are a lot of harms associated with regular screening in younger women, and these stories aren't reaching the public."
The controversy. The most controversial change in the recommendations is that women at average risk for breast cancer begin screenings at age 50: "[t]he decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."
"We're not saying that younger women shouldn't be screened," said Melnyk. "Our recommendation is against routine screening starting at age 40."
In addition, the recommended time between screenings went from one year to two in women ages 50 to 74 years. The USPSTF also recommended against teaching breast self-examination and concluded that current evidence is insufficient to evaluate the benefit of clinical breast examination.
Who's in agreement. Despite the media's focus on opposition to the guidelines, many clinicians and professional organizations support the new recommendations. In an interview on MSNBC, physician and breast cancer expert Susan Love stated that the new recommendations were "on target" and that they "bring us into line with the rest of the world" and with the scientific data. "We've been doing mammography in younger women—based on wishful thinking and hoping that it's going to work," said Love. "And the evidence is that the risks are higher than the benefits in younger women."
A number of advocacy groups, including the National Breast Cancer Coalition, Breast Cancer Action, and the National Women's Health Network, support the new guidelines. The American College of Physicians issued its own screening guidelines in 2007, which basically mirror the new recommendations of the USPSTF. The World Health Organization also issued guidelines in 2009, recommending mammography every one to two years in women ages 50 to 69 years.
The National Cancer Institute refused to take a position, stating that it needs "to evaluate [its own guidelines] in light of the Task Force's recommendations—for all women, not only for those of average risk."
Who's opposed. The American College of Radiology (ACR) has strongly and vocally opposed the new recommendations, stating on its Web site that the "unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily. . . ."
The ACR has since issued its own guidelines. Despite accusing the USPSTF of ignoring scientific data, the ACR guideline authors admit that not all of their recommendations are based on hard evidence: "Where data [were] lacking, the recommendations reflect expert consensus opinions by the fellows of the [Society of Breast Imaging] and the members of the Breast Imaging Commission of the ACR." The ACR urges women to follow the current American Cancer Society (ACS) breast screening guidelines, which are consistent with their own.
The ACS, for its part, has long recommended that annual mammograms begin at age 40 and continue for as long as a woman is in good health. "We acknowledge that there are false positives and that they're more common in the 40-to-49-year age group," said Terri Ades, a nurse and director of cancer information at the ACS. "Women may be called back for repeat mammograms and biopsies, and breast cancer may be overdiagnosed. Even with those limitations, we believe that mammography saves lives, and that's why we stand behind our guidelines."
The nonprofit organization Breastcancer.org also strongly opposes the new recommendations and has gone so far as to circulate a petition against them on its Web site (http://bit.ly/5wNjLX). Strong condemnation also came from the Access to Medical Imaging Coalition, which represents, among others, imaging-equipment manufacturers. The coalition stated in a November 16 press release that the new recommendations will "turn back the clock on the war on breast cancer" and open the door for private insurers and Medicare to deny payment for screening mammograms.
An opportunity for nurses. Supporters of the new recommendations agree that younger women need to be talking with their primary care providers. The small benefit associated with early screening needs to be weighed against the possible risks.
The Oncology Nursing Society (ONS) acknowledges that evidence regarding the benefits of mammography screening and breast self-examination has been conflicting but also stands by its position that benefits, risks, and possible limitations of screening methods need to be discussed with and tailored to the individual woman. "As an organization, we base things on evidence rather than opinion," said Brenda Nevidjon, president of the ONS. "Nurses need to be aware of what the evidence is saying and be able to support and listen to the patient. This is a teaching opportunity for nurses. There's a lot of misinformation out there."
Roxanne Nelson, BSN, RN