ARA Responds to USPSTF Draft Recommendations on Mammography

Austin Radiological Association

Draft USPSTF Breast Cancer Screening
Recommendations Put Women’s Lives at Risk
Austin Radiological Association Responds

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Austin Radiological Association (ARA), in accord with the American College of Radiology (ACR), the Society for Breast Imaging (SBI) and the American Cancer Society (ACS) continues to strongly recommend that women begin their routine mammograms at age 40 and get annual screenings thereafter. ARA stands behind the National Cancer Institute data that shows that since mammography screening became common in the mid-1980s, U.S. deaths from breast cancer have dropped 35%.

ARA agrees with the ACR/SBI statement as follows:

“Adoption of draft United States Preventive Services Task Force (USPSTF) breast cancer screening recommendations would result in thousands of additional and unnecessary breast cancer deaths each year. Thousands more women would experience more extensive and expensive treatments than if their cancers were found early by a regular mammogram. Adoption of these USPSTF recommendations could also strip millions of women 40 and older of private insurance coverage with no copay for mammograms at the time of their choosing previously guaranteed by the Affordable Care Act.”

What are the draft USPSTF recommendations?
The USPSTF draft gives a “C” grade to routine screening of women ages 40-49, indicating that the decision to be screened is up to the woman. Additionally, the Task Force gave a “B” to screening women ages 50-74 every other year instead of annually. A “B” or higher given by the USPSTF requires private insurers to cover the exam under the Affordable Care Act. Unfortunately for U.S. women, these recommendations, if adopted, will open up the possibility that insurers will not cover mammograms for women 40-49 and will cover mammograms for women 50-74 only every other year instead of annually.

Reasons the USPSTF approach is seriously flawed:
•     No breast imaging or breast cancer experts were included in the panel or at the meeting. The USPSTF did not allow participation of breast cancer experts at meetings where evidence was reviewed.

•     The USPSTF does not follow Institute of Medicine (IOM) recommendations for guideline development. The IOM has recommendations for the creation of screening guidelines that are considered the “gold standard” in the medical community. The Task Force’s methods did not meet requirements to be considered “trustworthy guidelines.” There is a concern in the medical community about the Task Force’s lack of transparency.

•     Outdated data was used to inform the recommendations. The USPSTF did not include data and information available from current studies that take into account improved mammography techniques and technology. The older data 1) creates a bias suggesting greater over-diagnosis rates; 2) does not take into account the life-years saved; and 3) does not credit the improved and sometimes less-expensive treatments possible when cancer is detected earlier.

•     No direct research was used. The Task Force chose to use statistics and computer models to estimate screening mammography benefits. Accepted research approaches include randomized, double-blinded studies that measure actual outcomes. Research trials that use this gold standard approach show a 30 % decrease in mortality from breast cancer since 1990 due to screening women 40+ and improved treatments. The National Cancer Institute puts the drop in mortality as high as 35% since the mid-1980s.

•     The USPSTF gave screening for women in their 40s a “C” grade, even while stating that “evidence shows that mammography screening can be effective for women in their 40s.” The Task Force justified this by stating that the number of lives saved is smaller and the number of false-positives is higher. ARA believes this is a flawed conclusion, as cancers in women under 50 are often more aggressive, making screening even more important. Furthermore, a reduced risk of death from breast cancer, the possibility of less impactful treatment and the prospect of being around to take care of family members are all highly valued and offset any associated harms.

•     The USPSTF concludes that screening mammography is more beneficial for women ages 40-49 with a family history of breast cancer. However, considering that 75% of women diagnosed have no family history, the majority of breast cancers will go undetected under this regimen.

•     USPSTF recommendations are based on a presumption that women want to avoid the discomfort of mammography, the possibility of a false positive and the chance for over-diagnosis at the cost of finding and treating deadly forms of breast cancer. In fact, past research has shown that most women who have a false positive experience are still in favor of routine mammography.

•     The USPSTF gave breast tomosynthesis (3D mammography) effectiveness an “I”, maintaining that data on whether it will result in improved health, quality of life or fewer deaths is “Inconclusive.” Mortality data takes decades to accumulate, so it is too soon to assess this for breast tomosynthesis. However, breast tomosynthesis has been shown to detect up to 41% more invasive breast cancers and result in substantially fewer recalls, which helps lessen the anxiety of false positives cited as a harm by the USPSTF.

In short, ARA finds the USPSTF draft recommendations to be seriously detrimental to the health of U.S. women and urges anyone concerned with future access to mammography to contact the USPSTF.  

The USPSTF is taking public comments through May 18, 2015. Comments can be entered here:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1%E2%80%8E

Other sources:
American College of Radiology press release:
http://www.acr.org/About-Us/Media-Center/Press-Releases/2015-Press-Releases/20150420-Draft-USPSTF-Breast-Cancer-Screening-Recommendations-Would-Cost-Thousands-of-Lives​

Society for Breast Imaging /American College of Radiology joint statement (download):
http://www.sbi-online.org/Portals/0/Position%20Statements/2015/2015%20USPSTF%20-%20ACR%20SBI%20Joint%20Position%20Statement.pdf​

American Cancer Society:
http://pressroom.cancer.org/USPSTFbreast2015​

Austin Radiological Association