The United States Preventive Services Task Force was created with the purpose of reviewing the most up to date information on important health care topics and making evidence based decisions. Recently, United States Preventive Services Task Force concluded that American women with average risk for breast cancer should start mammography screening at the age of 50, instead of 40 years of age which is now the current standard of care followed by thousands of doctors and their patients.The United States Preventive Services Task Force recommends that women between the ages of 40 and 49 only discuss with their doctor the benefits of mammography with their doctor.
Recently Human Services Secretary Kathleen Sebelius, who is probably happy to talk about something other than the H1N1 flu, stated that the Health Department still recommends that women receive mammograms at the age of 40, and more importantly states her positioned that the Federal government and private health insurance companies will continue to offer mammograms to women 40 years of age and above. The American Cancer Society agrees with Kathleen Sebelius and the Health Department by standing by its longstanding recommendations that women 40 and above receive mammograms. Not surprisingly, the American College of Radiology agrees with the recommendations of the American Cancer Society that women begin annual mammogram screening at the age of 40. This is because, radiologists earn fees from the reading of mammograms in addition to other imaging procedures which may be needed when the suspicious lesions are discovered on mammography.
Cost was a big issue factored into the United States Preventive Services Task Force’s decision. Women in their forties are less likely to develop breast cancer than women 50 and above, and limiting screening to women 50 and above would save health care dollars. Perhaps the more radical recommendation put forth by the United States Preventive Services Task Force is that women above the age of 50 have a mammogram at most once every two years instead of the common practice of annual mammograms.
Does the decision by the United States Preventive Services Task Force make sense? Some women, such as those who have a first degree relative such as a parent or sibling who have breast cancer, should have yearly mammograms starting at the age of 40. This is because their risk is higher than that of the general population. The United States Preventive Services Task Force acknowledges that mammography for women between the ages of 40 and 50 does save lives, however, it was unable to determine exactly how many lives are saved. Even if a medical procedure or diagnostic test does save lives, if the expense per life saved eager than a certain amount of money, then the United States Preventive Services Task Force and other health care bodies such as insurance companies will not pay for the intervention. The United States Preventive Services Task Force also factored into their decision the negative effects that mammography can have on women which include psychological distress over what turns out to be a benign lesion.
While absolute numbers will be scrutinized more closely, it appears that the United States Preventive Services Task Force recommends mammography in women above the age of 50 because screening 1,339 women in this age bracket saves one life. However, screening 1,904 women in the 40 to 49 bracket saves one life. Obviously, more women below the age of 40 need to be screened to save a life. However, it is obvious that mammography screening in women in their forties does save tens of thousands of lives each year. Perhaps many more lives are saved each year through mammography for women in their forties than were lost in the 9/11 terrorist attacks. While mammography is a inconvenience for many women, and that waiting for biopsy results can be nerve wracking, there is no doubt that this preventive effort does save lives. And given that women in their forties are younger than women above the age of fifty, it could be argued that mammography in women in their forties saves more “years of life” than does mammography screening at an older age. However, the United States Preventive Services Task Force also found a lack of evidence supporting mammography for women above the age of 75 as there isn’t enough iron clad evidence proving that it is worthwhile. My grandmother had mammography screening in her late seventies, had a cancerous lump removed, and lived into her late eighties. Again, it comes down to number of lives saved versus the cost of doing the screening. Sadly, the The United States Preventive Services Task Force’s decisions appear too abstract and lack a certain amount of common sense when applied to millions of women.
If the United States Preventive Services Task Force’s decision does prompt more women to have discussions with their doctor concerning mammography, then detecting women who are at greater than average risk for breast cancer becomes more important than ever. In the coming decade, this may include genetic screening tests which screen for less common genetic mutations associated with breast cancer. In addition to genetic tests, doctors should also take into account other lifestyle factors associated with breast cancer such as race and body weight. In the end, the informed woman who knows her risk for developing breast cancer will be able to request mammography at an earlier age than that recommended in national guidelines.
One aspect of the new guidelines provided by the United States Preventive Services Task Force is that women from lower socioeconomic backgrounds may lack the education to help them decide if they need a mammogram. Such patients may have to totally rely upon their doctor to help them decide if they need a mammogram. This could be concerning because many such women may not get a mammogram, even if they are high a risk, because their doctors may decide against screening them due to failure to recognize certain risk factors. In this case, it may be that if health insurance companies begin to decrease funding for mammograms for women under the age of 40, than the women who are more active participants in the their health care will get the mammograms that they may need. However, given the high public profile that breast cancer occupies in the national spotlight, it seems unlikely that insurance companies will drop mammography for women below the age of 50.
Given that the technology behind other types of imaging procedures such as MRI is in the early stages of development, it might make sense to keep women in the habit of obtaining regularly mammographic screening beginning at age forty as one day such procedures may be more likely to save additional lives from breast cancer.
While the United States Preventive Services Task Force’s intentions are good as the group attempts to make a decision based on costs and proven benefits, the task force often sits on the fence with regards to important decisions such as breast cancer screening and encourages patients to have discussions with their doctors to decide for themselves whether mammography or another procedure is good for them. While encouraging discussion between patients and doctors over important health care decisions is good, the United States Preventive Services Task Force’s recent decision may do more harm than good.