As I head off to San Antonio for the annual breast cancer symposium (SABCS), I’m finalizing Breast Cancer Action’s comments to submit to the U.S. Preventive Services Taskforce (USPSTF) about mammography screening guidelines.
The USPSTF has announced that they will be updating mammography screening guidelines, and has made available their proposed analytic framework along with 6 Key Questions for public comment. The public comment period ends today, December 11, 2013. You can view the proposed framework on their website.
In 2009, the USPSTF released new mammography screening guidelines for women at average risk that sparked a controversy that has not waned in the years since. At BCAction, we believe any screening recommendation must be based on the clinical evidence available. And as new studies are completed with new data to add to our understanding of breast cancer screening programs, this new evidence should be reviewed by an unbiased panel to affirm or update the existing recommendations. And the USPSTF is doing just that.
Population-based breast cancer screening via mammography has been a mainstay of the mainstream breast cancer movement since the 1980s and continues to be a focus of much education and awareness. Unfortunately, we cannot screen our way out of the epidemic, as I’ve written about elsewhere. Breast cancer screening programs do not prevent cancer but rather detect something that is already there. Any reductions in breast cancer mortality are largely attributed to advances in treatment rather than screening, etc. And the harms of mammograms are overlooked by catchy mainstream slogans like “early detection saves lives.”
It’s important to recognize the essential limits of mammography screening while seeking optimal population-based screening protocols based on clinical evidence. The task of the USPSTF is to develop screening recommendations that maximize the potential benefits of screening (such as reduced harms from treatment when disease is found early and reducing death from disease) while minimizing the harm of the screening itself (including radiation exposure from mammograms, expense, etc.) and the harm from the results of the screening (false-positives, biopsies, over diagnosis and over treatment, etc.).
As the USPSTF embarks on this challenging job, we should not expect controversy to fall by the wayside. There are deep vested interests in this long-standing debate about breast cancer screening. In addition to evaluating current clinical evidence and developing breast cancer screening recommendations, the USPSTF has a chance to address some of the most critical issues in routine breast cancer screening including:
- The need for evidence-based recommendations for women at intermediate risk of breast cancer;
- The need for evidence-based recommendations for women of color, who bear a disproportionate burden of breast cancer incidence and deaths;
- The need to dramatically reduce the harms of over-diagnosis and over-treatment associated with the high rates of DCIS that result from routine mammography screening;
- The need for alternative non-invasive screening modalities that are better at finding aggressive cancers (vs. non-lethal cancers), while not exposing women to the harms of radiation.
Breast Cancer Action has submitted comments to the USPSTF as well as a longer letter outlining our feedback and concerns. In summary, our comments are:
- We need clarification from the USPSTF regarding which women are at average risk for breast cancer and which women are at somewhat higher than average risk; that is women who are at some intermediate risk between average and the very high risk of women with BRCA mutations.
- The USPSTF needs to develop evidence-based screening recommendations for these women at intermediate risk of breast cancer. This issue is all the more pressing in light of recent legislation in several states requiring that women be notified of their breast density when they undergo mammography screening, and may as a result be told they are at somewhat higher than average risk of breast cancer.
- We are deeply concerned that the experiences of women of color will get lost in the broad category “average-risk women age 40 years and older.” Given the unequal burden that women of color bear when it comes to breast cancer morbidity and mortality, key questions should be amended to include race and ethnicity (along with age, risk factor, and screening interval) in order to understand the specific experiences of women of color. Screening recommendations for women of color are conspicuously absent from this draft plan and are urgently needed.
- In evaluating the rates of specific adverse effects of current treatment regimens for invasive breast cancer and ductal carcinoma in situ (DCIS), Breast Cancer Action strongly urges the Taskforce to include active surveillance or “watchful waiting” under treatment regimens that are evaluated.
- The USPSTF should include both thermography and breast self-exam among the different screening modalities to be investigated. Many women want answers to their questions about thermography and breast self-exam as alternatives to mammography in their search for non-invasive screening options that don’t expose them to radiation.
- The “Proposed Contextual Question” to evaluate “women’s values regarding breast cancer screening” requires further scrutiny regarding the definition and understanding of “values.” Specifically, how do women’s values change as women age, how do values change between different ethnic and racial communities, and for women with a family history of breast cancer? Furthermore, how do misleading mainstream awareness campaigns like “early detection saves lives” factor into these so-called values? Instead, how can evidence-based messages reinforce women’s values with a balanced understanding of the harms, benefits, and limits of screening?
- Finally, we suggest that clinical practice would be better informed by including menopausal status rather than simply relying on age as a proxy of this important biological event.
Breast cancer is a complex disease, and we know that not all cancers that are detected early need to be treated and not all cancer deaths can currently be prevented even if the cancer is discovered and treated early. The USPSTF has an important job ahead to evaluate existing data and develop evidence-based, patient-centered recommendations that maximize the potential benefits of breast cancer screening programs while minimizing the associated harms.