Correction: Mammogram Recommendations

Correction: On November 17 post on mammogram recommendations contained a misstatement. Based on the studies available in 2002, the USPSTF DID recommend in women age 40-49 receive annual mammograms. Since the verification hotlink was not included in the post, the only reasonable explanation for this error was that I had mistakenly viewed the previous recommendations (also found in the 2nd Print Edition of the US Guides) of the Task Force, which agreed with the present recommendations - my apologies. We will make certain the hotlinks are included in future posts. As of November 22, these post have been peer-reviewed by the AOCOPM publications committee, which will hopefully catch any errors prior to posting.


Some medical commentators, such as Bernadine Healy MD, have said that the Task Force is always flip-flopping on their recommendations. However, the Task Force is really looking at the whole body of scientific evidence available to us at a given point in time. Naturally, over time as evidence accumulates and studies are repeated, theories are either verified or disproven. This is why the standard of care for any disease typically does not change with one study. How many health recommendations have changed over the years – such as to use margarine rather than butter, would anyone still make that recommendation today? How is public health any different from any other area of medicine practice?

This mammogram discussion also brings to light the conflicting recommendations as to what constitutes the standard of care in medicine today. The issue is that there are different standards for the same disease across specialties and across the first world. Ironically, the USPSTF is recognized as “the standard” worldwide for making prevention guidelines because of the extensive review of medical research that goes into the process to determine public health guidelines for the general population. The American Cancer Society and other groups are looking at the sub-segment of the population diagnosed with cancer, not the proportion of those people relative to the entire population. Interestingly, no one has mentioned that these groups may have their own political, legal or monetary concerns.

From a public health perspective, if it costs more to screen people to find one case of disease than it does to treat one case of disease (at the average stage it would be found), there is no point in screening. It costs more than it’s worth. [Obviously the individual who may have cancer doesn’t feel that way. But from a societal standpoint, where money is not an unlimited commodity, we must seek the biggest bang for our healthcare buck.] In this case, a better screening test that does not yield a cumulative 43% false-positive rate by the ninth mammogram or a cheaper one to make it worthwhile for this age group.

USPSTF: Rationing or Rational Use of Screening Tools for Detecting Breast Cancer

Yesterday, the US Guide to Preventive Services released the latest guidelines on breast cancer screening recommendations. The press went wild and said this was government rationing of preventive testing. The "US Guide to Preventive Services Task Force Guidelines show stark differences of opinion with the specialty groups regarding screening, diagnostic and treatment methods. When the numbers came in, physicians following specialty colleges' recommendations were overtesting, overtreating and unnecessarily worrying patients. The research did not back up the specialty standards." Most of these recommendations are by convention rather than by scientific medical evidence.


Let's set the record straight - The USPSTF never recommended routine screening at 40 - there was insufficient evidence to recommend for or against routine mammography or clinical breast exams in the 40-49 y.o. age group for the general population - NOTHING CHANGED. It was the specialty & disease societies such as American Cancer Society, AMA and American College of Obstetrics and Gynecology that made these recommendations. Other groups, such as the American College of Physicians, said it should be based on the risk of the individual patient. It should always be based on the individual patient's need - these are population guidelines - of course, the patient in front of you may have different needs.

What did change? The 2002 Guidelines said mammography every 1-2 years was recommended for women age 50-69y.o., although recommendations for high risk women 40-49 and healthy women > or = 70 may be made on other grounds. Today's Guidelines say: Mammography screening is recommended every 2 years for women age 50-74. The USGPSTF is recommending screening for a LONGER period of time, NOT less.

Why every two years screening? Because mammograms are not benign - they expose a patient to radiation. The USPSTF also says "Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." Subsequent biopsies will change the breast architecture and make it more difficult to interpret future exams. Evidence also shows that the more mammograms a woman has the more likely she will have a "false-positive" mammogram. According to a Harvard Pilgrim Healthcare study in the Journal of the National Cancer Institute which followed women over a 10-year period with "9747 screening mammograms, 6. 5% were false-positive; 23.8% of women experienced at least one false-positive result. After nine mammograms, the risk of a false-positive mammogram was 43.1%." Clearly more diagnostic testing does NOT equate to higher quality medical care.