Panel Recommends Against Mammograms in Young Women

There's a firestorm of controversy surrounding the recent recommendations of the US Preventative Services Task Force (a part of the US Dept. of Health and Human Services) that suggests women aged 40 to 50 should not have routine mammograms as is recommended by many other healthcare groups.

Here are the actual recommendations on the HHS website:
http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm

Here's the article in Annals of Internal Medicine where the task force published their recommendations:
http://www.annals.org/content/151/10/716.full

Here's an LA Times article about the recommendations:
http://www.latimes.com/news/nationworld/nation/la-na-mammogram17-2009nov17,0,3942708.story

Here's the statement from the American Cancer Society disagreeing with the HHS recommendations:
http://www.cancer.org/docroot/MED/c..._Changes_to_USPSTF_Mammography_Guidelines.asp

Here's the stance of the American Congress of OB/GYN that advises its fellows to continue to recommend mammograms for those 40 to 50:
http://www.acog.org/from_home/Misc/uspstfResponse.cfm

So is this recommendation based on cost containment as many suggest?

If it is does that necessarily make it a bad thing?

The task force points to the high number of false positives mammography creates in this age group as a defense of the recommendations. Other fields have started to limit testing in groups with a preponderance of false positives such as cardiology limiting stress testing in chest pain patients under 35 with TIMI 2 or less risk factors due to the false positives leading to unnecessary catheterizations. Is the task force's explanation about false positives legitimate?

What will you be telling your patients?

Interestingly, the USPSTF recommendations aren't much different from those that the NIH issued in 1997:

The National Institutes of Health (NIH) Consensus Development Conference on Breast Cancer Screening for Women Aged 40-49 … concluded that data on the benefits and risks of screening mammography for women aged 40 through 49 are sufficiently mixed that informed decision making, rather than a blanket recommendation for all women, is an appropriate course of action.

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If you look at it purely from the standpoint of the evidence, the benefits of screening mammography are probably overstated.

I suspect that younger women will likely be accepting of the new recommendations. Women who are already in the habit of getting annual mammograms may be reluctant to stop.

At any rate, I intend to leave it up to the patients. My "mammogram talk" will probably start to sound more like my "PSA talk." Most men still choose to have a PSA test, despite the limitations and risks of false positives. People are scared of getting cancer, and want any test that will give them some peace of mind, even if it's not perfect.

Look at all of the people paying out of pocket for "LifeLine" screenings for carotid artery stenosis, PAD, and AAA, despite no basis in evidence. Some people are still pushing for full-body CT scans. It's absurd.

Blue Dog said:

If you look at it purely from the standpoint of the evidence, the benefits of screening mammography are probably overstated.

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Precisely! As part of my graduate course, I had a look at the evidence for breast cancer screening earlier this year. There's the the harms of over-screening: the radiation exposure and the false positives resulting in further, invasive investigations. And on top of that, there's no evidence that DCIS always leads to metastatic disease. But if you find it, you have to treat it.

The old recs struck me as based more on defensive medicine rather than evidence-based.

Aren't the new digital mammogram machines more accurate now?

womp said:

Aren't the new digital mammogram machines more accurate now?

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Only in younger women, who typically have denser breasts.

Yes, this has been all over national news - TV, radio, you name it - for days. I don't think it's nearly as big of a controversy as the news is depicting. Basically, they just keep running the "Why would you not have women do it? It could SAVE A LIFE" headline over and over.

The fact is preventative care does not save money, something this administration just seems to refuse to accept. Preventative care in general may or may not improve overall public health, but study after study has shown it comes at a expensive price. These mythical "cost reductions from expanding care to the uninsured" talked about in health-care reform are unicorns and windmills. Mammograms are just another example of this IMHO, and that explains the public reaction to this study. The idea that preventative care will save billions of health-care dollars seems so obvious to the general public and media, they seem to be blind to the facts that stduies directly dispure this assumption.

RabbMD said:

Preventative care in general may or may not improve overall public health, but study after study has shown it comes at a expensive price.
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The idea that preventative care will save billions of health-care dollars seems so obvious to the general public and media, they seem to be blind to the facts that stduies directly dispure this assumption.

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Do you have any references to studies with data such as these? I'd be really curious to read more about them..

st0w said:

Do you have any references to studies with data such as these? I'd be really curious to read more about them..

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http://content.nejm.org/cgi/content/full/358/7/661

Is the NEJM a good enough resource? Yes some preventative care saves money, but that is mostly diet modification, smoking cessation, and wt loss.

Here is another, from what even seems to me to be liberally biased writers

http://www.annals.org/content/150/7/485.full

As this controversy continues it's really interesting to me to hear the strongly held yet totally misinformed opinions people have. No one understands the idea of causing harm by producing false positives. No one understands that "routine screening" means using it in women without significant risk factors and is different than denying it to women with strong family history, etc.

I think it's a great learning opportunity in medicine to see how people get all worked up without any real understanding.