Once again, the United States Preventive Services Task Force’s latest draft report on the potential benefits and harms of mammography screening was met by outcries from radiologists and others that thousands of women would die if the recommendations were followed. The Task Force concluded that women between the ages of 50 and 74 should get mammograms every two years. But for women under 50, the chances that a mammogram will help her rather than harm her are very small. For younger women, the decision to get a mammogram should be made on a case-by-case basis.
This is reasonable advice, but you wouldn’t know it from comments on Twitter and in some media outlets. In 2009, when the Task Force last issued recommendations on mammograms, everybody from breast cancer advocacy groups to members of Congress accused the panel of “killing women.” Radiologists, some of whom have a vested financial interest in mammography, claimed the panel used outdated evidence. One newspaper columnist suggested that Congress should “take pity on the Task Force and send it to the Death Panel for a humane end.” The reaction this time around has been only a little less negative.
Growing Evidence Of Over-Diagnosis And Over-Treatment
Since then, the number of studies of mammography has grown, and if anything, the evidence is even stronger: we are consistently over-diagnosing and over-treating breast cancer — and younger women are paying the highest price. Women under age 50 who get regular mammograms have a more than 50 percent chance of a false positive after 10 years. Every positive finding on a mammogram requires further testing, often a needle biopsy, which isn’t pleasant. Studies have found that even when it turns out to be a false alarm, women suffer for years from the worry that they really do have cancer.
More worrisome than false positives however, is that research now suggests that between one in five and one in three breast cancers detected by mammograms did not need to be treated, or could have been treated successfully at a later time in the woman’s life. Unfortunately, doctors often don’t know how to tell the difference.
The reality is most younger women contemplating a mammogram face three possible outcomes. There’s a tiny chance her life will be saved by catching a cancer that would have killed her. There’s a much greater likelihood she’ll be treated unnecessarily. And there’s some risk she’ll suffer significant harm from unnecessary treatment. No amount of believing in early detection can change that.
That’s why the U.S. Preventive Services Task Force gave mammograms for women in their forties a “C” rating, which means it’s not universally recommended. It also means that health plans are not required to provide coverage with no-copayment, which they must for all preventive services that receive an “A” or “B” recommendation from the Task Force. Women should make the decision whether or not to get screened only after discussing it with their doctors. By contrast, mammograms for older women got a “B” rating, which means there’s a better chance they will be helped rather than harmed.
Getting Women The Best Advice
Breast cancer is a terrifying disease. As anyone who has lived through the journey knows (and one of us has), each step of the diagnosis, treatment, and recovery is anguishing and exhausting. Breast cancer patients depend on the advice of their doctors to inform their decisions. They must trust that their doctors base their opinions on the latest evidence, from the best scientific studies.
Often, the sheer volume of new scientific findings is too great for any doctor to absorb. That is why researchers have developed systematic methods for using multiple studies, methods the U.S. Preventive Services Task Force employs to help guide doctors and nurses in their practices. Health plans also rely on task force recommendations to decide what to include in benefit packages.
Given the ongoing controversy over covering mammograms for women in their forties, one solution for payers would be to cover them provided that the women have been well-informed of the potential harms as well as benefits. Unfortunately, we know that physicians may not be very good at explaining such tradeoffs, and many of them are as likely as their patients to think that screening is always good. Payers should offer patients access to high quality, evidence-based decision aids about mammography, and provide incentives to physicians to engage in shared decision making. It won’t be a perfect solution, but it’s a start.
Saving Money, But More Importantly Saving Women From Harm
Opponents of the new recommendations will argue that money underlies the Task Force’s recommendations. There’s no denying we spend vast sums on mammograms and the downstream biopsies and treatment they trigger. A recent report in Health Affairs concluded that the costs associated with false-positive mammograms alone come to as much as $4 billion annually.
But first and foremost, women and their doctors need to understand that more screening is not always better. When it comes to cancer, “catching it early” has become an article of faith in the United States, and the poignant stories of women who believe they are alive today because of the mammogram they received in their 40s are important. However, these stories should not outweigh our science. As a nation, we’ve invested billions in research to improve our ability to prevent, screen for, diagnose and treat breast cancer. Let’s use it to better inform patients and their doctors and protect patients from unnecessary harm.
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