In April 2015, we were treated to the “new” breast cancer screening guidelines from the U.S. Preventive Services Task Force. We learned back then that there would be no major changes from the 2009 Task Force, demonstrating remarkable consistency. Because the 16-member Task Force rotates its volunteers, there is a changing of the guard each time new guidelines are announced. In the past, this has translated to waffling on the screening recommendations, with each new Task Force changing what the last group had done, beginning in 1989. This time, not so much. Maybe the one physician who served as liaison to the new group made the difference.
The Big Two guidelines stayed the same: 1) Start screening at 50 (no apology rendered to the 25% of eventual breast cancer victims under age 50 who are thus excluded from screening), and 2) Screen every 2 years rather than annually.
Other controversies were settled with an “I” for “insufficient evidence.” Given that the Task Force insists on prospective, randomized trials with a proven mortality reduction before they can accept what all other rational thinkers accepted long ago, the Task Force will always be playing catch up. For instance, in 2009, the Task Force issued an “I” for digital mammography. In spite of this, essentially every breast center in the U.S. switched from the older film screen technique to digital, so in 2015, the Task Force simply deleted this technology from their list upon which to pass judgment. They were so late to the party that it would have been an embarrassment to admit that there was STILL no evidence to support digital.
They replaced the digital issue with an “I” for tomosynthesis, even after admitting the early data on tomo (3-D mammography) is exactly what critics have been demanding of mammography – better detection and fewer call-backs. That said, by the time the Task Force meets again on this issue, every breast center in the U.S. will have already replaced their 2-D units with 3-D. Tomosynthesis is the greatest single advance made in mammography technology since its introduction. The evidence is clear to those of us who don’t demand a prospective, randomized trial for each and every step we take.
As usual (since 2009 at least), the Task Force recommendations prompted a media storm, with many believing that the Task Force is the “official” policy even though few had even heard of them prior to 2009. In a way, they are “official.” The Affordable Care Act uses Task Force guidelines, so who cares if every other organization in the U.S. recommends screening earlier than 50. The Task Force “C” recommendation for (not) screening at 40-49 will mean no insurance coverage through ObamaCare. After the disastrous 2009 introduction of this “less is more” recommendation for screening 40-49, the Task Force softened the definition of “C” such that many thought they had reversed their position. They did not. The wording is kinder and gentler, but a C is a C is a C. Screening in the decade of the 40s is still a “C.” And C’s don’t count when it comes to the Affordable Care Act.
After the 2009 media brouhaha died down, we continued screening as we had before, based on the American Cancer Society guidelines, only to have that rug halfway pulled from beneath us as well when the ACS changed the starting age to 45 (covered in another blogatorial).
Then, in January 2016, it started all over. Double trouble from the Task Force. The Task Force announced their new guidelines – AGAIN – and we went through the same media storm as we’d done 9 months earlier. What had happened during this gestational period?
Pretty much nothing. As it turns out, the April 2015 announcement was only their “draft,” whereupon they invited public comment (getting more than they bargained for). Of course, this is largely for show, because they didn’t change a thing, nor would you expect them to after their expert analysis of numbers. In fact, it gave them the opportunity to field the criticisms in advance, and put their answers in writing, as part of the official 2016 guidelines. Good strategy – allow the critics to expose their best arguments ahead of time. Nothing like having the last word.
Yet, the sad truth is that the “less is more” approach may be applicable to many aspects of medicine and breast cancer in particular, but it translates to more breast cancer deaths when applied to screening. The benefit of screening, as calculated by mortality reductions, did not change for the Task Force from 2002 to 2009. What changed was a new way to calculate harms, such that the balance tipped away from screening.
Many of us believe, however, that the harms have been grossly exaggerated, while the benefits understated, and the result is going to be more breast cancer deaths. For women currently in their 30s, opting for Task Force guidelines, it has been calculated that 2,000 more women will die each year of breast cancer (currently at 40,000 per year). Drop in the bucket? Not if you’re one of the 2,000. Furthermore, women currently in their 30s are facing 50 years of breast cancer risk, on the average, so when you multiply 2,000 per year X 50 – ugh – 100,000 more breast cancer deaths over the next 50 years? Inconceivable?
Not really. The calculations were made by two prominent radiologists who have expertise in screening (RE Hendrick and MA Helvie in the February 2011 edition of the American Journal of Radiology), using the same database that the Task Force used. The “100,000 more deaths” tells us what would occur if all women were compliant with the standard “start at 40, then every year” guidelines, but then backed off according to Task Force recommendations. So, rest easy. If we look at a more practical number than 100% compliance, taking into account that many women don’t bother with mammograms at all, Drs. Hendrick and Helvie calculated “only” 64,889 more deaths over the next 50 years. Ah, that’s better. As Jimmy Fallon might say, “Thank you, Task Force, for reducing the number of call-backs, unnecessary biopsies, overtreatment of breast cancer, and for saving the system so much money…now, if we could figure out why more women are dying of breast cancer, we’d be even happier.”