Until 2009, few clinicians had heard of the U.S. Preventive Services Task Force (USPSTF), but in fact, they’ve been around since 1989 when they first endorsed screening mammograms, starting at age 40. The controversy about the “starting age” actually began in the late 1960s, and was already a hot topic for debate in the 1970s. Professional organizations were split down the middle, half favoring 40 and the other half favoring 50 as the starting age (supposedly based on data, not emotion)
The Task Force was conceived as an independent group of experts in public health and screening programs. Today, 16 members monitor over 100 screening recommendations for all sorts of diseases, with updates every few years. The Task Force is quick to point out that they are not a governmental agency, but they are funded by the government, with oversight by the government, so what does it matter? To complicate things, members rotate through the committee with relatively short terms, which might explain their remarkable inconsistency with regard to breast cancer screening. For breast screening recommendations, the USPSTF tries to update their position every 6-7 years, based on “new evidence.” Yet, if you read closely, that “new evidence” is often related only to the harms of screening (such as psychological trauma with a benign biopsy). Meanwhile, the benefits are calculated using obsolete data from primitive mammography used in the historic trials of the 1970s and 1980s. “Well, it’s all we’ve got,” they announce pitifully, while ignoring a mountain of data that supports screening average risk women beginning at age 40.
And while few had heard of the USPSTF in 2002, everyone heard by 2009 when they shocked the breast cancer community (and the world) with “Start mammograms at age 50, then every 2 years.” Those who understood the impact quickly calculated how many women would die unnecessarily each year due to these recommendations (“many thousands” for purposes here). So, by following the rules of “good science” and “evidence-based medicine” here’s what the USPSTF has done to make fools of themselves with regard to screening at 40 vs. 50:
1989 — start at 40
1996 — no policy, 40 or 50 is fine
2002 — start at 40
2009 — start at 50 and screen every 2 years
2016 — same as 2009
2023 — start at 40 and screen every 2 years
Meanwhile, other organizations (including the American Cancer Society) said “start at 40” throughout the entire controversy. Only recently, did the ACS switch to 45 to try and mediate the bitter arguments generated by the USPSTF. Of course, the American College of Radiology has maintained “start at 40” throughout the decades, but sad to say, no one trusts experts anymore. They are allegedly biased for their own personal gain, so insurers pay no attention to them. But what about “mostly neutral” organizations like the American Society of Breast Surgeons who make no money through screening programs? Doesn’t matter. They’re “friends” of the radiologists, and they can’t be trusted either. (Point of information and disclosure: I was a member of the most recent Screening Guideline Committee of the American Society of Breast Surgeons, and our group was nearly unanimous — “start at 40 with annual mammograms”).
The American Academy of Family Physicians, however, strongly (blindly?) endorses the USPSTF, as does the American College of Physicians (internal medicine specialists), making it so hard to battle the USPSTF that my own hospital in 2009 began telling its employees to wait until age 50 to begin screening (while I’m serving at the national level, endorsing 40). And I can assure you my hospital didn’t give a rip about what I said, or what Dr. Stough said, because the employee guidelines were drawn up by members of the American College of Physicians (read: USPSTF), located at the St. Louis hub, who voted along party lines — hook, line, and sinker — for age 50.
Screening is far more complicated than most imagine. I became heavily involved as an advocate of MRI screening, which was tied to risk assessment and genetic testing. I even started writing a book on MRI screening, getting about halfway in my efforts when the 2009 tsunami hit, and we went from 40 to 50. I abandoned my MRI intent, seeing a greater need to clarify screening in general, including the history of breast cancer screening, and how deeply flawed the USPSTF was in their assessment. When I finished, my publisher asked me to provide 10 possible titles for the book. They rejected all 10, not wanting to see “MRI” in the title. They renamed my book, “Mammography and Early Breast Cancer Detection: how screening saves lives.” Even today, I don’t know of any book that covers the controversy like I did. Sadly, few have even heard of the book, but I’ve received personal comments from experts around the world. One retired academic radiologist from the University of Manchester, U.K. wrote this: “I wish I had this book back when I was training residents in breast imaging. Everyone doing breast imaging should read it. To be honest, even I didn’t fully understand the controversies and complexities surrounding screening.”
There’s a huge difference between the skills needed to interpret mammograms and the epidemiology behind general population screening. Most practicing radiologists are unaware of the theories of screening and how statistics can be twisted. They might be superb at identifying cancer on a mammogram, but that has nothing to do with a controversy like “overdiagnosis.” But by the same token, the epidemiologists and others of the Task Force ilk do not understand breast radiology, leaving them often with empty-headed opinions.
Yes, you can use high-powered stats and sophisticated means of twisting those statistics to assess both the BENEFITS of screening and the HARMS of screening. But after the necessary calculations are made, and you put the two on a scale…they cannot be balanced! It’s entirely subjective at this point. BENEFITS vs. RISKS. How many benign biopsies does it take to neutralize the benefit of an early detection? It’s the final balancing act that keeps this controversy from being purely scientific.
I learned about the 2023 Task Force update like most everyone else — watching the evening news, then online coverage. Sounded simple, and as the USPSTF committee member told us about the NEW guidelines, it was crocodile tears as far as I was concerned (“We must be attentive to the fact that breast cancer incidence is increasing in younger women.” But who abandoned those women in 2009?).
Another neglected issue: younger women often need more than mammography, i.e., ultrasound at a minimum and perhaps MRI. And yet, the Task Force has been irresponsible in ignoring the data we have now on ultrasound screening and MRI screening. Guess what the Task Force says about breast density….”no proof that there’s any benefit from adding ANYTHING to mammography in women with dense breasts — that means no 3D, no ultrasound, no MRI, no molecular imaging, and no to anything else you can think of.” That leaves digital mammography as the sole recommendation, yet of all the types of imaging I just listed, 2D digital mammograms are the WORST at detecting cancer, or scientifically speaking, 2D mammograms have the lowest sensitivity for cancer detection among the wide array of options. And THAT’S the recommendation of the Task Force. I consider their approach to dense breasts to be an act of “malpractice by committee.” And if you think that’s harsh, there are applicable words that make “malpractice” sound soft. The Task Force has done more to harm breast cancer screening than any other organization — even more than those mammography-deniers who don’t believe mammograms save ANY lives. The difference between the Deniers and the Task Force? The Task Force claims, “We’re the authority on this, and we’re here to help you.”
The emergence and adoption of breast cancer screening is a remarkable story of the power of human bias. So, rather than the MRI book I had envisioned, it ended up being a book about screening for breast cancer in general, a soap opera when it comes to the history that continues to this day. Although the genre of the book is classified as “medical text,” it’s anything but. It’s human drama, the same as my novels. Sadly, the book got stuck with a bad title and a bad cover. But as one reviewer said, “In this era of doing less screening, Hollingsworth makes a convincing case that we ought to be doing more, not less. And for sheer entertainment, don’t miss the Endnotes.” (In fact, I had placed what became endnotes in the text itself, spicing up the story. But the editor supervened again, and pulled out many of the juicy tidbits and placed them in the Endnotes).
As I review my Task Force critiques throughout the years, I find THREE Powerpoint talks that I used to give to physicians at CME courses — one talk is 30 minutes, one is 45 minutes, and the one I preferred to give lasted a complete 60 minutes. Then, most of the book I’ve already mentioned is tied to the same topic. And finally, many of the essays in my book The Best Breast Blogatorials cover the Task Force and their wily ways. So, to make sure crocodile tears on the evening news don’t sway you, read one or both of my breast cancer books.
PS: I’m having trouble providing links in this Blog template, so the Blogatorial book will need a search using the title/author.
Early Breast Cancer 