New screening mammography guidelines

Commentary By: Tori Hudson, ND

The U.S. Preventative Services Task Force (USPSTF) has recently updated their 2002 guidelines after two systematic evidence-based reviews of randomized trials and statistical models of screening effects on breast cancer mortality.

The key 2009 guidelines are as follows:

• No universal screening mammography for women ages 40-49 and urging an individualized informed decision making process based on specific benefits and harms.
• Biennial screening mammography for women ages 50-69.
• Extend screening to women in the 70-74 year old group
• Insufficient evidence to assess the benefits and harms of screening mammography in women 75 and older
• Insufficient evidence to asses the benefits and risks of clinical breast exams in women aged 40 years and older that undergo mammography, digital mammography, and MRI versus film mammography.
• Teaching self-examination is harmful and not recommended
• These recommendations do not apply to women who are at excess risk for breast cancer due to known genetic mutations or histories of chest radiation

Commentary: The most significant change from the USPSTF 2002 recommendations, is to advise against routine mammograms for women younger than 50. This conclusion is the main feature of the firestorm of controversy. The main arguments that can be presented to challenge this lack of screening in average risk women ages 40-49 comes from some key issues:

1. More than 10% of all breast cancer deaths occur in women in their 40s.
2. Meta-analyses of randomized clinical trials have concluded that in this age group, there was a bout a 20% reduction in breast cancer mortality in women offered mammogram screening.
3. A randomized trial in the United Kingdom of annual mammographic screening beginning ate age 40 concluded a 24% reduction in breast cancer mortality in screened women.
4. Breast cancer tends to grow faster in younger women, and currently, cancers detected between screenings have lower survival rates, in any age group.

Some argue that these reasons are enough to actually recommend annual screening mammography in women ages 40-49. The Susan Komen Foundation, which has advocated early detection as their main message, takes this point of view, and as of this writing, has not changed their recommendations of annual screening starting at age 40. They would point out that the death rate from breast cancer in the United States has declined 3.2% in women younger than age 50, compared with only 2% in women older than 50. Obviously, breast cancer treatment has a role here, and improvements in treatment as well as early detection, can both account for these improvements.

The USPSTF recommendations are based not only on their review of the evidence, but also a judgment of benefit vs. harm; harm being screening in younger women and self breast exams leading to additional testing and biopsies for benign disease than for breast cancer diagnoses. This discussion also includes the emotional, financial and physical costs due to these additional diagnostic procedures that again, are more likely to lead to benign disease than to cancers. An individual woman may not want the government to decide what is harm for her, in these kinds of ways.

I will continue to approach each woman individually--- not just in term of her breast cancer risk and subsequent recommendations, but let her know of these controversies in recommendations, and provide her with information that helps her to decide what she wants to do. My patients choose strategies ranging from annual mammograms starting at age 40, to never choosing a screening mammogram, and all those in between.

The old and the new guidelines leave me the most indecisive about the 40-49 year old group. What we are truly missing is an individualized approach to screening mammography. What we should work for is more research to determine risk factors and cause, better tools and tests to assess risk, more accurate and non-ionizing radiation imaging techniques for screening, laboratory testing for markers of breast cancer, and more aggressive risk reduction strategies.

Tori Hudson, ND, graduated from the National College of Naturopathic Medicine and has served the college in several capacities, including: Medical Director, Associate Academic Dean, and Academic Dean. She has been practicing for 25 years, is currently a clinical professor at The National College of Naturopathic Medicine and Bastyr University, is medical director of her clinic in Portland, Ore., and director of product research and education for VITANICA. She is the author of Women's Encyclopedia of Natural Medicine second edition. Dr. Hudson serves on several editorial boards, advisory panels, and as a consultant to the natural products industry.