Does the Mammography Debate Miss a Key Point?

Every time the US Preventive Services Task Force issues a recommendation about when women should start getting mammograms – and how often they should have these screenings – it sends shockwaves through the breast-cancer world.

modiglianiThis last time was no different.

But now two influential breast cancer experts assert that – as important as the debate is – it misses an essential point about evaluating a woman’s individual risk of getting breast cancer.

Those experts – Dallas breast surgeon Dr. Peter Beitsch and Nashville breast surgeon Dr. Pat Whitworth – say the key question is how to evaluate “risk.”

The latest recommendations from the task force call for women at “average risk for breast cancer” to begin every-other-year screening at age 50. It casts doubt on the true value of screening beginning at age 40 – citing the high number of false-positive test results in women 40 to 50, plus potential harm from overdiagnosis and unnecessary treatment.

Many advocates in the breast cancer world maintain that screening should start at age 40 rather than 50. Women who have had breast cancer at an earlier age often credit screening mammography with catching their cancer in time. And of course many of us know someone who has been struck by the disease at an early age.

There is also some scientific evidence to support earlier screening. In contrast, the task force has its own reasons to recommend that screening begins at 50. For some context on those questions, see this discussion from Susan G. Komen.

The debate has become so heated that advocates, including the influential Washington DC-based Tigerlily Foundation, were successful in getting Congress to incorporate the PALS Act into the most recent federal omnibus spending bill.

The bipartisan PALS provision places a two-year hold on the task force’s final screening recommendations for breast cancer.

There’s been an interesting split among clinicians. The American College of Radiology, for example, oppose the recommendations and said that women should get annual mammograms beginning at age 40 – a position outlined in this press release. The American Academy of Family Physicians, by comparison, supported the task force’s recommendations in this statement.

It seems inevitable that this controversy will continue for years. Whatever the outcome, say breast surgeons Pat Whitworth and Peter Beitsch, most people in the debate are overlooking a key point:

In the endless discussions over when women of “average risk” should begin screening mammography — exactly how are women and their physicians to determine who is at “average risk”?

“This is a continuation of an egregious failure of professional societies, medical organizations, the USPSTF, the ACS, the media, and virtually everyone else,” says Dr. Whitworth. He’s one of four physician founders of Targeted Medical Education, a group of leading community-based breast cancer doctors.

“Every one of these groups pays lip service to the ‘individualized discussion between physician and patient’, without empowering women and doctors with the simple fact that individual risk can be more precisely calculated,” he adds.

Many women are familiar with some of the risk factors for breast cancer. They include, to varying degrees:

  • Age
  • Family history
  • Race
  • Carrying the BRCA1 or BRCA2 gene mutation
  • Use of combined hormone therapy after menopause
  • Breast density, and
  • Whether (and at what age) a woman has given birth.

But the general guidance from clinical organizations is often of little help here, asserts Dr. Beitsch, another TME founder: “One such group actually says that women at intermediate risk should ‘consider using a risk assessment model.’ ” He calls that advice “completely bass ackward” and adds: “Decisions about when to begin screening should begin with risk assessment using widely available models. Being 40 and female is no longer adequate for risk assessment.”

So what is the best model to do use?

The Society of Surgical Oncology cites six of them, including the well-known Gail Model developed by the National Cancer Institute.

Drs. Whitworth and Beitsch, point to the Tyrer-Cuzick model or, in another form, the Hughes RiskApp (after Kevin Hughes, M.D., of Massachusetts General Hospital.) Women wanting to calculate their personal risk can use several different sites, including this website. For physicians there are more sophisticated offerings here.

The doctors at TME are leaders in educating their peers about breast cancer treatment. They’ve also got the right idea about the need for better and more widely available risk assessment.

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