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If the brouhaha following a government advisory panel's recent change in breast-cancer-screening recommendations has proved anything, it is that even modern medicine does not rely on statistics, scientific facts and clinical outcomes alone.

That's the hard lesson that the U.S. Preventive Services Task Force (USPSTF) learned when it changed course on its recommendations for mammography screening and advised women to delay having the screen until they are 50, rather than beginning evaluations at 40, as they have recommended previously. Over the past two decades, annual mammograms for women over 40 had become a standard of preventive care in the U.S.  right up there with daily exercise, quitting smoking and getting a flu shot. But after taking a more in-depth look at the numbers, the task force decided that the risks of mammography for women in their 40s do not outweigh the small benefit that the screens provide. On top of that, the panel recommended that doctors no longer urge women to perform monthly breast self-exams at home, citing a lack of scientific evidence to support that they save lives. Immediately, almost every major cancer organization and physicians' group  including the American Cancer Society, the Susan G. Komen Breast Cancer Foundation and the American College of Ostetricians and Gynecologists  questioned the new recommendations.

That is the biggest worry boiling up among doctors and women across the country  that a procedure that undeniably reduces the risk of breast cancer is no longer being recommended for millions of women. Another worry: will insurance begin denying coverage of breast-cancer screens in women under 50 who want them? The Obama Administration quickly disputed that notion, as well as the suggestion that the panel's advisory was a government strategy to cut costs by rationing health care.  There is a robust body of clinical-trial evidence showing that routine screening reduces breast-cancer deaths,  the task force attests to that as well. But while everybody, to varying extent, agrees that mammograms are beneficial, what's less clear is the age at which routine mammography screening should begin. That depends in part on breast cancer risk, which increases with age  for every 100,000 women, the risk of developing breast cancer is 1 in 69 in women in their 40s, 1 in 38 in women in their 50s, and 1 in 27 among women in their 60s. Consensus on this question would be helpful because professional cancer organizations, cancer hospitals and doctors base their screening guidelines on the advice of nationally recognized groups  like the American Cancer Society and the National Comprehensive Cancer Network (or NCCN, a coalition of National Cancer Institute–designated hospitals), and the USPSTF.

The panel also commissioned computer-modeling studies that weighed the benefits of routine screening (reduction in death rate) against its risks, depending on the ages of the women being screened and how often they were tested  every year or every other year. Overall, based on a review of mammography trials, the panel found that having a yearly mammogram screening cuts the risk of breast-cancer death 15% in women ages 40 to 49. That reduction, it should be noted, is relative, not absolute. The absolute risk of breast-cancer death after age 40 is 3% without annual screening, according to the computer models. That means that with routine screening, which leads to a 15% lower risk of death from breast cancer, a woman's absolute risk drops to 2.6%. Small numbers in either case. Put another way, the panel concluded, the benefit of routine mammograms for women in their 40s is one fewer death for every 1,904 women screened annually for up to a decade. That benefit increases, however, with the age of the women being screened, as the risk of breast cancer rises: among women 50 to 59, one death is averted for every 1,339 women routinely screened; among women 60 to 69, 377 mammograms would be needed to prevent one death. The task force's computer models further showed that shifting women's screening schedule from yearly to once every two years retains 81% of the benefit of screening while reducing the harms like false positives by half. Combined, the findings led the panel to reverse their 2002 recommendations on mammography, which extended the advice, originally targeting women over 50, to also include women in their 40s. The new guidelines were meant to trigger and inform discussion between women in their 40s and their doctors about routine screening. 

Source: TIME

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