New Breast Cancer Screening Guidelines Provoke Controversy

The United States Preventive Services Task Force recently updated their guidelines related to breast cancer screening and their announcement of the new guidelines was greeted by significant controversy. Many mixed feelings were expressed in response to the revised guidelines, including outrage associated with the idea that women would in any way be formally discouraged from taking precautions related to a disease that is more easily treated when detected early. Breast cancer is the second leading cause of cancer death among women in the United States. According to the Agency for Healthcare Research and Quality, breast cancer death rates have been decreasing since 1990 and the organization credits early detection among the top reasons for this decrease. Early detection is likely linked to the promotion of women being diligent about screening for the disease, so some are wondering what good reason there could possibly be for suddenly promoting a different and less diligent set of guidelines. I wonder this myself. Better safe than sorry seems like a pretty good motto when it comes to precautionary measures that could detect and prevent the advancement of a potentially fatal disease before it's too late. That was my first thought, but before I offer more opinion, let's take a closer look at the revised guidelines themselves.

Before the recent revision, the standard guidelines suggested that women should start receiving annual mammograms at age 40 (earlier if there was a history of breast cancer in their family or other increased risk factors) and also encouraged regular breast self exams at home. The newly revised guidelines recommend against mammograms for women under age 50; for women aged 50-74, mammograms are recommended once every two years. The newly revised guidelines also recommend against the teaching of breast self exams. My first thought is that this seems absurd and potentially harmful to women, but let's consider some of the reasoning of the USPSTF. Their main reasoning seems to be that there is insufficient evidence available to illustrate the efficacy of these procedures. Also, part of the new guidelines related to mammograms states that, "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms." That part does not sound totally ludicrous to me. Certainly, the importance of having a good doctor who is able to help a patient pinpoint benefits versus risks based on one's own personal health history cannot be undervalued. And certainly, it is true that there are some risks associated with the mammogram procedure, as it is an X-ray like procedure that involves exposure to radiation. And so perhaps if one had no clear risk factors at all and was able to discuss the matter with her doctor and they decided together that the woman would be fine holding off on the procedure at this time, then yes, that would be a viable option.

However, it seems to me that there is a substantial difference between promoting the consideration of other viable options versus downright recommending against certain options that are closely linked to early detection of breast cancer. As far as there being insufficient evidence for the USPSTF to strongly stand behind certain procedures, that may be true, but even if so, there is still a difference between not recommending certain procedures versus downright recommending against those procedures. The language of recommends against seems basically as if they are officially discouraging those preventive measures and this is what a lot of women find especially upsetting about the new guidelines, myself included. Some women are also questioning the motivation behind the new guidelines. I have read some uneasiness-provoking suggestions that the new guidelines are not based on any genuine concern for the health of women, but are mainly intended to reduce health costs.

Granted, I don't think many of us are overeager to pay the high health care costs associated with potentially risky procedures that may be unnecessary. However, that's a tricky but largely unavoidable aspect of preventive health measures; there's really no foolproof way to know in advance whether or not certain procedures are necessary; isn't that kind of the nature of the beast? Indeed, when patients choose to undergo health-related screening procedures, such as mammograms, they're obviously hoping that nothing is really wrong, but if nothing is really wrong, that doesn't necessarily mean that the procedure wasn't worth it. What if something had been wrong? I understand there are some risk factors associated with mammograms and I am certainly in favor of the idea of carefully discussing the matter with one' s doctor, but is an annual procedure that has saved numerous lives really something excessive? What if the new USPSTF guidelines have little to do with helping individual women weigh benefits versus harms, including the harm of unwanted medical costs for individual women and are more related to reducing medical costs within the health care system itself, a system that most would agree is suffering from some serious problems and in need of reform. I think that most would also agree that an attempt to cut costs within a problematic system should not come at the cost of women's health.

Among those expressing the most outrage over the new guidelines are some feminist groups, cancer survivors (many of whom are still alive today due to the early detection of their cancer by one of the procedures that are now being recommended against), and doctors who are concerned that the new guidelines will communicate to women age 50 and younger that skipping exams is fine because they are at less of a risk for the disease, which is entirely untrue. I can certainly understand these groups' concerns and think that they are very valid. Especially when it comes to breast self exams, I think that recommendation against them is ridiculous. Whereas the mammogram procedure does include certain risk factors, manually examining one's own breasts has no risk factors as far as I can discern. Even if there is supposedly insufficient evidence of this procedure's efficacy, I don't think that's any good reason to recommend against a procedure that has no harmful effects and could lead to early detection of cancer. If insufficient evidence must be stated in the guidelines, then state insufficient evidence, but don't recommend against a harmless procedure that encourages women to be empowered about taking their health into their own hands and that could save their lives.

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http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm

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