Mammography in crisis

Mammography is making headlines again with the recently released United States Preventive Services Task Force (USPSTF) draft breast cancer screening recommendations—bookended by a humbling prediction from the National Cancer Institute that breast cancer cases could increase by 50 percent over the next 15 years. Could the new recommendations make those forecasts even worse? Maybe.

The draft regs are a re-do of the 2009 recommendations, and it seems everyone is concerned. The first reaction is “science ignored” once again, as Hendrick and Helvie concluded in 2011. They showed, using the 2009 methodology, that if women ages 40-49 go unscreened, and women 50-74 are screened biennially, approximately 6,500 additional women each year in the U.S. would die from breast cancer.

The other top concerns today with the draft recommendations are reductions in access and higher cost-sharing for routine mammograms—both of which could mean women forego or skip screenings. Experts say confusion will continue among women about appropriate screening protocols and associated risk.  

To try to lock in access, industry associations and senators are calling for HHS to mandate that full, no-copay mammogram coverage continue for women over 40 that is currently guaranteed under the Affordable Care Act (ACA). The HHS secretary holds that power. The ACA presently requires private insurers to cover exams with a grade of “B” or higher USPSTF. However, the task force gave routine screening of women ages 40-49 a grade of “C” and gave a “B” grade only to biennial screening for women 50-74.

We know that mammography has helped reduce breast cancer mortality in the U.S. by nearly one-third since 1990. But the new NCI study predicts a curve in the other direction for older women largely fueled by longer life spans and increased detection of cancers. The study estimated new breast cancer cancers in the U.S. will surge substantially from 283,000 in 2011 to 441,000 in 2030. The proportion of new cases among women ages 70-84 is expected to be 35 percent in 2030, up from 24 percent in 2011. Yet, the proportion of new cases among women ages 50 to 69 is expected to decline, to 44 percent in 2030, down from 55 percent in 2011. Collectively though, it adds up to a lot more clinical burden to manage and prepare for. The question is: Will the number of breast cancers detected actually be higher if the new guidelines mean fewer women get screened earlier and throughout life? We hope not.

Annual screening mammography is endorsed by the American Cancer Society, American College of Radiology, Society of Breast Imaging, American College of Obstetricians & Gynecologists and many breast imaging experts. The recommendations state that the average patient should begin annual breast cancer screening at age 40, which high-risk patients beginning by age 30 (but not before 25). ACR says there is no defined upper age limit at which mammography may not be beneficial, with screening mammography considered as long as the patient is in good health and is willing to undergo additional testing, including biopsy, if an abnormality is detected.

Data run deep that early detection of breast cancer (when tumors are <14mm) increases treatment options, saves lives and improves outcomes. Breast cancer screening works. We need to make sure widespread, affordable access to screening mammography continues for all the women who need and want it.