Physician editorialist claims breast cancer screening at 40 will sow confusion; ACR fires back
In an editorial published Monday, a physician and researcher charged that screening women for breast cancer at 40 lacks evidence and could sow confusion. The American College of Radiology fired back the same day, contending the piece relies on “obsolete, hyperbolic information.”
Russell P. Harris, MD, penned the editorial for the Annals of Internal Medicine, spurred by new recommendations issued by the U.S. Preventive Services Task Force in May. Harris, trained in internal medicine, performed systematic reviews for the USPSTF and was present at task force meetings in which previous breast cancer screening recommendations were discussed and finalized in 2002 and 2009.
He charged that the latest update—shifting from starting screening at 50 down to age 40—lacks backing from randomized control trials. Harris cited USPSTF research, which found that up to half of women in their 40s would experience at least one false-positive mammography result over 10 years of screening. Sometimes, this led to unnecessary biopsies and added anxiety.
“There are dangers both for women in their 40s and for the USPSTF in adopting a new recommendation not backed by evidence,” Harris, with the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, wrote Feb. 5. “For women in their 40s, it means many more undergoing screening with a low probability of benefit and definite potential for harm. The USPSTF risks abandoning its role in setting the standard for using evidence and sound judgment to make medical decisions. This would be a loss for all of medicine.”
The American College of Radiology—a fervent supporter of screening at 40—issued a response to the editorial late Monday. It noted that, “Total reliance on outdated randomized controlled trials to inform screening policy can cost lives.” The most recent such trial started over three decades ago, while the first is over 60 years old.
“All used outdated, film-screen technology, many obtained only single views of each breast and there were limited screening rounds with variable screening intervals,” ACR said in its response. “Today, digital mammography with tomosynthesis, which acquires dozens of views of each breast, has increased cancer detection, and a decrease in callbacks and false positives is standard.”
The college also contended that these trials did not have adequate statistical power to evaluate cancer mortality for women in their 40s. Meta-analyses that have followed, however, have proven a “clear mortality benefit” when screening at this age.
Harris noted that the new 2023 USPSTF recommendations stem from a “commendable desire” to reduce the disparity of high cancer morality for Black women. The task force relied heavily on decision analytic models, making “several debatable assumptions,” which found that earlier screening would help reduce deaths for racial minorities. He also criticized an absence of urging women to individualize the decision to start screening, as had previous guidelines.
“I remain hopeful that the USPSTF will reverse course and reconsider its draft recommendation,” Harris closed. “I am also hopeful that the many evidence-based healthcare professionals who spend time helping women in their 40s to make individualized decisions will continue their important work.”
ACR also said that concerns about nonlethal screening risks are “overstated” and based on “faulty assumptions, methodology and hyperbole in articles on which these claims are based.” “Well designed” studies have proven risk of overdiagnosis at 10% or less. And false positives are typically easily addressed, with anxiety often resolved quickly with no lasting impact.
“Foregoing or delaying screening—resulting in breast cancer not being discovered until at an advanced stage—is often lethal,” the ACR statement closed. “Screening only women ages 50-74 every other year may result in up to 10,000 additional, and unnecessary, breast cancer deaths in the United States each year. Thousands more would likely endure extensive surgery, mastectomies and chemotherapy for advanced cancers.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.