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article imageAgency Changes Mammogram and Self-Examination Recommendations

By Bob Gordon     Nov 18, 2009 in Health
Most women should start regular breast cancer screening at age 50, according to new guidelines released Monday by the United States Preventive Services Task Force. Only seven years ago the Task Force set the ideal start age for regular mammograms at 40.
The United States Preventive Services Task Force (USPSTF) is appointed by the Department of Health and Human Services and falls under the authority of the Agency for Healthcare Research and Quality (AHRQ). According to its website, "the USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services."
Its mission "is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care."
In terms of mammograms and breast self-examination the USPSTF is not suggesting that they are ineffective or harmful, but rather that the previous recommendations and protocols are not cost-effective. Cost-effective in terms of economics and also cost-effective in terms of risk (or harm) versus benefits. The report on their findings was published in the Nov. 17 issue of the Annals of Internal Medicine.
The report concludes that mammograms reduce the breast cancer death rate by 15 percent. However, this benefit must be balanced against the potential harm or risk. The New York TImes reports that the risk of harm is too great for women 40-49 to make the test beneficial for that age cohort:
Those [potential] harms loom larger for women in their 40s, who are 60 percent more likely to experience them than women 50 and older but are less likely to have breast cancer, skewing the risk-benefit equation. The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69.
For women over 49 the report recommends that mammograms only be done every second year rather than annually.
The Times notes that a false positive can create extreme anxiety and lead to other intrusive and ultimately unnecessary procedures such as biopsies. It also states, "mammograms can find cancers that grow so slowly that they never would be noticed in a woman’s lifetime, resulting in unnecessary treatment."
With regard to breast self-examination, the report dismisses it as of little value. This has provoked almost universal criticism. Breast self-examination is not intrusive and it is free. Critics say there seems to be little risk or potential harm and, therefore, by the Task Force's own criteria of cost-benefit analysis no reason to advocate against it.
"I think one of the more radical things they say is stop self-examination," Dr. Jon Ekstrom, a radiologist with Oregon Imaging Centers told KVAL in Eugene, Oregon. "We see woman after woman after woman come in here and say, 'hey doc, I felt this lump. I'm concerned about it.' And those things I think are important."
While many non-governmental agencies are considering the changes the American Cancer Society is not and remains a strong proponent of annual mammograms after age 40. The American Cancer Society's chief medical officer, Dr. Otis Brawley, issued a statement challenging the panel's findings. "This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over."
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