Why not lower the recommended mammogram age to 30? or 20?

The controversy over the recent mammogram screening recommendation from the United States Preventive Services Task Force (USPSTF) is quite interesting. The pieces of the recommendations that have generated the most controversy are as follows:

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. 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.

The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.

Yesterday’s New York Times letters to the editor section and news section was typical of the unsophisticated coverage I’ve seen: a number of letters and quotes from women diagnosed in their 40s complaining that the new guidelines would have killed them, someone pointing out that cancer can grow a lot in two years, along with a couple people pointing out that a pile of anecdotes does not equal a well-conducted scientific study.

I’d like to see this discussion pushed to its logical conclusion. If the minimum screening age shouldn’t be increased to 50, why should it be left at 40? Why not lower it to 30? Or 20? Or even lower? And if two years is too long of an interval, are we sure one year is frequent enough? How about every 6 months? Or every 3 months? Or every day?

Surely it does make sense to have some guidelines. Mammography appears to have modest benefits, but there is also potential harm associated with screening. From the National Breast Cancer Coalition.

Myth #2: Mammograms can only help and not harm you.

False: What’ the risk? False positive results may lead to unnecessary, intrusive surgical interventions, while false negative results will not find cancerous tumors.

The American Cancer Society¬†recommends annual screening mammograms, those performed without symptoms present,¬†starting at age 40. But…¬† it has been estimated that a woman’s cumulative risk for a false-positive result after ten mammograms is almost 50%; the risk of undergoing an unnecessary biopsy is almost 20%. In addition, women who are screened with mammography often have more aggressive and unneeded treatments. It is estimated that mammography screening has increased the number of mastectomies by 20% and the number of mastectomies and lumpectomies combined by 30%.

USPSTF does not take cost into account, although many have jumped to the conclusion that cost and “ObamaCare” are behind the recommendations. Personally I think it’s a good idea to take cost into account, although it should be done as a separate, transparent step after the clinical evidence is considered.

Although we don’t like to admit it, cost has to play a role somewhere along the way. If a mammogram is reimbursed ~$100 as it is now, cost may not be a big deal. But what if the cost were $1000, $10,000, $100,000, or $1,000,000? Should that not impact the guidelines?

I understand why people are worried about changes to guidelines, and I don’t totally disagree with their concerns. But diagnostic screening in general has risks as well as benefits. The aggregate benefits are often overstated by those who feel they’ve gained from screening –and especially by physicians, equipment makers, hospitals and labs that earn their living this way– while risks are not recognized or are suppressed.

Prostate screening is another good example of this phenomenon. See my coverage from a few years ago when the push began to lower the recommended age for PSA testing from 50 to 40.

November 19, 2009

5 thoughts on “Why not lower the recommended mammogram age to 30? or 20?”

  1. Pingback: healthbizblog at 11/20/09 12:39:25 | Exectweets
  2. Why stop there? Let’s take it the other way. Why start screening at 50? Why start at all? Once people get cancer, why treat them? Let ’em all die.

    Hope you don’t ever get cancer…

  3. In a way not having a lower bound on the age would be beneficial to one group of women who often have trouble getting diagnosed. That’s women in their late 20s early 30s.

    It’s not unusual for them to have a lump go to the doctor and be told it’s a cyst or that they’re “too young” to have breast cancer.

    Perhaps knocking the lower age off and letting the decision be between a woman and her doctor would reduce the “you’re too young” mindset and help those oddball women get diagnosed.

    Women with various risk profiles would have target screening start dates, but they’d be flexible.

  4. First let me say I was extremely disappointed by your posting. I’ve read your blog before and have found it to be thoughtful and articulate. Sadly, that rigor was lost in your effort at a cheeky posting. Doubly sad is that your posting also shows a general lack of education and research on the topic.

    Here’s my argument – don’t change the guidelines. There have been two decades of scientific rigor put into the guidelines that came out in 2002. The medical results in the decline of breast cancer mortality speak for themselves. The burden of changing guidelines rests with those who wish to change them.

    You’ve noted that the media coverage contained, “…a pile of anecdotes does not equal a well-conducted scientific study.” Where is the well-conducted scientific study that brought about this change in guidelines? Point to it. You can’t. These guidelines were issued, not in response to new medical data, but in response to changing political beliefs about an economic one.

    You make a pretty bold statement in your editorial: “USPSTF does not take cost into account…” Sadly, your rush to editorialize seems to have run headlong into your lack of research and knowledge. My recommendation: take some time and actually read the USPSTF recommendations and the paper published in the Annals. Cost is defined in the recommendations as “resource requirements” and was taken into account. In fact, you’ll see costs noted throughout. Economics was a strong driver of these recommendations (and 3 of the 16 panelists work in healthcare economics). The USPSTF members received a financial analysis of mammography spending as part of their deliberation process. So, the USPSTF has, most definitely, taken cost into account.

    The guidelines were last reviewed in 2002. Since that time, there was one actual new study…a study that shows for every 1904 women you screen in the age group 39-49, you’ll save 1 from dying of breast cancer during the study period (not much longitudinal accounting here). This is not a burning bush or a stunning medical breakthrough calling for significant changes to the guidelines.

    What is missing in your posting (which focuses solely on the lower-bound) are the two other parts of the task-forces recommendation: the upper bound and frequently. The task force also recommended that women over age 75 are, essentially, too old and not worth saving/screening. The task force also recommended screening every other year for women 50-74 – a move not supported in the medical literature (but seems to have quite a bit of support in the world of healthcare economics). Both of these parts of the USPSTF guidance you have conveniently ignored.

    I think it’s nearly criminal that at least one member of this “expert panel” hasn’t been in a room with a patient in so long that Clinton was probably President – hardly keeping up on the science (instead they serve in the capacity of rent-a-doc to the government and industry, lending the credentialed title “M.D.” to whatever sham science comes their way). And I’m sure the three pediatricians and the one pedtriatic nurse practitioner (4 of 16 members of the panel – or 25%) added a lot to the discussion on breast cancer in women age 40+. There isn’t single, actual expert on this panel: not a radiologist, not an expert in breast cancer, and not even a general oncologist (but I’m sure the three medical economists had a lot to say).

    The burden of proof for changing medical guidelines lies in those who wish to change it. My recommendation, leave it at 40. Unless there is new clear and compelling evidence to do otherwise (we’re talking prospectively designed trials). All else is just political window dressing.

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