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 "They made it really clear this time around, unlike 2009, that the
discussion between a woman and a clinician about breast cancer
screening should begin at 40," said Dr. Richard Wender, chief cancer
control officer at the American Cancer Society.
The Department of Health and Human Services provided for mammogram
coverage for women age 40 to 49 after the health panel made its
recommendation in 2009. The department said on Monday that the
guidelines are only in draft form and that nothing has changed
regarding access to mammograms or other preventive services.
Critics stressed that keeping 50 as the starting age for screening –
a change first introduced by the panel six years ago - could
threaten insurance coverage for millions of women age 40 to 49.
"If this becomes the final guideline, coverage of mammograms would
no longer be mandated under the ACA," said Wender.
President Barack Obama's Affordable Care Act (ACA) requires
preventive medical services with a grade of "B" or higher be
covered, unless the administration specifies otherwise.
Under the draft guidelines released on Monday, mammogram screening
every two years for women 50 to 74 got a grade of "B", meaning
doctors should offer the service. Screening for women in their 40s
remained a "C" grade, meaning doctors should offer the service for
select patients, depending on individual circumstances.
The draft guidelines from the government-backed U.S. Preventive
Services Task Force also prompted renewed debate over when women
should be screened for breast cancer, as patients parse conflicting
advice from health experts and advocacy groups.
Some prominent physician groups welcomed the shift in the panel's
language after its abrupt change in screening recommendations in
2009, in which it recommended women should have mammograms every
other year starting at age 50 rather than annual tests starting at
age 40.
Many groups including the American College of Obstetrics and
Gynecology (ACOG) and the American College of Radiology recommend
annual mammograms start at age 40. The American Cancer Society
shares that view, but is reviewing its guidelines.
The health panel's updated recommendations are now "more closely in
line with ACOG’s," said Dr. John Jennings, ACOG president. Both
groups recognize that the decision to screen women in their 40s is a
personal one that reflects potential benefits of detecting cancer
early and the harm of receiving a false positive, he said.
WEIGHING THE EVIDENCE
The new health panel guidelines are based on a review of scientific
evidence showing the benefits of cancer screening outweigh the risk
of overtreatment for women age 50 to 74.
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They acknowledge that mammograms in women 40 to 49 may reduce the
risk of dying of breast cancer, but say that the number of deaths
averted is "much smaller" and the "number of false-positive tests
and unnecessary biopsies are larger."
Women with a parent, sibling, or child with breast cancer may
benefit more than average-risk women from beginning screening
between the ages of 40 and 49 years.
"The value of mammography increases with age," said Task Force chair
Dr. Michael LeFevre, a professor of family medicine at the
University of Missouri School of Medicine.
Dr. Daniel Kopans, a professor of radiology at Harvard Medical
School, said the task force should still emphasize the potential for
saving lives by beginning screening at age 40.
"They should support screening annually beginning at the age of 40
while providing women with accurate, scientifically derived
information so that each woman (not the panel) can decide for
herself whether or not to participate in screening," Kopans said in
a written statement.
The panel's review included clinical trials that showed over a
10-year period, mammography prevents four deaths per 10,000 women
age 40 to 49 years, five to eight deaths for women age 50 to 59, and
12 to 21 deaths for women age 60 to 69.
The panel also considered new simulation models from six independent
research teams that analyzed data from digital mammograms, the cost
commonly used technology.
That modeling unanimously projected that screening every two years
from age 50 to 74 would, over a lifetime, prevent seven breast
cancer deaths per 1,000 women screened. Starting screening every two
years from age 40 would prevent one more death from breast cancer
and generate 576 more false positive tests.
(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and
Lisa Shumaker)
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