The Breast Cancer Screening Debate: A Matter of Life and Death

Is a 45-year-old woman "too young" for regular mammograms? Federal guidelines say screening should begin at age 50, but new studies are challenging that recommendation.

Breast cancer is the most prevalent form of cancer among the female population and the second leading cause of cancer death among women after lung cancer.¹ According to 2010 statistics from the National Institutes of Health National Cancer Institute, breast cancer accounted for an estimated 207,090 new cases in women and 1970 new cases in men, with reported deaths at 39,840 among women and 390 among men.^2,3 Yet according to the American Cancer Society, breast cancer deaths are decreasing.¹ In addition, according to 2010 statistics, there are approximately 2.5 million breast cancer survivors in the United States—likely due to increasing awareness, earlier detection, and treatment options.¹

Research has shown that mammography screening assists in decreasing the mortality rate associated with breast cancer among women between the ages of 40 and 74.⁴ However, there has been a great debate regarding breast cancer screening guidelines and preventative care, especially since November 2009, when the United States Preventive Services Task Force (USPSTF) released its recommendations for breast cancer screening, which advise biennial screening mammography for women aged 50 to 74 years instead of yearly mammography screening.⁵ These recommendations do not apply to women with high-risk factors for breast cancer, and the task force believes that these guidelines may decrease the harm from overtreatment.⁶ The USPSTF also recommends against health care providers teaching breast self-examination.^5,6 Many experts believe that these new recommendations may confuse women and many organizations continue to make their own recommendations for mammography screening. The Table lists the recommendations of major US organizations.^7-9

Since the USPSTF recommendations were released, various studies have been conducted to investigate them and have generated much debate regarding this issue. For example, results from 2 studies were presented at the annual meeting of the American Society of Breast Surgeons, held April 27, 2011, to May 1, 2011, that challenged the USPSTF recommendations. According to the results from these studies, the USPSTF recommendations against routine mammography screening in women between the ages of 40 and 49 years may actually increase the number of women presenting with more advanced disease upon diagnosis and may also disproportionately affect minorities, possibly leading to diagnosis of more advanced stage disease.^10-12 Paul Dale, MD, reported that mammography-detected cancers in women aged 40 to 49 years were smaller, had less nodal metastasis, and were associated with increased survival.^10,11

Results from a study published in the April 5, 2011, online issue of the American Journal of Preventative Medicine reports that the USPSTF recommendations may actually confuse patients more than help them understand the proper time to get a mammogram. 13 The study included 1221 women between the ages of 40 and 74 who had never had breast cancer. An estimated 51.9% did not support the screening recommendations and only 17.6% were in favor of the new recommendations. Less than 25% were even aware of the new recommendations.¹³ The study concluded that the new recommendations confused an estimated 30% of the study population and that this confusion was greatest among those patients between the ages of 40 and 49 who had never had a mammogram or had a mammogram more than 2 years ago.¹³

Another study, published in the February 2011 issue of the American Journal of Roentgenology, examined the scientific evidence considered by the USPSTF in recommending against screening mammography in women 40 to 49 years old and against annual screening mammography in women 50 years and older.¹⁴ The study analyzed the same data looked at by the task force. The study investigators compared the task force’s recommendations for screening every other year in women 50 to 74 years old to American Cancer Society guidelines of screening every year in women 40 to 84 years old.¹⁴ Conducted by Hendrick and Helvie, the study used 6 model scenarios of screening mammography created by the Cancer Intervention and Surveillance Modeling Network.¹⁴ The investigators reported that if a woman begins yearly mammograms at age 40, it reduces breast cancer deaths by an estimated 40%.¹⁴ When screening begins at age 50 and occurs every other year, it reduces breast cancer deaths by only 23%.¹⁴

The study also reported that the USPSTF recommendations emphasized the potential harm mammography can cause—including pain during the screening exam and anxiety from false positives, which can lead to additional imaging or biopsy.¹⁴ The study, however, also reported that on average, women between the ages of 40 and 49 years who are screened annually may have a false-positive mammogram once every 10 years, may be called for retesting once every 12 years, will undergo a false-positive biopsy once every 149 years, and concluded that the task force overemphasized potential harms of screening mammography.¹⁴ In the study, Hendrick et al also reported that the panel ignored more recent data from screening programs in Sweden and Canada, which demonstrated that 40% of deaths due to breast cancer were prevented in patients who obtained regular mammography screenings. The study concluded that their modeling results agree completely with the results from that screening program with regard to the large number of women’s lives saved by regular screening mammography.¹⁴

The issues regarding the frequency of mammography screening will probably be debated among health care professionals for the foreseeable future. In the meantime, patient care should not be compromised. Through patient education, health care professionals can increase awareness of breast cancer, its risks, and the importance of routine screening for prevention and early detection. Mammography screening is one tool that can aid in detecting breast cancer and has been shown to save lives; therefore, it is imperative that women discuss these issues with their primary health care provider, especially if they have a familial history of breast cancer and/or other risk factors.

The Role of The Pharmacist

As one of the most accessible health care professionals, pharmacists are in a pivotal position to increase awareness regarding the detection, screening, and treatment of breast cancer. During patient counseling, pharmacists should utilize every opportunity to encourage and remind their patients about the importance of routine breast cancer screening, including mammography, routine medical checkups, yearly clinical breast exams, and monthly self-breast exams, because early detection may save a life and increase the number of breast cancer survivors in the United States.

Pharmacists can also answer patients’ questions about both the risk factors and symptoms associated with breast cancer as well as direct them to the various resources available to patients regarding risk factor assessments and treatments. As health care professionals, we can provide our patients with the pertinent information they need to make informed decisions about their health. We should also encourage patients to take a proactive approach to maintaining good health and always ask questions when in doubt. PT

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

1. How many women get breast cancer? American Cancer Society Web site. www.cancer.org/Cancer/BreastCancer/OverviewGuide/breast-cancer-overview-key-statistics. Accessed May 7, 2011.

2. Breast cancer. National Cancer Institute Web site. www.cancer.gov/cancertopics/types/breast. Accessed May 11, 2011.

3. What are the key statistics about breast cancer? American Cancer Society Web site. www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. Accessed May 9, 2011.

4. Breast Cancer Information. National Cancer Institute Web site. www.cancer.gov/cancertopics/screening/breast/mammogram. Accessed May 11, 2011.

5. Screening for breast cancer. US Preventive Services Task Force Web site. www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Accessed May 11, 2011.

6. Panel urges mammograms at 50, not 40. The New York Times Web site. www.nytimes.com/2009/11/17/health/17cancer.html?pagewanted=print. Accessed May 10, 2011.

7. Mammogram Screening. National Cancer Institute Web site. www.cancer.gov/cancertopics/screening/breast/mammography-benefits-harms. Accessed May 11, 2011.

8. Interpreting the U.S. Preventive Services Task Force breast cancer screening recommendations for the general population. The American Congress of Obstetricians and Gynecologists Web site. www.acog.org/from_home/Misc/uspstfinterpretation.cfm.Accessed May 11, 2011.

9. Mammography screening. American Cancer Society Web site. www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-detection. Accessed May 11, 2011.

10. ASBS: mammogram studies suggest use in younger women. Med Page Today Web site. www.medpagetoday.com/HematologyOncology/BreastCancer/26256. Accessed May 11, 2011.

11. Dale P et al. Mammography in 40-year-old women: the potential impact of the U.S. Preventative [sic] Services Task Force (USPSTF) mammography guidelines. ASBS2011. Abstract 1754.

12. AragonRJ et al. The potential impact of USPSTF recommendations on the early diagnosis of breast cancer. ASBS2011. Abstract 1670.

13. Squiers LB, Holden DJ, Dolina SE, Kim AE, Bann CM, Renaud JM. The public’s response to the U.S. Preventive Services Task Force’s 2009 Recommendations on mammography screening. Am J Prev Med. 2011;40(5):497-504. www.ajpmonline.org/webfiles/images/journals/AMEPRE/AMEPRE3036.pdf. Accessed May 11, 2011.

14. Hendrick RE, Helvie MA. United States Preventive Services Task Force screening mammography recommendations: science ignored. Am J Roentgenol. 2011;196(2):W112-W116.