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What is the US Preventive Services Task Force?
What does the Task Force say about breast cancer screening?
Does this mean that women in their 40s will not be able to get mammograms?
How did the Task Force decide on the recommendations?
Is this the first time we have heard these guidelines?
What changed? Why did the Task Force significantly change its recommendations?
What does the National Breast Cancer Coalition say about the new guidelines?
Has breast cancer screening had a significant impact on mortality from breast cancer?
But doesn’t early detection save lives?
Why doesn’t mammography work as well for women in their 40s?
But shouldn’t a woman in her 40s have a mammogram if she feels a lump?
What’s the harm in trying to detect breast cancer early, even if our methods don’t work that well?
Why did the Task Force not recommend self breast exam when many people find their breast cancers by feeling them?
So it’s still important for women to be familiar with their breasts?
Is it true that some women will die under these guidelines?
A mammogram/self examination found my breast cancer and I am alive today so these methods clearly work, right?
Isn’t it better to give women a simple public health message?
Aren’t these guidelines really about saving money?
There has been so much controversy over these guidelines. Do you think the public will ever accept the new guidelines?
How do we move forward?
What is the US Preventive Services Task Force?
The Task Force is a panel of 16 experts in prevention and primary care. They are not government employees, but are volunteers appointed by the Agency for Healthcare Research and Quality. They review scientific evidence for a broad range of clinical preventive services. The Task Force’s recommendations are used as a guide for health care providers and are considered the “gold standard” for clinical preventive services.
What does the Task Force say about breast cancer screening?
On November 16, 2009, the Task Force released the following new guidelines for healthcare providers:
• The Task Force does not recommend that women automatically begin mammography screening at the age of 40. Instead the Task Force recommends that the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.
• The Task Force recommends every other year screening mammography for women aged 50 to 74 years.
• The Task Force concludes that there is not enough evidence to determine the harms and benefits of screening mammography in women over 74.
• The Task Force recommends against healthcare providers teaching breast self-examination.
• There was not enough evidence for the Task Force to make a recommendation on clinical breast examinations, digital mammography, or MRI.
Does this mean that women in their 40s will not be able to get mammograms?
NO. That is a misrepresentation of what the Task Force said. The Task Force said that the decision to start regular mammography before age 50 should not be automatic but should be an individual decision and take into account the patient’s values regarding specific benefits and harms. It gives women more control over their health care decisions.
How did the Task Force decide on the recommendations?
The Task Force reviewed eight clinical trials on mammography and asked for six different academic centers to perform statistical models of the harms and benefits based on actual data of breast cancer incidence. They also had input from various stakeholder groups. In addition, the paper announcing and explaining the guidelines was submitted for publication to a scientific journal and underwent peer review by outside experts. At various levels of review and discussion, cancer experts wre involved, including medical, radiation and surgical oncologists as well as physician/epidemiologists. Individuals representing the views of the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians weighed in. The American Cancer Society also provided the Task Force with a statement of its recommendations on breast cancer screening.
To read about the studies the Task Force reviewed, go to http://www.annals.org/content/151/10.toc#clinicalguidelines.
Is this the first time we have heard these guidelines?
No, these recommendations and the controversy are not new. The American College of Physicians made similar recommendations a few years ago. In 1997, The National Institutes of Health convened a consensus conference and also concluded that there was not enough evidence to recommend routine screening for women in their 40s. But politicians got involved and the Senate voted to overrule the consensus panel, and yearly mammograms beginning at 40 were promoted.
What changed? Why did the Task Force significantly change its recommendations?
First, these new recommendations are not significantly different from the recommendations issued in 2002 by the Task Force. These new recommendations came about because the breast cancer screening guidelines came up for consideration in due course. Clinical guidelines are periodically reviewed to reflect new knowledge in science and matured data from older clinical trials. In this instance one of the new pieces of information for the Task Force was the results of the Age trial, the only clinical trial designed to test whether screening reduces mortality in women ages 40-49. The trial did not find a statistically significant mortality benefit in this age group. In addition, new knowledge about the biology of breast cancer discovered over the years has an impact on screening recommendations. Researchers and health care providers know more about the harms associated with screening and the effect of screening on different subtypes of breast cancer.
What does the National Breast Cancer Coalition say about the new guidelines?
The National Breast Cancer Coalition commends the release of the new guidelines, and hopes that these new guidelines will put screening and its limitations into proper perspective. The public has increasingly put their faith in screening and early detection, though we have never had good evidence that this would have a significant impact. Focusing on screening as the answer prevents us from looking for what we really need. For over ten years, NBCC has reviewed and analyzed each newly published trial on mammography screening. After each analysis, NBCC has continued to take the position that mammography screening has significant limitations and should be a personal choice rather than a public health message.
Has breast cancer screening had a significant impact on mortality from breast cancer?
No, over 40,000 women continue to die of breast cancer each year, despite the emphasis on breast cancer screening in our country. To change this, we must address the facts about breast cancer and not simply accept what we want to believe. The fact is that all breast cancers are not equal and that we don’t currently have tools for “early detection” that are good enough for the life-threatening breast cancers.
But doesn’t early detection save lives?
Not necessarily. Some breast cancers are slow-growing and have a good prognosis, whenever they are found, whether small or large. Other breast cancers are aggressive and fast growing, and we don’t have the tools to catch them early enough or treatments that will work.
Why doesn’t mammography work as well for women in their 40s?
Younger women have more dense breast tissue, making mammography less accurate. Also, mammography is better at detecting slower growing tumors more common in older women, than the fast-growing, aggressive tumors more often found in younger women. And the balance of benefit vs. harm changes as women get older since the likelihood of breast cancer increases with age. The disease is relatively rare in younger women.
But shouldn’t a woman in her 40s have a mammogram if she feels a lump?
Certainly. The Task Force recommendations are meant to be guidelines for broad public health policy for healthy women with no symptoms, and an average risk for breast cancer. These guidelines are not meant for any woman with an increased risk or for any woman who feels a lump or change in her breast. Women who have any concerns need to visit their doctors and may need diagnostic mammograms. Mammograms taken to assess a problem are not the kind of mammograms we are talking about with these guidelines.
What’s the harm in trying to detect breast cancer early, even if our methods don’t work that well?
The harms from screening too early or too often include increased false positives, leading to increased imaging and radiation exposure, biopsies and scarring that can affect the accuracy of future mammograms, and anxiety. There is also the harm of overdiagnosis of breast cancer. This would involve treatment of cancers that would never be life threatening, and treatment of cancers that may regress, or go away on their own. The treatments for breast cancer are not aspirin, they are toxic and can be life threatening; the scenario of overdiagnosis should not be taken lightly.
Why did the Task Force not recommend self breast exam when many people find their breast cancers by feeling them?
The majority of women do find their breast cancers because they feel them, while going about their lives. But the large clinical trials that the Task Force reviewed demonstrated that monthly regimented examinamtions of breasts to search for cancer did not lead to discovering more cancers or earlier cancers and at the same time doubled the amount of biopsies taken. However, this does not mean women who feel a lump or notice a change in their breasts should ignore it. These women should visit a doctor to address their concerns.
So it’s still important for women to be familiar with their breasts?
Absolutely! Being familiar with your breasts, and reporting any changes or concerns to your doctor, is different from a monthly self examination done with a certain technique in order to search for cancer. This is a common misconception of what the Task Force said. The Task Force looked at teaching the monthly, regimented search for cancer that women have been told to do. That is “breast self examination.” The Task Force did NOT speak to women knowing their bodies, being aware of changes and differences. That happens while women go about their daily lives, showering, dressing, love making, for example.
Is it true that some women will die under these guidelines?
As often happens with press coverage, many relevant details have been left out of the reporting. In this case, there hasn’t been much coverage of the large randomized clinical trials that found no statistical difference in breast cancer mortality from screening under 50 years of age, or from breast self examination at any age. That may seem surprising when you or a loved one has found a breast cancer in one of these ways, and you assume it would have been lethal if it hadn’t been found in this way. But there are several explanations for this that involve the science and natural history of breast cancer.
A mammogram/self examination found my breast cancer and I am alive today so these methods clearly work, right?
It is understandable that many people would think that they are alive today because their breast cancer was discovered through screening. But this makes many assumptions that just can’t be known, such as how life-threatening the cancer would have been, if the cancer may have regressed on its own, and whether the cancer would have been discovered in other ways and would have had the same prognosis. The point is, individual stories are not evidence of effectiveness. Detection, screening, breast cancer…these are all very complicated issues.
Look at bone marrow transplant for breast cancer. It seemed to make sense: if chemotherapy works, maybe even more chemotherapy would work better. Bone marrow transplant is a method of giving patients lethal doses of chemotherapy, then replacing their bone marrow. It was believed that level of dosing would kill all the cancer. And in some cancers, usually blood based, it worked. So women with breast cancer received this incredibly toxic treatment outside of clinical trials. When the trials were actually performed and we had the scientific evidence, it showed that not only was bone marrow transplant not more effective than standard treatment, but it actually resulted in deaths from the treatment itself. Health care should always be based on the highest level of scientific evidence or well designed studies to get that evidence.
Many large, prospective randomized clinical trials are needed to make certain that an individual result isn’t simply due to “statistical chance.” Or that they simply tell a woman that she has breast cancer earlier, with no effect on the ultimate outcome. Actually, neither benefit nor the associated harms of a screening intervention can be proven through individual stories. One of the issues that seems to be lost in this debate is the fact that screening is for a healthy population. Millions and millions of healthy women undergo these tests and have to balance harm and benefit for themselves, with the knowledge that the vast majority of them will never get breast cancer. That is why public health policy looks carefully at both benefit and risk. Guidelines for interventions in populations of women who have been diagnosed with breast cancer balance benefit and harm differently.
Isn’t it better to give women a simple public health message?
These issues are complex. We would like it to be a simple message, but we also want it to be truthful. Women deserve the truth and are capable of understanding the facts and making their own decisions.
Aren’t these guidelines really about saving money?
These recommendations are not about saving money or about the current health care debate. The Task Force began their review of breast cancer screening well over two years ago. The recommendations and accompanying scientific literature were published in the Nov. 17 issue of Annals of Internal Medicine. The recommendations were made by scientists and physicians based on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit. There were no economists involved and the recommendations were not based on considerations of cost.
There has been so much controversy over these guidelines. Do you think the public will ever accept the new guidelines?
NBCC is aware that change takes time. These recommendations challenge deeply held beliefs, the reasons some organizations exist and significant financial interests. The firestorm will subside. We and others will continue our push for a reasoned approach to the evidence. NBCC believes it will happen, once the fear and anger lessen. We are committed to what is best for women.
How do we move forward?
The Task Force concluded that our current knowledge about the development of breast cancer is limited, and that future evaluation of screening techniques must take into account more than the size of the tumor, but must address the different biology and natural history of tumors.
As advocates, we move forward by pushing for the right research, and for screening and diagnostic tools that will work and get us closer to eradicating this disease.
Now, please SHARE THIS FAQ with others and learn more about the guidelines, breast cancer screening and NBCC.
Download and print a PDF version of the FAQ.
Read our press statement and official analysis about the new USPSTF guidelines.
NBCC President Fran Visco testifies before Congress. Watch and read the testimony.
Review our October 2009 Statement on Mammography Screening.
Educate yourself about the myths and truths about breast cancer, specifically those related to mammography and breast self-exam (BSE).
NBCC needs your support so that we can keep educating the public about the truth about breast cancer. We’ve always been ahead of the curve in examining and sharing the evidence with women and men everywhere. Join NBCC and become a member today.
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