Special report: Should 50 be the new 40?

May 27, 2011

by Sean Ruck, Contributing Editor

This report originally appeared in the May 2011 issue of DOTmed Business News

Less than two years ago, the Radiological Society of North America annual meeting had a last-minute hot topic to add to discussions. On Nov. 16, 2009 the United States Preventive Services Task Force announced revisions to its mammography screening guidelines and the public, already on heightened alert about all things health care due to the ongoing coverage about reform, did not take the news well.

Dr. Michael LaFevre, co-vice chair for the USPSTF, admits the timing of the announcement was unfortunate but unavoidable. “The timing of announcements is out of our control. When there’s something to announce, it’s submitted and put into a publication queue,” he says.

The timing of the announcement was one problem; the actual message was another. For some, it felt like a flashback to 1996. That year, the task force recommended women aged 50 to 69 go for screening every one to two years. While the new guidelines did bump the maximum age to 74, the frequency was increased to two years. The minimum age recommendation had been lowered in 2002 when the guidelines introduced that year suggested screening every one to two years after a woman reached 40.

[Looking for the lowdown on the latest mammography equipment? Read about it here]

Reasons for the revisions
It’s not unreasonable for the panel to revise or even reverse recommendations over time. The average stint on the panel is just three years, although panelists can serve longer, depending on circumstances.

That means there are different individuals and different interpretations of research. Further, new research may influence the need for revisions. “We try to update our recommendations every five years,” LaFevre says. “But some may drift out longer because of other work.”

Dr. Deanna Attai, communications committee chair for the American Society of Breast Surgeons, is among the large group of professionals who wish the updated recommendations were delayed longer, choosing to stick with the previous incarnation. “We’re basically endorsing annual screenings for women over 40,” she says of the ASBS’s own guidelines.

While she acknowledges there are some drawbacks to early screening such as the increase in false-positives among younger women due to denser breast tissue, she supports screening at the earlier age because catching cancer early in younger women is often a lifesaver since it’s more likely to be an aggressive form.

“Early detection provides a number of benefits,” Attai explains. “An early stage 1 breast cancer versus a stage 3 means the difference between getting chemo and not getting chemo. It means the difference between a lumpectomy and a mastectomy.”

The balancing act
But there are a number of gray areas in the screening debate.

For one, there are the false-positives Attai previously noted. The USPSTF expressed concern about false-positives and the anxiety they might produce for women getting an unneeded screening call backs. LaFevre backs that concern. “If a woman screens regularly, there’s about a 50 percent false-positive rate for women in their 40s. I actually tell women that when they’re screening as a reassurance.”

Dr. Sara Fredrickson, chair of the breast imaging technologies certification and accreditation committee for the ASBS, says the extra screenings mean more things will be identified in a mammogram requiring further evaluation. “That generates extra tests,” she says. And she says some of those potential red flags ultimately turn out to be benign, with doctors treating findings that might never become health risks.

Still, Fredrickson says her recommendations to her patients mirror the American Society of Breast Surgeons, the American Cancer Society and the American College of Radiology recommendations. In her experience, most women are against following the USPSTF guidelines. “I don’t think there’s been as much impact from those revisions as people thought,” she says.

Dr. Robert Eng, chief of radiology at San Francisco’s Chinese Hospital, echoes that sentiment. Eng hasn’t seen any impact in terms of volume due to the 2009 guidelines. “We’re unique in that our patient population is 95 percent ethnic Chinese and the age skews higher,” he says. “Our average age is about 72 for outpatient and inpatient is in the low 80s.”

Although the revised guidelines bumped the maximum recommended age up by half a decade over the 1996 recommendations, if women based their decisions about screening by them, the majority of Eng’s patients would no longer have the procedure. The 2002 revisions didn’t set a maximum age.

Clarification and emphasis
For Dr. Carol H. Lee, chair of the ACR breast imaging commission, believes there shouldn’t be a debate. “Breast cancer mortality has dropped substantially since the introduction of regular screening,” she says. “We have a public health measure that proven in practice to work, why roll it back at all?”
Lee says ACR stands by the earlier [2002] screening guidelines saying no additional compelling evidence has come to light — including what the USPSTF based its recommendations on — for ACR to alter its decision.

“They [the USPSTF panelists] made recommendations based on science and data, but there are interpretations and value judgments placed on them, so it’s not pure mathematical analysis,” Lee says.

It is important to note that they are just recommendations. What lawmakers decide to do with them is a different story. In this case, the health care reform bill clearly states that routine mammograms must be covered by insurance providers for women 40 and above, but that action isn’t necessarily inconsistent or unsupportive of the panel.

“The task force gave the recommendation a C grade. That meant we still felt the recommendation was valid, but the net benefit is small,” LaFevre explains. “However, I don’t see why any third party provider wouldn’t cover a C recommendation. There is no D against mammo.”

LaFevre also highlights what he believes was the biggest cause of the backlash against the recommendations — phrasing. “We thought the way it was phrased in publication may have contributed to the confusion. We’ve since removed the sentence we felt was causing part of the problem.”

The sentence in question stated, “The task force recommends against routine screening mammography in women aged 40-49 years.” LaFevre says the word “routine” was overlooked or should have been clearly emphasized. He says women with risk factors would not be included under routine screening.

The guidelines have their foundation in reasonable science. LaFevre says in a group of 1000 40-year-old women, about 30 will die from breast cancer if they don’t have screening. “If we screen from 50 to 74, we can reduce that number by seven, which is a pretty good drop in mortality.” He goes on, “If we back that down to 40, we may be able to save one more. It’s not zero, but it’s small.” He also notes that women in their 40s will roughly undergo the about the same number of biopsies as those in their 60s, but the 40-year-olds will have far fewer cases of cancer.

LaFevre is a member of the task force, but also a practicing physician and has his own take on the recommendations. He translates the guidelines to mean for women with no risk factors aged 40 to 49, screening should be discussed. For 50 to 59, encouraged, 60 to 74, strongly encouraged.

Although the task force doesn’t tackle anything beyond 74, he believes its sometimes worth discussing with patients. “Taking off the task force hat, as a professional, family physician and teacher, as a physician, if I’m seeing a healthy, active 70-year-old, I’m likely to suggest they might want to continue screening until at least 80 if not 85, even though there’s insufficient scientific data to currently support that opinion, so it’s an expert opinion, not a task force recommendation.”

Bigger problems than the guidelines
Since the guidelines have so far proven to be without teeth, some might assume mammo is trouble-free. But questions about dose exposure are still being discussed and another issue may have ironically been exacerbated by the earlier guidelines supporting screening starting at 40.

LaFevre has seen what he calls “screening burnout” a few times during his three decades of practice. “Women start in their 40s and by the time they reach 60, they’ve had a few false positives, or possibly an unnecessary biopsy and they’ve had enough. Precisely at the time when they should be most actively screening, they’re stopping. I have to convince them back into it.”