November 18, 2009
To The BCRF Community
From Larry Norton, MD, BCRF Scientific Director; Chairman, BCRF Executive Board of Scientific Advisors, and
Clifford Hudis, MD, Chairman, BCRF Scientific Advisory Committee
Over the last few days there has been extensive discussion within the medical community and especially in the general press about a report from the United States Preventative Services Task Force (USPSTF), a private-sector advisory body to the U.S. Department of Health and Human Services, that was published Monday in the Annals of Internal Medicine. The most controversial aspect of the report was based on mathematical models using old data, which concluded that the best ratio of benefit over risk would
accrue to mammographic screening every two years in the general population of women between the ages of 50 and 74 years old. This differed from the previous recommendation in 2002, which advised screening mammography every year starting at age 40.
BCRF Advisors have reviewed this report carefully, and we do not endorse the proposed guideline changes. There has been a clear and consistent reduction in the rates of death from breast cancer in every country--including the United States--that has instituted a regular screening program. In addition, finding smaller tumors by yearly screening has other advantages, which includes higher rates of breast conserving surgery, less need to use adjuvant chemotherapy, and fewer cases of metastatic disease with attendant suffering and need for treatment.
While the USPSTF report focused on death rates--concluding that death rates from breast cancer would be slightly higher were mammograms offered every two years rather than yearly--these other factors were not taken into account. In addition, the USPSTF put a great emphasis on the extra short-term anxiety potentially caused by an estimated 3% increase in negative biopsies over a woman's lifetime by yearly mammography (starting at age 40) compared with the proposed changed guidelines. However, they did not consider that because bi-annual screening would yield larger tumors, women so diagnosed would experience a lifetime of greater anxiety caused by knowledge of a worse prognosis than had the tumor been found at a smaller size a year earlier.
Furthermore, the clinical data upon which the USPSTF performed their mathematical analyses was old, and did not reflect more recent changes in mammographic techniques, use of new adjuvant hormonal treatments (aromatase inhibitors), new and more effective chemotherapy strategies, adjuvant trastuzumab for cases of HER2 positive disease, and the availability of molecular tests that allow physicians to not advise chemotherapy for many cases when the cancer is found early. It is therefore not clear if the results of the USPSTF mathematical models would be applicable in the setting of modern breast cancer management.
The greatest danger to the widespread adoption of the new guidelines is that they may reduce the rates of regular screening, which are even now--with current guidelines--disturbingly low. More than a third of women who are now candidates for screening have not had a mammogram within two years, and should these rates drop even lower, we will clearly see an increase in breast cancer deaths as a result.
For all of these reasons, we assert that current guidelines, as supported by the American Cancer Society and many professional groups, remain intact. We need to focus on increasing the utilization of regular screening and on improving all aspects of breast cancer management--from prevention to treatment, including detection. Accepting a higher death rate from breast cancer is not consistent with the mission of BCRF.
Larry Norton, MD
BCRF Scientific Director; Chairman, BCRF Executive Board of Scientific Advisors
Clifford Hudis, MD
Chairman, BCRF Scientific Advisory Committee