In 2009 the United States Preventative Services Task Force (USPSTF) updated their now infamous breast cancer screening recommendations. In their report, the so-called experts (many of whom had no direct affiliation with patient breast cancer screening) voted that a total of 12 mammograms throughout a woman’s lifetime should be enough to effectively screen women for a disease that is the second leading cause of death among women in the United States and kills an average of 40,000 women every year.
These new recommendations came at a time when studies throughout the world were repeatedly confirming annual screening mammograms reduce breast cancer deaths anywhere between 30-45% with newer advances in screening and treatment decreasing the death rate an additional 2.5% each year. In essence, the recommendation to cut back on screening mammograms was made by the USPSTF at a time when mammography was being hailed as the poster-child of a successful cancer screening program.
Not unexpectedly, when the report was originally released, most of the medical community and media gathered around the report like co-workers around the water cooler—everyone expected to discover the missing piece of evidence—perhaps there was some flaw in the system and perhaps mammograms were not as useful as we thought?
However, a review of the report still left most of the medical community scratching their heads. The report contained no evidence that mammograms were not doing their job or saving lives. There was actually evidence to the contrary. In fact, the USPSTF data even acknowledged that if their recommendations were followed, additional women would die. Some experts even estimated that up to 100,000 more women would die over time if the recommendations were adopted into mainstream clinical practice. Sure, most of the medical community understood the report was trying to make an argument for the potential harms that a woman could endure as a result of over-diagnosis from too many mammograms, but they couldn’t justify the lives lost. As a result, most in the medical community left the water cooler that day and returned to their desks unswayed from their decision to recommend annual mammograms. Most believed the task force simply voted the wrong way and that ultimately there was no more to the story.
But the story didn’t actually end there.
The majority of the media and a few impressionable souls in the medical community remained gathered around the water cooler that day. While the concept of mortality in the setting of breast cancer screening was perhaps the “real” news of the day, it wasn’t “exciting” news and quickly became overshadowed by discussion of the relatively new and intriguing concept of “over-diagnosis.” By 6 o’clock, all major networks became pseudo-educators for the masses and carried stories about the “harms of over-diagnosis” from annual screening mammography. In some circles, knowledge of the concept even became a surrogate marker for supposedly intelligent discussion of breast cancer screening.
All of this occurred without significant mention of the fact that more of the women we love—wives, mothers, and friends would die if these recommendations were adopted.
This month, JAMA Internal Medicine published a research letter showing that most practicing clinicians continue to recommend annual screening mammograms contrary to the USPSTF recommendations. While that’s no surprise, you wouldn’t know it by the recent headlines. You would think most doctors have lost their minds. I even read one article that went so far as to suggest insurance companies should take the lead and quit paying for yearly mammograms. Think about that for a moment. In any event, it seems that now is a good time to remind a majority of the media and some in the medical community about the original takeaway from the “water cooler discussion” in 2009.
Ultimately and always—Do no harm.
Ryan Polselli, M.D.
Breast Imaging Radiologist