by The Country Doctor

“I don’t believe in breast cancer screening” – a puzzling, yet not uncommon statement heard (in variation) more often these days,  thanks to the stupefying  information floating around out there about breast cancer screening.  First, let us all unanimously agree- breast cancer screening does, in fact, exist.  Second, breast cancer is not an insignificant disease – about 1 in 8 women will get to experience invasive breast cancer in their lifetimes.  This is the same number of people in the population who are left-handed.  Or the percentage of veterans in the homeless population.  Or the number of people who would like to change their vote from Mr. Trump to anyone else.  Literally. Anyone.   The point is, chances are either you or a close family member has had or will have some uncomfortable/intimate experience with this disease.  The breast cancer screening controversy affects all of us; and the reality is the major insurance companies, following the lead of Medicare and Medicaid, will base their decisions to cover breast cancer screening on the recommendations made by the United States Preventative Services Task Force (USPSTF), which are as follows:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49  
  • Women aged 50 to 74 should undergo screening mammography every other year
  • Current evidence is insufficient to determine additional benefits and harms of screening mammography in women 75 years or older
  • In women 40 years or older, current evidence is insufficient to determine the additional benefits and harms of clinical breast exam
  • The USPSTF recommends against clinicians teaching women the technique of breast self-exam (AKA Buddy Check 9)
  • Current evidence is insufficient to determine additional benefits and harms of either digital mammography or MRI vs film mammography as screening modalities for breast cancer.

I find these recommendations unsettling, specifically because:

  • There is no magical or physiological significance about a woman reaching the age of 50, also breast cancer is not an irrelevant disease just because you have not reached the age of 50
  • Performing a mammogram every other year instead of every year can miss up to 30% of cancers (i.e., the bad ones grow fast)
  • I know plenty of healthy women aged 75 and older that have a lot more life to live
  • Women often find a lump on the self-breast exam that turns out to be significant (in women younger than 50 years, more than 70% of cases of breast cancer are found by self-breast exam)
  • Digital mammography and MRI are clearly of higher quality than traditional film (this is kind of like comparing a flip phone camera to an I phone 8 camera); additionally, it is a moot point as most breast cancer screening centers are only using digital mammography.

The USPSTF describes itself as “an independent, voluntary body supported by the Agency for Healthcare Research and Quality (AHRQ). Recommendations made by the USPSTF are independent of the US government.” This description fascinates me; as the director of a governmental agency (AHRQ) is solely responsible for appointing the members of the task force that decide on the recommendations.   So, around the same time that the ACA/Obamacare was about to require insurance companies to cover breast cancer screening, a government-appointed task force was asked for a breast cancer screening recommendation.  Appointees included shrinks, family docs, geriatricians, hospitalists, pediatricians, ob/gyns and nurses, and probably most of these folks have not examined a pair of boobs since medical school.  At any rate, these breast care deficient practitioners were the ones that decided, without the advice of actual experts in the field, on the current breast cancer screening guideline.  Hmm.  What is a physician to do when there is conflicting evidence, conflicting guidelines, conflicting interests?  Personal experience aside, we presumably turn to expert opinion.  Here are the current breast cancer screening recommendations from specialist/expert societies:

American Cancer Society (ACS) recommendations: Women with an average risk of breast cancer should undergo annual screening mammography starting at age 45.  Women 55 years and older should be given the option to have screening every other year.  Women should have the opportunity to begin annual screening between the ages of 40 and 44. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.  All women should be familiar with how their breasts normally look and feel and report any changes to their health care provider right away.

Society of Breast Imaging (SBI) AND American College of Radiology (ACR) recommendations: Women at average risk for breast cancer should have an annual screening mammogram starting at age 40.

American College of Obstetricians and Gynecologists (ACOG) recommendations: For women at average risk of breast cancer, screening mammography is recommended every 1–2 years beginning at age 40 and no later than age 50. Screening should continue until at least age 75. Breast self-awareness (breast self-examination), is recommended. The patient should immediately report changes in her breast to her physician.  A clinical breast examination should be performed annually in women aged 40 and older. In women aged 20–39, a clinical breast examination should be done every 1–3 years.

Why is there even a conflict of recommendations?  And where the deuce did it come from?  You might be thinking “it must have been a novel, brilliantly well-done randomized controlled trial that generated new, useful information!”  Nope.  What happened was, two European researchers (with a conspicuous lack of breast tissue) analyzed about 8 clinical trials that had been done between 1960-1980’s.  Apparently they could not be bothered to conduct their own study; and decided to scrutinize the work of others instead.  Eureka!  We found an error in your patient randomisation [sic] method!  Anyhow, they used various criteria- many of which are superfluous and insignificant – to determine that most of the studies (specifically the ones showing a clear benefit to breast cancer screening) were inadequate/un-usable, and they threw the baby out with the bathwater.  There are several problems with this approach, aforementioned baby aside.  These types of studies (of the general population) are extremely challenging to conduct; and require the collection of a lot of data over a long period of time – leaving ample opportunity for errors or gaps to occur (this does not necessarily render them useless).   In addition, I’m moderately certain the researchers of the 60’s, 70’s and 80’s were more concerned about mitigation of a terrifying breast disease then the opinion of some stuffy futuristic European fops.   This backward-looking analysis and subsequent rejection of data would be akin to modern scientists rejecting the conclusion that cholera (explosive diarrhea resulting in death) was coming from water contaminated with excrement (in the general population of London in the 1850’s) – because the research method was not sound.  If these modern scientists decided that the study criteria, participant demographics, and method was dubious (which they were); and they made recommendations that we should NOT to adopt water sterilization methods after all (admittedly saving the government a lot of money), shouldn’t we go back to vapidly sipping sewage-contaminated water with some lovely little cholera sprinkles?  You decide.  Bottoms up!  

To be fair, some organizations, such as the USPTSF, assert that the potential risks and harm associated with breast cancer screening are significant.  These include:

  • Over-diagnosis (finding tumors and/or pre-cancer that may not ultimately cause the patient harm)
  • Anxiety associated with the need for additional testing (diagnostic MRI, breast ultrasound, biopsy, etc.)
  • Cost
  • False negatives
  • Discomfort of a mammogram and breast exam

These “concerns” are particularly difficult for me to stomach, specifically because:

  • Isn’t the whole point of a cancer screening to detect a cancer before it becomes a life-threatening tyrant?  Unfortunately, we currently don’t have the ability to decipher between the pre-cancer tumors that are harmless, and the ones that will kill you.
  • I don’t think the “anxiety” about having further testing to rule out invasive breast cancer can hold a candle to the “anxiety” associated with being diagnosed with actual invasive breast cancer.  Ignorance is not bliss in breast cancer screening, people.
  • Cost?  Seriously!?  Nobody I know would choose not to screen just because it might save the insurance companies or government a little cash; presumably so money can be spent on “more important” things- such as CEO bonuses and research on gas emissions from dairy cows.    
  • I won’t argue with false negatives.  A normal mammogram and normal breast exam does not guarantee that you don’t have breast cancer.  But having no screening at all ALSO does not guarantee that you don’t have breast cancer.
  • Yes, the squashing of the ta-tas can be uncomfortable.  Additionally most people don’t enjoy a cold-handed groping from a physician/practitioner.  I’m not sure what to say about that.  Suck it up.  

Personally, I am for screening as defined by the ACS, ACOG, SBI, ACR, and NFL (yes, that is the National Football League) – but I’m also aware that the current screening is limited/could be better.  In the pipe are a slew of screening tools that are currently under scrutinization – genetic testing, advanced imaging (MRI), risk calculators, etc.  Until such a time comes that new/improved screening can be used; we have to make do with what we’ve got.  So at least have the conversation with your physician or practitioner, so you can make an intelligent decision (ignorance, denial, or procrastination are NOT examples of good decisions) about what is right for you.