Last week, the American Cancer Society changed its recommendations for normal-risk women regarding screening mammograms: they took a middle road between their prior advisories and those of the United States Preventive Services Task Force (USPSTF): ACS no longer recommends routine mammograms for women age 40-44, and advised reducing frequency to every two years for women aged 55 and older.
Sometimes scaring, sometimes shaming, three ladies with high-falutin' credentials in breast-related issues took to the NYTimes op-ed page to promulgate their viewpoint: not too many, rather too few mammograms are being done. No further! they say. And they have withdrawn their previous close ties to the ACS.
In their polemic, "Why the Annual Mammogram Matters," Drs. Susan Drossman, Elisa Port and Emily Sonnenblick raise their hands against the tide of allegations of over-diagnosis and over-treatment ascribed to our nation's focus on frequent mammography. The reason to be concerned is that such over-testing leads to way too many false positives — "incidentalomas" — and subsequent biopsies, mutilating women needlessly. This was discovered using large-scale epidemiological studies assessed by the USPSTF, and — et tu, Brute! — the American Cancer Society.
The relevant studies show that while, sure, mammograms do pick up breast cancers, they also detect "lesions" that are not real or not a threat far too often.
The doctor-authors' opinions pack quite a bit of weight: they are, respectively, a breast radiologist in private practice in New York City; the author of “the New Generation Breast Cancer Book" and chief of breast surgery at Mt. Sinai Hospital in New York; and a breast radiologist at that same institution. Further, and importantly, they have been closely affiliated with the American Cancer Society.
Not any more. They are withholding their support due to the new mammogram recommendations, and they tell you why in their essay. Their main complaint is that skipping mammograms will allow some breast lesions to grow undetected, and some women may actually die because they allowed two years to pass without a film.
These women, well-trained professionals all, must know that they are missing the point: Yes, more breast cancer will be detected, but at what cost? If every woman got a mammogram every 6 months beginning at age 25, there would probably be a drastic reduction in deaths from breast cancer — but there would be a massive increase in needless breast surgeries and costs of health care for everyone. While the authors assert, "In our collective experience of 60 years, none of us have ever seen a potentially life-threatening complication related to a breast biopsy."
Tsk tsk, fellow doctors: the plural of anecdote is not data. I can assure them (and you) that many breast procedures initiated by an "abnormal" (but false positive) mammogram have led to serious, often permanent untoward consequences. Complications of indicated surgery are bad, but do happen. Complications of needless surgery are a tragedy.
Here's the crux of their argument: "Mammography in all age groups, starting at 40 years old, is the only test that has been proven to do exactly this: reduce the risk of dying from breast cancer, by up to 30 percent." (emphasis mine).
But what about dying of a surgical misadventure, or any other cause that's not breast cancer? The objective evaluations found that the benefit of screening mammography in younger women without unusual risk factors leads to more problems than solutions. Breast cancer deaths may decline somewhat, but too many other concerns are raised by needless mammograms to outweigh the benefits.
Then, in a sadly counterproductive foray into the low road, the doctors imply that the changing recommendations — by The American Cancer Society and the USPSTF (an objective, volunteer Federal panel of experts) — are somehow only concerned about money: "We know there are pressures to reduce health care costs in the United States, and that health spending cannot be a bottomless pit. But those who will suffer most from these cancer society recommendations will be women from underserved communities who do not have the means to pay for their own breast cancer screening if insurers follow the new guidelines and stop providing yearly coverage."
I have an idea for those poor under-served women: Don't get that needless mammogram, then no one has to pay for it! No one responsible for caring for America's women, or for making such determinations (outside of the insurance industry), would limit mammograms to save money for "the health care system" they did all that training to work in.
More sophistry: "False positives are a reality for screening tests of all kinds. Let’s stop overemphasizing the “harms” related to mammogram callbacks and biopsies."
Don't you love the way they scare-quote harms as though this issue was made-up just to keep women from getting their life-saving tests.
Look, the mammogram debate will be going on for many more years. Certainly, these X-Rays do save some lives, but to do so they have to detect a potentially-lethal cancer in an early enough stage such that intervention will be curative. It just so happens that many breasts and non-threatening lesions have to be removed to save those few. The three authors should know that.