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In a reversal of its 2002 recommendations, the U.S. Preventive Services Task Force (USPSTF) has issued new guidelines against routine screening mammography in women aged 40 to 49 years, against teaching women breast self-examination and advocating biennial screening mammography only for women aged 50 to 74 years.

The USPSTF, part of the Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ), is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.

Recommendations from USPSTF are graded from A to D. The recommendation against routine screening mammography in women aged 40-49 years received a C grade: moderate certainty on the part of the Task Force that the net benefit is small. However, there may be considerations that support providing the service in an individual patient.

The recommendation against teaching women breast self-exam techniques was given a D grade: moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

The USPSTF based its new recommendations on a study published in the November Annals of Internal Medicine, which found that biennial mammography screening achieved most of the benefits of annual screening.

Of note in that study, and possibly overlooked by USPSTF, was the finding that if screening is begun at age 40, compared with age 50, and performed every other year, there is a median mortality reduction of 19.5 percent but an increase of false positives, unnecessary biopsies and anxiety.

To read more about the AIM study, please click here.

Reaction from medical imaging professionals and advocacy organizations was both swift and censorious.

“More than any diagnostic test, mammography is responsible for the decline in breast cancer deaths over the last thirty years,” said Paula Y. George, MD, the medical director of breast imaging at the Center for Diagnostic Imaging and a radiologist at Midwest Breast Care in St Louis. “Today’s USPSTF recommendations fly in the face of President Obama’s support for preventive healthcare and I urge his administration to reject these scientifically unfounded Task Force recommendations and continue to support women’s health by reimbursing for annual mammograms and urging women over age 40 to receive them.”

According to the Access to Medical Imaging Coalition (AMIC), a Washington, D.C.-based advocacy organization, the recommendations advise that women in their forties should only be screened regularly if they are at high-risk for breast cancer. Because only 10 to 25 percent of women who develop breast cancer are at elevated risk, screening only high-risk women will disenfranchise a significant percentage of breast cancer patients resulting in later-stage diagnosis and many more preventable breast cancer deaths, AMIC stated.

“The President has made clear that preventative screening like mammography saves lives and saves money. We agree,” said Tim Trysla, executive director at AMIC. “Unfortunately, Medicare has already refused to cover new technologies to increase the detection of colon cancer, is cutting payments for advanced diagnostic tests such as MRI of the breast by 50 percent and now the USPSTF is paving the way for insurers to deny mammography coverage. This type of policy, which puts millions of women of all ages at risk, is contrary to the evidence and the President’s own words, makes no sense and should be rejected.”

The American College of Radiology (ACR) was quick to share its objections to the USPSTF recommendations; stating that if they were adopted as policy, two decades of decline in breast cancer mortality could be reversed and countless American women may die needlessly from breast cancer each year.

"These unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against over the past 20 years," said Carol H. Lee, MD, chair of the ACR Breast Imaging Commission. "Mammography is not a perfect test, but it has unquestionably been shown to save lives, including women aged 40-49. These new recommendations seem to reflect a conscious decision to ration care. If Medicare and private insurers adopt these incredibly flawed USPSTF recommendations as a rationale for refusing women coverage of these life-saving exams, it could have deadly effects for American women.

"The USPSTF claims that the 'harms' of mammography, including discomfort of the exam, anxiety over positive results and possibility of overtreatment because medical science cannot distinguish which cancers will become deadly most quickly, outweigh the greatly decreased number of deaths each year resulting from breast cancer screening. Without doubt, the possibility of having one’s life saved through early detection far outweighs any of these concerns. Their premise is tragically incorrect and will result in many needless deaths if their recommendations are adopted by the American public,” said Lee.

W. Phil Evans, MD, president of the Society of Breast Imaging (SBI), holds that the recommendations will trade lives for cost savings.

“The USPSTF recommendations are a step backward and represent a significant harm to women's health,” he said. “To tell women they should not get regular mammograms starting at 40 when this approach has overwhelmingly been shown to save lives is shocking. At least 40 percent of the lives saved by mammographic screening are of women aged 40-49. These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives.”

Although USPSTF recommendations are not policy, the ACR believes its recommendations pose a two-fold danger:

• Congress has expressed its desire to broaden the authority of the task force and enhance its role in terms of its impact on coverage for existing services; and
• Private insurers may incorporate the AHRQ-funded USPSTF recommendations as a cost-savings measure.

“I am deeply concerned about the actions of the USPSTF in severely limiting screening for breast cancer,” said James H. Thrall, MD, chair of the ACR Board of Chancellors. “These recommendations, in combination with recent CMS imaging cuts, jeopardize access to both long proven and cutting-edge diagnostic imaging technologies. Government policy makers need to consider the consequences of such decisions. I can’t help but think that we are moving toward a new healthcare rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives.”