RSNA: Panel questions whether new mammo recommendations ration care
CHICAGO—The recent recommendations by the U.S. Preventive Services Task Force limiting breast cancer screening for women in various age groups, as well as the frequency of those exams, ignited a flurry of criticism by a panel of breast imaging experts, hosted by the Radiological Society of North America (RSNA) on Wednesday morning at their annual scientific sessions.

The new guidelines recommend that women begin screening at age 50 (as opposed to the previous age of 40), and then every two years rather than annually, as well as eliminating breast cancer screening entirely for women at age 75. Each member of the three-person panel said that these decisions were not based on the available clinical data.

“Screening mammography represents one of the great medical achievements of our time,” reducing mortality for women aged 40 to 75 screened annually by 40 to 50 percent, despite an increase in the disease, according to Stephen A. Feig, MD, professor of radiology at the University of California Irvine School of Medicine and president-elect of the American Society of Breast Disease.

To support his statement, Feig cited two randomized, controlled trials: the Swedish two-county trial, which resulted in a 32 percent mortality reduction rate, and the Swedish seven-county service screening study (real-life population), which resulted in a 44 percent mortality reduction—both of which assessed women aged 40 to 74.

Interestingly, 75 to 90 percent of women who are diagnosed with breast cancer are not high-risk patients, according to Daniel B. Kopans, MD, senior radiologist in the breast imaging division at Massachusetts General Hospital in Boston.

The Task Force has promulgated that the decrease in breast cancer incidence has only decreased 2.7 percent per year since 1990. “The death rate from breast cancer had remained unchanged for the 50 years prior to the onset of mammography screening,” Kopans said. “It’s since come down a total of 30 percent, if you add the year-by-year accumulative decrease of 2.7 percent annually since 1990.

“The Task Force admits that annual mammography will save more lives compared with screening every two years, but their argument is that biennial screening will lead to fewer false positives,” Kopans said. “The Task Force talks about unnecessary biopsies, but they don’t seem to worry about unnecessary deaths.”

“We would save money, but we will lose more lives,” Feig concurred. In assessing expenses, Feig noted that the mean cost per year-of-life gained is $17,000 for annual mammography screening for U.S. women, aged 40 to 60. He added that based on the standards used for other preventive measures, the cost per year-of-life gained is $32,000 for automobile seatbelts/airbags and $50,000 for annual pap-smears from age 21.

Feig questioned whether “healthcare rationing” played a role in this decision.

The new guidelines also strongly encourage women to discuss treatment methods with their primary care physicians, who often use these types of recommendations to guide their practice, according to the panel. “Women are now forced to be smarter than their doctors,” Kopans said.

Also, the panel assessed the expertise of the Task Force to accurately evaluate breast cancer screening clinical data. W. Phil Evans, MD, director of the Center for Breast Care at the University of Texas Southwestern Medical Center in Dallas, and president of the Society of Breast Imaging, noted that among the 16-member task force, there were 13 MDs, four PhDs, eight MPHs and two RNs—the majority of whom had backgrounds in primary care and epidemiology.

The panel added that radiologists have also been excluded from the Senate hearing regarding the recommendations, which took place Tuesday morning in Washington, D.C.

Kopans expressed concern that the “experts in mammography screening are not being consulted due to ‘conflicts of interest.’ However, a radiologist’s conflict of interest is counteracted by his/her expertise. Therefore, if you have no conflict of interest, you probably have no expertise.”

Despite these controversies, these recommendations could have an immediate impact on health insurance coverage. The Task Force assigns grades to their recommendations, which payors, including the Centers for Medicare & Medicaid Services (CMS), use to determine coverage.

Under provision 2713(a)(1) in the current healthcare reform bill (HR 3590), private insurers would be required to provide coverage for breast cancer screening for women between the ages of 40 and 49, since the Task Force gave a grade C for this age group. Women older than 74 may not be covered for screening at all as the Task Force assigned a grade I (or insufficient evidence) for this age group.

The Task Force recommendations are taken tremendously seriously, and insurers will follow suit, according to Evans. “This is our real concern. However, we’re hoping that most health insurance companies and managed care providers see the benefits of breast cancer, and we’re hoping that will prevail.”

The panel members all expressed support of the current American Cancer Society guidelines, which remain unchanged, in support of screening women at average risk for breast cancer should begin at age 40 and continue on an annual basis until after the age of 74.