Patrick I. Borgen, MD, explains his strong opposition to the USPSTF guidelines and view that annual mammograms must remain a standard in clinical practice.
Patrick I. Borgen, MD
A hotly debated move by the US Preventive Services Task Force (USPSTF) in January called for an individualized approach to routine mammograms for asymptomatic women under aged 50 years and biennial testing for women aged 50 to 74 years.
In their final set of breast cancer screening guidelines, the USPSTF recognized “adequate evidence” that mammography screening has reduced breast cancer mortality, but maintained that most of the benefit for women at average risk for breast cancer is derived by those aged 50 to 74 years who undergo screening every 2 years.
This has been an issue debated for more than 5 years between oncologists, radiologists, and the national panel of USPSTF experts. Even so, the Task Force stands by these recommendations, which they originally drafted in 2009.
Agencies such as the American College of Radiology and the Society of Breast Imaging said in a joint statement that following the recommendations would result in lethal consequences for thousands of women each year.
Some medical experts agree with the USPSTF position that although mammography is a lifesaving tool for early detection of breast cancer, biennial screening is sufficient. Others, including Patrick I. Borgen, MD, feel that the scaled-back approach will end up doing more harm and, ultimately, losing more lives.
In an interview with OncLive, Borgen, who is chair of the Department of Surgery, head of the Brooklyn Cancer Center, Maimonides Medical Center, explains his strong opposition to the USPSTF guidelines and view that annual mammograms must remain a standard in clinical practice.Borgen: This is about the fourth time that they have issued their final recommendations, so we can only hope that these are not their final recommendations. In a nutshell, what their recommendations involve is moving up the age of commencement of breast cancer screening from age 40 all the way up to 50, to have mammograms every other year until age 74, and then have no screening after age 74.I am vehemently opposed to these recommendations. I believe they are based on 2 problems. One is that they incorporate trials that were deeply flawed, which really do not tell us what we need to know about screening.
The second problem with the recommendations is that they use survival as the endpoint, and there are other endpoints which are equally or more important. The fact that a woman can have a delay in diagnosis, but get chemotherapy, radiation, or a mastectomy, is not a consolation.
Women want less treatment, less disfigurement, less chemotherapy, and less radiation. What gives us the best chance for that is early detection and early diagnosis. These guidelines are a step in the wrong direction from early detection.The group in this argument with the most dense breast tissue is the 40 to 49 age group. We are not talking about whether mammograms find breast cancers in those women, which they do, but we have to remember that 50% of the life years lost to breast cancer happens in women aged 40 to 49. We are not going to be screening those women at all. While there are challenges with digital mammography and dense breasts, it is way better to face those challenges than to simply not screen these women.
The solution for the future is likely to be 3D mammography, or tomosynthesis. This sees through breast density a lot better than current digital mammography does, and my guess is that it will become the standard in the future. If we are not screening those women from 40 to 49, we are going to face a lot of advanced breast cancer in a group that really does not deserve that.A standard, digital mammogram takes 2 views—a top view and a side view. With a 3D mammogram, or a tomosynthesis mammogram, it’s a little bit like a fragment of a CT scan. The source of the energy moves through an arc. Then, a detector captures many images as that moves through an arc.
It’s the same way our eyes can detect distance. There’s a difference between the left and the right eye; our brain calculates distance. That is very much how tomosynthesis works. These images are then reconstructed into a video tube to traverse through the breast density.I think the message is, certainly, that they are less important. It also implies that breast cancers grow slower than we actually know that they grow. All of these recommendations are quite soft and are based on interpretation of data and trials. For someone who has literally been in the trenches treating breast cancer for 25 years, it’s an abomination.
There are so many times—every week, every month—we see women with really aggressive breast cancer picked up on screening mammograms. Remember that the mortality rate from breast cancer, since 1990, has fallen by 1% to 2% per year.
Granted, some of that is from better treatment, but some of it is from early detection. Most of it is finding node-negative breast cancers, smaller breast cancers, and stage I/II breast cancer rather than stage III/IV. That is what screening buys us.I think it’s a grey line. I think that insurance carriers would certainly rather, on the surface, pay for an every 2-year screening. However, if in the aggregate, they wind up paying for the treatment of breast cancers that are more advanced, this will be a penny-wise and dollar-foolish decision. Therefore, I think that remains to be seen.
We are in a legal period of moratorium. I don’t think that these guidelines can be implemented overnight, and I believe that there is a vetting period that we are in right now. Hopefully, cooler, calmer, smarter minds will prevail in this because, really, these guidelines are an assault on women, they’re an affront to women, and they’re an affront to our common sense as a nation.
The argument has been, “mammograms lead to anxiety.” I don’t think we’re giving women the credit they deserve. Women are a lot better at handling anxiety than men are, I can tell you that.
There is also the argument that it can lead to some unnecessary biopsies, which is true. However, for women who have early-stage breast cancer, it’s lifesaving. Most women will put up with a certain number of false alarms to save a life. These guidelines ignore what women really value, what their priorities are, and what we as a nation should do to protect ourselves.
We are not talking about the expensive seatbelts or putting helmets on kids who ride bicycles. We are talking about a lifesaving screening to detect a disease that 1 in 10 American women are likely to get.The fact that there are several guidelines will confuse the public, doctors, and insurers. Both guidelines are a step in the wrong direction. The newest one is a big step in the wrong direction; the ACS is a medium step in the wrong direction.
The ACS moved the date of commencement up 5 years; that’s better than 10 years. It seems to be a relatively arbitrary date that was chosen as a compromise. The studies that looked at women from 40 to 49 are very clear in their benefit for this disease, and I don’t think we should be selling that short for any reason—not the fear of anxiety or that we might have false positives. Every screening does.
Remember, we are not talking about pap smears, or chest X-rays for lung cancer, or skin mole detection, where we do many biopsies. Breast cancer seems to be held to a different standard here, and it’s one that we have to rebel against and protect women in America. My wife’s mother had breast cancer, her grandmother had breast cancer, and the notion that we would change the point when we would start screening any woman by 10 years, to me, is crazy.That’s a great question. Make no mistake about it, women are not looking forward to their next mammogram. They are uncomfortable, they involve compression of the breast, and they’re anxiety provoking.
Therefore, if a woman reads from the government, “you don’t need a mammogram at 40, 45, or 47,” many women will say, “Oh, thank goodness.” That’s a natural thing to do. We will see a decline in the utilization of mammography. Also, the stage at diagnosis will go up and we will lose more lives.In terms of the latest iteration of the Task Force’s guidelines, I wish that this would stop. I wish calmer and cooler heads would prevail, that the data would be viewed in a constructive way, and that the big picture would be looked at.
It is not just about survival, it’s about avoiding big operations that I do, or avoiding chemotherapy and radiation therapy, fertility issues after chemotherapy, and the possibility of leukemia. We want to minimize the treatment burden on the patient. The best way to do that is by finding the disease early.