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.
OncLive: Can you discuss the recommendations’ key points?
: 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.
What are your views on this?
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.
How might these guidelines affect women who have dense breasts?
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.
Can you elaborate on the process of tomosynthesis?
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.
By labeling biennial screenings for women over 50 as a grade B, is a message being sent that mammograms aren’t that important?
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.