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ACOG issues formal statement opposing legislative interference
Concerned by state and federal laws that force physicians to give or withhold specific information when counseling patients, as well as laws that mandate specific treatments, tests, and procedures, the American College of Obstetricians and Gynecologists (the College) and the American Congress of Obstetricians and Gynecologists (ACOG) issued a Statement of Policy opposing such interference.
The policy statement, issued in May 2013, opposes government interference with the patient-physician relationship without a substantial public health justification. The statement reads, in part:
Efforts to legislate elements of patient care and counseling can drive a wedge between a patient and her health-care provider, be that a physician, certified nurse-midwife, certified midwife, nurse practitioner, or physician assistant. Laws should not interfere with the ability of physicians to determine appropriate treatment options and have open, honest and confidential communications with their patients. Nor should laws interfere with the patient’s right to be counseled by a physician according to the best currently available medical evidence and the physician’s professional medical judgment. The College and ACOG strongly oppose any governmental interference that threatens communication between patients and their physicians or causes a physician to compromise his or her medical judgment about what information or treatment is in the best interest of the patient.1
ACOG highlighted several examples of ill-advised laws that either interfere with physicians counseling their patients or that force patients to have unnecessary tests and procedures:
- laws that prohibit physicians from speaking to their patients about firearms and gun safety
- statutes that dictate a script about what must be communicated to women about breast density and cancer risk
- laws that require women to undergo unnecessary ultrasound imaging before an abortion.
“Given the relentless legislative assault on the patient-physician relationship that we’ve seen in the past few years—and unfortunately continue to see—we were compelled to issue a formal Statement of Policy,” said ACOG President Jeanne A. Conry, MD, PhD. “A disproportionate number of these types of laws are aimed at women’s reproductive rights and the physicians that provide women’s health-care services.”
We want to hear from you! Tell us what you think.
Reference
1. American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists. Statement of Policy: Legislative Interference With Patient Care, Medical Decisions, and the Patient-Physician Relationship. Washington, DC: ACOG; 2013.
Concerned by state and federal laws that force physicians to give or withhold specific information when counseling patients, as well as laws that mandate specific treatments, tests, and procedures, the American College of Obstetricians and Gynecologists (the College) and the American Congress of Obstetricians and Gynecologists (ACOG) issued a Statement of Policy opposing such interference.
The policy statement, issued in May 2013, opposes government interference with the patient-physician relationship without a substantial public health justification. The statement reads, in part:
Efforts to legislate elements of patient care and counseling can drive a wedge between a patient and her health-care provider, be that a physician, certified nurse-midwife, certified midwife, nurse practitioner, or physician assistant. Laws should not interfere with the ability of physicians to determine appropriate treatment options and have open, honest and confidential communications with their patients. Nor should laws interfere with the patient’s right to be counseled by a physician according to the best currently available medical evidence and the physician’s professional medical judgment. The College and ACOG strongly oppose any governmental interference that threatens communication between patients and their physicians or causes a physician to compromise his or her medical judgment about what information or treatment is in the best interest of the patient.1
ACOG highlighted several examples of ill-advised laws that either interfere with physicians counseling their patients or that force patients to have unnecessary tests and procedures:
- laws that prohibit physicians from speaking to their patients about firearms and gun safety
- statutes that dictate a script about what must be communicated to women about breast density and cancer risk
- laws that require women to undergo unnecessary ultrasound imaging before an abortion.
“Given the relentless legislative assault on the patient-physician relationship that we’ve seen in the past few years—and unfortunately continue to see—we were compelled to issue a formal Statement of Policy,” said ACOG President Jeanne A. Conry, MD, PhD. “A disproportionate number of these types of laws are aimed at women’s reproductive rights and the physicians that provide women’s health-care services.”
We want to hear from you! Tell us what you think.
Concerned by state and federal laws that force physicians to give or withhold specific information when counseling patients, as well as laws that mandate specific treatments, tests, and procedures, the American College of Obstetricians and Gynecologists (the College) and the American Congress of Obstetricians and Gynecologists (ACOG) issued a Statement of Policy opposing such interference.
The policy statement, issued in May 2013, opposes government interference with the patient-physician relationship without a substantial public health justification. The statement reads, in part:
Efforts to legislate elements of patient care and counseling can drive a wedge between a patient and her health-care provider, be that a physician, certified nurse-midwife, certified midwife, nurse practitioner, or physician assistant. Laws should not interfere with the ability of physicians to determine appropriate treatment options and have open, honest and confidential communications with their patients. Nor should laws interfere with the patient’s right to be counseled by a physician according to the best currently available medical evidence and the physician’s professional medical judgment. The College and ACOG strongly oppose any governmental interference that threatens communication between patients and their physicians or causes a physician to compromise his or her medical judgment about what information or treatment is in the best interest of the patient.1
ACOG highlighted several examples of ill-advised laws that either interfere with physicians counseling their patients or that force patients to have unnecessary tests and procedures:
- laws that prohibit physicians from speaking to their patients about firearms and gun safety
- statutes that dictate a script about what must be communicated to women about breast density and cancer risk
- laws that require women to undergo unnecessary ultrasound imaging before an abortion.
“Given the relentless legislative assault on the patient-physician relationship that we’ve seen in the past few years—and unfortunately continue to see—we were compelled to issue a formal Statement of Policy,” said ACOG President Jeanne A. Conry, MD, PhD. “A disproportionate number of these types of laws are aimed at women’s reproductive rights and the physicians that provide women’s health-care services.”
We want to hear from you! Tell us what you think.
Reference
1. American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists. Statement of Policy: Legislative Interference With Patient Care, Medical Decisions, and the Patient-Physician Relationship. Washington, DC: ACOG; 2013.
Reference
1. American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists. Statement of Policy: Legislative Interference With Patient Care, Medical Decisions, and the Patient-Physician Relationship. Washington, DC: ACOG; 2013.
Top gynecologic surgeons gather for 2012 PAGS
Mark Walters, MD
Susan B. Levy, MD
Tomasso Falcone, MD
Amy Garcia, MD
More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:
- a laparoscopist’s view of pelvic and abdominal anatomy
- case-based discussion of the evaluation of female pelvic floor disorders
- a surgical video fest with expert discussion and audience participation
- an in-depth look at fibroid management
- a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
- a panel discussion of pelvic pain and its management
- tips on avoiding and managing laparoscopic and other complications
- a breakout session on endometriosis surgery
- the latest on evaluation and management of fetal incontinence.
Here are a few additional highlights of the 2012 program:
Surgery for stress incontinence: Which sling is for which patient?
When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .
Surgical approach to prolapse—what I do and why I do it
“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.
While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.
Keynote address: The economics of surgical gynecology
She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.
After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .
Myomectomy: Open to robotic approaches
“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.
He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.
Laparoscopic supracervical hysterectomy
As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.
Join me in Las Vegas for FUUS 2013!
“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.
“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.
Mark Walters, MD
Susan B. Levy, MD
Tomasso Falcone, MD
Amy Garcia, MD
More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:
- a laparoscopist’s view of pelvic and abdominal anatomy
- case-based discussion of the evaluation of female pelvic floor disorders
- a surgical video fest with expert discussion and audience participation
- an in-depth look at fibroid management
- a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
- a panel discussion of pelvic pain and its management
- tips on avoiding and managing laparoscopic and other complications
- a breakout session on endometriosis surgery
- the latest on evaluation and management of fetal incontinence.
Here are a few additional highlights of the 2012 program:
Surgery for stress incontinence: Which sling is for which patient?
When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .
Surgical approach to prolapse—what I do and why I do it
“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.
While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.
Keynote address: The economics of surgical gynecology
She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.
After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .
Myomectomy: Open to robotic approaches
“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.
He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.
Laparoscopic supracervical hysterectomy
As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.
Join me in Las Vegas for FUUS 2013!
“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.
“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.
Mark Walters, MD
Susan B. Levy, MD
Tomasso Falcone, MD
Amy Garcia, MD
More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:
- a laparoscopist’s view of pelvic and abdominal anatomy
- case-based discussion of the evaluation of female pelvic floor disorders
- a surgical video fest with expert discussion and audience participation
- an in-depth look at fibroid management
- a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
- a panel discussion of pelvic pain and its management
- tips on avoiding and managing laparoscopic and other complications
- a breakout session on endometriosis surgery
- the latest on evaluation and management of fetal incontinence.
Here are a few additional highlights of the 2012 program:
Surgery for stress incontinence: Which sling is for which patient?
When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .
Surgical approach to prolapse—what I do and why I do it
“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.
While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.
Keynote address: The economics of surgical gynecology
She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.
After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .
Myomectomy: Open to robotic approaches
“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.
He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.
Laparoscopic supracervical hysterectomy
As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.
Join me in Las Vegas for FUUS 2013!
“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.
“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.
Confused about mammography guidelines? 7 questions answered
Some clinicians were reconsidering the need for an annual mammogram even before the US Preventive Services Task Force (USPSTF) issued new guidelines late last year.1
Andrew M. Kaunitz, MD, is one of those clinicians. In an editorial in the December issue of OBG Management, he was bold enough to declare: “My plan is to be more acquiescent when a woman says ‘No’ to an annual mammogram.”2
Among the evidence he cited to justify that acquiescence was a recent article in the Journal of the American Medical Association that expressed concern about the high number of early cancers—including ductal carcinoma in situ—that are detected by mammography and treated even though many are unlikely to progress or ever become clinically significant.3 This phenomenon—termed “over-diagnosis”—is one of the risks of breast cancer screening.
Dr. Kaunitz is professor and associate chairman of obstetrics and gynecology at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.
Although the USPSTF is the only official body to revise its recommendations on breast cancer screening so far, more changes seem likely. This article aims to sift through the static on the airwaves of late and offer concrete recommendations for practice. In the process, it addresses seven questions:
- How did USPSTF guidelines change?
- Why did they change?
- Why did the changes attract so much attention?
- What is ACOG’s position?
- What do thought leaders make of the new guidelines?
- Are the USPSTF recommendations likely to affect insurance coverage for mammography?
- What should you tell your patients about breast cancer screening?
1. How did USPSTF guidelines change?
In an article published November 16, the USPSTF made a number of revisions to earlier breast cancer screening guidelines for women at average risk of the disease:
Approximately 39 million women undergo mammography each year in the United States, costing the health-care system more than $5 billion.
- Routine screening mammography is no longer recommended in women 40 to 49 years old. Rather, the decision about when to begin regular screening should be individualized and should “take into account patient context, including the patient’s values regarding specific benefits and harms” (Grade C recommendation).
- Screening mammography in women 50 to 74 years old should be biennial rather than annual (Grade B recommendation).
- Breast self-examination (BSE) is not recommended for any age group (Grade D recommendation).1
2. Why did the USPSTF guidelines change?
The changes were based on new data and analysis in the following areas:
- Mortality among women 40 to 49 years old. Although mammography screening reduces breast cancer mortality by 15% in this age group, the USPSTF concluded that “there is moderate certainty that the net benefit is small” in this population.1,4
- The effectiveness of BSE in decreasing breast cancer mortality among women of any age. Studies of BSE published since 2002 found no significant differences in breast cancer mortality between women who perform BSE and those who don’t.4
- The magnitude of harms of screening with mammography. Mammography screening in women 40 to 49 years old involves a significant risk of harms.4 Although the USPSTF observed that the benefits of mammography in women 40 to 49 years old appear to be equivalent to the benefits of mammography among women 50 to 59 years old, it concluded that the harms outweigh benefits in the younger women.
Harms cited by the USPSTF include:
- radiation exposure
- pain during the procedure
- anxiety and distress
- an increased rate of false-positive results
- greater need for additional imaging and biopsies.4
The USPSTF conceded that the radiation exposure from a mammogram is minimal, but questioned whether cumulative exposure in young women might be problematic. It also noted that “many women experience pain during the procedure (range, 1% to 77%), but few would consider this a deterrent from future screening.”4
As for false-positive results, the group observed: “Data from the [Breast Cancer Screening Consortium (BCSC)] for regularly screened women…indicate that false-positive mammography results are common in all age groups but are most common among women aged 40 to 49 years (97.8 per 1,000 women per screening round).”4
“The BCSC results indicate that for every case of invasive breast cancer detected by mammography screening in women aged 40 to 49 years, 556 women have mammography, 47 have additional imaging, and five have biopsies.”4
It is the significant rate of false positives that creates the need for additional screening, diagnostic imaging, and biopsy. These additional imaging and invasive procedures increase anxiety and distress among many women. The USPSTF concluded that these harms outweighed the benefits of mammography screening in women 40 to 49 years old.
After publication of the new US Preventive Services Task Force (USPSTF) breast cancer screening guidelines late last year, it was only a matter of hours before official bodies and professional organizations began to weigh in on the changes, and the verdict was unanimous—disagreement. Among those chiming in were the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), the American College of Radiology, the American Society of Breast Surgeons, the Society for Breast Imaging (SBI), and Susan G. Komen for the Cure, among others. Here are excerpts from their statements.
American Cancer Society
The ACS immediately refuted the USPSTF recommendations:
The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider….[T]he American Cancer Society’s medical staff and volunteer experts overwhelmingly believe the benefits of screening women aged 40 to 49 outweigh its limitations.7
ACOG
The College reaffirmed its support for screening mammography every 1 to 2 years in women 40 to 49 years old and every year for women 50 and older, as well as breast self-examination for women of all ages:
At this time, The American College of Obstetricians and Gynecologists recommends that Fellows continue to follow current College guidelines for breast cancer screening. Evaluation of the new USPSTF recommendations is under way. Should the College update its guidelines in the future, Fellows would be alerted and such revised guidelines would be published in Obstetrics & Gynecology.5
American College of Radiology
The College minced no words in opposing the changes:
If cost-cutting US Preventive Services Task Force (USPSTF) mammography recommendations are 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 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,” said Carol H. Lee, MD, chair of the American College of Radiology Breast Imaging Commission.8
American Society of Breast Surgeons
The organization released a statement describing its position as “strongly opposed” to the USPSTF recommendations:
We believe there is sufficient data to support annual mammography screening for women age 40 and older. We also believe the breast cancer survival rate of women between 40 and 50 will improve from the increased use of digital mammographic screening, which is superior to older plain film techniques in detecting breast cancer in that age group.
While we recognize that there will be a number of benign biopsies, we also recognize that mammography is the optimal screening tool for the early diagnosis of breast cancer in terms of cost-effectiveness, practical use, and accuracy.9
Society for Breast Imaging
In its statement, the SBI noted the confusion caused by revision of the USPSTF guidelines, calling it “unnecessary and potentially deadly”:
Mammography has been shown unequivocally to save lives and is primarily responsible for the 30% decline in breast cancer mortality in the United States over the past 20 years. The USPSTF conclusion—that women under age 50 should not undergo routine screening—conflicts with their own report, which confirms a benefit of mammography to women age 40–49 that is statistically significant.
We strongly urge women and their physicians to adhere to the American Cancer Society recommendations of yearly screening beginning at age 40.10
Susan G. Komen for the Cure
This public advocacy group issued a statement in late November acknowledging “mass confusion and justifiable outrage” in the aftermath of the USPSTF changes:
”We have worked so hard to build public trust and urge people to get screened,” said Nancy G. Brinker, founder of Susan G. Komen for the Cure, “and now they hear that maybe they shouldn’t bother. That is dangerous….Let me say this as clearly as I can: Mammography saves lives, even this report says that. Keep doing what you are doing. And always, talk with your doctor.” Brinker also noted that Komen for the Cure was not changing its guidelines, continuing to recommend annual mammograms beginning at age 40.11
3. Why have the guidelines captured so much media attention?
Most of the controversy that has arisen since publication of the new guidelines has centered on the recommendation against screening mammography in women 40 to 49 years old. A number of media outlets have highlighted women whose breast cancer was detected by screening mammography when they were in their 40s, and many survivors with a similar history have spoken out against the new recommendations.
In addition, the American Cancer Society (ACS), the American College of Radiology, Susan G. Komen for the Cure, and other groups have publicly opposed the new guidelines. (See “Among professional organizations, a resounding chorus of disagreement”)
4. What is ACOG’s position on the new recommendations?
The American College of Obstetricians and Gynecologists (ACOG) was quick to weigh in on the new USPSTF guidelines, emphasizing that the College’s recommendations have not changed. They include:
- screening mammography every 1 to 2 years for women 40 to 49 years old
- screening mammography every year for women 50 years and older
- BSE for all women.
ACOG did note, however, that “the College is continuing to evaluate in detail the new USPSTF recommendations and the new evidence considered by the USPSTF.”5
5. What do thought leaders make of the USPSTF changes?
Although the USPSTF guidelines sparked a firestorm of media coverage, the change did not come as a shock to leaders in the ObGyn specialty.
Legitimate concerns about screening mammography have increasingly been raised by experts in the field.
ANDREW M. KAUNITZ, MD “I was not surprised,” said Dr. Kaunitz. “As I pointed out in my editorial in OBG Management, legitimate concerns about screening mammography have increasingly been raised by experts in the field.2 Proposals to stop routinely screening women in their 40s were made earlier in this decade, but were met with major pushback from the ACS, breast cancer advocacy organizations, and medical specialty groups. These same groups are now pushing back against the new USPSTF guidelines,” he added.
Robert L. Barbieri, MD, was not taken aback by the guidelines themselves, but he was surprised by the manner and timing of their release. Dr. Barbieri is Kate Macy Ladd professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and chief of obstetrics and gynecology at Brigham and Women’s Hospital in Boston. He serves as editor-in-chief of OBG Management.
“I was surprised that the USPSTF did not weigh the potential impact of its analysis on the key stakeholders: patients, disease-based coalitions such as the American Cancer Society and Susan G. Komen for the Cure, and professional societies such as the American College of Radiology and ACOG,” he said. “If I were supervising the process, I would have asked for a comment period before releasing the report. I would have included the comments from key stakeholders in an appendix to the report.”
Are other organizations—besides the USPSTF—likely to change their recommendations for mammography screening in the near future? In the case of ACOG, Dr. Barbieri doesn’t think so.
“I don’t think ACOG will change the age at which to initiate screening,” he said. “I believe it will stick to its recommendation to start screening at 40 and continue every 1 to 2 years from 40 to 50 years of age. However, I could see ACOG becoming a bit more flexible on the question of whether screening should take place at 1- or 2-year intervals after age 50.”
Dr. Kaunitz sees things differently.
“It seems possible that, going forward, the College will give Fellows and their patients permission to implement the new guidelines without mandating their implementation. For example, if women in their 40s wish to defer screening, that would be OK, as would biennial screening for women in their 50s and 60s.”
6. Are the USPSTF recommendations likely to affect insurance coverage?
In a press release issued soon after the new guidelines were published, US Health and Human Services Secretary Kathleen Sebelius addressed Americans directly to reaffirm her support for mammography in women 40 to 49 years old: “There is no question that the US Preventive Services Task Force recommendations have caused a great deal of confusion and worry among women and their families,” her statement read.6 She made it clear that the new recommendations are unlikely to affect federal coverage of mammography.
“The US Preventive Services Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government,” she said.6
But Dr. Barbieri thinks some changes in insurance coverage are inevitable.
“Any claims that the new guidelines do not represent a major change would be disingenuous,” he said. Because the USPSTF rated its recommendation against mammography for women 40 to 49 years old as grade ‘C,’ that change in guidelines is likely to trigger at least some change in coverage.
“In reality, the ‘C’ rating will require many insurance companies—by their own rule—to stop reimbursing for this screening test,” he said. “The ‘C’ rating means that the test has little benefit.”
ACOG also deems it likely that insurance coverage may be affected for some women.
“Fellows should be aware that the new USPSTF recommendations against routine screening mammography for women aged 40–49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an ‘A’ or a ‘B’ by the USPSTF. Fellows should counsel their patients that insurance coverage for ‘routine screening’ mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.”5
7. What should you tell your patients?
With all the media attention devoted to the change in guidelines, it’s little surprise that patients are asking questions.
“Patients are aware of the USPSTF report,” said Dr. Barbieri. “They are largely ignoring the recommendations and sticking with annual mammograms.”
“I think, as always, women are looking to their ObGyn for guidance,” added Dr. Kaunitz.
So what are these clinicians telling patients about mammography screening?
As he was to begin with, Dr. Kaunitz is acquiescent if patients prefer to defer mammography screening to their 50s.
“Because it seems that insurance coverage, over the short term, is unlikely to restrict current access to mammograms,” said Dr. Kaunitz, “my evolving philosophy is that the new USPSTF guidelines, along with ACOG and other existing guidelines, give ObGyns and their patients permission to:
- proceed or not proceed with mammograms for women in their 40s, with the decision based on issues such as patient preference, family history of breast cancer, and body mass index (BMI)
- be flexible regarding 1- to 2-year screening intervals among women in their 50s, 60s, and 70s, with the decision based on issues such as patient preference, use or non-use of estrogen-progestin hormone therapy, family history of breast cancer, and BMI.”
Dr. Barbieri believes some effort to integrate the ACOG and USPSTF recommendations is called for. “Accordingly,” he said, “I suggest the following:
I suggest actively recommending biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
ROBERT L. BARBIERI, MD
- Actively recommend biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
- Aggressively search for high-risk women, with high risk defined as a lifetime risk of breast cancer exceeding 15%. Among the variables contributing to high-risk status are a history of thoracic radiotherapy, a strong family history of breast cancer, and BRCA mutation. For these women, I would recommend annual mammography and biennial MRI of the breasts.
- Perform annual or biennial clinical breast exam.
- Obtain imaging for any woman who has a palpable breast lump, and resect or biopsy the lump even if that imaging is negative.”
1. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-726.
2. Kaunitz AM. I’ve been rethinking my zeal for breast cancer screening. OBG Management. 2009;21(12):6-8.
3. Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685-1692.
4. Nelson HD, Tyne K, Nalk A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009;151:727-737.
5. American College of Obstetricians and Gynecologists. Response of the American College of Obstetricians and Gynecologists to new breast cancer screening recommendations from the US Preventive Services Task Force. Available at: http://www.acog.org/from_home/Misc/uspstfResponse.cfm. Accessed Nov. 25, 2009.
6. US Department of Health and Human Services. Secretary Sebelius statement on new breast cancer recommendations [news release]. Nov. 18, 2009. Available at: http://www.hhs.gov/news/press/2009pres/11/20091118a.html. Accessed Dec. 4, 2009.
7. American Cancer Society responds to changes to USPSTF mammography guidelines [news release]. American Cancer Society. Nov. 16, 2009. Available at: http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_
Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp. Accessed Dec. 4, 2009.
8. American College of Radiology. USPSTF mammography recommendations will result in countless unnecessary breast cancer deaths each year [news release]. Nov. 16, 2009. Available at: www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/USPSTFMammoRecs.aspx. Accessed Dec. 4, 2009.
9. American Society of Breast Surgeons. Society responds to USPSTF changes in mammography guidelines [news release]. Available at: http://www.breastsurgeons.org/news/article.php?id=57. Accessed Dec. 4, 2009.
10. Society of Breast Imaging. Official Society of Breast Imaging response to the announcement by HHS Secretary Sebelius regarding USPSTF mammography recommendations. Available at:http://www.sbi-online.org/associations/8199/files/OFFICIAL%20SOCIETY%20OF%20
BREAST%20IMAGING%20RESPONSE%20TO%20THE%20ANNOUNCEMENT%20
BY%20HHS%20SECRETARY%20
SEBELIUS%20REGARDING%20USPSTF%20MAMMOGRAPHY%20RECOMMENDATIONS.pdf. Accessed Dec. 4, 2009.
11. Susan G. Komen for the Cure founder, Nancy G. Brinker, calls new mammography guidelines a “set back”; makes call to action [news release]. Nov. 23, 2009. Available at: http://ww5.komen.org/KomenNewsArticle.aspx?id=6442451516. Accessed Dec. 7, 2009.
Some clinicians were reconsidering the need for an annual mammogram even before the US Preventive Services Task Force (USPSTF) issued new guidelines late last year.1
Andrew M. Kaunitz, MD, is one of those clinicians. In an editorial in the December issue of OBG Management, he was bold enough to declare: “My plan is to be more acquiescent when a woman says ‘No’ to an annual mammogram.”2
Among the evidence he cited to justify that acquiescence was a recent article in the Journal of the American Medical Association that expressed concern about the high number of early cancers—including ductal carcinoma in situ—that are detected by mammography and treated even though many are unlikely to progress or ever become clinically significant.3 This phenomenon—termed “over-diagnosis”—is one of the risks of breast cancer screening.
Dr. Kaunitz is professor and associate chairman of obstetrics and gynecology at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.
Although the USPSTF is the only official body to revise its recommendations on breast cancer screening so far, more changes seem likely. This article aims to sift through the static on the airwaves of late and offer concrete recommendations for practice. In the process, it addresses seven questions:
- How did USPSTF guidelines change?
- Why did they change?
- Why did the changes attract so much attention?
- What is ACOG’s position?
- What do thought leaders make of the new guidelines?
- Are the USPSTF recommendations likely to affect insurance coverage for mammography?
- What should you tell your patients about breast cancer screening?
1. How did USPSTF guidelines change?
In an article published November 16, the USPSTF made a number of revisions to earlier breast cancer screening guidelines for women at average risk of the disease:
Approximately 39 million women undergo mammography each year in the United States, costing the health-care system more than $5 billion.
- Routine screening mammography is no longer recommended in women 40 to 49 years old. Rather, the decision about when to begin regular screening should be individualized and should “take into account patient context, including the patient’s values regarding specific benefits and harms” (Grade C recommendation).
- Screening mammography in women 50 to 74 years old should be biennial rather than annual (Grade B recommendation).
- Breast self-examination (BSE) is not recommended for any age group (Grade D recommendation).1
2. Why did the USPSTF guidelines change?
The changes were based on new data and analysis in the following areas:
- Mortality among women 40 to 49 years old. Although mammography screening reduces breast cancer mortality by 15% in this age group, the USPSTF concluded that “there is moderate certainty that the net benefit is small” in this population.1,4
- The effectiveness of BSE in decreasing breast cancer mortality among women of any age. Studies of BSE published since 2002 found no significant differences in breast cancer mortality between women who perform BSE and those who don’t.4
- The magnitude of harms of screening with mammography. Mammography screening in women 40 to 49 years old involves a significant risk of harms.4 Although the USPSTF observed that the benefits of mammography in women 40 to 49 years old appear to be equivalent to the benefits of mammography among women 50 to 59 years old, it concluded that the harms outweigh benefits in the younger women.
Harms cited by the USPSTF include:
- radiation exposure
- pain during the procedure
- anxiety and distress
- an increased rate of false-positive results
- greater need for additional imaging and biopsies.4
The USPSTF conceded that the radiation exposure from a mammogram is minimal, but questioned whether cumulative exposure in young women might be problematic. It also noted that “many women experience pain during the procedure (range, 1% to 77%), but few would consider this a deterrent from future screening.”4
As for false-positive results, the group observed: “Data from the [Breast Cancer Screening Consortium (BCSC)] for regularly screened women…indicate that false-positive mammography results are common in all age groups but are most common among women aged 40 to 49 years (97.8 per 1,000 women per screening round).”4
“The BCSC results indicate that for every case of invasive breast cancer detected by mammography screening in women aged 40 to 49 years, 556 women have mammography, 47 have additional imaging, and five have biopsies.”4
It is the significant rate of false positives that creates the need for additional screening, diagnostic imaging, and biopsy. These additional imaging and invasive procedures increase anxiety and distress among many women. The USPSTF concluded that these harms outweighed the benefits of mammography screening in women 40 to 49 years old.
After publication of the new US Preventive Services Task Force (USPSTF) breast cancer screening guidelines late last year, it was only a matter of hours before official bodies and professional organizations began to weigh in on the changes, and the verdict was unanimous—disagreement. Among those chiming in were the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), the American College of Radiology, the American Society of Breast Surgeons, the Society for Breast Imaging (SBI), and Susan G. Komen for the Cure, among others. Here are excerpts from their statements.
American Cancer Society
The ACS immediately refuted the USPSTF recommendations:
The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider….[T]he American Cancer Society’s medical staff and volunteer experts overwhelmingly believe the benefits of screening women aged 40 to 49 outweigh its limitations.7
ACOG
The College reaffirmed its support for screening mammography every 1 to 2 years in women 40 to 49 years old and every year for women 50 and older, as well as breast self-examination for women of all ages:
At this time, The American College of Obstetricians and Gynecologists recommends that Fellows continue to follow current College guidelines for breast cancer screening. Evaluation of the new USPSTF recommendations is under way. Should the College update its guidelines in the future, Fellows would be alerted and such revised guidelines would be published in Obstetrics & Gynecology.5
American College of Radiology
The College minced no words in opposing the changes:
If cost-cutting US Preventive Services Task Force (USPSTF) mammography recommendations are 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 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,” said Carol H. Lee, MD, chair of the American College of Radiology Breast Imaging Commission.8
American Society of Breast Surgeons
The organization released a statement describing its position as “strongly opposed” to the USPSTF recommendations:
We believe there is sufficient data to support annual mammography screening for women age 40 and older. We also believe the breast cancer survival rate of women between 40 and 50 will improve from the increased use of digital mammographic screening, which is superior to older plain film techniques in detecting breast cancer in that age group.
While we recognize that there will be a number of benign biopsies, we also recognize that mammography is the optimal screening tool for the early diagnosis of breast cancer in terms of cost-effectiveness, practical use, and accuracy.9
Society for Breast Imaging
In its statement, the SBI noted the confusion caused by revision of the USPSTF guidelines, calling it “unnecessary and potentially deadly”:
Mammography has been shown unequivocally to save lives and is primarily responsible for the 30% decline in breast cancer mortality in the United States over the past 20 years. The USPSTF conclusion—that women under age 50 should not undergo routine screening—conflicts with their own report, which confirms a benefit of mammography to women age 40–49 that is statistically significant.
We strongly urge women and their physicians to adhere to the American Cancer Society recommendations of yearly screening beginning at age 40.10
Susan G. Komen for the Cure
This public advocacy group issued a statement in late November acknowledging “mass confusion and justifiable outrage” in the aftermath of the USPSTF changes:
”We have worked so hard to build public trust and urge people to get screened,” said Nancy G. Brinker, founder of Susan G. Komen for the Cure, “and now they hear that maybe they shouldn’t bother. That is dangerous….Let me say this as clearly as I can: Mammography saves lives, even this report says that. Keep doing what you are doing. And always, talk with your doctor.” Brinker also noted that Komen for the Cure was not changing its guidelines, continuing to recommend annual mammograms beginning at age 40.11
3. Why have the guidelines captured so much media attention?
Most of the controversy that has arisen since publication of the new guidelines has centered on the recommendation against screening mammography in women 40 to 49 years old. A number of media outlets have highlighted women whose breast cancer was detected by screening mammography when they were in their 40s, and many survivors with a similar history have spoken out against the new recommendations.
In addition, the American Cancer Society (ACS), the American College of Radiology, Susan G. Komen for the Cure, and other groups have publicly opposed the new guidelines. (See “Among professional organizations, a resounding chorus of disagreement”)
4. What is ACOG’s position on the new recommendations?
The American College of Obstetricians and Gynecologists (ACOG) was quick to weigh in on the new USPSTF guidelines, emphasizing that the College’s recommendations have not changed. They include:
- screening mammography every 1 to 2 years for women 40 to 49 years old
- screening mammography every year for women 50 years and older
- BSE for all women.
ACOG did note, however, that “the College is continuing to evaluate in detail the new USPSTF recommendations and the new evidence considered by the USPSTF.”5
5. What do thought leaders make of the USPSTF changes?
Although the USPSTF guidelines sparked a firestorm of media coverage, the change did not come as a shock to leaders in the ObGyn specialty.
Legitimate concerns about screening mammography have increasingly been raised by experts in the field.
ANDREW M. KAUNITZ, MD “I was not surprised,” said Dr. Kaunitz. “As I pointed out in my editorial in OBG Management, legitimate concerns about screening mammography have increasingly been raised by experts in the field.2 Proposals to stop routinely screening women in their 40s were made earlier in this decade, but were met with major pushback from the ACS, breast cancer advocacy organizations, and medical specialty groups. These same groups are now pushing back against the new USPSTF guidelines,” he added.
Robert L. Barbieri, MD, was not taken aback by the guidelines themselves, but he was surprised by the manner and timing of their release. Dr. Barbieri is Kate Macy Ladd professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and chief of obstetrics and gynecology at Brigham and Women’s Hospital in Boston. He serves as editor-in-chief of OBG Management.
“I was surprised that the USPSTF did not weigh the potential impact of its analysis on the key stakeholders: patients, disease-based coalitions such as the American Cancer Society and Susan G. Komen for the Cure, and professional societies such as the American College of Radiology and ACOG,” he said. “If I were supervising the process, I would have asked for a comment period before releasing the report. I would have included the comments from key stakeholders in an appendix to the report.”
Are other organizations—besides the USPSTF—likely to change their recommendations for mammography screening in the near future? In the case of ACOG, Dr. Barbieri doesn’t think so.
“I don’t think ACOG will change the age at which to initiate screening,” he said. “I believe it will stick to its recommendation to start screening at 40 and continue every 1 to 2 years from 40 to 50 years of age. However, I could see ACOG becoming a bit more flexible on the question of whether screening should take place at 1- or 2-year intervals after age 50.”
Dr. Kaunitz sees things differently.
“It seems possible that, going forward, the College will give Fellows and their patients permission to implement the new guidelines without mandating their implementation. For example, if women in their 40s wish to defer screening, that would be OK, as would biennial screening for women in their 50s and 60s.”
6. Are the USPSTF recommendations likely to affect insurance coverage?
In a press release issued soon after the new guidelines were published, US Health and Human Services Secretary Kathleen Sebelius addressed Americans directly to reaffirm her support for mammography in women 40 to 49 years old: “There is no question that the US Preventive Services Task Force recommendations have caused a great deal of confusion and worry among women and their families,” her statement read.6 She made it clear that the new recommendations are unlikely to affect federal coverage of mammography.
“The US Preventive Services Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government,” she said.6
But Dr. Barbieri thinks some changes in insurance coverage are inevitable.
“Any claims that the new guidelines do not represent a major change would be disingenuous,” he said. Because the USPSTF rated its recommendation against mammography for women 40 to 49 years old as grade ‘C,’ that change in guidelines is likely to trigger at least some change in coverage.
“In reality, the ‘C’ rating will require many insurance companies—by their own rule—to stop reimbursing for this screening test,” he said. “The ‘C’ rating means that the test has little benefit.”
ACOG also deems it likely that insurance coverage may be affected for some women.
“Fellows should be aware that the new USPSTF recommendations against routine screening mammography for women aged 40–49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an ‘A’ or a ‘B’ by the USPSTF. Fellows should counsel their patients that insurance coverage for ‘routine screening’ mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.”5
7. What should you tell your patients?
With all the media attention devoted to the change in guidelines, it’s little surprise that patients are asking questions.
“Patients are aware of the USPSTF report,” said Dr. Barbieri. “They are largely ignoring the recommendations and sticking with annual mammograms.”
“I think, as always, women are looking to their ObGyn for guidance,” added Dr. Kaunitz.
So what are these clinicians telling patients about mammography screening?
As he was to begin with, Dr. Kaunitz is acquiescent if patients prefer to defer mammography screening to their 50s.
“Because it seems that insurance coverage, over the short term, is unlikely to restrict current access to mammograms,” said Dr. Kaunitz, “my evolving philosophy is that the new USPSTF guidelines, along with ACOG and other existing guidelines, give ObGyns and their patients permission to:
- proceed or not proceed with mammograms for women in their 40s, with the decision based on issues such as patient preference, family history of breast cancer, and body mass index (BMI)
- be flexible regarding 1- to 2-year screening intervals among women in their 50s, 60s, and 70s, with the decision based on issues such as patient preference, use or non-use of estrogen-progestin hormone therapy, family history of breast cancer, and BMI.”
Dr. Barbieri believes some effort to integrate the ACOG and USPSTF recommendations is called for. “Accordingly,” he said, “I suggest the following:
I suggest actively recommending biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
ROBERT L. BARBIERI, MD
- Actively recommend biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
- Aggressively search for high-risk women, with high risk defined as a lifetime risk of breast cancer exceeding 15%. Among the variables contributing to high-risk status are a history of thoracic radiotherapy, a strong family history of breast cancer, and BRCA mutation. For these women, I would recommend annual mammography and biennial MRI of the breasts.
- Perform annual or biennial clinical breast exam.
- Obtain imaging for any woman who has a palpable breast lump, and resect or biopsy the lump even if that imaging is negative.”
Some clinicians were reconsidering the need for an annual mammogram even before the US Preventive Services Task Force (USPSTF) issued new guidelines late last year.1
Andrew M. Kaunitz, MD, is one of those clinicians. In an editorial in the December issue of OBG Management, he was bold enough to declare: “My plan is to be more acquiescent when a woman says ‘No’ to an annual mammogram.”2
Among the evidence he cited to justify that acquiescence was a recent article in the Journal of the American Medical Association that expressed concern about the high number of early cancers—including ductal carcinoma in situ—that are detected by mammography and treated even though many are unlikely to progress or ever become clinically significant.3 This phenomenon—termed “over-diagnosis”—is one of the risks of breast cancer screening.
Dr. Kaunitz is professor and associate chairman of obstetrics and gynecology at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.
Although the USPSTF is the only official body to revise its recommendations on breast cancer screening so far, more changes seem likely. This article aims to sift through the static on the airwaves of late and offer concrete recommendations for practice. In the process, it addresses seven questions:
- How did USPSTF guidelines change?
- Why did they change?
- Why did the changes attract so much attention?
- What is ACOG’s position?
- What do thought leaders make of the new guidelines?
- Are the USPSTF recommendations likely to affect insurance coverage for mammography?
- What should you tell your patients about breast cancer screening?
1. How did USPSTF guidelines change?
In an article published November 16, the USPSTF made a number of revisions to earlier breast cancer screening guidelines for women at average risk of the disease:
Approximately 39 million women undergo mammography each year in the United States, costing the health-care system more than $5 billion.
- Routine screening mammography is no longer recommended in women 40 to 49 years old. Rather, the decision about when to begin regular screening should be individualized and should “take into account patient context, including the patient’s values regarding specific benefits and harms” (Grade C recommendation).
- Screening mammography in women 50 to 74 years old should be biennial rather than annual (Grade B recommendation).
- Breast self-examination (BSE) is not recommended for any age group (Grade D recommendation).1
2. Why did the USPSTF guidelines change?
The changes were based on new data and analysis in the following areas:
- Mortality among women 40 to 49 years old. Although mammography screening reduces breast cancer mortality by 15% in this age group, the USPSTF concluded that “there is moderate certainty that the net benefit is small” in this population.1,4
- The effectiveness of BSE in decreasing breast cancer mortality among women of any age. Studies of BSE published since 2002 found no significant differences in breast cancer mortality between women who perform BSE and those who don’t.4
- The magnitude of harms of screening with mammography. Mammography screening in women 40 to 49 years old involves a significant risk of harms.4 Although the USPSTF observed that the benefits of mammography in women 40 to 49 years old appear to be equivalent to the benefits of mammography among women 50 to 59 years old, it concluded that the harms outweigh benefits in the younger women.
Harms cited by the USPSTF include:
- radiation exposure
- pain during the procedure
- anxiety and distress
- an increased rate of false-positive results
- greater need for additional imaging and biopsies.4
The USPSTF conceded that the radiation exposure from a mammogram is minimal, but questioned whether cumulative exposure in young women might be problematic. It also noted that “many women experience pain during the procedure (range, 1% to 77%), but few would consider this a deterrent from future screening.”4
As for false-positive results, the group observed: “Data from the [Breast Cancer Screening Consortium (BCSC)] for regularly screened women…indicate that false-positive mammography results are common in all age groups but are most common among women aged 40 to 49 years (97.8 per 1,000 women per screening round).”4
“The BCSC results indicate that for every case of invasive breast cancer detected by mammography screening in women aged 40 to 49 years, 556 women have mammography, 47 have additional imaging, and five have biopsies.”4
It is the significant rate of false positives that creates the need for additional screening, diagnostic imaging, and biopsy. These additional imaging and invasive procedures increase anxiety and distress among many women. The USPSTF concluded that these harms outweighed the benefits of mammography screening in women 40 to 49 years old.
After publication of the new US Preventive Services Task Force (USPSTF) breast cancer screening guidelines late last year, it was only a matter of hours before official bodies and professional organizations began to weigh in on the changes, and the verdict was unanimous—disagreement. Among those chiming in were the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), the American College of Radiology, the American Society of Breast Surgeons, the Society for Breast Imaging (SBI), and Susan G. Komen for the Cure, among others. Here are excerpts from their statements.
American Cancer Society
The ACS immediately refuted the USPSTF recommendations:
The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider….[T]he American Cancer Society’s medical staff and volunteer experts overwhelmingly believe the benefits of screening women aged 40 to 49 outweigh its limitations.7
ACOG
The College reaffirmed its support for screening mammography every 1 to 2 years in women 40 to 49 years old and every year for women 50 and older, as well as breast self-examination for women of all ages:
At this time, The American College of Obstetricians and Gynecologists recommends that Fellows continue to follow current College guidelines for breast cancer screening. Evaluation of the new USPSTF recommendations is under way. Should the College update its guidelines in the future, Fellows would be alerted and such revised guidelines would be published in Obstetrics & Gynecology.5
American College of Radiology
The College minced no words in opposing the changes:
If cost-cutting US Preventive Services Task Force (USPSTF) mammography recommendations are 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 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,” said Carol H. Lee, MD, chair of the American College of Radiology Breast Imaging Commission.8
American Society of Breast Surgeons
The organization released a statement describing its position as “strongly opposed” to the USPSTF recommendations:
We believe there is sufficient data to support annual mammography screening for women age 40 and older. We also believe the breast cancer survival rate of women between 40 and 50 will improve from the increased use of digital mammographic screening, which is superior to older plain film techniques in detecting breast cancer in that age group.
While we recognize that there will be a number of benign biopsies, we also recognize that mammography is the optimal screening tool for the early diagnosis of breast cancer in terms of cost-effectiveness, practical use, and accuracy.9
Society for Breast Imaging
In its statement, the SBI noted the confusion caused by revision of the USPSTF guidelines, calling it “unnecessary and potentially deadly”:
Mammography has been shown unequivocally to save lives and is primarily responsible for the 30% decline in breast cancer mortality in the United States over the past 20 years. The USPSTF conclusion—that women under age 50 should not undergo routine screening—conflicts with their own report, which confirms a benefit of mammography to women age 40–49 that is statistically significant.
We strongly urge women and their physicians to adhere to the American Cancer Society recommendations of yearly screening beginning at age 40.10
Susan G. Komen for the Cure
This public advocacy group issued a statement in late November acknowledging “mass confusion and justifiable outrage” in the aftermath of the USPSTF changes:
”We have worked so hard to build public trust and urge people to get screened,” said Nancy G. Brinker, founder of Susan G. Komen for the Cure, “and now they hear that maybe they shouldn’t bother. That is dangerous….Let me say this as clearly as I can: Mammography saves lives, even this report says that. Keep doing what you are doing. And always, talk with your doctor.” Brinker also noted that Komen for the Cure was not changing its guidelines, continuing to recommend annual mammograms beginning at age 40.11
3. Why have the guidelines captured so much media attention?
Most of the controversy that has arisen since publication of the new guidelines has centered on the recommendation against screening mammography in women 40 to 49 years old. A number of media outlets have highlighted women whose breast cancer was detected by screening mammography when they were in their 40s, and many survivors with a similar history have spoken out against the new recommendations.
In addition, the American Cancer Society (ACS), the American College of Radiology, Susan G. Komen for the Cure, and other groups have publicly opposed the new guidelines. (See “Among professional organizations, a resounding chorus of disagreement”)
4. What is ACOG’s position on the new recommendations?
The American College of Obstetricians and Gynecologists (ACOG) was quick to weigh in on the new USPSTF guidelines, emphasizing that the College’s recommendations have not changed. They include:
- screening mammography every 1 to 2 years for women 40 to 49 years old
- screening mammography every year for women 50 years and older
- BSE for all women.
ACOG did note, however, that “the College is continuing to evaluate in detail the new USPSTF recommendations and the new evidence considered by the USPSTF.”5
5. What do thought leaders make of the USPSTF changes?
Although the USPSTF guidelines sparked a firestorm of media coverage, the change did not come as a shock to leaders in the ObGyn specialty.
Legitimate concerns about screening mammography have increasingly been raised by experts in the field.
ANDREW M. KAUNITZ, MD “I was not surprised,” said Dr. Kaunitz. “As I pointed out in my editorial in OBG Management, legitimate concerns about screening mammography have increasingly been raised by experts in the field.2 Proposals to stop routinely screening women in their 40s were made earlier in this decade, but were met with major pushback from the ACS, breast cancer advocacy organizations, and medical specialty groups. These same groups are now pushing back against the new USPSTF guidelines,” he added.
Robert L. Barbieri, MD, was not taken aback by the guidelines themselves, but he was surprised by the manner and timing of their release. Dr. Barbieri is Kate Macy Ladd professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and chief of obstetrics and gynecology at Brigham and Women’s Hospital in Boston. He serves as editor-in-chief of OBG Management.
“I was surprised that the USPSTF did not weigh the potential impact of its analysis on the key stakeholders: patients, disease-based coalitions such as the American Cancer Society and Susan G. Komen for the Cure, and professional societies such as the American College of Radiology and ACOG,” he said. “If I were supervising the process, I would have asked for a comment period before releasing the report. I would have included the comments from key stakeholders in an appendix to the report.”
Are other organizations—besides the USPSTF—likely to change their recommendations for mammography screening in the near future? In the case of ACOG, Dr. Barbieri doesn’t think so.
“I don’t think ACOG will change the age at which to initiate screening,” he said. “I believe it will stick to its recommendation to start screening at 40 and continue every 1 to 2 years from 40 to 50 years of age. However, I could see ACOG becoming a bit more flexible on the question of whether screening should take place at 1- or 2-year intervals after age 50.”
Dr. Kaunitz sees things differently.
“It seems possible that, going forward, the College will give Fellows and their patients permission to implement the new guidelines without mandating their implementation. For example, if women in their 40s wish to defer screening, that would be OK, as would biennial screening for women in their 50s and 60s.”
6. Are the USPSTF recommendations likely to affect insurance coverage?
In a press release issued soon after the new guidelines were published, US Health and Human Services Secretary Kathleen Sebelius addressed Americans directly to reaffirm her support for mammography in women 40 to 49 years old: “There is no question that the US Preventive Services Task Force recommendations have caused a great deal of confusion and worry among women and their families,” her statement read.6 She made it clear that the new recommendations are unlikely to affect federal coverage of mammography.
“The US Preventive Services Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government,” she said.6
But Dr. Barbieri thinks some changes in insurance coverage are inevitable.
“Any claims that the new guidelines do not represent a major change would be disingenuous,” he said. Because the USPSTF rated its recommendation against mammography for women 40 to 49 years old as grade ‘C,’ that change in guidelines is likely to trigger at least some change in coverage.
“In reality, the ‘C’ rating will require many insurance companies—by their own rule—to stop reimbursing for this screening test,” he said. “The ‘C’ rating means that the test has little benefit.”
ACOG also deems it likely that insurance coverage may be affected for some women.
“Fellows should be aware that the new USPSTF recommendations against routine screening mammography for women aged 40–49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an ‘A’ or a ‘B’ by the USPSTF. Fellows should counsel their patients that insurance coverage for ‘routine screening’ mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.”5
7. What should you tell your patients?
With all the media attention devoted to the change in guidelines, it’s little surprise that patients are asking questions.
“Patients are aware of the USPSTF report,” said Dr. Barbieri. “They are largely ignoring the recommendations and sticking with annual mammograms.”
“I think, as always, women are looking to their ObGyn for guidance,” added Dr. Kaunitz.
So what are these clinicians telling patients about mammography screening?
As he was to begin with, Dr. Kaunitz is acquiescent if patients prefer to defer mammography screening to their 50s.
“Because it seems that insurance coverage, over the short term, is unlikely to restrict current access to mammograms,” said Dr. Kaunitz, “my evolving philosophy is that the new USPSTF guidelines, along with ACOG and other existing guidelines, give ObGyns and their patients permission to:
- proceed or not proceed with mammograms for women in their 40s, with the decision based on issues such as patient preference, family history of breast cancer, and body mass index (BMI)
- be flexible regarding 1- to 2-year screening intervals among women in their 50s, 60s, and 70s, with the decision based on issues such as patient preference, use or non-use of estrogen-progestin hormone therapy, family history of breast cancer, and BMI.”
Dr. Barbieri believes some effort to integrate the ACOG and USPSTF recommendations is called for. “Accordingly,” he said, “I suggest the following:
I suggest actively recommending biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
ROBERT L. BARBIERI, MD
- Actively recommend biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
- Aggressively search for high-risk women, with high risk defined as a lifetime risk of breast cancer exceeding 15%. Among the variables contributing to high-risk status are a history of thoracic radiotherapy, a strong family history of breast cancer, and BRCA mutation. For these women, I would recommend annual mammography and biennial MRI of the breasts.
- Perform annual or biennial clinical breast exam.
- Obtain imaging for any woman who has a palpable breast lump, and resect or biopsy the lump even if that imaging is negative.”
1. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-726.
2. Kaunitz AM. I’ve been rethinking my zeal for breast cancer screening. OBG Management. 2009;21(12):6-8.
3. Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685-1692.
4. Nelson HD, Tyne K, Nalk A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009;151:727-737.
5. American College of Obstetricians and Gynecologists. Response of the American College of Obstetricians and Gynecologists to new breast cancer screening recommendations from the US Preventive Services Task Force. Available at: http://www.acog.org/from_home/Misc/uspstfResponse.cfm. Accessed Nov. 25, 2009.
6. US Department of Health and Human Services. Secretary Sebelius statement on new breast cancer recommendations [news release]. Nov. 18, 2009. Available at: http://www.hhs.gov/news/press/2009pres/11/20091118a.html. Accessed Dec. 4, 2009.
7. American Cancer Society responds to changes to USPSTF mammography guidelines [news release]. American Cancer Society. Nov. 16, 2009. Available at: http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_
Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp. Accessed Dec. 4, 2009.
8. American College of Radiology. USPSTF mammography recommendations will result in countless unnecessary breast cancer deaths each year [news release]. Nov. 16, 2009. Available at: www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/USPSTFMammoRecs.aspx. Accessed Dec. 4, 2009.
9. American Society of Breast Surgeons. Society responds to USPSTF changes in mammography guidelines [news release]. Available at: http://www.breastsurgeons.org/news/article.php?id=57. Accessed Dec. 4, 2009.
10. Society of Breast Imaging. Official Society of Breast Imaging response to the announcement by HHS Secretary Sebelius regarding USPSTF mammography recommendations. Available at:http://www.sbi-online.org/associations/8199/files/OFFICIAL%20SOCIETY%20OF%20
BREAST%20IMAGING%20RESPONSE%20TO%20THE%20ANNOUNCEMENT%20
BY%20HHS%20SECRETARY%20
SEBELIUS%20REGARDING%20USPSTF%20MAMMOGRAPHY%20RECOMMENDATIONS.pdf. Accessed Dec. 4, 2009.
11. Susan G. Komen for the Cure founder, Nancy G. Brinker, calls new mammography guidelines a “set back”; makes call to action [news release]. Nov. 23, 2009. Available at: http://ww5.komen.org/KomenNewsArticle.aspx?id=6442451516. Accessed Dec. 7, 2009.
1. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-726.
2. Kaunitz AM. I’ve been rethinking my zeal for breast cancer screening. OBG Management. 2009;21(12):6-8.
3. Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685-1692.
4. Nelson HD, Tyne K, Nalk A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009;151:727-737.
5. American College of Obstetricians and Gynecologists. Response of the American College of Obstetricians and Gynecologists to new breast cancer screening recommendations from the US Preventive Services Task Force. Available at: http://www.acog.org/from_home/Misc/uspstfResponse.cfm. Accessed Nov. 25, 2009.
6. US Department of Health and Human Services. Secretary Sebelius statement on new breast cancer recommendations [news release]. Nov. 18, 2009. Available at: http://www.hhs.gov/news/press/2009pres/11/20091118a.html. Accessed Dec. 4, 2009.
7. American Cancer Society responds to changes to USPSTF mammography guidelines [news release]. American Cancer Society. Nov. 16, 2009. Available at: http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_
Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp. Accessed Dec. 4, 2009.
8. American College of Radiology. USPSTF mammography recommendations will result in countless unnecessary breast cancer deaths each year [news release]. Nov. 16, 2009. Available at: www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/USPSTFMammoRecs.aspx. Accessed Dec. 4, 2009.
9. American Society of Breast Surgeons. Society responds to USPSTF changes in mammography guidelines [news release]. Available at: http://www.breastsurgeons.org/news/article.php?id=57. Accessed Dec. 4, 2009.
10. Society of Breast Imaging. Official Society of Breast Imaging response to the announcement by HHS Secretary Sebelius regarding USPSTF mammography recommendations. Available at:http://www.sbi-online.org/associations/8199/files/OFFICIAL%20SOCIETY%20OF%20
BREAST%20IMAGING%20RESPONSE%20TO%20THE%20ANNOUNCEMENT%20
BY%20HHS%20SECRETARY%20
SEBELIUS%20REGARDING%20USPSTF%20MAMMOGRAPHY%20RECOMMENDATIONS.pdf. Accessed Dec. 4, 2009.
11. Susan G. Komen for the Cure founder, Nancy G. Brinker, calls new mammography guidelines a “set back”; makes call to action [news release]. Nov. 23, 2009. Available at: http://ww5.komen.org/KomenNewsArticle.aspx?id=6442451516. Accessed Dec. 7, 2009.