Susan G. Komen For The Cure® Recommends No Impediments To Breast Cancer Screening

Until Science Improves, Current Screening Recommendations Should Remain, World’s Leading Breast Cancer Organization Reports

DALLAS – Nov. 16, 2009 – Susan G. Komen for the Cure®, the world’s leading breast cancer advocacy organization, has carefully reviewed the data and new recommendations from the U.S. Preventive Services Task Force (USPSTF) concerning mammography screening. Komen for the Cure issued the following statement today from Eric P. Winer, M.D., chief scientific advisor and chair of Komen’s Scientific Advisory Board.

“Susan G. Komen for the Cure wants to eliminate any impediments to regular mammography screening for women age 40 and older. While there is no question that mammograms save lives for women over 50 and women 40–49, there is enough uncertainty about the age at which mammography should begin and the frequency of screening that we would not want to see a change in policy for screening mammography at this time. Komen’s current screening guidelines can be found at www.komen.org and would not be changed without serious consideration.

Our real focus, however, should be on the fact that one-third of the women who qualify for screening under today’s guidelines are not being screened due to lack of access, education or awareness. That issue needs focus and attention: if we can make progress with screening in vulnerable populations, we could make more progress in the fight against breast cancer.

Mammography is not perfect, but is still our best tool for early detection and successful treatment of this disease. New screening approaches and more individualized recommendations for breast cancer screening are urgently needed. Susan G. Komen for the Cure is currently funding research initiatives designed to improve screening, and we believe that it is imperative that this research move forward rapidly. Komen also provides funding for more than 1,900 education, awareness and screening programs.

We encourage women to be aware of their breast health, understand their risks, and continue to follow existing recommendations for routine screenings including mammography beginning at age 40.

A more detailed explanation of Komen’s position follows:

From the Susan G. Komen for the Cure Scientific Advisory Board Regarding U.S. Preventive Services Task Force (USPSTF) Recommendations on Breast Screening
Nov. 16, 2009

There has been a longstanding debate over the most appropriate age to begin mammography screening and the frequency of screening examinations. As with all screening tests, the decision to perform a mammogram must include an evaluation of the benefits and the risks of the screening tool, as well as a consideration of patient preference. 

The recent controversy about mammography should not suggest that there is debate about the most important issues. Most breast cancer experts agree far more than they disagree. For example, there is no debate that mammography reduces the risk of dying from breast cancer. As stated in the new USPSTF recommendations, extensive scientific evidence demonstrates that mammography reduces breast cancer mortality both among women aged 50 and older, as well as among women aged 40 to 49. 

Because breast cancer false positive results are more common in women under 50, some argue for a different screening approach in women 40-49 than in those over 50. The USPSTF suggests that women 40-49 consider their individual risk of developing breast cancer before making a decision about screening mammography. They further suggest that those women at increased risk should strongly consider regular mammography screening. Women at lower risk, who wish to initiate screening in their 40s should recognize that the benefits of screening are less than in older women. 

As to the timing of mammography, the USPSTF also suggests that screening every other year is likely to be as effective as annual screening, and that this approach would decrease false positives. Biennial screening is already practiced in many countries. Different organizations, based on a review of the same data, may recommend either yearly or every other year screening for women at average risk of breast cancer between the ages of 40-75. We believe that the timing of assessment is best left to a woman and her health care provider. We call upon third party payers to fund annual mammography if a woman and her health care provide opt for this approach. There are no studies that directly address the role of mammography in women over the age of 75. We recommend that older women, particularly those in excellent health, discuss the role of ongoing screening with their health care provider.  

One-third of all American women do not undergo regular screening. The failure of age appropriate women to undergo mammography costs lives and reflects problems with access to care and breast cancer education. We need to work as rapidly as possible to correct these deficiencies, and Susan G.  Komen for the Cure continues to fund research and education designed to eliminate health care disparities.

We want to eliminate any impediments to regular mammography screening for women age 40 and older. It is our view, however, that the exact timing of assessments is less important than guaranteeing access to screening. New screening approaches and more individualized recommendations for breast cancer screening are urgently needed. Susan G. Komen for the Cure supports research initiatives designed to improve screening, and we believe that it is imperative that this research move forward rapidly. 

As a breast cancer community, we must all recognize that both breast cancer screening and breast cancer treatment are moving targets. As treatment continues to evolve in the years ahead, these changes may have an impact on the optimal approaches to screening as well. 

In the meantime, honest differences in opinion can and do exist, and such differences represent attempts on the part of individuals and/or organizations to provide the best possible care to women of all ages and to minimize mortality and suffering from breast cancer. We encourage women with unresolved questions about breast cancer screening to engage in discussion with their health care providers.

NATIONAL BREAST CANCER COALITION

Analysis of USPSTF 2009 Revised Breast Cancer Screening Recommendations

November 16, 2009- In trying to deal with the toll that breast cancer continues to take in our country, the public has followed the lead of public health officials and increasingly put their faith in screening and early detection, though we have never had good evidence that this would have a significant impact.  The over-emphasis on the importance of screening, despite a lack of strong evidence, has been elevated to such a degree that some even equate screening with prevention of breast cancer.   The National Breast Cancer Coalition hopes that today’s release of the US Preventive Services Task Force (USPSTF) revised recommendations will put the brakes on this run-away train and will put screening and its limitations into proper perspective.

The revised  guidelines1 were issued by the USPSTF, a government-appointed, independent panel of experts in primary care and prevention that systematically reviews the evidence and develops recommendations for clinical preventive services.  Revisions include recommending against universal screening mammography for women aged 40-49, recommending every other year screening for women 50-74, rather than annual screening and recommending against teaching breast self examination.

For over ten years, the National Breast Cancer Coalition has reviewed and analyzed each newly published article looking at the trials of mammography screening.  After each analysis, NBCC has continued to take the position that mammography screening has significant limitations and should be a personal choice rather than a public health message.  NBCC has also reviewed all articles and studies on breast self examination and historically informed the public that there was no evidence that monthly breast self examination saved lives. When the evidence from well designed prospective randomized trials in addition to that of other studies showed harm and no benefit from this practice, NBCC changed its message accordingly. We continue to affirm those positions and are gratified that the US Preventive Services Task Force has changed their recommendations to be more in line with the existing evidence.  

The issues are not simple, but we believe women can comprehend the complexities of breast cancer and screening for the disease.  Women deserve to know the facts and have the right to make informed decisions regarding their health care.

The truth about breast cancer and screening:

• There is no statistically significant evidence that screening women age 40-49 years reduces breast cancer mortality. The USPSTF now recommends against universal screening mammography for women aged 40 to 49 years.   The Task Force changed their recommendation based on a systematic review2 of randomized clinical trials and on six statistical models of the risks and benefits of mammography screening.   A major consideration for the change was the addition of recent results from the only clinical trial designed to specifically evaluate mammography in this age group.  The Age trial4 found no statistically significant difference in breast cancer mortality between those women who were screened during their 40s and those who were not.



• False-positive results and additional imaging as a result of mammography are most prevalent in women aged 40 to 49 years.  When screening is started at age 40 years, about 60% more false-positive results have been estimated to occur than if screening is started at age 50 years. 



• The evidence for a benefit of mammography after 50 is not strong.  To reduce the harm while still maintaining the small benefit, the USPSTF now recommends biennial (every other year) instead of annual  screening mammography for women aged 50 to 74 years.   The USPSTF concludes  that the benefit of screening mammography is maintained by biennial screening, and changing from annual to biennial screening is likely to reduce the harms of mammography screening by approximately 50%, based on the statistical modeling, a systematic review of randomized clinical trials, a population-wide screening program report, and on a community-based study.



• Mammography can miss cancers that need treatment, and in some cases find disease that does not need treatment, leading to overtreatment with toxic therapies.  Harms for healthy women who do not have cancer can include unnecessary imaging tests and biopsies, unnecessary exposure to x-ray radiation, and psychological trauma and anxiety.   



• All breast cancers are not equal.  Some patients will have fast-growing, aggressive tumors while others will have slower-growing, less aggressive tumors that are less likely to metastasize and, therefore, have a better prognosis.  Screening is more likely to identify the slower-growing, less aggressive tumors because of longer asymptomatic periods.  This “length-time” bias can make screening appear more beneficial than it is.  “Lead-time” bias can also contribute to a misrepresentation of the benefit of mammography.  If a lethal cancer is found earlier through screening, the patient would appear to live longer because of “lead time.”  Screening is not helping patients in these situations live longer, it is only helping them find out about their cancers sooner.



• Breast self-examination (BSE) is ineffective and potentially harmful.  Two large, randomized, clinical trials of BSE, both found that women who did BSE were no less likely to die of breast cancer than those who did not do BSE.  In both studies, the number of invasive cancers diagnosed in the two groups was about the same, but women in the BSE group had more breast biopsies and more benign lesions diagnosed than did women in the control group.   The USPSTF recommends against teaching breast self-examination. 



• The USPSTF concludes that there is insufficient evidence to evaluate the benefit of clinical breast examinations.

We encourage women to make informed decisions regarding screening based on the actual evidence.  To learn more about the myths and truths concerning breast cancer and screening, and to find out how to take action against this disease, visit www.stopbreastcancer.org.

Sebelius Statement on New Breast Cancer Recommendations

HHS Secretary Kathleen Sebelius issued the following statement today on new breast cancer screening recommendations from the U.S. Preventive Services Task Force:

"There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive 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. 

"There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.

"What is clear is that there is a great need for more evidence, more research and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women.

"My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years - talk to your doctor about your individual history, ask questions, and make the decision that is right for you."