New ACS recommendations for mammography
Last week, in a Journal of the American Medical Association (JAMA) article, the American Cancer Society (ACS) broke with its own traditions and changed its recommendations for when average-risk women should start getting mammograms and how often they should get them. This was a very significant change, and I applaud the process and outcomes. The Society changed its process of reviewing evidence to one that more closely approximates those used in practice by evidence-review committees. Thus, Society leaders commissioned an evidence review team that substantially followed procedures recommended by an Institute of Medicine panel. Previously, the ACS relied far too much upon expert opinion and, knowing that screening is beneficial, upon assumptions that starting screening earlier and conducting it more often is better.
I grew up with a father who was vice-president for public information at the American Cancer Society. For many years, the organization’s tagline was “Fight cancer with a check-up and a check.” It took a long time for recommendations about the yearly check-up to change. In spite of evidence on multiple fronts, beliefs have persisted that “if mammography is good, then younger is better and more frequently is preferable.” The contention has been particularly emotional where breast cancer is concerned. Arguments have tended to focus on benefits without adequate assessment of mammography’s risks and limitations or where societal investments are likely to have the greatest impact; e.g., investing in developing new screening technologies and better treatments. In the Oct. 24 Cancer Letter, Otis Brawley, MD, FACP, chief medical officer for the ACS, wrote: “In the case of mammography for breast cancer, there have been years of overly simplistic messaging hyping the benefits and not recognizing the limitations.”
Otis Brawley speaks out in The Cancer LetterIt is widely accepted that more than a third of American women over 50 do not get regular mammography, and some do not get good quality mammography. It is also accepted that a good proportion of American women with diagnosed breast cancer do not receive good cancer treatment. It is a fact that the number of lives that could be saved by the logistical move of providing quality care to all is far greater than the number of lives that might be saved by screening all women in their 40s.
–Otis Brawley, MD
Personal historical perspective
I’ve been part of a few different evidence review processes, including the 1993 “Report of the International Workshop on Screening for Breast Cancer,” published in the Journal of the National Cancer Institute, which resulted from a very careful process. We concluded that the evidence did not support mammograms for women in their 40s. The public outcry from many quarters was deafening, and it was a very emotional experience, with many claiming that recommendations were made based upon cost, not evidence. It wasn’t true, but that didn’t matter, because it was a great media story.
I know, then, how important it is to be guided by evidence, and how much courage it takes to do that when recommendations challenge cherished beliefs. As a result of that experience, I spent a number of years developing, testing and working with others to disseminate research-based interventions to help women make good, informed personal decisions about when to start mammography and how often to get mammograms. Colleagues worked on interventions for other cancer screening tests. I was particularly glad to see the strong evidence in the ACS review about informed, individual decision making. It is critical that women have the opportunity to learn about the evidence and then make personal decisions about what is right for them, and insurance programs should continue to cover screening mammograms for women in their 40s and older.
What’s new? See the full JAMA article for details, and the text box below for a summary of the new recommendations for screenings for normal-risk women. The report includes strong emphasis on informed decision making by women, with clearer messages about this than were offered by prior ACS reports.
The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).
While some consumers and medical organizations do not like the recommendations, I believe strongly that we should make guidelines on the basis of evidence, following evidence-review processes that are themselves based on evidence. Yet, while doing that, we also should recognize, as the ACS report does, that individuals should be encouraged to educate themselves about important health issues and come to their own personal decisions, usually in consultation with health-care providers. I wrote a blogpost about this issue based on my recent experience with surgery for retinal detachment.
It is only in the last 15 years or so that we, as a society, have come to accept more widely that consumers and patients can and should make many health-care decisions, particularly those which involve no public health risk and, especially, when there is ambiguity in the evidence. Over time, more and more physicians and other health-care providers should become comfortable with and conversant in communicating with patients about the patients’ preferences for various medical procedures.
Kudos to the American Cancer Society for daring to change—and to Otis Brawley for a compelling editorial in one of my favorite sources of cancer information.
Happy Monday. Barbara
Photo of Otis Brawley, MD, courtesy of University of Illinois. Brawley is among the cancer specialists at the American Cancer Society who blog at Expert Voices.