Big week for breasts! On the news and social media, new breast cancer screening from the United States Preventive Services Taskforce (USPSTF) were everywhere. It’s the first update in 8 years and set off a storm of messages:
- Saw screening starts at 40 yrs old now – I thought it always did?! [insert shoulder shrug emoji]
- I only need to get my mammogram every other year now? Sweet! One less squeeze #ouch
- Didn’t you JUST celebrate the national density inform law? Why does this say there’s not enough evidence that it helps? Am I dense?!
- Should I talk to mom about stopping her mammograms now that she’s 75?
- Dumb question: How do I know if I am at average risk? HELP!
This confusion, and celebration, hurts my heart and is doing real harm. We can do better! For heaven’s sake, can we not provide clear, consistent guidelines based on what we know is true already!
- Starting at age 40: USPSTF lowering the starting age to 40 aligns with other guidelines and addresses the fact that today 10 percent of all breast cancers occur in women under 45 years of age. This is good news, and we can finally retire the “wait until 50” outdated recommendation.
- Annual screening: Yearly mammograms reduce breast cancer mortality by up to 40 % because they find cancers earlier in less aggressive stages. Beyond reducing pain and suffering, we can reduce the 5–4x increase in treatment costs when a cancer is found in stage IV vs. 0—that’s the benefit of annual screening.
- Supplemental imaging for dense breasts: Women with dense breasts—nearly 50 percent of women 40 and over—can improve their chance at detection with additional screening, like ultrasounds or MRIs. That’s a fact and supported by an FDA ruling to tell women whether they have dense breasts or not. We’ve seen the impact with the DENSE trial in the Netherlands. The 10-year study showed that using Volpara to select women with extremely dense breasts and then having breast MRI performed led to a significant drop in interval cancers—those cancers that appear between screenings and are more aggressive. Why in the world would we tell a woman that she has dense breasts, which means that she is higher risk of cancer, and there is a chance that she may have cancer that can’t be seen on a mammogram, but then do nothing about it? Are we telling her, “Here is some information, now just worry for ?!?”
- Risk assessment before age 30: Recommendations like the USPSTF’s are mainly for those at average risk for breast cancer. In this latest update they specifically highlight the increased risk of black women which is a step forward. But how does the average woman know if they are average risk? Ashkenazi Jewish women are at elevated risk. Do they know that? There are many factors that impact a woman’s risk, not just family history. Many primary care doctors don’t realize the risk factors go beyond family history. Effective screening compliance is only possible if risk assessment and education is done for ALL women before the age of 30 (ideally starting at age 25)—which is rarely happening in practice. Shout out to Dr. Betsy Winga at Advocate Aurora in Wisconsin for assessing risk on all of her patients coming in for well woman checks. Great standard of care and it’s what everyone should do!
I’m not naive to the time and costs associated with following both the USPSTF guidelines and the best practices above will have—an increase in screening volume, additional imaging procedures and patient visits/procedures–and, yes, some false positives. But it will also catch cancers far earlier, even prevent them through early genetic testing, and for those (and their families) who avoid the trauma of late-stage cancer, it is well worth it. it is what is truly needed.
Dr. Nina Vincoff at Northwell Health, a Volpara customer, puts it well:
“The USPSTF is calling for more research. Unfortunately, these women need guidance today. Their lives may depend on it.”
I will be urging the USPSTF in my public comment to do what’s right for patients and I hope you will join me.
I also welcome your response or comments on how we reduce this confusion and create a system with the best chance of saving more families from cancer.