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When I had an office practice, I tried to provide patients with preventative screening for things like colon, cervical and breast cancer, including checking for blood in stool, scheduling colonoscopies, doing PAP smears, teaching self-breast exams and arranging mammograms.
The checklist in each chart would help me remember which tests and exams to recommend for each patient because I could never keep all of the recommendations straight, partly because some organizations differed on what to do and when.
When the U.S. Preventive Services Task Force (USPSTF) put together a book of evidence-based guidelines, I was happy to have one authoritative source for reference. However, over the years, they keep changing the book and not everyone agrees with the book in the first place.
This past week, the USPSTF issued new breast cancer screening guidelines and published its updated recommendations in the Annals of Internal Medicine magazine. The task force now recommends against routine mammography screening for women before age 50 years and suggests that screening end at age 74 years. These guidelines also recommend changing the routine screening interval from one year to two years.
This recommendation is a change from their 2002 statement, which endorsed mammography screening, with or without breast exam by a trained professional, every year for women 40 years or older.
The new guidelines suggest that women aged 40 to 49 years who are at high risk for breast cancer consult their doctor concerning the best time to begin regular screening mammography.
Because the USPSTF did not find adequate evidence that teaching self-examination is associated with a decrease in breast cancer death rates, the task force recommended against teaching breast self-examination.
Current evidence is insufficient to evaluate additional benefits and harms of clinical breast examination for women aged at least 40 years.
Mammography is associated with decreased breast cancer death rates, particularly in women aged 50 to 74 years, based on evidence so far. Women aged 60 to 69 years appear to get the most benefit.
So far, evidence is insufficient to recommend either digital mammography or magnetic resonance imaging (MRI) for breast cancer screening compared to mammography done on x-ray films.
To review, the specific USPSTF recommendations are as follows:
• No routine screening mammography in women aged 40 to 49 years. However, individual decisions should be made regarding starting regular, biennial screening mammography before age 50 years in higher risk women. (Ask your doctor.)
• Women aged 50 to 74 years should have screening mammography every other year, instead of every year.
There is not enough evidence to recommend screening mammography in women 75 years or older.
• Even in women 40 years or older, there is not enough evidence to recommend breast exams by trained professionals beyond just doing the screening mammography.
The USPSTF recommends against clinicians teaching women the technique of breast self-examination.
These new guidelines are not popular with many groups because, among other reasons, they draw a new boundary for testing where there is no clear cut-off point.
What is clear, however, is that some cases of breast cancer in women aged 39 to 49 years will be missed since mammography screening has been associated with a 15 percent decrease in breast cancer mortality rates.
If you look at this in another way, 15 percent of a small number of women is an even smaller number. After all, there are a few tragic cases of breast cancer in women in their 20s that might be detected earlier by screening mammograms. There is nothing magic about ages 40 or 50 years that makes them perfect ages for beginning screening mammograms.
It is also very important to remember that these guidelines are for low risk women with no personal or family history of breast cancer.
From my point of view, the new guidelines make some sense in order to decrease the cost of health care. However, I would recommend earlier screening for anyone with any risk factor, as determined by her personal health care provider.
Finally, for women with a strong family or personal history of breast cancer, genetic testing should be considered. These women should consider bilateral mastectomies with or without implants, which is statistically the best way to avoid breast cancer death.
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