Cath Lab Digest

Women Told to Have Fewer Mammograms, Pap Smears

While lawmakers on Capitol Hill were debating comprehensive healthcare reform, updated recommendations for mammograms and Pap tests provoked a more focused debate on the potential benefits and harms of regular preventive screening. In mid-November, the United States Preventive Services Task Force (USPSTF) announced that its guidelines for mammography no longer recommend routine screening for women between the ages of 40 and 49 and advise women to be screened biennially, rather than annually, between the ages of 50 and 74. Days later it was reported that the American College of Obstetricians and Gynecologists (ACOG) would publish new guidelines calling for less frequent cervical cancer screening than previously recommended beginning at age 21. Although the new recommendations were made using current clinical evidence, critics said they represent an attempt to control costs rather than save the most lives.

Mammograms
The USPSTF recommendation statement on mammography was published on November 17 in Annals of Internal Medicine [2009;151(10):716-726]. USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The US Public Health Service first convened USPSTF in 1984, and since 1998 it has been sponsored by the Agency for Healthcare Research and Quality.

In addition to new recommendations pertaining to mammograms, USPSTF recommended against teaching breast self-examination. Women in their 40s do not need to undergo annual mammograms, and the task force recommends biennial screening mammography for women aged 50 to 74 years. The USPSTF says the decision to begin this screening before the age of 50 should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

“So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values,” said Diana Petitti, MD, MPH, vice chair, USPSTF.

The American Cancer Society (ACS) estimates that in 2008 there were 182,460 newly diagnosed cases of invasive breast cancer and 67,770 cases of noninvasive breast cancer. The disease was responsible for 40,480 deaths. Early detection of breast cancer through the use of regular screening is widely recognized as a driver of better treatment outcomes and reductions in mortality. The potential downside of early screening includes psychological harms, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. USPSTF said these harms seem moderate for each age group.

In the evidence update article published along with the new mammography guidelines [Ann Intern Med. 2009;151(10):727-737], USPSTF says that based on the results of 8 trials, mammography screening reduces breast cancer mortality by 15% for women aged 39 to 49 years (relative risk, 0.85; 95% credible interval, 0.75-0.96). In addition, the report notes that false-positive mammograms and performance of additional imaging are common, radiation exposure is low, and adverse experiences are transient.