The Blog

Stop Worrying, It May Cost You Your Mammogram!

Now we may have to say to patients, stop checking your breasts or you may begin to suffer from the current epidemic syndrome: "Breast Cancer Worry."
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Yes, "breast cancer worry" is a factor listed as one of the "harms" of breast cancer screening. In fact, this "syndrome" is partly responsible for why the United States Preventive Services Task Force (USPSTF) recently stated that this "test" is no longer a screening recommendation for most 40-something women. Wait, there is more... physicians are also not to instruct women on self-breast exam because it too raises the ghastly specter of "breast cancer worry." The evidence to support this includes a study from Shanghai demonstrating that a self exam may cost more than it we may have to say to patients, stop checking your breasts or you may begin to suffer from the current epidemic syndrome: "Breast Cancer Worry."

Reading the very article in The Annals of Internal Medicine announcing the USPSTF recommendation changes sends a chill up my spine. Yes, my livelihood depends on the care and screening of women, but I also care about those women, many of whom are my dear friends, long loved patients, and relatives of mine. I don't want them to end up with unnecessary biopsies, but one in eight (the incidence of breast cancer) is a very scary statistic. My fear is that actuarial tables analyzing benefits do not consistently reflect what is best for the individual patient. Consider this excerpt from the USPSTF statement:

"Thus, the absolute risk reduction from screening (as shown by the number needed to invite to screen) is greater for women aged 50 to 59 years than for those aged 40 to 49 years."

Basically, the task force analysis indicates that the acceptable number of women tested with mammogram to save one life is somewhere between 1300 (for 50-somethings) and 1900 (for 40-somethings). It clearly takes fewer 50-somethings screened to save a life than 40-somethings, and a line had to be drawn somewhere--so it was drawn at 50. Apparently due to lack of scientific data all bets are off from age 75, so no recommendation can be made for these women.

This (from a separate supporting article in The Annals of Internal Medicine) is even scarier:

"If program benefits are measured in life-years, the measure most commonly used in cost-effectiveness analysis, then our results suggest that initiating screening at age 40 years saves more life-years than extending screening past age 69 years (albeit at the cost of increasing the number of false-positive mammograms)."

In other words, the 40-something has more to gain than the 70-something from mammography screening...but apparently not as much as the 50-something who is at even higher risk than the 40-something. After all, if you start screening at 40, the 40-something will have 10 extra years of "Breast Cancer Worry" to deal with than the 50-something.

If you are confused, you are not alone. Most of the leading experts on the USPSTF panel have backgrounds in public health. That may mean that policy recommendations are weighted toward cost effectiveness, not merely saving or extending lives. Most medical organizations are responding to this recommendation with "ask your doctor," advisories. The problem is that insurance companies may run with the task force advice; it would save them millions.

The American Congress of Obstetrics and Gynecology has suggested that we docs in the trenches ignore the USPSTF change for now. The Department of Health and Human Services seems to be distancing themselves from the report (although the task force website link ends in .gov). The patients are questioning the controversy, and clinicians are trying to put out the mixed messages fires.

In the meantime I recently called another 40-something about the early breast cancer found on her mammogram. She is very worried, and very much alive. She is not going to die from "Breast Cancer Worry", or for that matter: breast cancer...she started having screening mammograms at age 40.