Women Told to Have Fewer Mammograms, Pap Smears

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.

The USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women ≥75 years. Citing insufficient evidence to assess benefits and harms, USPSTF did not make recommendations concerning clinical breast examination beyond screening mammography in women ≥40 years of age. USPSTF also declined to make an assessment of the benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

Pap Smear Tests
The new Pap smear guidelines published by ACOG in the December issue of Obstetrics & Gynecology [Practice Bulletin #109 “Cervical Cytology Screening”] call for cervical cancer screening to begin at age 21 years regardless of sexual history. Screening before age 21 should be avoided because women <21 years of age are at very low risk of cancer, and ACOG says it could lead to unnecessary and harmful evaluation and treatment.

Cervical cytology screening is now recommended every 2 years for women between the ages of 21 and 29 years, and ACOG said evidence shows that screening women every year has little benefit over screening every other year. “The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” says Alan G. Waxman, MD, professor of obstetrics and gynecology at the University of New Mexico in Albuquerque, who headed the document developed by ACOG’s Committee on Practice Bulletins-Gynecology. “A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”

ACOG said moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents, which can have economic, emotional, and future childbearing implications. ACOG previously recommended that cervical screening begin 3 years after first sexual intercourse or by age 21, whichever occurred first.

According to ACOG, cervical cancer rates have fallen >50% in the past 30 years in the United States due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The ACS estimates that there will be 11,270 new cases of cervical cancer and 4070 deaths from it in the United States in 2009. The majority of deaths from cervical cancer in the United States are among women who are screened infrequently or not at all.

Reaction
In a statement responding to the new USPSTF mammography guidelines, Otis W. Brawley, MD, chief medical officer, ACS, said that based on similar data, ACS continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. “Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider,” he said.

“The USPSTF says that screening 1339 women in their 50s to save 1 life makes screening worthwhile in that age group. Yet USPSTF also says screening 1904 women ages 40 to 49 in order to save 1 life is not worthwhile,” Dr. Brawley continued. “The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.”

In addition to provoking disagreement from doctors’ groups, the announcement of new breast cancer screening guidelines elicited a strong reaction from activists. Nancy G. Brinker, founder and CEO of Susan G. Komen for the Cure and the global leader of the breast cancer movement, said that the changes to the national mammography guidelines have led to mass confusion and justifiable outrage among women who are worried that future generations of women will lose access to a critical tool that might have saved their life.

“We have worked so hard to build public trust and to urge people to get screened. And now they hear that maybe they shouldn’t bother. That is dangerous,” Ms. Brinker said. “Let me say this as clearly as I can: mammography saves lives, even this report says that. Keep doing what you are doing. And always talk with your doctor.” She also announced that Komen for the Cure was not changing its guidelines, continuing to recommend annual mammograms beginning at age 40.

Noting that mammography, while the best currently available screening tool, is not perfect, Ms. Brinker called on the government and the scientific community to close the technology gap and develop tools that are more predictive, available, and personal, but are less expensive and aggressive. “I’d also like to say that any insurance company that thinks this report could be used as a way to reduce coverage for mammography now or at some point in the future…we’ll be watching,” she added.

Shortly after the USPSTF issued its new mammography guidelines, the Senate added an amendment to its healthcare reform bill that would prevent the new recommendations from restricting mammograms for women. Sen. David Vitter (R-LA) introduced the amendment, which was approved without a vote. “This is an important victory for women’s health but also for walking back the influence of government task force recommendations that seem to be based more on cost-cutting and less on what is the best quality medicine,” Rep. Vitter said.

Too Few Screened
The same week that new recommendations for breast and cervical cancer screening were released, a report prepared by the Centers for Disease Control and Prevention, AARP, the Gerontological Society of America, and the American Medical Association found that only 25% of adults aged 50 to 64 get recommended preventive screenings. The report, “Promoting Preventive Services for Adults 50-64: Community and Clinical Partnerships,” focuses on opportunities to improve the health of the growing number of adults in the 50 to 64 age bracket to broaden the use of potentially lifesaving preventive services. The report identifies recommended preventive services such as influenza vaccine, cholesterol screening, breast and cervical cancer screening, as well as preventive screenings for behaviors that could negatively impact health.—Charles Boersig