Opinion: Mammography guidelines have chilling effect on breast cancer screening

By Lara Hardesty, M.D.

New studies show that women in their 40s are getting mammograms less frequently after much-publicized new guidelines came out in 2009. I am greatly concerned that these guidelines are subjecting women to unnecessary risk.

I have been director of Breast Imaging at the University of Colorado since 2005 and have been sub-specializing in all aspects of breast imaging (mammography, breast ultrasound, breast MRI, breast needle biopsies) since 1997. As such, I recommend annual screening mammography for my patients beginning at age 40, as recommended by the American Cancer Society and the American College of Radiology.

In November 2009, the United States Preventative Services Task Force (USPSTF) released new recommendations regarding mammographic screening for breast cancer: mammogram every two years for women ages 50 to 74. They specifically recommended no screening for women ages 40 to 49 of average risk, and said there was insufficient evidence to recommend screening of women older than 74.

My colleague Dr. Edward Hendrick conducted a recent study and found that when screening begins at age 50 and only happens every-other year, as the USPSTF recommends, breast cancer deaths are reduced only by only 23 percent. When women begin yearly mammograms at age 40, breast cancer deaths are reduced by 40 percent. That means starting annual mammography screening at age 40 will save 71 percent more lives.

I also wanted to evaluate the impact of the USPSTF recommendations. In my study, I analyzed how the new recommendations are influencing the behavior of our patients and referring providers.

To determine the effect on our patients, I looked at the number of screening mammograms performed at the University of Colorado Hospitals Breast Imaging Center in the nine months before the new guidelines were released and in the nine months afterward.

The number of 40 to 49 year olds undergoing screening at UCH decreased by 15 percent after the guidelines were released.

Surprisingly, the number of 50 and older patients receiving screening mammograms at UCH increased slightly (although the guidelines recommended they be screened every two years instead of every year, so I expected their number to decrease as well).

To determine the effect on our referring providers, Radiology resident Dr. Jayme Takahashi and I sent an email survey to the internal medicine, family practice and gynecology physicians and nurse practitioners at UCH. The survey asked what they recommended for their patients regarding screening mammography both before and after the new USPSTF guidelines.

There had been a significant change in what our providers were recommending for women in all three age groups.

The USPSTF guidelines led to fewer of our 40- to 49-year-old patients coming in for screening mammograms and led to a marked decrease in the percentage of our referring providers recommending annual screening mammograms for their patients. We found a 51 percent drop in physician recommendations for screening in 40- to 49-year-old women.

The USPSTF recommendations greatly concern me. If women ages 40 to 49 and older than 74 do not undergo mammography, their cancers will not be found until they are large enough to be detected as a lump by either the patient or her health care provider.

We know that cancers found as a palpable lump are larger on average than cancers found on mammographic screening, and we know that the earlier breast cancer is detected, the more treatable it is.

I strongly recommend that women aged 40 and older undergo screening mammography every year to enable detection of breast cancer as early as possible, when it is most treatable.

Lara Hardesty, MD, is director of breast imaging at the University of Colorado Hospital and section chief of breast imaging and associate professor of radiology at the University of Colorado School of Medicine.

<div><strong> Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.</strong></div>