Breast Cancer Screening I

Recently, the U.S. Preventive Services Task Force (USPSTF) revised breast cancer screening guidelines to recommend against routine screening mammography in women age 40-49. This is a landmark change. Previously in 2002 the recommendation was routine screening mammography every 1-2 years for women 40 and older. The USPSTF is an independent panel of experts in primary care and prevention (not including oncologists) that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This change in recommendation has garnered quite a bit of press and criticism from patients and providers alike. It is not clear-cut; the American Cancer Society and other expert panels argue against this change.

I think this is a great moment for several reasons. First, it is a bold move for the task force; how can you recommend against looking for something that kills so many people each year? Indeed, the USPSTF has remained neutral on many cancer-screening recommendations; they conclude there is insufficient evidence to recommend for or against screening for skin cancer, prostate cancer, or lung cancer. (I'm not even that ambivalent; I reviewed the literature on CT for lung cancer screening and concluded it is neither effective nor cost-effective.) But here, the USPSTF has taken a bold move, changing a previous recommendation to screen to one against it. Millions of women 40-49 have faced the discomfort of mammogram; many have had abnormal results; some have had cancers detected that otherwise would have been missed. Now, the USPSTF is simply saying stop. Don't do it. It's not worth it.

This is also a great moment because it shows that evidence is dynamic and recommendations evolve. What we learned as dogma (I'm certain this appeared on my Board examinations) changes. This is real life medicine. Nothing is certain; nothing is set in stone. As we learn more, we change what we do. Good doctors must be skeptical; they must challenge what is foisted upon them, and if new ideas persevere through those challenges, they must learn to adopt them. Research, and understanding the principles of solid research are fundamental to the practice of good medicine.

I'm going to reserve my opinion on the change for tomorrow's post. But I want to encourage you to look at the evidence. Why did they change their recommendation? Do you believe their reasons are valid? This is what I did as an undergraduate philosophy major. It doesn't matter to me what you conclude, only that you can support your reasoning. Don't use anecdote (we've all seen that unfortunate 45 year old who has metastatic breast cancer); don't use a gut feeling. Use real data. As much as you need to convince yourself. What will make someone a good doctor has nothing to do with whether they mammogram their patients 40-49; rather, a good doctor will think independently, use guidelines as guidelines, apply research to individual patients as best they can, educate the patient, and decide in a patient-doctor partnership.