US government mammogram recommendations

Denial of breast cancer screenings will have deadly consequences

By Joanne Laurier
18 November 2009

A US government panel’s recommendation that women under the age of 50 not undergo annual mammogram screenings has provoked outrage from oncologists and other health care professionals, as well as breast cancer patients and survivors.

Compelling evidence suggests that following the advice of the United States Preventive Service Task Force (USPSTF) will lead to thousands of new breast cancer deaths. One in eight women in the US (13 percent) will be afflicted by the disease at some point in their lives. An estimated 182,000 American women were newly diagnosed in 2008 with breast cancer, and more than 40,000 women died from the illness.

After decades of promoting mammograms as the best tool for early detection of breast cancer, the USPSTF is recommending against yearly screenings for women between the ages of 40 and 49, claiming the risks outweigh the benefits.

The recommendations announced Monday have been denounced by a wide range of specialists in the field and people who deal on a daily basis with the devastation that breast cancer inflicts upon hundreds of thousands of women and their families every year. Both the American Cancer Society and the National Cancer Institute condemned the change.

Otis W. Brawley, chief medical officer of the American Cancer Society, commented in a statement: “As someone who has long been a critic of those overstating the benefits of screening, I use these words advisedly: this is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member.

“With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives, just not enough of them.”

Convened in 1984 by the US Public Health Service, the USPSTF makes recommendations that are treated as a guide for coverage by health care providers and insurance carriers. Despite any assurances to the contrary, the mere announcement of a change will have far-reaching implications. Whatever the claims of the task force members, the new guidelines are bound up with cost-cutting efforts in line with the Obama administration’s health care restructuring, aimed at rationing care and placing the financial burden increasingly on the backs of the population.

In all versions of health care restructuring working their way through Congress, various bodies are being proposed to utilize comparative effectiveness research (CER) to determine which tests, treatments and procedures should be allowed, and which are “unnecessary” and should be denied. Beginning first with Medicare, the government-run health care program for the elderly, the recommendations of these bodies will undoubtedly be adopted by private insurers to deny procedures—such as breast cancer screenings—that can mean the difference between life and death for millions.

At present, 49 states (all but Utah) mandate that private health insurance companies cover routine mammograms, the vast majority requiring a baseline mammogram screening from age 35 and above, routine mammograms every two years for women 40-49, and annual mammograms for women older than 50. Private insurers are sure to seize upon the new USPSTF guidelines as a license to deny these vital screenings for millions of women.

Besides arguing against routine screening mammography for women under 50, the task force recommends screening for ages 50 to 74 only on a biennial basis. According to their own data, conducting mammograms once every two years is as little as 67 percent as effective as annual readings. For older women, it adds that the “current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.”

The task force also advises against teaching breast self-examination, and concludes that it is impossible to determine whether the more advanced digital mammography or magnetic resonance imaging (MRI) provide additional benefits as opposed to film mammography. Project coordinator for the agency, Therese Miller, admitted to the WSWS that film mammography is far more cost-effective than the digitized technology, which has been well established as a more precise form of imaging.

It is broadly acknowledged that the onset of regular mammography screening since 1990 has been a major factor in decreasing the breast cancer death rate—which had been unchanged for the preceding 50 years—by a massive 30 percent.

“The USPSTF recommendations are a step backward and represent a significant harm to women’s health,” said Dr. W. Phil Evans, president of the Society of Breast Imaging, in a statement. “At least 40 percent of the years of life saved by mammographic screening are of women aged 40-49.”

The society’s web site states that there “is universal agreement that screening mammography saves lives... They [the USPSTF panel members] reason that because more women aged 40-49 are needed to save one life than in the other age groups, the harms are too great to justify screening beginning at 40, despite a similar mortality reduction. We would argue that the earlier in her life that a woman’s life is saved by screening, the better.” The “harms” cited by the USPSTF include anxiety from false positives and, above all, the resulting “over-treatment,” i.e., primarily fiscal risks, not physical ones.

Michele Wittling, the society’s executive director, told the WSWS: “Which women does the USPSTF want to die? When they openly state that people will die, I cease to be able to understand the discussion. I believe thinking along these lines is criminal.”

In a comment to the WSWS, Murray Rebner MD, Fellow of the American College of Radiology and Co-Director of the Division of Breast Imaging and Intervention at William Beaumont Hospital in Royal Oak, Michigan, stated: “The USPSTF's recommendations are a slap in the face to American women. If followed they will cause many potentially preventable deaths.”

Perhaps protesting too much, Dr. Diana Petitti, vice chair of the USPSTF, claims that the “cost was not a part of what the task force looked at.” For many involved in the breast cancer field, such statements strain credulity.

ABC News reports the blunt comment of Hillary Rutter, director of the Adelphi New York Statewide Breast Cancer Hotline and Support Program, who said, “I think a lot of it is about money, and we know that we need to make health care cuts, but this isn’t the way we need to make money.”

And Dr. Evans of the Society of Breast Imaging stated, “These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives.”

A joint statement from the American College of Radiology and the Society of Breast Imaging declares: “These new recommendations seem to reflect a conscious decision to ration care. If Medicare and private insurers adopt these incredibly flawed USPSTF recommendations as a rationale for refusing women coverage of these life-saving exams, it could have deadly effects for American women.”

Tellingly, seven years ago the USPSTF advised that women have mammograms every one to two years starting at age 40.

“It’s hard to believe that these recommendations don’t have something to do with the health care bill and cost cutting,” Mary Jo McGovern, Clinic Coordinator for University of Michigan Breast Oncology, told the WSWS. “I don’t have the data at my fingertips, but I can assure you that the breast cancer population is getting younger. In my wildest dreams, I could never envision that these things would be proposed. For years we’ve been teaching women about the benefits of early detection and self-examination. Now they want to erase all of these previous efforts.

“First you hear they don’t want to do ‘unnecessary’ biopsies. Then they want to deny scans to women under 50 and deny the value of the latest technology; that digital mammograms and MRIs are superior to film mammography. In my opinion, it all comes down to money. I would really like to know who this task force is and how they figured these things out. Their decisions are counter to what we who deal with breast cancer every day know to be true. It will amount to the fact that those who can afford will get what they need and those who can’t won’t. This needs to be opposed.”

Defending the recommendation, USPSTF’s Dr. Petitti said that the change “was voted on almost a year-and-a-half ago.” She claimed, “It is, in reality, entirely an accident that it is coming out on the heels of a lot of information about breast cancer screening, and certainly accidental in relationship to anything that’s being talked about in politics.” This merely underscores the reality that rationing health care is a consensus policy of the American political establishment, and that these policies are being promoted across the board, particularly by the Obama White House.

That the increased deaths will occur primarily within the poorest sections of the population was spelled out by Eric Winer, chief scientific adviser of Susan G. Komen for the Cure, a breast-cancer advocacy foundation, and director of the Breast Oncology Center at Dana-Farber Cancer Institute in Boston. “At a minimum, what we can say is that women [at 40] and their doctors have a right to make a decision about whether they should be screened. If they don’t have financial coverage, then they don’t have that right,” Winer told the Wall Street Journal.

The USPSTF’s recommendations are further proof of the reactionary character of the Obama administration’s drive for a cost-cutting overhaul of the health care system. Far from representing a step toward universal coverage and increased access to quality care, the health care proposals represent a social regression, a concerted effort to roll back gains associated with the enactment of Medicare in 1965. In its drive to reduce costs and defend the profits of the corporate aristocracy, the American ruling elite is prepared to sacrifice thousands and thousands of lives.