AMA rejects federal mammography guidance

The American Medical Assn.’s House of Delegates updated its mammogram screening recommendation to include all women starting at age 40, flying in the face of guidance from the U.S. Preventative Services Task Force that caused a commotion among healthcare providers.

The USPSTF, an independent body funded and staffed by the U.S. Dept. of Health & Human Services, holds that routine mammogram breast cancer screenings are not necessary for women under the age of 50 who aren’t at increased risk.

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The agency further recommended mammograms every 2 years for women aged 50 to 74, rather than the previously accepted yearly screenings, and cautioned against teaching women under the age of 50 to conduct breast self-examination.

The USPSTF guidance had the backing of the American Academy of Family Physicians and was in line with the World Health Organization’s recommendations.

However, it was at odds with recommendations of the American Cancer Society, the National Comprehensive Cancer Network, the Canadian Task Force on Preventative Health Care and the American College of Obstetrics & Gynecology, the 2009 USPSTF report noted.

"Early detection of breast cancer increases the odds of a patient’s survival, and mammography screenings are an important tool in discovering this cancer," AMA board member Dr. Patrice Harris said in prepared remarks this week. "All patients are different and have varying degrees of cancer risk, and patients should regularly talk with their doctors to determine if mammography screening is right for them."

Following the agency’s 2009 report, USPSTF members later expressed "regret" over what was perceived as a "poorly worded" recommendation, according to the AMA. The members clarified that woman of all ages should have access to mammogram screenings if they so choose, but that the risks associated with routine screening mustn’t be discounted.

The USPSTF issued the 2009 guidance after finding that the risk of breast cancer false positives were higher for women aged 40-49 while the risk of developing breast cancer was lower than that of women over the age of 50. USPSTF urged "the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms."

"The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older," according to the agency’s 2009 recommendation. "Although false-positive test results, over-diagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years."

The agency’s 2009 decision overturned a 2002 report recommending mammograms in women aged 40 and older, but changed its mind in light of new data, including a randomized, controlled clinical trial and the Cancer Intervention & Surveillance Modeling Network’s modeling studies.

"For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ."

It’s not the 1st time the AMA has come up against USPSTF recommendations for common screening programs. The AMA and other nationwide physicians’ groups issued an outcry against a recent agency report urging physicians to set aside a commonly used prostate cancer screening tool.

Known as the prostate-specific antigen test, or PSA, the tool may pose more risks than benefits, according to the USPSTF panel.

"Many people have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found," American Cancer Society chief medical officer Dr. Otis Brawley wrote in an accompanying commentary on the panel’s decision. "There is little appreciation of the harms that screening and medical interventions can cause."

The AMA delegates this week expressed "concern regarding recent recommendations by the USPSTF on screening mammography and prostate specific antigen screening and the effects these recommendations have on limiting access to preventive care for Americans."

The group didn’t go so far as to recommend breast cancer screening for woman beginning at age 40, but wrote that "the AMA has adopted policy that starting at age 40, all women should be eligible for screening mammography. The policy also supports insurance coverage for this screening."