I have been reading screening mammograms and diagnosing curable cancers for about 15 years now. The benefits of mammography screening have never been in doubt in my mind. Yet, about every ten years or so, much ado is made about someone's claim that they are less effective (or, in some cases, completely useless) than previously thought. When a new doubt is raised, it causes concern and confusion in the minds of both patients and their referring providers.
This is not how it should be.
The main test of a mammography's ability to detect disease early enough to alter the course of that disease were Randomly Controlled Trials (RCTs) performed 30-50 years ago. In these trials, one randomly assigned group was offered mammography screening and the other group got 'usual care' which, back then, was essentially nothing unless she or her doctor found a lump. Some women assigned to the screening group did not get screened (remember, they were just offered the screen) and some women in the 'usual care' group went outside of the study and got exams. Nevertheless, all participants were counted in the group to which they were assigned. These 8 or 9 trials were conducted in four countries between 1964-1980 and most lasted 4-6 years.
Even with then-technology which we would now consider woefully inadequate (essentially unusable), cross-contamination of the study groups and some serious concerns about the methodology of the two studies from Canada, analyses of all of the studies consistently showed at least a 20% reduction in the death rate from breast cancer.
Several things have changed since then.
First, we have now had over 20 years of widespread screening in most of the 'Western' world. Dr. Laszlo Tabar from Sweden, was the principle investigator of two of the largest RCTs in Sweden and is a personal friend of mine. He has followed his study patients for the last 20 years and has made a significant discovery: most of the survival benefit of screening mammography took place in the last 10 years or so of screening. What this means is this: the benefit of screening mammography continues to increase the more times a woman is screened.
Second, studies have looked at women who have actually get screens (as opposed to merely being offered to be screened). Among women who have actually gotten screened, the death rate from breast cancer has decreased by over 50%. This is one of the main faults of the 2009 US Preventative Task Force recommendations against screening women in their 40s. They looked at data among women offered to be screened, not actually screened.
Third, technology has vastly improved since those first screening studies. Consider this: non-digital mammography continuously improved over 20 years of utilization. By the late 1990s, it was about as good as it could get. A few years later, digital mammography was developed and, on the first day it was used, it was at least as good (and better in certain patients) as non-digital mammography. And now, we're already considering a move to 3D digital mammography which may prove to be a significant improvement over current '2D' mammography. This means detection of more curable cancers that can be seen on imaging before they can be felt.
Ever since the beginning of mass population screening in the mid-late 1980s, we have seen a continuous decline in the death rate from breast cancer. This is true in both the 40-49 year age group as well as women 50 and over. In fact, for the first time that I've seen, the estimate of U.S. breast cancer deaths for 2012 by the NCI is now less than 40,000. Still an obscenely high number, but an important milestone nonetheless. Most research has indicated that at least 2/3 of the survival benefit is from screening mammography with improved treatment accounting for the other 1/3.
The Affordable Care Act guarantees no-cost (no co-pays or deductibles) annual screening mammograms for all women 40 and older. This took effect in August and applies to most policies made or renewed after the effective date. This also applies to Medicare/Medicaid recipients. You can read more about it here: http://www.healthcare.gov/
We are lucky to live in a progressive state like Colorado as we were a step ahead of the federal government by guaranteeing similar coverage when CO House Bill 10-1252 went into effect on January 1, 2011. This bill requires all insurance companies doing business in the Colorado to guarantee annual screening mammography for all women 40 years old or older.
Mammography shouldn't be confusing. It should be easy, covered and comfortable. In future blogs, I'll talk more about the myths and facts of breast cancer screening and even how you can get your annual mammogram at a happy hour 'party!'
Until then...
This is not how it should be.
The main test of a mammography's ability to detect disease early enough to alter the course of that disease were Randomly Controlled Trials (RCTs) performed 30-50 years ago. In these trials, one randomly assigned group was offered mammography screening and the other group got 'usual care' which, back then, was essentially nothing unless she or her doctor found a lump. Some women assigned to the screening group did not get screened (remember, they were just offered the screen) and some women in the 'usual care' group went outside of the study and got exams. Nevertheless, all participants were counted in the group to which they were assigned. These 8 or 9 trials were conducted in four countries between 1964-1980 and most lasted 4-6 years.
Even with then-technology which we would now consider woefully inadequate (essentially unusable), cross-contamination of the study groups and some serious concerns about the methodology of the two studies from Canada, analyses of all of the studies consistently showed at least a 20% reduction in the death rate from breast cancer.
Several things have changed since then.
First, we have now had over 20 years of widespread screening in most of the 'Western' world. Dr. Laszlo Tabar from Sweden, was the principle investigator of two of the largest RCTs in Sweden and is a personal friend of mine. He has followed his study patients for the last 20 years and has made a significant discovery: most of the survival benefit of screening mammography took place in the last 10 years or so of screening. What this means is this: the benefit of screening mammography continues to increase the more times a woman is screened.
Second, studies have looked at women who have actually get screens (as opposed to merely being offered to be screened). Among women who have actually gotten screened, the death rate from breast cancer has decreased by over 50%. This is one of the main faults of the 2009 US Preventative Task Force recommendations against screening women in their 40s. They looked at data among women offered to be screened, not actually screened.
Third, technology has vastly improved since those first screening studies. Consider this: non-digital mammography continuously improved over 20 years of utilization. By the late 1990s, it was about as good as it could get. A few years later, digital mammography was developed and, on the first day it was used, it was at least as good (and better in certain patients) as non-digital mammography. And now, we're already considering a move to 3D digital mammography which may prove to be a significant improvement over current '2D' mammography. This means detection of more curable cancers that can be seen on imaging before they can be felt.
Ever since the beginning of mass population screening in the mid-late 1980s, we have seen a continuous decline in the death rate from breast cancer. This is true in both the 40-49 year age group as well as women 50 and over. In fact, for the first time that I've seen, the estimate of U.S. breast cancer deaths for 2012 by the NCI is now less than 40,000. Still an obscenely high number, but an important milestone nonetheless. Most research has indicated that at least 2/3 of the survival benefit is from screening mammography with improved treatment accounting for the other 1/3.
The Affordable Care Act guarantees no-cost (no co-pays or deductibles) annual screening mammograms for all women 40 and older. This took effect in August and applies to most policies made or renewed after the effective date. This also applies to Medicare/Medicaid recipients. You can read more about it here: http://www.healthcare.gov/
We are lucky to live in a progressive state like Colorado as we were a step ahead of the federal government by guaranteeing similar coverage when CO House Bill 10-1252 went into effect on January 1, 2011. This bill requires all insurance companies doing business in the Colorado to guarantee annual screening mammography for all women 40 years old or older.
Mammography shouldn't be confusing. It should be easy, covered and comfortable. In future blogs, I'll talk more about the myths and facts of breast cancer screening and even how you can get your annual mammogram at a happy hour 'party!'
Until then...
